When WHO added Disease X to its R&D Blueprint in 2018, the reality of an unknown pathogen that could cause a serious international epidemic was just beyond the limits of the imagination. 2 years later, at the time of writing this Editorial—the beginning of April, 2020—over 1 million people around the world have been infected with COVID-19 virus and 80 000 people have died from the disease. One-third of the world's population is in lockdown. As the world's most advanced economies struggle to repurpose state and private sector capacity to meet the growing demands on health services, the spotlight is shifting to countries without formal social safety nets or the massive monetary injections needed to bolster their economies.
COVID-19 is yet to establish a firm foothold in low-income nations, but African countries are already feeling the economic impact of the stall in global demand for oil, gas, and commodity products. UNDP has estimated income losses of US$220 billion in low-income and middle-income countries (LMICs) and that nearly half of all jobs in Africa could be lost. This, combined with the potential health impact, could be catastrophic. A Comment published in The Lancet Global Health in April found that a rapid acceleration in the number of cases in west Africa, as has been seen in Europe, could quickly overwhelm vulnerable health systems that typically have fewer than five hospital beds per 10 000 population. UNDP has called on the international community to pool resources to not only support the public health response but also to prevent economic collapse in the poorest countries. Similarly, the African Development Bank has appealed for a globally coordinated fiscal stimulus. The UN Economic Commission for Africa's Executive Secretary, Vera Songwe, expressed her disappointment at the global response with a reminder that, “If one of us has the virus – all of us have it.”
But with many borders closed and wealthy nations increasingly looking inwards, we are reminded of the asymmetrical power structures that still dominate the largely high-income-country concept of global health and development, and the dangers of the poorest countries being left in the dark as traditional powers shift their focus to the overwhelming problems at home. “The global health model is based in large part on technical assistance and capacity building by the US, the UK, and other rich countries, whose response has been sclerotic and delayed at best”, wrote Sarah Dalglish in a letter to The Lancet in March. Criticising the established notion of global health expertise being concentrated in legacy powers and historically rich states, she laments that “relatively little has been heard from African veterans of the Ebola epidemics in west and central Africa”.
The scientific community has fervently responded to the call for a treatment for COVID-19, with the first results of Gilead's experimental antiviral, remdesivir, due to be released this month. However, in the rush to register trials—over 300 so far—a sinister undercurrent has re-emerged. At the beginning of April, two French doctors sparked an intense backlash over comments made during a live television discussion about COVID-19 trials in Europe and Australia by saying that the studies should be done in Africa first “where there are no masks, no treatments, no resuscitation”, reasoning that certain studies on AIDS had been carried out in prostitutes “because we know that they are highly exposed and that they do not protect themselves”.
Africa is a continent where the legacy of colonialism is particularly heavy. It is shocking to hear these remarks from scientists in the 21st century, at a time when the work of epidemiologists, infectious disease modellers, public health specialists and, indeed, all health workers, is in the public spotlight like never before. At the WHO press briefing on April 6, Director-General Tedros Adhanom Ghebreyesus responded plainly, “To be honest, I was so appalled, and it was at a time when I said we needed solidarity. These kinds of racist remarks will not help. It goes against solidarity. Africa cannot and will not be a testing ground for any vaccine…The hangover from a colonial mentality has to stop.”
Territorial colonialism may have ended long ago but this contemporary global health crisis can serve as a reminder that the colonisation of medicine, economics, and of politics, remains alive. We must reflect on practices that have their origins in 19th century imperialism and replace them with new systems that are rooted in values of recognition, reciprocity, and respect.