"You will not be safe from COVID-19, until everyone is safe from COVID-19"

MSF International President calls on governments to address health care inequality

MSF COVID-19 Response in Lebanon

Lebanon 2020 © Diego Ibarra Sánchez

Doctors Without Borders/Médecins Sans Frontières (MSF) International President Dr. Christos Christou delivered the following statement today at the 2020 ECOSOC Humanitarian Affairs Segment high-level panel on the increasing complexity of health challenges in humanitarian contexts.

Thank you, Your Excellency, Vice-President of ECOSOC, and Under-Secretary Lowcock for the invitation. 

MSF teams are treating patients all over the world: my words today come from their experiences.

This pandemic has brought suffering, fear, and death to populations everywhere. But its impact is not shared equally. Many of the most vulnerable have already suffered terribly due to a lack of state investment in health care for all. Others are living through conflicts, witnessing the erosion of international humanitarian law. 

As humanitarian teams have been partially evacuated and not replaced, those reliant on aid and those suffering from neglected diseases are suffering disproportionately. Others have been forced to flee their homes—forced to navigate a world where conventions protecting refugees, asylum seekers, and internally displaced people are frequently disregarded, and where little consideration is given to migrants.

Today, we must acknowledge that this pandemic comes after years of questioning humanitarian assistance and principles, and innumerable cases of violence against health workers and facilities.

One of the terrible paradoxes now, is that the very governments that have created conditions in which the vulnerable are left disproportionately exposed to COVID-19, are the same governments who are now making calls for solidarity and cooperation.

Whilst money is vital, financial contributions alone cannot fix health care inequality and exclusion. Use your influence, your power, your domestic and foreign policy to bring health care for all.

The COVID crisis amplifies and deepens existing inequalities. MSF sees this on the front line every day.

Health care for all people: without excluding the homeless, undocumented migrants, prisoners, or indigenous people. They have all been terribly affected by COVID, as have the elderly in many countries.

MSF is committed to caring for all of these groups, but governments must step up and recognize their own responsibilities. You have a duty to ensure no one is excluded from health care—and you will not be safe from the coronavirus until you fulfill it. And that means [caring for] marginalized communities too.

“Crisis within a crisis”

Health care workers all around the world are risking their lives to provide care. Today, we are still facing serious shortages of basic protective equipment. Without proper PPE, we cannot protect our staff and patients.

In addition to safety, we need access to those at most need, and essential medical tools like oxygen and testing.  

In Yemen, COVID is compounding the existing problems caused by the conflict and collapsing health system, and the man-made tragedy that has unfolded there.

Our work is being greatly diminished by the failure to allow access to patients. Restrictions imposed by governments—limiting the movement of equipment, staff, and patients—are constricting the care we can provide. Even when we have some access to patients, we often lack supplies; even when we have supplies, we are often unable to protect our staff. Our staff are often forced to make choices about care that no one should have to make.

To treat COVID in Yemen, like in some other countries, is to treat a crisis within a crisis.

In some areas we have been able to adapt and innovate the way we deliver care, maintaining a limited and reduced service for our patients. But elsewhere, such as at our pediatric surgery operation in Monrovia [Liberia], we have had been forced to suspend our work. Projects in Bangladesh and dozens of other locations also risk suspension for lack of capacity.

In northeast Syria, where health care provision is already inadequate, only 3 out of the 279 public health centers are fully functional.

You have the power to change these situations. Governments must immediately lift restrictions and allow humanitarians access. More vulnerable populations, like those in Bangladesh, Democratic Republic of Congo (DRC), Haiti, or in the new epicenter of [the pandemic] South America, must be supported with real solidarity.

And they will also need you to take responsibility for what is coming next. Because COVID is creating devastating waves [of crisis]. Increased poverty, malnutrition, excess mortality. We are increasingly worried about countries like Central African Republic, where the cumulative impact risks producing critical humanitarian needs. We must prepare now for these secondary impacts, which will be at least as devastating as the virus itself, and will follow the current situation where many facilities have been overwhelmed.

Communicable diseases will have an increased impact as a result of COVID measures.

In April, 24 of the world’s poorest nations postponed vaccination programs in response to the limitations imposed upon them by COVID. So, something like 120 million people—mostly children—may not be vaccinated during the outbreak or will miss their scheduled vaccines. Of countries where data is available, more than half report disruption or total suspension of their vaccination services.

MSF knows from previous epidemics that the reduction in access to health care has a devastating effect. In Liberia and Sierra Leone, the 2014-2016 Ebola outbreak led to a vast increase in deaths linked to tuberculosis (TB), HIV, and malaria. In the most recent Ebola outbreak in DRC, many more children died as a result of the secondary effect on the measles vaccination program, than from Ebola itself.

Our staff see how women and girls are bearing a disproportionately heavy burden from these secondary impacts. Sexual and reproductive health services, including safe abortion care, are not a luxury. They are always essential health care. During emergencies, these needs become even greater.

Vaccines and treatments for COVID-19 must be available to all

Finally, whilst we welcome initiatives like the [World Health Organization's] ACT Accelerator and call to action, governments must ensure that health care tools are made accessible to all.

Treatments and vaccines cannot become opportunities either for profit, or political control.

A “business as usual” approach is not only unacceptable, it will be ineffective.

