For many sub-Saharan African countries, the COVID-19 pandemic looms on the horizon. Global health experts like Professor Allyala Nandakumar, who directs the MS in Global Health Policy and Management program and the Institute for Global Health and Development (IGHD) at the Heller School, are stepping up to help them prepare. He’s bringing together his colleagues at Heller to support those at the Office of the Global AIDS Coordinator in the U.S. State Department, where he serves as chief economist to make federal HIV/AIDS spending more efficient and sustainable.
It’s important to remember that when pandemics hit, people die in three ways. One, of course, is from the pandemic itself. The second is from health system collapse—people can’t get critical medical care for other health issues because hospitals and the primary health care system are overwhelmed. The third is from economic collapse—people lose the ability to support themselves, and we know that for example, suicides, substance abuse, mental health problems, and domestic abuse all increase during economic recessions. These second and third problems are delayed by several months, but they’re very serious.
Countries in sub-Saharan Africa face difficult tradeoffs. First, as we are seeing in the U.S. and other countries, efforts to flatten the curve through mandatory shutdowns will come with very high economic costs. On the other hand, if countries shorten the lockdown period and encourage the restart of economic activity, they run the risk of a resurgence of the disease.
While these choices are difficult and need to be made, one thing is clear: a sequential approach—like the one we are taking in the U.S.–of first saving lives and then figuring out how to save jobs, is not the way. From the outset, countries in sub-Saharan Africa have to work simultaneously on saving lives and saving jobs.
When the Ebola crisis happened, we saw more people in West Africa die from measles than from Ebola because routine immunizations stopped. The frontline health system collapsed, health care workers started dying and some left their posts out of fear.
Most low- and middle-income countries have fairly fragile health systems. We spend about $12,000 per person on health care in the U.S., versus $50 -$150 per person in low- and middle-income countries. But, these countries bear 80-85% of the burden of disease. So, they spend 15% of the money on 85% of the health burden. That’s a huge financial stress.
When a pandemic completely overwhelms the primary care system, frontline workers in these countries rarely have PPE [personal protective equipment], ventilation systems to circulate the air at the clinics or ways to effectively triage patients. Our media are very fixated on ICUs [intensive care units], but in many of these countries the real danger is the implosion of primary care.
Routine care gets disrupted for months on end, which can lead to a lot of adverse health outcomes. All elective and routine surgeries, immunizations, cancer screenings like colonoscopies and mammograms, all of it—put off by three months. Then there’s a huge pent-up demand, and three months turns into six months. This cascading effect on the health system…the longer it goes on, the worse it gets.
We’re seeing these things start to happen now in the U.S.: elective surgery has stopped, cancer screening has stopped, even in the U.S. There’s a cost to be paid for that, and we don’t usually factor that in. And I also mean a literal, financial cost: hospitals in the U.S. are losing millions of dollars and likewise medical practices are losing tens of thousands of dollars a month because routine care is not being provided.
We have a grant from the U.S. State Department to set up an analytics hub for the Office of the Global AIDS Coordinator (OGAC). We are putting together 20-year panel data for some key countries in Africa that we believe will be impacted by COVID-19. The goal is to use this panel data to start predicting the lagged effects on key health outcomes.
In addition, OGAC is putting together a way of systematically tracking information to see how COVID-19 may impact the State Department’s HIV/AIDS treatment and prevention programs. This is a population at high risk of comorbidities like tuberculosis, etc. We are looking to routinely capture data indicators to serve as an early warning system that something is going wrong for these patients, that COVID-19 may be impacting their HIV/AIDS care.
We’re looking at the number of people on treatment—if you see a big dip, you know something is wrong. Another is the number of people who don’t show up for follow-up treatment, or get routine testing. In addition, the supply chain becomes very important and is increasingly global in nature. Actions taken by one country can impact the availability of antiretroviral drugs in another country. For example, India has banned essentially all international flights, but they’re a major manufacturer of antiretroviral drugs. The world has become so interconnected, the position that one country takes can have huge impacts on the rest of the world
It’s extremely complex, and in the absence of data, everyone will be flying blind.
In most of these countries we’re pretty close to viral load suppression of HIV/AIDS. If treatment gets disrupted, it’s unlikely to lead to an immediate spike in new cases. But if people are not getting appropriate treatment, it’s likely that they’ll have adverse health outcomes and you’d see a higher mortality rate. We also need to be able to constantly diagnose and treat new cases, if you’re not doing that, there’s risk they could spread the virus. Given that COVID-19 disproportionately impacts people with comorbidities including HIV and TB, there is the opportunity of using this time to encourage more people to get tested for HIV.
The good news is that the virus hasn’t really hit Africa yet. They’ve had three or four months to prepare. At a minimum, they need to protect the primary health system from the immediate onslaught. They need to obtain protective gear for frontline health care workers, and transportation so they don’t have to take public transport. They need to set up tents outside of hospitals for basic triage, to identify people with fevers. Simple things, like having oxygen available at these centers, can help a lot.
Extensive testing will be needed both to detect new cases, but also is key when actions are taken to reopen the economy. Testing millions of people is a major effort needing lab capacity, a supply chain to procure test kits as well are other reagents and supplies, and finally a cadre of health care workers that can carry out the tests. Similarly, contact tracing is critical to identify and isolate individuals exposed to the virus.
But all of this costs a lot of money. And the wealthier countries—the U.S., U.K., Italy, France, Germany—they’re all dealing with their own COVID-19 problems. There are lots of things we can do if high-income countries are willing to be generous at this time.
