PUBLISHED BY THE NEW HUMANITARIAN
Health authorities around the globe are scrambling to prepare for and contain the rapidly spreading coronavirus. But the job is even more daunting in countries already facing long-running crises.
The World Health Organisation on Wednesday called the coronavirus emergency a “pandemic” for the first time – a sign of the gravity of an outbreak that is quickly reaching new frontiers already struggling with conflict, displacement, or other health emergencies.
To delve into the complexities of how countries in crisis can prepare, The New Humanitarian spoke with Dr. Mike Ryan, who leads the WHO’s Health Emergencies Programme and is a trained epidemiologist.
Ryan has worked in conflict-hit countries and steered responses to high-impact epidemics for 25 years. In a wide-ranging interview, Ryan discussed the risks of ignoring the health needs of refugees and migrants, the political high-wire act of fighting epidemics in conflicts – and why, despite the challenges, some health systems in the so-called “Global South” might be better prepared for Covid-19, the disease caused by the coronavirus, than their neighbours in the north.
(This interview has been edited for length and clarity.)
The New Humanitarian: What are the key concerns in terms of preparedness and access?
Mike Ryan: If we take countries that are considered to be fragile or affected by conflict, unfortunately, these same countries have some of the weakest health systems in the world. So that means that those countries as a whole are very vulnerable to Covid-19 – in terms of their capacity to detect, confirm, and manage the public health component, and equally to manage the clinical and health impact of the disease in a population.
Within that context, there are also highly vulnerable populations because of these weak health systems. When we talk of northern countries, people are concerned about the condition of the elderly, people with hypertension, or other underlying conditions. But in addition to these, there is a whole other series of vulnerabilities in conflict zones. These include other infectious diseases, and living in overcrowded conditions where the potential for the spread of disease is increased and their underlying health status is already compromised.
We have seen the stress of acute respiratory infections in children in camps, for example. What would pass for a cold in a child in a normal setting could kill a child in a camp. So all of those things put together mean that the whole population in a conflict zone is at risk because of a weak health system.
We are particularly concerned about people living in camps – the Rohingya living in Bangladesh, people living in internal displacement camps in Syria and Yemen, refugees living across borders in Turkey and others. The fact is that the health systems around them are already weak and not necessarily functional.
There is another vulnerability that we are not speaking about, and that is the vulnerability of the under-nourished child or the stressed refugee living in an overcrowded camp. I am a little concerned that the impact on those populations is going to be potentially much more than people are expecting.
But the last thing I want is for refugees to be worried about something more. They have enough to be worried about. This is more a call to action.
TNH: Which specific conflict settings are most at risk? Is it the Middle East, in Syria, because of the large number of cases in Iran and other adjoining countries?
Ryan: Syria has a risk from Iran, yes, in terms of population movement. But it is equally just as much at risk from an international worker bringing it. We saw how the polio virus came into Syria all the way from Pakistan. Who knew! We saw the UN itself bring cholera into Haiti. It’s very easy to say that Iran is going to be the Typhoid Mary of the Middle East, but it’s not the case.
Refugee populations and vulnerable populations have been infected from many sources over the years. So focusing on the source is important to try and reduce the risk, but it is more important to focus on the readiness and the preparedness.
TNH: Is Syria more susceptible than other conflict areas?
Ryan: Right now, Syria, Iraq, and Yemen, are in the middle. You have got [Covid-19 infections] in Lebanon, Israel, Palestine, Iran, Bahrain, the United Arab Emirates, and Saudi Arabia. So in fact, the disease may already be there and we are not aware. That is an issue.
In the great scheme of things, the issues that Syria, Iraq, and Yemen face, this is still, in relative terms, a very low risk. If one is in Syria right now, the worry is not about Covid-19, but about bombs falling from the sky; kids being blown to pieces. One is worried about parents dying of not getting insulin drugs. So it’s all relative.
But this is a manageable risk so we need to do something about it. We are trying to do two things. One is: all of the humanitarian action plans must have Covid-19 built in. The national action plans in host countries need to take into account refugees, migrants, IDPs and others – particularly migrants: there is rarely any organisation standing up for migrants.
When the national authorities are meeting and talking, it is really important that the humanitarian coordinators are there with the WHO representatives and with the NGOs, pushing and advocating for the rights of these groups of people within those national plans. The UN and the NGOs are not there to replace the governments; we need to be very clear in our advocacy. If UN reform [in short, a more unified and focused approach] means anything, this is what it should be.
