The Burden of COVID Is Shifting to the Global South

Americans, by and large, are putting the pandemic behind them. Now that Omicron is in the rearview mirror and cases are plummeting, even many of those who have stayed cautious for two full years are spouting narratives about “going back to normal” and “living with COVID-19.” This mentality has also translated into policy: The last pandemic restrictions are fading nationwide, and in his State of the Union address on Tuesday night, President Joe Biden declared that “most Americans can remove their masks, return to work, stay in the classroom, and move forward safely.” Other rich, highly vaccinated countries are following much the same path. In the U.K., for example, those with COVID-19 no longer have to self-isolate. It helps that these countries have more vaccine doses than they know what to do with, and a stockpile of tools to test and treat their residents if and when they get sick.

But in the global South, COVID-19 is much harder to ignore. More than a year after the start of the mass-vaccination campaign, nearly 3 billion people are still waiting for their first shot. While an average of 80 percent of people in high-income countries have gotten at least one dose, that figure stands at just 13 percent in low-income countries. In the poorest countries, virtually no booster shots have been administered. Such low vaccination rates are taking their toll. Although the official death count in India is about 500,000, for example, the reality might be closer to 5 million excess deaths—and most of those deaths happened after vaccines were introduced in the global North.

The rush in the rich countries to declare the pandemic “over” while it continues to ravage the global South is completely predictable—in fact, the same trend has played out again and again. Infectious diseases such as malaria, tuberculosis, and AIDS that are now seen as “Third World diseases” were once serious threats in rich countries, but when incidence of these diseases began to decline there, the global North moved on and reduced investments in new tools and programs. Now, with COVID-19, the developing world has once again been left to fend for itself against an extremely transmissible virus without the necessary vaccine doses, tests, and treatment tools. Some pandemics never truly end—they just become invisible to people in the global North.

You may know malaria as an infectious disease that affects poor “tropical” countries. But for several thousands of years, malaria was a global menace. During the 20th century alone, the disease is estimated to have accounted for up to 5 percent of all human deaths. It was eradicated from the global North by the 1970s, but the rest of the world was left behind. In 2020, there were an estimated 240 million malaria cases, and nearly all of the 627,000 deaths occurred in sub-Saharan Africa. For a disease that affected even our neolithic ancestors, the world had to wait until 2021 for the first-ever malaria vaccine. Though the World Health Organization recently endorsed this partially effective malaria vaccine, expanded manufacturing and scale-up plans remain undetermined.

The same phenomenon has unfolded with tuberculosis, a disease so old that DNA of TB bacteria have been identified in Egyptian mummies. “Consumption,” as TB was once called, was highly prevalent in Europe and North America. From the 1600s to the 1800s, TB caused 25 percent of all deaths in Europe. By the 1980s, TB case numbers had decreased significantly in the West, largely thanks to drug treatments and reductions in poverty. But again, TB remains a problem in developing countries (and among marginalized populations within the global North). In 2020, TB killed 1.5 million people, more than 80 percent of whom lived in low- and middle-income countries. Investments and innovations to make the disease less devastating have been scarce: For example, the TB vaccine we use today is more than 100 years old, and it has limited efficacy in adults.

Unlike malaria and tuberculosis, HIV/AIDS was identified only 40 years ago, and still we’ve seen the same trend. After the infection emerged in the early 1980s, it went from a condition thought to affect only gay men in the global North to a global pandemic that, yes, mostly affects the global South today. In 2020, nearly 38 million people globally were living with HIV, and 680,000 people died from AIDS-related illnesses, with two-thirds of both cases and deaths in Africa. When effective antiretroviral drugs first became available in the early 1990s, they were expensive and mainly accessible to people in high-income countries. For these lifesaving tools to reach the global South took incredible activism and years of effort, and millions of people (mostly Africans) died as a result of this inaction. Even today, we do not have a vaccine against AIDS.

Despite the continued toll of these “big three” infectious diseases, they are rarely spoken of as pandemics. “By epidemic we actually mean a pandemic that no longer kills people in rich countries,” wrote Peter Sands, the CEO of the Global Fund, an international group that combats these diseases. “By endemic we actually mean a disease the world could get rid of but hasn’t. HIV/AIDS, TB and malaria are pandemics that have been beaten in rich countries. Allowing them to persist elsewhere is a policy choice and a budgetary decision.”

With the coronavirus, the global South is being left behind once again. Rich countries are already rapidly losing interest, and if the virus continues to fizzle out in these areas, they might show less urgency in sharing vaccines and other resources, stop investing in new products to fight the virus, and place the burden of disease control primarily on resource-strapped low-income countries. Rich countries such as the United States have donated hundreds of millions of doses to the COVID-19 Vaccines Global Access Facility (COVAX), but citing supply issues, the initiative didn’t even get halfway to its goal of delivering 2 billion doses last year.

Even if rich nations continue to offer charity and donations, they seem less likely to support efforts that would let lower-income countries procure and manufacture their own tools to battle this virus. HIV medication became affordable to the global South only when countries such as India started manufacturing their own generic pills. The same must happen for COVID-19 vaccines to be more accessible. After Omicron, some have suggested that it’s too late to meet the WHO’s target of vaccinating 70 percent of the world by mid-2022. When we should be redoubling efforts to increase vaccination, the narrative that it’s too late to vaccinate the world could have a chilling effect on the global COVID-19 vaccination campaign.

The developed world is repeating its mistakes again, and this will have devastating consequences for billions of people. Diseases becoming “endemic” should not be code for inaction or lack of consideration for those with few resources and many vulnerabilities—in both the global North and the global South. Even when they’re invisible to some, high death and infection rates cannot be seen as acceptable or normal.

For now, the biggest problem with the global North proclaiming that the coronavirus pandemic is “over” is that it manifests the opposite outcome. Eventually, even rich countries will bear the brunt of tuning out COVID-19. Allowing infectious diseases to circulate in any part of the world within large populations of unvaccinated people will almost surely result in the emergence of new variants that will affect all nations.

Privileged people should not get to decide on their own that a global pandemic is over. The way out is the same as it’s always been: making sure we get everyone to the finish line, not just a select few. Humanity did this with smallpox and could soon achieve this with polio and guinea-worm infections. The real barrier to ending this COVID-19 crisis around the world is not science or resources—it’s us.

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