What developing countries can teach us about how to respond to a pandemic
By Manu Mormina and Ifeanyi M Nsofor
Nine months into the pandemic, Europe remains one of the regions worst affected by COVID-19. Ten of the 20 countries with the highest death count per million people are European. The other ten are in the Americas. This includes the US, which has the highest number of confirmed cases and deaths in the world.
Most of Africa and Asia, on the contrary, still seems spared. Of the countries with reported COVID-related deaths, the ten with the lowest death count per million are in these parts of the world. But while mistakes and misjudgements have fuelled sustained criticism of the UK’s handling of the pandemic, the success of much of the developing world remains unsung.
Of course, a number of factors may explain lower levels of disease in the developing world: different approaches to recording deaths, Africa’s young demographic profile, greater use of outdoor spaces, or possibly even high levels of potentially protective antibodies gained from other infections.
But statistical uncertainty and favourable biology are not the full story. Some developing countries have clearly fared better by responding earlier and more forcefully against COVID-19. Many have the legacy of Sars, Mers and Ebola in their institutional memory. As industrialised countries have struggled, much of the developing world has quietly shown remarkable levels of preparedness and creativity during the pandemic. Yet the developed world is paying little attention.
When looking at successful strategies, it’s the experiences of other developed nations – like Germany and New Zealand – that are predominantly cited by journalists and politicians. There is an apparent unwillingness to learn from developing countries – a blind spot that fails to recognise that “their” local knowledge can be just as relevant to “our” developed world problems.
With infectious outbreaks likely to become more common around the world, this needs to change. There is much to learn from developing countries in terms of leadership, preparedness and innovation. The question is: what’s stopping industrialised nations from heeding the developing world’s lessons?
Good leadership goes a long way
When it comes to managing infectious diseases, African countries show that experience is the best teacher. The World Health Organization’s weekly bulletin on outbreaks and other emergencies showed that at the end of September, countries in sub-Saharan Africa were dealing with 116 ongoing infectious disease events, 104 outbreaks and 12 humanitarian emergencies.
For African nations, COVID-19 is not a singular problem. It’s being managed alongside Lassa fever, yellow fever, cholera, measles and many others. This expertise makes these countries more alert and willing to deploy scarce resources to stop outbreaks before they become widespread. Their mantra might best be summarised as: act decisively, act together and act now. When resources are limited, containment and prevention are the best strategies.
This is evident in how African countries have responded to COVID-19, from quickly closing borders to showing strong political will to combat the virus. While Britain dithered and allowed itself to sleepwalk into the pandemic, Mauritius (the tenth most densely populated nation in the world) began screening airport arrivals and quarantining visitors from high-risk countries. This was two months before its first case was even detected.
And within ten days of Nigeria’s first case being announced on February 28, President Muhammadu Buhari had set up a taskforce to lead the country’s containment response and keep both him and the country up to date on the disease. Compare this with the UK, whose first case was on January 31. Its COVID-19 action plan wasn’t unveiled until early March. In the intervening period, the prime minister, Boris Johnson, is said to have missed five emergency meetings about the virus.
African leaders have also shown a strong desire to work together on fighting the virus – a legacy of the 2013-2016 West African Ebola outbreak. This epidemic underlined that infectious diseases don’t respect borders, and led to the African Union setting up the Africa Centres for Disease Control and Prevention (CDC).
In April, the Africa CDC launched its Partnership to Accelerate COVID-19 Testing (PACT), which is working to increase testing capacity and train and deploy health workers across the continent. It’s already provided laboratory equipment and testing reagents to Nigeria, and has deployed public health workers from the African Health Volunteers Corps across the continent to fight the pandemic, applying knowledge picked up when fighting Ebola.
The Africa Union has also established a continent-wide platform for procuring laboratory and medical supplies: the Africa Medical Supplies Platform (AMSP). It lets member states buy certified medical equipment – such as diagnostic kits and personal protective equipment – with increased cost effectiveness, through bulk purchasing and improved logistics. This also increases transparency and equity between members, lowering competition for crucial supplies. Compare this with the underhand tactics used by some developed nations when competing for shipments of medical equipment.
The AMSP isn’t unique. The European Union has a similar platform – the Joint Procurement Agreement. However, a bumpy start together with slow and overly bureaucratic processes led some countries to set up parallel alliances in an attempt to secure access to future vaccines. The AMSP avoided sharing this fate thanks to the African Union handing over its development to the private sector under the leadership of the Zimbabwean billionaire Strive Masiyiwa. He pulled together the expertise needed to quickly develop a well-functioning platform, drawing on his contacts and businesses across the digital and telecoms sectors.
This contributed to the AMSP’s popularity with vendors and created high demand from member states. There are now plans to expand access to hospitals and local authorities approved by member states, and for additional support to be included from donors (such as the Bill and Melinda Gates Foundation and MasterCard Foundation). Again, a decisive decision, focusing on installing strong leadership, has paid dividends.
Strong leadership on COVID-19 hasn’t been limited to African countries. The Vietnamese government has been widely praised for its clear and engaging public health campaign. This has been credited with bringing the country together and getting a wide amount of buy-in on efforts to control the virus.
Vietnam has also shown that good leadership involves acting on the lessons from the past. The 2003 Sars outbreak led to strong investment in health infrastructure, with an average annual increase of 9% in public health expenditure between 2000 and 2016. This gave Vietnam a head start during the early phases of the pandemic.
