The COVID-19 Pandemic
Authors: Sheila L. Klassen, Gene F. Kwan, Gene Bukhman
Journal: Circulation (2020)

he coronavirus disease 2019 (COVID-19) pandemic has significantly affected the poorest billion people worldwide.This is not only because of the challenges specific to COVID-19 infection (establishing this complex diagnosis and managing severe cases of infection), but also because of the interruptions in routine medical care, disruptions in local and global supply chains, and increase in health care costs, all leading to further poverty and food insecurity. 1 In this article, we discuss the unique vulnerabilities of the poorest billion population with cardiovascular disease (CVD) to the COVID-19 pandemic and explore possible contributions of the global CVD community to mitigate these disastrous effects.The poorest billion people predominantly live in rural regions of low-and middle-income countries (LMICs) in sub-Saharan Africa and South Asia.In this population, CVD causes an estimated 3600 disability-adjusted life years per 100 000, 2 even though the majority who live in LMICs are <30 years old.There is a high burden of CVD risk factors, such as hypertension, diabetes, and smoking, 2 that are also associated with worse COVID-19 severity. 3Major contributors to CVD in poor countries include unrepaired congenital heart disease, rheumatic heart disease, and cardiomyopathies. 2 Individuals with these conditions are at particularly high risk of severe complications from COVID-19 infection because of their complex intracardiac hemodynamics. 4espite the greater susceptibility of patients with CVD in LMICs to severe CO-VID-19 illness and sequelae, there are numerous environmental, health system, health care workforce, and patient-related barriers that facilitate viral transmission and impair access to care (Figure).Regional lockdown measures are physical barriers for the poorest billion populations who need to travel to seek routine health care during the pandemic.These measures have also caused a massive increase in unemployment in the informal sector in places like India. 1 The pandemic has exposed the lack of rudimentary supplies such as pulse oximeters and bedside oxygen at many health care facilities in LMICs, 1,3 and preexisting gaps in essential care will become much larger if cases of acute respiratory illness in LMICs continue to climb. 3 A major threat of the pandemic is also the disruption of routine health services, 1 such as rheumatic heart disease screening and treatment.Redirecting medical staff, supplies, and care areas toward the COVID-19 response in LMICs has greatly amplified the problem of undiagnosed and untreated CVD in those regions and will continue to do so as long as pandemic activities are ongoing.Concurrently, social distancing measures and border closures have been implemented internationally, disrupting fragile global supply chains for essential medicines and exacerbating food insecurity.Recommendations for self-isolation, which are central to containment efforts for COVID-19, disproportionately affect the most marginalized in society: the poor, elderly, and chronically ill, in particular, those without adequate social protection.Thus paradoxically, whereas the high burden of chronic