By Iman Ahmed
Spring Magazine spoke with Iman Ahmed, a global health specialist, about COVID-19 from an international health perspective. All opinions expressed are personal and do not represent any other entity.
Can you tell us about your experience as Pandemic Preparedness and Response Coordinator? What were the main things you learned from that experience from both a health care and activist point of view?
I worked as the United Nations High Commissioner for Refugees (UNHCR) Regional Coordinator for Pandemic and Epidemic Preparedness and Response for the Middle East and North Africa (MENA). UNHCR had a global program to ensure pandemic preparedness and response for both refugees based in camps and those living in cities (urban refugees). The program adopted a smart, equitable approach to health: that epidemics and pandemics leave no one behind, and affect disadvantaged populations hardest. The program’s prime focus was preparedness for the then Novel Influenza virus H1N1. The world ultimately experienced an Influenza H5N1 pandemic, where those preparedness measures contributed to better response. It was a lesson in global health leadership.
The UNHCR program covered Asia, East, Central, West and Southern Africa as well as MENA region, which I was responsible for. It addressed capacity for both outbreaks of commonly occurring diseases (such as cholera, malaria and viral heamorrhagic fevers) and put in place a pandemic response system. My task involved working with over 10 countries to: a) develop contingency plans; b) train front-line clinical teams on case definitions, identification and management; c) work with public awareness teams to develop culturally sensitive health education materials; and d) build the capacity of public (human) and veterinary health managerial staff from relevant government Ministries on relevant aspects of preparedness and response—including forecasting needs, estimating costs, advocating for government funding, procurement and stockpiling of supplies, and monitoring of the country-based projects. I was impressed by the level of receptiveness and ownership of the host governments to include refugees in their national response plans. UNHCR helped finance the activities, delivered technical support through us coordinators, and ensured that plans for refugees dove-tail and strongly enmesh with those of host communities.
I highlight the major lessons:
1. Disease outbreaks do not recognize international borders. They do not discriminate based on citizenship status and they are not here to stigmatize anyone. Furthermore, influenza-like illnesses can affect almost anyone, hence, we cannot demarcate their incidence by socio-economic status. Outbreaks and pandemics have happened throughout human history. They will continue to happen, and we are seeing them more often. I never thought that as an adult and a doctor, I would witness two pandemics, only ten years apart. Zoonotic diseases resulting from emerging and re-emerging pathogens are part of the impact of climate change and the destruction of the original natural habitat of some animals which act as vectors or are the primary hosts of such diseases. Once the pathogen crosses the animal-human interface, we start seeing human-to-human transmission. The over-crowded cities and urban centers we live in nowadays represent fertile grounds for massive spread. International travel, as good as it is, multiplies pandemic potential many-fold and we end up in situations like the present one, with COVID-19.
2. The old saying goes: prevention is better than cure. As an emergency preparedness and response specialist I wish to adapt it to: preparedness is better than response! At the time of the H5N1 pandemic, there was a United Nations-wide system that was effectively and rapidly put in place. International Organizations other than the UN also played their part in the preparedness and response programs. National governments stepped up and showed great leadership. Global donors contributed, recognizing the importance of ensuring health for the most vulnerable populations around the world.
Comparing the present to the H5N1 pandemic, it is clear that many health systems of High-Income Countries (HICs, including Canada, China, the United States, Italy, France and Germany) are not prepared for COVID-19. The current global shortage of medical supplies is the result of planning that overlooked forecasting pandemic risks, anticipating and quantifying related needs and putting in place necessary preparedness measures. Less than optimal preparedness leads to us operating in “crisis mode”. This is where we are at today!
3. The third lesson, which I will use as a warning, is that when global public health crises hit, they hit those countries with fragile health systems hardest. COVID-19 has started in HICs and we are yet to see its impact on Lower and Middle-Income Countries (LMICs). Health disparities on the global scale mean that by the time COVID-19 takes a full circle around the world, we may see a second wave striking the already exhausted health systems of Europe and North America. This might not happen, but as a public health emergency specialist, I always have to think ahead and anticipate scenarios that we would be lucky not to witness.
How does the concept of “health for all” have meaning in the age of COVID-19?
