How to scale up the COVID-19 response around the world

COVID-19 is sweeping through developing countries such as Brazil, Mexico, South Africa and India. With teeming urban centres, cramped quarters for migrant workers, massive health disparities, and far fewer physicians and hospital beds per capita than the US or UK, these countries face grave health risks from the pandemic.

The large economic damage that follows health catastrophes could further erode countries' health capacity. As we await a drug or vaccine, this article identifies seven global health security risks exposed by the pandemic and proposes concrete solutions to mitigate these risks, both for the current pandemic and the next one.

1. A shortage of healthcare workers: A report from Moscow claimed that 75% of healthcare staff - doctors, nurses and support staff – fell ill from COVID-19. Healthcare workers are the most precious nonrenewable resource, but also the most vulnerable. How can we scale up healthcare with a shortage of healthcare staff?

2. A lack of available beds: A shortage of hospital beds throughout Latin America impeded timely COVID-19 care, but there are bright spots in Asia. The world watched in awe when China built a 1,000-bed makeshift emergency hospital to treat coronavirus patients in just 10 days. In Delhi, Radha Soami spiritual centre was converted to create 10,000 makeshift hospital beds within 10 days. How can we replicate these examples more broadly?

3. An insufficient supply of personal protective equipment (PPE) supply to protect health workers: The World Health Organization (WHO) estimates that PPE supply must be increased by at least 40% to meet the current global demand. Without PPE, hospital transmission will place both healthcare workers and the community at risk.

4. Scaling diagnostic testing at a population level: Insufficient testing leads to delayed detection and isolation, which in turn increases community transmission.

5. The lack of life-saving medical devices such as ventilators and dialysis machines: Carrying large stocks of these devices just in case of a pandemic may not be economically feasible, which makes just-in-time (JIT) manufacturing a priority.

6. Difficulties in building community trust: This is frequently impeded by misinformation and a lack of enforcement. Violence, political instability and economic malaise compound community transmission.

7. Accelerating an effective treatment or vaccine: The latter demands worldwide data collection and coordination to support best practices.

Strategic policy and investment in emerging health technologies may mitigate these seven health security risks. Here's how:

1. Using telehealth to scale up healthcare: During the ebola epidemic, survivors were trained to become nursing assistants on the frontline. Nurse assistants can do many of the jobs of nursing staff, be trained more quickly, and rapidly scaled in number. A similar model could work for COVID-19 if pandemic survivors can be recruited, incentivized and trained quickly. India now has one of the fastest-growing coronavirus caseloads. Telehealth can expand the geographic reach of specialists in places like rural India, where COVID-19 has spread from the cities and where physician shortages predated the pandemic.

2. Decentralizing health infrastructure: The traditional argument for larger hospitals is that they reduce costs due to scale and lead to better clinical outcomes as specialists can be relieved from seeing routine cases. Unfortunately, as witnessed during the pandemic, everyday medical care such as obstetrics, cardiac and cancer care has been jeopardized. One pregnant woman in India died after being turned away from eight hospitals in 15 hours. Decentralized and specialized hospitals reduce population health risks while protecting routine care for the sick and elderly.

3. Rational healthcare, also known as rationing: Healthcare rationing is inevitable and takes various forms. Some countries exclude the poor, some exclude the sick with poor health prospects, and some enforce economic reality via long waiting lists – but what principles should govern healthcare rationing during a pandemic? Community-level outcomes should take precedence over individual ones. Capacity planning is crucial for rationing; ideally resources should be fully utilized, and customers should never wait. Sharing helps. For example, France sent patients to Germany and Switzerland, where there were empty beds, during the peak of the pandemic. Smart inventory management can maximize the utility of tests, masks and PPE.

4. Prevention through testing and contact tracing: Protocols for testing and contact tracing need a tailored approach for each country. For example, Japan performed a limited number of COVID-19 tests due to extensive contact tracing while South Korea invested in testing. Testing and contact tracing assume availability of tests and tracing technologies.

However, in a populous country such as India, contact tracing, social distancing and widespread testing have not been logistically or economically feasible. Sharp rises in COVID-19 cases across the country demand innovative solutions. For example, public-private partnerships could help to distribute older smartphones to underserved populations to widen contact tracing. Digital health records aid patient risk assessment, an area in which India has made recent progress with its national information initiatives.

5. Producing life-saving medical devices just-in-time (JIT): Modern medicine relies on medical devices such as ventilators to treat the sickest patients. Stockpiling such devices for a pandemic may not be economically feasible, but scaling up production at the time of need is vital. JIT manufacturing should be cheap and rapid – not fulfilled by proprietary technologies, which are often expensive and restrictive. One potential solution is open-source technology.

Open-license standardized designs can be assembled quickly based on commercial-off-the-shelf parts with components sourced from multiple suppliers. However, without a financial incentive, private companies will not invest in such efforts. I call on governments to fund research and development initiatives for developing open-source medical device technology, testing and device certification for both current and future pandemics. This is not without precedence. During the ventilator shortage in Spain, volunteers worked together to create 3D-printed ventilators.

India is particularly ripe for open-source technology. With its manpower and manufacturing resources, the supply chain could be amplified to unparalleled levels if products such as ventilators are manufactured locally based on open-source design.

6. Immunization against misinformation: Young people are mistrustful of politicians and government, and rely instead on new media for information. In this context, how can institutions improve their messaging and reputation? They need to employ youth media channels and follow their style.

7. Health in a post-COVID world: The coronavirus has exposed new global health safety threats which are especially ominous for developing countries. There is, however, reason to hope that COVID-19 can be a catalyst for planning and rethinking healthcare to cope with future pandemics – starting now.