MSF has for decades witnessed people suffering and dying because of an absence of affordable medical tools. We have already the experience in previous years of millions of people denied treatment for diseases such as HIV/AIDS, TB, and Hepatitis C, as a result of unaffordable patented medicines.

Affordability must be a non-negotiable commitment.

Funds for vaccine and therapeutic development must only be given to pharmaceutical companies with the concrete commitment that any product is sold at cost, and universally accessible.

You will not be safe from COVID-19, until everyone is safe from COVID-19. From the poorest displaced families to the richest individuals: This virus will continue to be a global threat for as long as it takes for vaccines and treatments to be available to all.

Responses to questions for the panelists [as prepared for delivery] 

Q1: There seems to be agreement (and have heard from other a number of speakers today) that a focus needs to remain on ongoing programming in the time of COVID, and the second-order impacts of the pandemic may in fact have larger consequences on vulnerable populations. Perhaps we can drill down on this question a bit deeper. From an MSF perspective, what are you seeing on the ground now and where are your biggest concerns?
Well, the first thing to say is that it is not only possible but very likely that the secondary impacts of this virus and the measures to contain it will be as bad or worse than the virus itself. This is something we have seen in previous epidemics, and it is something that we need to start addressing right now.

Take the situation with malaria in sub-Saharan Africa, where under the worst case scenario, a reduction in access to effective antimalarial medicines during COVID, would lead to estimated malaria deaths in 2020 of 769, 000, according to WHO projections. That’s twice the number of deaths reported in the region in 2018.

I’ve already mentioned in my presentation how the interruption to projects for TB and HIV patients have the potential to bring devastating effects for patients as well. 

I want to underline the impact on the interruption of sexual and reproductive health programs. Frontline health providers are already reporting shutdowns of services as a result of COVID, and we know that even a very small reduction in services can cause a dramatic increase in maternal and neo-natal deaths, a devasting lack of services for survivors of sexual violence, and a dramatic increase in the life-threatening consequences of unsafe abortions.

During the Ebola outbreak in West Africa, a decrease in utilization of lifesaving sexual and reproductive health services in Sierra Leone alone translated into 3,600 additional maternal, neonatal, and stillbirth deaths in the year 2015—under the most conservative scenario. 

This topic gets used as a political football and gets narrowly defined to suit political agendas. We need people to focus the medical facts here: sexual and reproductive health programs save lives.

In 2018, MSF treated 24,900 cases of sexual violence and over 24,000 women* with post-abortion complications. A significant number of women face not only life-threatening scenarios but suffer from ongoing physical and mental trauma. The vast majority of complicated cases could have simply been avoided through access to contraception, emergency care, and safe abortion care.

We must stand up and say clearly that women and girls must be able to access lifesaving health care, during the pandemic and always. This is a right. And to do otherwise is only multiplying their disproportionate suffering. 
Q2: Dr. Christou, you mentioned in your introduction the need to ensure new COVID vaccines are accessible and affordable for everyone. This is a topic that has generated significant discussion lately among a variety of State and non-State actors. Based on MSF experience, what do you see as some of the challenges that lie ahead to arrive at this objective?
Well there are two major points here to start with. The first is that this simply cannot be a profit-making exercise for the pharmaceutical industry. It can’t be a business as usual approach because that will mean that the vaccine remains out of reach for millions of people. The second point is linked to this, insofar as if a vaccine is developed, it needs to be prioritized to reach those who need it, not those who can afford to pay for it. 

I’ll expand on these points. In recent weeks we’ve heard lots of talk about this being the “people’s vaccine” and things like that. But those will just be nice words unless there is a solid commitment to distribute the vaccine equitably and make sure any prioritization happens objectively. I want at this stage to welcome the Costa Rica initiative, but stress that we would like to see it go further, with the Solidarity Call to Action for equitable global access to COVID-19 health technologies through sharing of knowledge, intellectual property, and data. While the WHO/Costa Rica Solidarity Call is an important step, it will require effective implementation and enforceable measures to guarantee access to both existing and future COVID-19 technologies for everyone. 

Now is not the time to allow business-as-usual approaches from pharmaceutical corporations and short-sighted nationalism from governments to stand in the way of global cooperation on medical tools to respond to this pandemic. COVID-19 will not be over until it is over for everyone.

It is essential that governments place the common good above individual nationalist interests. We need to remember that no one is safe until everyone has access to this. Individualistic approaches will make us all less safe.

Fundamentally, it is clear that the vaccine needs to be sold at cost, and made available to those who can’t pay. That’s the only way it can be effective. If wealthy countries allow the market to take control, then the vaccine won’t be brought under control.

MSF has seen the market fail in the past. All around the world in our projects, we witness people dying from diseases because of the lack of affordable medical tools. It is entirely unacceptable that people die as a result of drug monopolies. But in the case of COVID, it would also mean that vaccination would not be successful.

Governments need to make sure that history doesn’t repeat itself on this. We need governments to do the right thing, and we’ll be ready to hold them to account. We’ve already seen cases of stockpiling of PPE and other equipment, and it cannot be allowed to continue. The only way forwards on this is solidarity between countries, and that means wealthy countries also stepping up and joining in solidarity with poorer ones.

*This article was updated to provide the correct number of women with post-abortion complications who were treated by MSF in 2018.