An appeal for practical social justice in the COVID-19 global response in low-income and middle-income countries
Authors: Maureen Kelley, Rashida A Ferrand, Kui Muraya, Simukai Chigudu, Sassy Molyneux, Madhukar Pai, Edwine Barasa
Journal: The Lancet Global Health (2020)

The coronavirus disease 2019 (COVID-19) pandemic hit the world's wealthiest countries first, shaping global public health responses and messaging. As the pandemic escalates in low-income and middle-income countries (LMICs), there is a growing call to identify locally tailored solutions.1Dalglish SL COVID-19 gives the lie to global health expertise.Lancet. 2020; 3951189Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar, 2Ayebare RR Flick R Okware S Bodo B Lamorde M Adoption of COVID-19 triage strategies for low-income settings.Lancet Respir Med. 2020; 8: e22Summary Full Text Full Text PDF PubMed Scopus (77) Google Scholar Because outbreaks are not only public health emergencies, but also political and socioeconomic emergencies, we can learn from African Ebola and cholera responses and avoid "biomedical tunnel vision"3Richardson ET Barrie MB Kelly JD Dibba Y Koedoyoma S Farmer PE Biosocial approaches to the 2013–2016 Ebola pandemic.Health Hum Rights. 2016; 18: 115-128PubMed Google Scholar by actively addressing wider socioeconomic and health inequities.4Chigudu S The political life of an epidemic: cholera, crisis and citizenship in Zimbabwe. Cambridge University Press, Cambridge2020Crossref Google Scholar Otherwise, the pandemic response might do more harm than good. Practical social justice—linking principles of justice with actions tailored to specific contexts—can help to guide decisions. We offer five key points to inform decision making in LMICs grounded in principles of social justice. First, the self-determination and agency of LMICs are important to uphold and respect, which means that LMICs develop and shape contextually relevant public health interventions, drawing on international partners as needed. Resource constraints should not affect the agency of LMICs to shape their responses. Although international cooperation is essential, regional networks are best placed to assess needs and lead planning. Importantly, while high-income countries are focused on addressing the epidemic in their own countries, international support remains crucial to ensure that development gains are not reversed.5Abi-Habib M Millions had risen out of poverty. Coronavirus is pulling them back.https://www.nytimes.com/2020/04/30/world/asia/coronavirus-poverty-unemployment.html?action=click&module=Top%20Stories&pgtype=HomepageDate: April 30, 2020Date accessed: May 1, 2020Google Scholar Second, measures to address COVID-19 in LMICs should give priority to the poor and marginalised who have least capacity to absorb the shocks from the pandemic. In India, lockdown has put about 400 million informal workers out of work; many now face deeper poverty and starvation.5Abi-Habib M Millions had risen out of poverty. Coronavirus is pulling them back.https://www.nytimes.com/2020/04/30/world/asia/coronavirus-poverty-unemployment.html?action=click&module=Top%20Stories&pgtype=HomepageDate: April 30, 2020Date accessed: May 1, 2020Google Scholar, 6International Labour OrganizationILO Monitor: COVID-19 and the world of work. Second edition.https://www.ilo.org/wcmsp5/groups/public/@dgreports/@dcomm/documents/briefingnote/wcms_740877.pdfDate: April 7, 2020Date accessed: April 13, 2020Google Scholar Essential supplies, including food, rely on informal supply chains that are easily disrupted in lockdowns. Immediate action is needed to maintain food and other essential supplies to prevent families dying from hunger. Cash transfers to such households will be needed to support vulnerable families during quarantine periods, requiring governments to redistribute resources from other sectors. Third, equity in health-care provision is crucial. In LMICs without adequate welfare safety nets, it is unclear who will pay for COVID-19 testing and treatment. If left to citizens, people will receive care according to ability to pay, meaning the poor and migrants will be denied services or pushed further into poverty by health-care costs.6International Labour OrganizationILO Monitor: COVID-19 and the world of work. Second edition.https://www.ilo.org/wcmsp5/groups/public/@dgreports/@dcomm/documents/briefingnote/wcms_740877.pdfDate: April 7, 2020Date accessed: April 13, 2020Google Scholar Front-line health workers also face economic hardships, reflected in ongoing health worker strikes in many LMICs. In Zimbabwe, for example, some clinical staff have not been paid for several months, and yet they are expected to lead the fight against COVID-19. Many staff have inadequate or no personal protective equipment, training in infection control, or health insurance.7Mackworth-Young CRS Chingono R Mavodza C et al.'Here, we cannot practice what is preached': early qualitative learning from community perspectives on Zimbabwe's response to COVID-19.Bull World Health Organ. 