Vietnam’s experience with Sars also contributed to the design of effective containment strategies, which included quarantine measures based on exposure risk rather than symptoms. Badly affected countries such as the UK, which received warnings that its pandemic preparedness wasn’t up to scratch years ago, should sit up and take note. Vietnam has one of the lowest COVID-19 death tolls.
Finally, let’s look at Uruguay. The country has the highest percentage of over-65s in South America, a largely urban population (only 5% of Uruguayans do not live in cities) and a hard-to-police land border with Brazil, so it should be a likely infection hotspot. Yet it has managed to curb the outbreak without enforcing lockdown.
Early aggressive testing strategies and having the humility to ask the WHO for information on best practices were among the ingredients of its successful response. Along with Costa Rica, Uruguay also introduced a temporary reduction in salaries for its highest paid government officials to help fund the pandemic response. The measure was passed unanimously in parliament and contributed to high levels of social cohesion.
Of course, strong leadership isn’t limited to the Global South (Germany and New Zealand get top marks), nor do all southern countries have effective leadership (think of Brazil). But the examples above show that good leadership – acting now, acting decisively and acting together – can go a long way to compensating for countries’ relative lack of resources.
Doing more with less
Necessity is said to be the mother of all invention – where money is in short supply, ingenuity abounds. This has been just as true during COVID-19 as at any other time, and is another lesson the developed world would do well to consider.
Early on in the pandemic, Senegal started developing a ten-minute COVID-19 test that costs less US$1 to administer and doesn’t need sophisticated laboratory equipment. Likewise, scientists in Rwanda developed a clever algorithm that allowed them to test lots of samples simultaneously by pooling them together. This reduced costs and turnaround times, ultimately leading to more people being tested and building a better picture of the disease in the country.
In Latin America, governments have embraced technology to monitor COVID-19 cases and send public health information. Colombia has developed the CoronApp, which allows citizens to receive daily government messages and see how the virus is spreading in the country without using up data. Chile has created a low-cost, unpatented coronavirus test, allowing other low-resource countries to benefit from the technology.
Examples of entrepreneurship and innovation in the Global South aren’t restricted to the biomedical field. In Ghana, a former pilot whose company specialises in spraying crops repurposed his drones and had them disinfect open-air markets and other public spaces. This quickly and cheaply got a job done that would normally have taken several hours and half a dozen people to do. And in Zimbabwe, online grocery start-ups are offering new opportunities for food sellers to retain customers wary of shopping in person.
While these are handpicked examples, they illustrate the importance of the capacity to innovate in conditions of scarcity – what is known as “frugal innovation”. They prove that simple, inexpensive or improvised solutions can solve complicated problems, and that frugal solutions don’t have to involve “chewing gum and baling wire” types of fixes.
The ability to deal with complex problems under resource constraints is a strength that can be useful for all, particularly given the pandemic’s eye-watering impact on high-income economies. Solutions coming out of developing countries may offer far better value for money than the elaborate and expensive “moonshot” solutions being mooted in countries like the UK.
Why not follow these examples?
This pandemic is another wake-up call. Since Ebola and Zika, governments around the world have known that they need to up the “global preparedness” agenda. It’s often said that when it comes to pandemics, the world is as weak as its weakest point.
Global action, however, requires moving beyond national interests to identify with the needs of others. We call this “global solidarity”. Unlike relationships of solidarity within nation states – which are based on a shared language, history, ethnicity and so on – global relationships need to recognise the interdependence of diverse actors. Global solidarity is so difficult to achieve because it must accommodate difference rather than rely on commonality.
The pandemic has shown why we need global solidarity. Globalisation has made countries interdependent, not just economically but also biologically. And yet in recent months, isolationist stances have prevailed. From the USA pulling funding from the WHO to the UK’s refusal to participate in the EU’s Joint Procurement Agreement, countries are instead pursuing do-it-alone strategies. Within this inward-looking context, it’s little wonder that industrialised nations are failing to capitalise on lessons from Africa, Asia and Latin America.
It’s not a lack of recognition that there’s knowledge and expertise outside the developed world; it’s just that such knowledge is not seen as relevant given the structural differences between developed and developing countries. On this point, consider this final example.
Between the start of April and the end of June, the Rural Development Foundation based in Sindh province in Pakistan on its own decreased the spread of infection in the region by more than 80%. It did this by engaging communities through information campaigns and sanitation measures. Community-level approaches have also been successfully deployed in the DRC and Sierra Leone. During these countries’ Ebola outbreaks, rather than relying on tech and apps, authorities trained local people to do in-person contact tracing instead.
These community-level strategies were advocated by developed world experts, including from the UK. And yet, despite the clear current need, tried-and-tested low-cost approaches like this remain underused in high-income countries. They’ve been disregarded in favour of high-tech solutions, which so far haven’t proved to be any more effective.
The problem, as this example illustrates, is the persistence of a pervasive narrative in global health that portrays industrialised countries as “advanced” in comparison with the “backward” or “poor” developing world, as described by Edward Said in his foundational book Orientalism. Europe’s failure to learn from developing countries is the inevitable consequence of historically ingrained narratives of development and underdevelopment that maintain the idea that the so-called developed world has everything to teach and nothing to learn.
But if COVID-19 has taught us anything, it’s that these times demand that we recalibrate our perceptions of knowledge and expertise. A “second wave” is already on Europe’s doorstep. Many countries in the southern hemisphere are still in the middle of the first. The much talked-up global preparedness agenda will require responses to be handled very differently from what we’ve seen so far, with global solidarity and cooperation front and centre. A healthy start would be for developed countries to get rid of their “world-beating” mindset, cultivate the humility to engage with countries they don’t normally look towards, and learn from them.