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The Third Wave: Preparing for COVID-19 in a crisis

‘It's like people have braced for a tidal wave.’

Composite image of the coronavirus
Composite image of the coronavirus made up of news images of people wearing face masks sourced from CDC and GDELT. (Ben Parker/TNH)

At a glance: Key points for relief aid

  • Previous experience with Ebola and other outbreaks offers lessons.
  • NGOs have to juggle staff welfare, logistics, business continuity, and social distancing while prepping for an unprecedented event.
  • Donors need to show new levels of flexibility.
  • Refugees can be stigmatised if singled out as especially at risk.
  • Aid operators hope for travel exemptions.
  • Cash-based aid schemes only work if markets are functioning.
  • The secondary social and economic effects could be even more grim.

Countries that are already struggling – with poverty, conflict, or natural disasters – will be hit hard by COVID-19. Governments, medics, and aid groups are scrambling to prepare, but face daunting challenges.

After forcing China to confine 750 million people to their homes, the virus brought rich countries to a standstill and overwhelmed their hospitals and economies. A “third wave” is starting to reach the crisis-affected and low-income countries of the Global South.

How is the humanitarian sector – typically ready and willing to respond anywhere – adjusting? What are the scenarios and priorities? What is different with this crisis?

TNH Senior Editor Ben Parker discussed some of the most pressing issues with leading specialists and practitioners from across the humanitarian sector:

Here are some key points from the discussion, condensed from the full hour’s recording.

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The impact

“The third wave – after China, after Europe” will hit poorer nations hard, said Karl Blanchet of the CERAH research centre. Blanchet said the capacities of healthcare systems in countries already facing other crises are “far too low” to cope with COVID-19. And the weakest and poorest places make a fertile ground for the disease. When it comes to crowded slums, informal settlements, or camps, “you would have a hard time designing a more dangerous setting”, said Jeremy Konyndyk of the Center for Global Development.

Not only will COVID-19 be an immediate health disaster, but it will take resources away from other lifesaving work. Normal health programmes need to continue. “We are still going to have a lot of deliveries. We still have a lot of chronic care patients,” said Blanchet. “We need to get access to their medication: diabetes, HIV/AIDS, and so on, make sure they've got 30 days of medication.”

“During the Ebola outbreak in West Africa, more people died of other diseases than died of Ebola,” Konyndyk said. Pre-existing aid projects outside of the health sphere can’t be abandoned either, he added: “If we focus all our attention on coronavirus and meanwhile… locusts eat up all the crops in a country, that is a pandemic impact.”

Blanchet urged caution. While aid agencies are talking about “business continuity”, he said NGOs should scale back now. “You need to identify what is essential and postpone anything else to avoid mass gathering,” he said. Social distancing should be a top priority for aid organisations, he said, adding: “I think that's your responsibility.”

Konyndyk said places where there is a crowded population, very poor sanitation, a low level of basic health within the community, very poor disease surveillance, and very poor health services combine to make the virus “extraordinarily dangerous”. “I don't think that's getting enough global attention yet,” he added.

The medical emergency will be accompanied by “enormous” secondary impacts on jobs, food production, and trade, Konyndyk said.

For example, Virginie Lefèvre of Lebanese NGO Amel Association, said Lebanon faces several interlinked crises, including a “very acute socio-economic crisis since mid-2019”, involving a near-collapse of the banking system and 200,000 job losses. “So it's quite difficult to be positive,” she said.

In Somalia, “it's like people have braced for a tidal wave”, said Suze van Meegen of the Norwegian Refugee Council, adding: “We're all kind of just sitting on tenterhooks waiting to see where this will go.”

The response strategy

NGOs and other humanitarian organisations face a difficult balancing act of keeping their current operations intact while “pivoting” to COVID-19. “On my mind is how we absorb this shock but maintain our existing programmes,” said van Meegen.

Responding to the looming emergency will be “an enormous challenge for the humanitarian world”, which is likely to be working on the outbreak in “the most compromised and most vulnerable settings”, Konyndyk said.

The scale of response needed, the operational and logistical challenges, the funding issues and coordination complexities are all daunting.

With international flight bans and lockdowns, the model of rushing foreign aid teams and cargo to frontline response is looking ill-suited to COVID-19. That could be an opportunity for local aid groups long hoping for greater recognition and resources. It’s a widely supported shift that has proven stubbornly hard to achieve. “It's going to really force a more effective, and more supportive, and frankly, more respectful and power-balanced way of working between international partners and local partners than I think we've seen before,” said Konyndyk.

Humanitarian response shouldn’t ignore the systems already in place, said Lefèvre. She said she was concerned that “we're going to develop a parallel system over the next six months” when, if anything good could come of the pandemic, it might leave behind a stronger national health system.

Van Meegen said donor countries that fund international relief programmes will need to show flexibility, as current projects will be disrupted and might need to change. How to design and implement programmes for the new threat is still a fresh problem. “I think the best thing donors could do now is ensure they are giving time and space to us to figure out what is needed in different contexts,” said van Meegen. That will take different amounts of time in different countries, she added. If things go wrong, donors need to share the blame, not pass all the risk onto their grantees, she said: “We're seeing ourselves carry the burden of all risks relating to security, financial management, the risk of fraud. And that's both time consuming and expensive”. And that tension is even greater where armed groups under terrorism sanctions are in control.