2020; (published online April 20.)DOI:10.2471/BLT.20.260224Google Scholar Key actions include lifting health facility user fees, ensuring fair pay, infection control training, provision of personal protective equipment, and COVID-19 testing for front-line staff. As vaccines and treatments are studied, it is essential that LMICs are included and the highest research ethics standards are upheld. Interventions should be tested in least vulnerable populations first with reasonable prospect for direct and immediate benefit for participants. LMIC scientists should be included as equal partners, and clinical care support should be provided. Fourth, improvements in standards of critical care should not come at the expense of essential care and routine health services. It is vital that immunisation, antenatal care, treatment of malaria, HIV, and tuberculosis, and chronic disease management continue. Failing this, many more people might die from preventable conditions than from COVID-19.8Measles & Rubella InitiativeMore than 117 million children at risk of missing out on measles vaccines, as COVID-19 surges.https://www.who.int/immunization/diseases/measles/statement_missing_measles_vaccines_covid-19/en/Date: April 14, 2020Date accessed: April 21, 2020Google Scholar To optimise COVID-19 care, even as intensive care capacity is improved, gaps in affordable essential care that will benefit many should be prioritised because the disparity between the ability of high-income countries and LMICs to provide COVID-19 care is stark.9Baker T Schell CO Petersen BD et al.Essential care of critical illness must not be forgotten in the COVID-19 pandemic.Lancet. 2020; 3951253Summary Full Text Full Text PDF PubMed Scopus (71) Google Scholar For example, in Kenya, 42% of general hospital beds lack oxygen supply, and only 16% of hospitals have pulse oximeters.10Barasa E Ouma PO Okiro EA Assessing the hospital surge capacity of the Kenyan health system in the face of the COVID-19 pandemic.medRxiv. 2020; (published online April 11.) (preprint).DOI: 10.1101/2020.04.08.20057984v1Google Scholar While aiming to provide high standards of care, we should not create new gaps in life-saving care or overlook essential care. Fifth, outbreaks can worsen existing vulnerabilities, inequities, and distrust in society. When implementing public health interventions, it is important for authorities to respect the human rights and dignity of people. Attention to gender-based violence, safeguarding, and exploitation of low-paid workers is especially crucial. For individuals who are homeless, living in overcrowded settlements and migrant camps, physical distancing might be impossible. Implementation of lockdowns without transparency and heavy-handed policing can undermine popular trust. However, trust can be earned by actively engaging with communities to develop and support implementation of COVID-19 measures.4Chigudu S The political life of an epidemic: cholera, crisis and citizenship in Zimbabwe. Cambridge University Press, Cambridge2020Crossref Google Scholar All countries are making decisions on the basis of imperfect and rapidly changing information. We will be more resilient acting together, in cooperation, than in isolation. More effective, equitable global solutions will come from LMIC expertise and leadership, grounded in principles of social justice. We declare no competing interests. MK and SM are supported by a Wellcome Trust and UK Medical Research Council (MRC) Newton Fund collaborative award (grant 200344/Z/15/Z) and Wellcome Trust strategic award (grant 096527). SM is also supported by the UK Economic and Social Research Council, MRC, and Wellcome Trust (grant MR/R013365/1). EB is supported by a Wellcome Trust core award (grant 092654). RAF is funded by the Wellcome Trust through a senior Fellowship in Clinical Science (206316/Z/17/Z). KM is supported through the DELTAS Africa Initiative (grant DEL-15-003). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences's Alliance for Accelerating Excellence in Science in Africa and is supported by the New Partnership for Africa's Development Planning and Coordinating Agency with funding from the Wellcome Trust (grant 107769/Z/10/Z) and the UK government. The views expressed in this commentary are those of the authors and not necessarily those of supporting sponsors.