TNH: The World Bank has pledged $12 billion in coronavirus funding, but only a quarter of that – $3.3 billion – is in the form of grants for lower-income countries. Are there concerns about funding preparedness and response for Covid-19?
Ryan: From the World Bank, my understanding is that a significant part of the $12 billion available is for programming. But there is a point here for countries – this is a national emergency. It is not fair to expect the multilateral donors to take on the needs of every single country in the world. It is an international responsibility to support, but this is also a national accountability issue to protect your citizens.
So yes, we would like to see more grant aid in there. We have been meeting multilaterals on a weekly basis. We met with 14 top humanitarian and development donors. What we have done is created a portal for the donors, for the World Bank, and for the countries, so that when countries produce their national plans, they will be available and everyone can see who needs what. It is a way of creating a transparent matching mechanism.
TNH: How will you address gaps in implementing basic hygiene plans in conflict settings? And how will needs such as data collection for epidemiological assessments be dealt with?
Ryan: In a lot of camp situations and humanitarian situations in general, we have very strong early warning systems. But very often those systems do not include respiratory syndromes (Covid-19, the illness caused by the new coronavirus, is a respiratory disease). These warning systems have acute jaundice and acute diarrhoea, among other syndromes, so we are now trying to include acute respiratory illnesses into these early warning systems.
Paradoxically, I actually think that many systems in developing and conflict settings are more resilient than some settings in the West. There is a syndromic approach to surveillance that does not exist in many northern countries. There is very much an epidemic and rapid-response approach. People in camps know that, historically, measles or meningitis or cholera is devastating, so very often camp managers and those who take care of vulnerable people are very tuned in to epidemics as a major factor. Fire and epidemics are the absolute killers – the two things that people are most concerned about in camp settings.
TNH: So you think there is a heightened consciousness around these issues in a conflict setting?
Ryan: I do. And there is a lot of skill, and communities have a lot of resilience. I do not think we should be at the mercy of the virus. I said it in New York last year when we launched the Global Preparedness Report for the Global Preparedness Monitoring Board (GPMB). I said that there is a bit of a feeling that all of this vulnerability we are talking about is in the south. But as I said, most of the vulnerability is in the north. And you will find out just how ready you are when we have the next outbreak with a new and emerging disease.
Take the example of Italy. They have run out of ventilators – northern Italy, one of the richest places in Europe! The thing is, preparedness is a long-term business. And preparedness is only as good as the number of responses you have had to do. The longer you are away from a response, the more that memory decays.
African countries and countries with conflicts are dealing with emergencies every day. I spoke with a colleague working in an African country and he said that we put up with cholera, we are worried about Ebola and Yellow Fever, so we will deal with Covid-19 too.
That is not to say that I am not concerned or that this will not be a big problem. But I am actually quite comforted. Many countries have a lot of skill and experience, but they need some inputs, personal protective equipment, good labs, tests. They need some retraining; they need coherence. Now it is more about coherence between the international community and the national response. The UN and NGOs must support and back up national plans. Because what we are seeing in most countries that are not doing well in the face of Covid-19 is it’s about governance and coordination.
If the population perceives that there is any lack of coherence on the part of the government, it is amazing how quickly they lose confidence. Confidence is a very important part of epidemic response. If I don’t trust that the doctors will act in my best interest, if I am a citizen and I don’t trust that the government is doing everything it possibly can in the most efficient way to take care of my kids, then I lose that trust really quickly.
TNH: Tedros Adhanom Ghebreyesus, the WHO’s director-general, said this week that he was deeply concerned about “alarming levels of inaction” among some countries. Can you comment on that?
Ryan: We never criticise member states! The point is, when we see a member state not doing the right thing, or not doing enough, or doing the right thing at the wrong time, there is a lot of context here, right? We try to engage with them robustly and try to offer them evidence for another path. You don’t change behaviour by public humiliation – we have learned that in society. That’s not the way. You change behaviour by getting to the same side of the table as the person you are criticising and saying, “how can I help you to solve this problem?” It’s for the others, like the media, to hold us all accountable. I would rather identify behaviours or actions that are unhelpful: for example, actions that profile particularly ethnic groups, or actions that increase tensions in groups.