The case of COVID-19, as painful and sobering as it is, presents a useful opportunity to advocate for health for all; which is the right of every individual in the world to basic health services, without impoverishment. This is one of the World Health Organization’s top priorities. WHO aims to achieve health for all through universal health coverage, as a condition to fulfilling the health objectives of the Sustainable Development Goals (SDGs). One in 17 world citizens lacks access to basic health care, making a total of 400 million world-wide. Treating health as a human right is one way to guard against people being pushed into poverty to cover their health expenses.
There have been cuts in most countries in the last decades to health care budgets. How have these affected the current health crisis and what needs to happen now?
There are two major levels where the cuts in health care budgets manifest: macro-economic and micro-economic. The macro-economic level is demonstrated by the government’s spending on health as a percentage of the country’s Gross Domestic Product (GDP). According to WHO (2017), Canada’s spending on health is around 40%, Australia 36%, China 32%, France 56%, Germany 44%, Italy 49% and the United States 38%. Are you surprised how Cuba, is sending medical teams to help other countries respond to COVID-19? I am not. Cuba’s spending on health was 65.98% in 2017 (68.24% in 2007). Spending on health includes investing in building strong Human Resources for Health. A strong health system will stand strong in the face of shocks and quakes like COVID-19.
The second level where budget cuts are felt is in the growing Out Of Pocket (OOP) spending by individuals and families on health care services. OOP is the devil in our wallets! This is exactly why WHO defines health for all as “access to universal health care – without impoverishment”, and the emphasis here is on guarding against pushing people into poverty as a result of OOP spending. Canadians know too well where the micro-level cuts are happening, and how they are impacting our bank accounts and our decisions around health and other aspects of life.
The current pandemic is an alarm that we need to increase government spending on health in order to strengthen health systems and cover more basic health services.
There’s been an alarming rise of state repression, from banning non-citizens to giving police powers to enforce quarantines. Can you discuss how a repressive response to pandemics makes them worse?
Knowledge is power! If we invest more in educating people, ahead of time, we will increase the level of social responsibility and reduce the need for measures enforced by the law under scenarios like the present. There is a fine line between infringing on the liberties of people and maintaining law and order. Investing in awareness will create more citizen leadership and buy-in. Repressive regimes may use law and order as excuses to clamp down on basic citizens’ rights. Even though law and order are needed, I cannot help but be reminded of medieval times, when a sick person had to be held down by force to undergo treatment while screaming, out of their intractable pain.
My other concern is that enforcing quarantines by law actually erodes the sense of solidarity and inter-connectedness and turns peoples’ attention to policing each other, instead of supporting each other in times of crises. We are in dire need for local and international solidarity, now more than ever. Spread awareness and fight rumours. Public health is about behaviour change and you cannot bring change through coercion; needless to mention that freedom comes with responsibility and we need to act in a collectively responsible way in order to protect all.
How do changes in the labour market (e.g. gig workers) affect needs in the health care system?
We have already seen the first wave of lay-offs once the state of lock-down was announced. Losing jobs may come with losses of health care benefits, in the midst of a global health crisis. While companies are governed by market values, I would like to echo Dr. David Nabarro in encouraging businesses to keep their workers employed and not throw them in the streets.
Even more at risk are those in the pool of “gig economy”; e.g. self-employed workers and professionals, artists and freelancers who do not necessarily have pensions or health insurance beyond the limited (and ever shrinking) package offered by the government. When the business of such gig workers comes to a standstill, they lose their savings and may well plunge into poverty. And in the midst of all this, what about the mental health of our society? We need to remind ourselves that health is a state of complete physical, mental and social wellbeing and not merely being safe from COVID-19!
How do we mobilize people to take up these demands?
Amartya Sen’s approach to development affirms the need to put people first and consider human beings as the centerpiece of development. We are now under a very demoralizing time and that reverses any gains in human development. Peoples’ awareness of their fundamental rights and freedoms, forming alliances around these rights (both locally and internationally), demanding more job security, drawing attention to the invisible sectors of the society (gig workers, the unemployed, the homeless and those with limited skills and education) are the cornerstones of this advocacy. expertise from various sectors and sharing information on what better health, education, housing and job security mean and how best we can work together to achieve them is crucial.
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