“We have closed our borders in a time where we need more international collaboration, and that's an issue for me.”

There will be many players involved. “Fundamentally, this is a huge coordination challenge” for the international aid system, said Konyndyk, and at “a much bigger scale than what we are used to dealing with.” Asked if we have the international machinery in place to manage, he said, “I don't think we do”, and referred to “a real struggle” during the West Africa Ebola crisis. At that time, the UN installed a “health-keeping mission” that “didn't work very well”, he said. This time, the UN-led international aid will be coordinated by the UN’s emergency aid coordination body, OCHA, and the World Health Organisation. “They're trying a different way,” said Konyndyk. “We will see how that works.”

Blanchet said he was heartened by evidence of national and local solidarity: “People are helping each other, helping elderly people, and doing the shopping for them. It's beautiful.” But does that translate internationally? “We have closed our borders in a time where we need more international collaboration, and that's an issue for me,” he said.

Frictions

“You have to be careful about the backlash” when drawing attention to those at particular risk, like some refugees, said Lefèvre. In Lebanon, pre-existing tensions could be worsened, putting people at greater risk. Handled badly, a “very acute health crisis” could “turn into internal clashes”, she warned.

The country already faces rifts between different Lebanese communities and between them and Syrian refugees in the country. “I’m always very, very careful, when it comes to tensions and stigma, not to over-exaggerate what is going on,” said Lefèvre. When it comes to “catastrophic language, I think that we have to be very, very careful”. In Lebanon, Lefèvre said her organisation was working to make sure that patients (especially refugees) who live in informal shelters and settlements get referred and treated in the official health system.

Competition for medical supplies will be critical. Konyndyk said “fights are coming” over “limited supplies of PPE (Personal Protective Equipment), limited supplies of vaccines, and limited supplies of therapeutics”.

“I’m always very, very careful, when it comes to tensions and stigma, not to over-exaggerate what is going on.”

If and when there is a vaccine, “there aren't going to be seven billion doses ready immediately”, he added. “This is more a political issue than a humanitarian one… When the first 100 million doses of vaccines come out, it's going to be a big fight over who gets those… and it's going to be very important that they not just go to those who can afford them.”

Duty of care

NGOs need to look after their staff and volunteers, as there's fear, and a lot of misinformation. Aid staffers, van Meegen thought, could be reluctant to get involved. “As the world has become more inward-looking”, she said, so too will some humanitarian staff. “They will be fearful for their own health, safety, and families.”

According to Lefèvre, “locally-led response, the community-based initiatives, are working despite the fear”. Frontline aid workers will be exposed to the virus more than others and are already facing “very high levels of stress”, she warned.

Response options and priorities

A core tool for modern humanitarian response is cash distribution, usually means-tested: hard-up aid recipients get money, vouchers, or a debit card and can spend as they choose. Ramping up the cash for COVID-19 response might seem relatively easy to scale up to large numbers of people (cash handouts are part of state relief packages in the richer countries). But there could be a serious flaw, according to van Meegen. What is there to buy?

Even before the coronavirus had arrived in Somalia, “markets were absolutely empty of basic medical supplies: of soap, of hand sanitiser, of buckets”, van Meegen said. “If markets aren't functioning and aren't able to meet those needs, how do we adapt?”

“I would caution against NGOs taking an excessively opportunistic approach to this and diving into something because the money's available.”

Could aid work get special permission to fly? Van Meegen hopes for “humanitarian exemptions” on travel restrictions. “We know that we'll be relying predominantly on national teams,” she said. “But how can we ensure that within countries and across borders – to the extent necessary – we are able to travel?”

Blanchet called for health and other efforts to be closely integrated. “This pandemic is a very good example of how multisectoral we have to be – and it's not a buzzword,” he said. “We need the private sector to be involved. We need transport. We need airlines to transport staff and products and we need international collaboration.”

Should NGOs switch what they are doing to go all-in on COVID-19? Van Meegen is wary: “I would caution against NGOs taking an excessively opportunistic approach to this and diving into something because the money's available.” Konyndyk said there had been valid examples of programmes “layering” additional elements into existing programmes during the Ebola epidemic. “The burial teams in Liberia, for example, those were built on top of an existing community WASH programme that already had community confidence and participation…. not in a sort of opportunistic way, but in a way that is strategic,” he said. “I think it could be a huge opportunity.”

“I think the information is one of our biggest concerns,” said van Meegen. Misinformation including rumours, theories, and unproven remedies are circulating at speed in Somalia, she said, part of a global parallel “infodemic”. We see irrational behaviour in “high-resource countries” too, she pointed out, where “people are believing all sorts of things… stockpiling, and panicking”. “The most vulnerable people will be hit very, very hard because they're the ones with even less access to reliable information.”

Other priorities

Konyndyk: “We need to be working on developing... low-tech approaches to things like personal protective equipment, infection prevention and control… a scalable low-tech solution to testing, and some of these settings will be really important.”

Van Meegen: Humanitarian organisations should “remind wealthy countries and high-resource countries” of the impact it’s going to have elsewhere, but “without seeming sensationalist or hysterical, because that messaging actually does a lot of damage.”

Blanchet: “We need to make sure we can create field hospitals to separate suspected cases with confirmed cases.”

Lefèvre: “This crisis shows, and there was no need to demonstrate it, but it shows that localised responses are the only solution in certain settings. But I don't think that this means no international actors.”

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