People said that the measures in China were rigid and draconian. The reality was that communities in China were accepting of those practices, because that is how Chinese society is structured – it is much more accepting of those measures. But if you try to do that in the streets of New York or London or Delhi, you will see what happens. So there is an issue of governments’ understanding of what the social contract is, and understanding the social acceptance of those measures. They must have a balance and keep human rights in mind. But at the same time, they must carefully balance the right of the community versus the right of the individual. How that is balanced and managed is something to consider. We saw that in HIV: the misunderstanding leading to prejudice; the lack of information and evidence leading to bad practice. Remember that it took us a decade to find out how to deal with behaviour change with respect to HIV. We are less than 10 weeks into this. We are not doing too bad collectively.
If a country has few cases or a few clusters, we are going to push them to do containment and to do contact-tracing and case-finding. But if we take the example of Italy with nearly 1,700 cases a day, they may have to give up on contact-tracing for a few days until they push the infection down and then maybe go back to tracing.
We are trying to be a strong and transparent adviser to our member states without losing our relationship with countries. If a country persistently will not implement, then we will have to step up and say what is not acceptable or good enough. We find that to be much more functional. People criticised us for praising China six weeks ago. The amount of abuse that Tedros got, that I got, that we were lackeys of China, all the abuse on social media. It was terrible. Six weeks later, China is not doing too bad, is it? We were not doing it based on politics; we were doing it based on what we observed and what we could see as scientists. They still aren’t out of the woods, but…
We will offer praise where we can. We said the same about Singapore, about [South] Korea. And each of these countries used a different strategy. Singapore has not closed its schools or closed itself off; it never locked down. It focused very much on case-finding and contact-tracing, on what it perceived would be very much accepted by the population.
TNH: Talking about politics in the midst of this outbreak, how would you address a potential outbreak in a seemingly intractable situation like that of Syria?
Ryan: Well, we do it already for surveillance, both in government- and non-government-controlled areas. We do it in the areas where we provide medical services, in the three zones of Syria in the government-controlled areas, and in the northeast and the northwest. I think there are always ways to do it – either through ourselves, or our local partners or NGOs, maintaining basic public health surveillance and essential health services.
I spent two years on polio eradication in Pakistan and Afghanistan, and in the Middle East, when the polio virus hit Syria, which was a huge shock. I was not working at WHO then, but was asked to come back and run that Middle Eastern polio response. And it was quite a challenge running a seven-country response in both north Syria and Damascus, Turkey, Iran, Iraq, Palestine, Jordan, Lebanon. If we could get those seven countries to synchronise surveillance, synchronise national immunisation days across a whole year, we were able to carry out campaigns, monitoring all the way through that.
But I think it is possible to contain these kinds of dangerous, easily spread epidemics. It takes a huge effort, it takes flexibility, it takes all sides recognising that the threat is common.
TNH: All sides?
Ryan: Yes, all sides. One of the things that killed us, quite literally, in the Democratic Republic of Congo, was this political gaming that was going on in North Kivu and Ituri, which we paid for with some of our lives. It wasn’t just conflict; the conflict was being gamed.
I have sat with the Syrian minister of health at the time of doing the polio campaigns in the north, and we were making efforts to get those off the ground and I remember there was a lot of resistance.
I asked him: “Do you accept that these children are Syrian?”
“Yes,” he said.
“Have you got access to them?”
“Well, do you mind if we vaccinate 1.8 million Syrian children?”
You turn the argument around and you get away from the politics and talk about the beneficiaries. And I think you can. It is amazing how much this kind of an event can itself become a way to build peace. People can stop focusing on the war. You come together, it might be for an hour or for a day – you never know, the seeds of peace are sown in some very small things. My own country in Ireland in the north… it’s incredible, so peace comes from strange places.
My view is, I have been through it personally, I have done it, I know it is possible. We just want to be able to highlight the fact that this is a very vulnerable population, especially when we talk about children. There is this perception growing globally that this is going to be a very mild disease in kids. Well, that might be true in a very well-nourished kid in England or in Korea, or in Brazil, but that might not be true for a kid in a camp in Yemen, who is stunted, exposed to multiple infections, has just recovered from malaria and is about to get dengue. We have to be very careful in making assumptions about the impact of this disease in vulnerable populations.
TNH: Are there potential lessons from Ebola that can be applied to Covid-19?
Ryan: I think that the approach of being strategically driven and having a plan is helpful. That helped with Ebola, having a strategic response plan. Also, organisational coherence – organisations coming together to support governments, whoever that entity is that represents the people. Having respect for that.
