Irrespective of geographical location, income per capita and political system, the gaps in countries’ systems to prevent and control infectious disease outbreaks are strikingly similar. Addressing these gaps is essential to combat COVID-19 – which looks likely to be a recurring challenge – and also presents an opportunity to make investments that simultaneously advance equity and well-being more broadly.
Access to quality healthcare, free at the point of use for everyone, has proven to be a game changer for countries’ ability to contain infectious disease outbreaks. A lack of universal health coverage (UHC) prevents some people – such as those who cannot afford to pay for services or are not covered by employers’ insurance schemes, or are undocumented migrants – from accessing testing and treatment services quickly.
This results in avoidable spread of infection and mortality in these groups, and in the country more widely. Such healthcare inequalities have played out in higher-income countries such as the US and in lower-income countries such as Kenya, where charges levied against patients who were quarantined owing to COVID-19 had to be dropped.
Cramped and unsanitary conditions
Similarly, structural inequalities in living and working conditions means that those who spend long periods in overcrowded conditions when they cannot practice physical distancing or optimal hygiene behaviours, are at most risk. Singapore is a clear example where an otherwise effective COVID-19 control strategy was blindsided by cramped and unsanitary conditions in some of its migrant worker dormitories.
Another gap in our societies is the lack of financial safety nets for large segments of the population such as informal workers – which means they have no income from their employers or the state if they are unable to work due to illness, family caring responsibilities or physical distancing requirements.
The impact of insecure income on COVID-19 control cannot be understated. Millions of people migrated from cities in India to rural areas as they had no source of income once the lockdown was announced; this has been blamed for transmission of the virus to rural areas. Guaranteed sick pay is also essential for people to take time off when symptomatic or exposed to the virus by a sick family member, to prevent infection spread in workplaces.
Then there is the issue of how much populations trust their governments, and this is affected by effective government communication during emergencies. Trust and communication are crucial for compliance with public health guidance, such as physical distancing. For example, the UK population compliance with physical distancing measures is thought to have dropped when trust in the Prime Minister and advisers was shaken. Other countries, including the US, Nigeria and Pakistan, have struggled to convince communities to avoid gathering at places of worship because they have greater trust in religious leaders who tell them it is safe to attend.
Surveillance is required to implement the core strategy for outbreak control – test, trace and isolation of people who could spread infection. This relies not only on strong data collection and management systems, but also on trust and compliance with government agencies. Many countries are weak on these aspects, and they take years to build up.
The extent to which countries have managed to coordinate and mobilise the range of service providers in their healthcare systems has also been important in influencing a country’s surge capacity. For example, being able to use private sector facilities to rapidly increase diagnostic testing capacity or access to ventilators is advantageous, but only possible if systems for coordination and data sharing are in place.
Finally, cracks in the foundation that all policies and regulations are built upon – a robust system for monitoring, accountability and enforcement – have also become apparent across the world. Power dynamics and corruption has allowed ‘connected’ people to evade rules on physical distancing and self-isolation following travel. Such sanctioned non-compliance can result in localised outbreaks as well as erosion of trust in authorities.
Despite substantial investment in preparedness to prevent and respond to pandemics, it is apparent that a siloed and biomedical approach – one that failed to see the connections between infectious disease control and equity, trust and accountability in societies – has worked against many countries.
The silver lining is that everyone, be they rich or poor, connected of disenfranchised, now has some interest in filling these gaps. COVID-19 has demonstrated that addressing structural inequalities not only benefits marginalised groups, it also protects the entire country from impacts of infectious diseases.
The solution is not simple, but it is clear: more equitable access to healthcare and financial safety nets; minimum standards for living and working conditions; greater government attention on building community trust and mechanisms to mobilize health resources at short notice; and strong, fair enforcement of rules.