In the Time of COVID-19: Public Health Perspectives from the Field.

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As the cases of COVID-19 in the US continue to increase and daily life remains at a standstill I am reminded of a young man I met in 2014 while interning at Kibong’oto Infectious Diseases Hospital (KIDH) in Tanzania during my MPH program at Boston University School of Public Health. The young man was a miner from the Mirerani area. Like most miners, he had silicosis, a lung disease that makes individuals susceptible to infectious diseases, so he was being tested at KIDH for TB and HIV.

When I informed him that mining without personal protective equipment was harmful to his health, he responded in Swahili, “Lakini ninahitaji pesa kwa chakula,” The Swahili phrase translates to, “But I need money for food.” Days later, I visited one of the mining sites and what I saw there was something I will never forget. The shimo (mining hole) was 800 meters deep and because it is narrow young adolescent boys, referred to as nyoka (snake) are sent down to mine. Throughout the area, miners worked with no protective wear and no access to healthcare.

The young man’s situation sheds light on the way in which epidemics, and infectious diseases at large, have disproportionately impacted developing countries, particularly impoverished populations. For centuries, infectious diseases have resulted in greater death rates in low- and middle-income countries, due to weak healthcare systems and scarce resources, among other limitations. Tuberculosis deaths reached epidemic proportions in Europe and North America during the 18^th and 19^th centuries and currently over 25 percent of TB deaths occur in the African region. From 2013 to 2016, Ebola caused over 10,000 deaths in West Africa. Since 2018, the Democratic Republic of the Congo has been affected with the second-largest epidemic of Ebola.

Since the World Health Organization characterized COVID-19 as a pandemic on March 11, US government officials and public health experts have urged everyone to wash hands, work remotely, practice social distancing, and in many cases, self-quarantine. Most recently, more than 20 states have mandated stay-at-home orders.

In these times, I am reminded of my colleagues and patients who live and work in developing countries. While many in the US have the privilege to work remotely, the miners in Mirerani have no choice but to return to work in congested spaces, even with the understanding that their work conditions are hazardous. The lack of choice, for financial reasons, puts them as well as their family members at high risk. The poor work conditions leave miners all over the world vulnerable to chronic diseases and thus, make them even more susceptible to infectious diseases. The same is true for waste management and factory workers who are constantly exposed to harsh work environments.

Lack of consistent internet access is another barrier to working remotely in developing countries. In the US, which ranks highest in the number of internet service providers, everything is at our fingertips. However, in most low-resource settings, internet access is sporadic, so people have to find innovative ways to get work done. When I worked in Haiti over the past two years, first as a TB laboratory consultant at Hôpital Universitaire de Mirebalais, and then as a grant manager at Saint Boniface Hospital, we utilized paper records due to the lack of consistent internet connections. The monitoring and evaluation team worked tirelessly to review all the patient registration records. Additionally, the nurses and community health workers conducted mass vaccination campaigns with paper records.

While social distancing is easier in the US where space is ample, in most developing countries, especially in rural areas, multiple people share small and cramped spaces. In South Africa, where I worked in 2010 most of our TB patients first spread the diseases to family members. In the South African town of Tugela Ferry, where large outbreaks of drug-resistant TB have occurred for years, people live in extreme poverty. In such places, multiple families share a house so social distancing is not possible.

My public health colleagues and I are now coming together from all over the world to understand COVID-19 and ways to combat the disease. I hope during this time we will draw upon the experiences of those in developing countries, to minimize the spread of the disease and to avoid inefficient spending of limited resources. I hope this pandemic will create a larger sense of awareness in the US, as we think about how young men in KwaZulu-Natal live every day with multiple-drug-resistant TB and how women in the DRC continue to fight against Ebola. I hope we will come together to help each other as a global community.

Most importantly, I hope that even when COVID-19 is under control, we will continue to fight alongside our sisters and brothers in low- and middle-income countries to combat infectious diseases like HIV, TB, Ebola, and many more.

Rupal Ramesh Shah (SPH‘15) works in the field of global health, and has worked in South Africa, Tanzania, and Haiti. She also holds a master’s degree in microbiology.