The UN, the NGOs, and others have to come to terms with the fact that most countries have something called a sovereign government, which is accountable to its citizens. Now, we would like those governments to be more accountable to their citizens, but we cannot make governments more accountable to their citizens unless we put them in positions to be more responsible and help them be responsible – rather than this paternalistic approach of sidelining the government on the basis that they do not represent our humanitarian principles. I think we should put governments back at the centre of this, recognising that we have to be very careful with that when it comes to humanitarian principles and making sure that we do not become instruments of regimes.
Countries like Mozambique and Indonesia have developed very strong emergency preparedness architecture, and now they just do not tolerate the international community, be it humanitarian, arriving and deciding what’s best. We generally don’t do that.
The other part is the community’s relationship with trust in the government or us. This is crucial. You are asking communities to make huge sacrifices. You are asking families to make sacrifices: isolation; quarantine. Building that community trust early, huge lessons have been learned from many outbreaks, not just Ebola.
The innovation part is another lesson. Being able to develop and deploy vaccines and drugs, and bring them to the most vulnerable. That was our problem. This last outbreak, we have been able to bring five new therapeutics right to the heart in the centre of the worst outbreak in a conflict zone. And we brought vaccines too.
TNH: But vaccines can take up to 18 months?
Ryan: Yes, but not for the drugs. We may find out that some of the therapeutics that have been trialled out, these are existing drugs, some of them might work. Our next challenge will be how do we make sure that we ensure that they are equitably distributed? How do we make sure that a granny in Bihar, India has the same chance of getting that drug as someone in Germany or Sweden?
That is my big fear: if we do find an effective intervention, it creates another moral hazard: who gets it? We have done that with Yellow Fever, with meningitis; we have done that over the years with cholera, making sure that these items are stockpiled and delivered to countries on the basis of need, with no cost to the beneficiary. And to do that on a grand scale is going to be a challenge. We are negotiating now on those issues. That is why we are working with [the vaccine alliance] CEPI and others. This is a central point, this is not something we think about after the fact.
TNH: Will the same infrastructure built during Ebola be used to fight Covid-19?
Ryan: Yes, certainly. Uganda is already demonstrating that, using the same mechanisms for their Covid training. Most countries are just taking the people they trained for clinical management for Ebola and just refreshing their training for Covid. It is essentially the same protective gear, the same process, the same design of a facility.
TNH: But in terms of lab capacities – is that a concern?
Ryan: The kits [to test for the coronavirus] are now in all African countries, which is amazing. Just three weeks ago, only two labs in Africa could do it. Now every country can diagnose Covid. They are actually quicker than other bigger countries, which shall remain unnamed. We are quite happy with the distribution of kits around Africa. The problem is the sub-national level. The problem is pushing that down to those levels, because, for example, Nigeria is a big place.
TNH: What about infection prevention and control in conflict settings?
Ryan: If the disease gets into a camp, we should get in quickly and isolate the case. But the real way to stop the disease spreading to the camp comes down to the basics: it’s camp design; it’s space; it’s hygiene.
Space is a killer in a camp during a respiratory disease. Trying to stop the spread of disease is going to require creating more space. If we do not do that, we are going to have a problem, especially in the winter time. If it was summer, and people were outside, the risk would be much lower. We are in a very risky period for the next month and a half, I would say, when people are packed into these tents. I do not know how we are going to solve it, but we are going to have much more handwashing. But again, water is at a premium and soap is at a premium. Seemingly simple things are hard to do in a camp. How do we ensure social distancing?
TNH: Roughly 900,000 refugees live in the Rohingya camps in Bangladesh. This must be a particular concern.
Ryan: They are, and we need to put pressure on the government of Bangladesh and others to create more space. We have been asking for space for a long time, and maybe now we have a justification for space and we leverage that. We all know camps are overcrowded, but it is in the interest of host governments to ensure that camps do not become epicentres to spread disease.
Treating Covid in camps is difficult, but getting refugees out of a camp and treating at health facilities is almost impossible in many countries. If they do have cases in camps, we also need protective equipment for health workers, and training on basic isolation care. We also need medical oxygen. We do not have ventilators in camps. But I do think the provision of basic oxygen will save a lot of lives. We have a big project now in Africa for accelerating the availability of medical oxygen, either through adapting the use through industrial oxygen supplies and/or oxygen generators, which are basically machines that pull the oxygen out of the air and concentrate it. One ends up breathing a mix of air that has a higher concentration of oxygen. It can be very effective.
The difficulty is providing support in so many countries. We have a response team in Italy! We have every country asking for advice, protective equipment, labs.