As a global health economist, how are you approaching the COVID-19 pandemic?
It’s important to remember that when pandemics hit, people die in three ways. One, of course, is from the pandemic itself. The second is from health system collapse—people can’t get critical medical care for other health issues because hospitals and the primary health care system are overwhelmed. The third is from economic collapse—people lose the ability to support themselves, and we know that for example, suicides, substance abuse, mental health problems, and domestic abuse all increase during economic recessions. These second and third problems are delayed by several months, but they’re very serious.
Countries in sub-Saharan Africa face difficult tradeoffs. First, as we are seeing in the U.S. and other countries, efforts to flatten the curve through mandatory shutdowns will come with very high economic costs. On the other hand, if countries shorten the lockdown period and encourage the restart of economic activity, they run the risk of a resurgence of the disease.
While these choices are difficult and need to be made, one thing is clear: a sequential approach—like the one we are taking in the U.S.–of first saving lives and then figuring out how to save jobs, is not the way. From the outset, countries in sub-Saharan Africa have to work simultaneously on saving lives and saving jobs.
What do these secondary effects look like in low- and middle-income countries?
When the Ebola crisis happened, we saw more people in West Africa die from measles than from Ebola because routine immunizations stopped. The frontline health system collapsed, health care workers started dying and some left their posts out of fear.
Most low- and middle-income countries have fairly fragile health systems. We spend about $12,000 per person on health care in the U.S., versus $50 -$150 per person in low- and middle-income countries. But, these countries bear 80-85% of the burden of disease. So, they spend 15% of the money on 85% of the health burden. That’s a huge financial stress.
When a pandemic completely overwhelms the primary care system, frontline workers in these countries rarely have PPE [personal protective equipment], ventilation systems to circulate the air at the clinics or ways to effectively triage patients. Our media are very fixated on ICUs [intensive care units], but in many of these countries the real danger is the implosion of primary care.
Routine care gets disrupted for months on end, which can lead to a lot of adverse health outcomes. All elective and routine surgeries, immunizations, cancer screenings like colonoscopies and mammograms, all of it—put off by three months. Then there’s a huge pent-up demand, and three months turns into six months. This cascading effect on the health system…the longer it goes on, the worse it gets.
We’re seeing these things start to happen now in the U.S.: elective surgery has stopped, cancer screening has stopped, even in the U.S. There’s a cost to be paid for that, and we don’t usually factor that in. And I also mean a literal, financial cost: hospitals in the U.S. are losing millions of dollars and likewise medical practices are losing tens of thousands of dollars a month because routine care is not being provided.
What are you doing in your role with the U.S. State Department to respond to these concerns for HIV/AIDS programs in Africa?
We have a grant from the U.S. State Department to set up an analytics hub for the Office of the Global AIDS Coordinator (OGAC). We are putting together 20-year panel data for some key countries in Africa that we believe will be impacted by COVID-19. The goal is to use this panel data to start predicting the lagged effects on key health outcomes.
In addition, OGAC is putting together a way of systematically tracking information to see how COVID-19 may impact the State Department’s HIV/AIDS treatment and prevention programs. This is a population at high risk of comorbidities like tuberculosis, etc. We are looking to routinely capture data indicators to serve as an early warning system that something is going wrong for these patients, that COVID-19 may be impacting their HIV/AIDS care.
Can you share a few examples of these early warning indicators?
We’re looking at the number of people on treatment—if you see a big dip, you know something is wrong. Another is the number of people who don’t show up for follow-up treatment, or get routine testing. In addition, the supply chain becomes very important and is increasingly global in nature. Actions taken by one country can impact the availability of antiretroviral drugs in another country. For example, India has banned essentially all international flights, but they’re a major manufacturer of antiretroviral drugs. The world has become so interconnected, the position that one country takes can have huge impacts on the rest of the world
It’s extremely complex, and in the absence of data, everyone will be flying blind.
Do you think there will be a spike in new HIV/AIDS cases?
In most of these countries we’re pretty close to viral load suppression of HIV/AIDS. If treatment gets disrupted, it’s unlikely to lead to an immediate spike in new cases. But if people are not getting appropriate treatment, it’s likely that they’ll have adverse health outcomes and you’d see a higher mortality rate. We also need to be able to constantly diagnose and treat new cases, if you’re not doing that, there’s risk they could spread the virus. Given that COVID-19 disproportionately impacts people with comorbidities including HIV and TB, there is the opportunity of using this time to encourage more people to get tested for HIV.
How should health care systems in these countries prepare?
The good news is that the virus hasn’t really hit Africa yet. They’ve had three or four months to prepare. At a minimum, they need to protect the primary health system from the immediate onslaught. They need to obtain protective gear for frontline health care workers, and transportation so they don’t have to take public transport. They need to set up tents outside of hospitals for basic triage, to identify people with fevers. Simple things, like having oxygen available at these centers, can help a lot.
Extensive testing will be needed both to detect new cases, but also is key when actions are taken to reopen the economy. Testing millions of people is a major effort needing lab capacity, a supply chain to procure test kits as well are other reagents and supplies, and finally a cadre of health care workers that can carry out the tests. Similarly, contact tracing is critical to identify and isolate individuals exposed to the virus.
But all of this costs a lot of money. And the wealthier countries—the U.S., U.K., Italy, France, Germany—they’re all dealing with their own COVID-19 problems. There are lots of things we can do if high-income countries are willing to be generous at this time.