Plus ça change: COVID-19 and Its Collateral Impact during the Vaccine Era

Over the past year we partnered with researchers in Kenya, the Philippines, South Africa, and Uganda to document, from a whole-of-health perspective, what we know about the nature, scale, and scope of COVID-19’s disruptions to essential health services in those countries, and the health effects of such disruptions. In a working paper released today, we build on a blog we published in March when we released working papers from each country team (the papers are available here: Kenya, the Philippines, South Africa, Uganda). In this new working paper, we summarize the results and lessons across the four countries in more detail. Using a mix of qualitative and quantitative methods, we show that each country experienced disruptions, but they varied in terms of which services, where, who was affected, and most importantly, the degree and duration of the disruptions. We also tie together many of the blogs we have written on this topic over the past year (this series of blogs can be found here).

The context for indirect health effects has evolved since we conducted our research, as we discuss below. We also consider how the promise of vaccines to protect against both the direct and indirect health effects remains unfulfilled in low- and middle-income countries (LMICs), with the collateral impact of COVID-19 enduring with each wave of infection in these settings, compounding the damage of previous waves. We urge careful planning of vaccine roll outs to minimize their effect on health services delivery, and encourage creative uses of the vaccine platforms to regain some of the lost ground.

Indirect health effects now and then

The work for these papers was conducted between August and November 2020. Globally, this was the first wave of infections, a period during which the world lacked effective vaccines and used a range of non-pharmaceutical interventions as its primary tool of control, including blunt lockdowns in many places. In early 2021, a second wave of infection hit many countries, which led to further lockdowns. However, during this second wave, a number of effective vaccines began to be rolled out globally, although the administration of vaccine doses to date has been concentrated in high-income countries. Today Canada leads the world with over 67% of its population having received at least one vaccine dose, with many other high-income countries not far behind.

Currently governments across LMICs are scrambling to reinforce health systems and accelerate vaccine drives as a third wave of COVID-19 infections threatens to overwhelm hospitals and cause devastating effects. The third wave has triggered a return to stricter lockdown measures. For example, Uganda’s President Yoweri Museveni reimposed a strict 42-day lockdown earlier this month that includes the closure of schools and the suspension of inter-district travel to help beat back a surge in COVID-19 cases. In contrast to Canada, less than 2 percent of Uganda’s population has received at least one dose. As we have learned from the last 18 months, the current third wave will cause more deaths both directly and indirectly. As long as vaccines remain unavailable, this double toll will continue, compounding the effects of previous waves.

Then

We feel the world was initially slow to acknowledge the collateral health damage—the non-COVID-19 excess morbidity and mortality—the pandemic was causing. When we wrote our first blog, the issue simply wasn’t receiving the attention it began to get later in the year, as disparate bits of information were reported and efforts to model the implications for certain programs were published (which we captured in our open access inventory of the indirect health effects of COVID-19).

As we note in our paper, there was—and continues to be—a lively debate about the extent to which the virus itself or the non-pharmaceutical measures have had the greatest impact on people’s lives and livelihoods, especially in many low- and middle-income countries. We did not seek to disentangle the damage that was caused by avoidance of health care due to fear of the virus from the damage caused by the response to mitigate the spread of the virus. Instead, we argued that the damage needs to be mitigated no matter its cause.

It remains unclear the extent to which lessons have been learnt from earlier waves that are informing how countries approach the use of restrictions in the face of new waves. Do we know which mitigations strategies have been most effective (and efficient) in reducing infections and minimizing disruptions to healthcare? While there is no shortage of papers—and opinions—on how some countries successfully contained the spread of the virus, such an evidence base is still largely lacking on how countries have successfully mitigated disruptions to essential health services. And of course, COVID-19 requires countries to constantly adapt to the changing circumstances—subsequent waves, new variants, limited availability of vaccines, vaccine hesitancy. Who is monitoring these responses, and using data to analyze the effectiveness of different responses? Are lessons being learnt and shared?

Now

Today, it feels that the focus has once again become narrower. It is of course imperative that vaccines get to all countries of the world. When this doesn’t happen, as we are currently observing, the virus spreads and kills.

But the vaccines don’t only protect against deaths due to COVID-19, they also reduce the fear of the virus—a fear that has grown with the emergence of new variants—and therefore have the potential to unlock the demand for essential health services that has built up over more than a year. According to UNICEF (see the answers to the question “What are the top reasons for health service/use disruptions across reporting Country Offices?”), the number one cause of disruptions to the use of health services has not been lockdowns—although it is clear that lockdowns do interrupt access—but fear of the virus. In short, vaccines will not only provide protection against COVID itself, they also have the potential to “protect” against the many indirect health effects of the pandemic.

And yet, vaccines may not be the panacea we all hoped for. First, strong levels of vaccine hesitancy and gaps in health systems will limit uptake. In the Philippines, one of the countries included in our study, vaccine hesitancy is so high that President Rodrigo Duterte has threatened to jail people who refuse to be vaccinated against COVID-19. And second, there is the very real possibility that vaccination campaigns will, initially at least, cause further disruption to essential health services. The diversion of human resources in already overstretched health systems to administer vaccines could mean the neglect of other important services. Those disruptions won’t necessarily be large—some countries will handle the challenge better than others, especially with adequate planning—but they are a real risk that needs to be acknowledged and mitigated.

Is it possible to imagine scenarios instead where COVID-19 vaccination campaigns don’t compound the pandemic’s indirect health effects, but actually allow us to catch up on some of the losses? With ambitious yet careful planning, the pandemic response may be an opportunity to push universal healthcare forward and strengthen services. What about co-locating COVID-19 vaccination sites with pop-up child wellness clinics? Once the pandemic is over, could the testing facilities rolled out for COVID be repurposed for testing communicable and non-communicable diseases? Vaccine incentives are another opportunity. In America, everything from free beer to college scholarships to a $5 million lottery have been offered to encourage the reluctant to get vaccinated. Some US states have even offered guns as an incentive. The evidence is mixed about whether these incentives are working. But what about offering other health services as an incentive in LMICs? Adding on other health services is not as simple as offering cash, but there is a clear pent-up demand for health services that have been skipped during the pandemic. Offering other health services like alongside vaccinations could be a way to prevent vaccination campaigns from further crowding out essential health services in poorer countries.

This will require planning and a specific look at indirect health impacts, to not only avoid further disruptions from vaccination campaigns, but to use them as an opportunity to build the path ahead. This thinking should be adopted by countries but also globally: vaccination donations are crucial to improving access in LMICs, but some richer countries are ‘charging’ their vaccine donations against their development aid, which implicitly means that funding for other important services have been cut. Attention must be paid to the funding of non-COVID programs, which is already under threat from cuts.

Conclusions

We are concerned that the research to inform decision-makers is not moving forward quickly enough when it comes to understanding the best ways of mitigating disruptions to essential health services during the pandemic. Our paper provides an overview of the nature, scale and scope of indirect health effects faced by Kenya, the Philippines, South Africa, and Uganda during the first wave of infections. These countries, along with other LMICs, are currently experiencing a third wave of COVID-19 without the benefit of vaccines. Unfortunately, they are facing this new wave with essentially the same approach to mitigation. That’s why it is critical that we capture and share lessons from waves one and two, to help countries ensure that their COVID mitigation strategies disrupt essential healthcare services as little as possible while controlling the virus. And while the first priority must be to get vaccines to these countries as soon as possible, plans must also be made to ensure that vaccination campaigns don’t compound the pandemic’s destructive impacts on healthcare even more.