In recent decades, the world has made dramatic progress in lowering the number of deaths from infectious diseases, including tuberculosis, HIV, malaria, and polio. But as campaigns are paused or cut back and as people miss routine care due to the coronavirus pandemic, these illnesses are getting a rare opportunity to come roaring back.
A new study in The Lancet Global Health estimates that deaths from tuberculosis could increase by 20 percent over five years — and deaths from malaria by 36 percent — if Covid-19 runs rampant in areas where these illnesses are prevalent. Others suggest that the impacts could be even worse.
Tuberculosis deaths had been down worldwide almost 50 percent over the past two decades (to 1.3 million a year). But the disease is likely infecting more people in many countries right now. One team of researchers, for example, estimated we could see as many as 1.4 million extra TB deaths over the next five years.
We know that previous disruptions to anti-malaria efforts (such as during recent Ebola outbreaks) led to thousands of additional deaths from the mosquito-borne virus. And polio, which has been on the cusp of global eradication in recent years, could come surging back in places that have been working diligently for decades to eliminate it.
Even in the US, where we have vanquished many of the most devastating infectious diseases, once-rare illnesses may rebound. As people stay at home and forgo routine medical care, including scheduled vaccinations for children, preventable diseases like measles and whooping cough will have more unprotected people to infect. And that puts not only more people at risk, but also more strain on the healthcare system.
“Any country is vulnerable when faced with multiple threats,” Claire Standley, a faculty member at Georgetown University’s Center for Global Health Science and Security, told Vox in an email. “Those most at risk are the ones with limited human, material, and financial resources to support outbreak response.”
And this is already playing out. The Democratic Republic of Congo is currently fighting Covid-19 alongside Ebola and the world’s largest outbreak of measles. And Yemen is battling Covid-19 in the midst of devastating armed conflict as well as a massive cholera outbreak.
This is not only an unmitigated disaster for the people who live in these countries. “An outbreak anywhere is a threat everywhere,” Standley says. “If disease threats proliferate elsewhere in the world, that poses a risk” of it spreading outside a nation’s borders too.
All of this comes as resources are drying up or being shifted away to fight the pandemic. The Trump administration moves to withdraw from the World Health Organization, which will likely take hundreds of millions of dollars — as well as many experienced personnel — out of the fight against infectious diseases around the world.
The Bill and Melinda Gates Foundation, which has focused on combating HIV, malaria, polio, and other infectious diseases for decades, is now giving “total attention” to the pandemic. And as the globe feels the grip of an international recession, other critical funding may slow down as well.
For those who hold the purse strings, the pandemic has created new challenges for determining how to allocate always-limited resources — and what to prioritize.
Is it better to pull staff off of a polio campaign — knowing more people will get that paralyzing and sometimes deadly virus — to improve contact tracing for Covid-19? What about efforts to combat malaria (which has been killing 405,000 people a year) or HIV (which leads to some 770,000 deaths a year)?
We don’t yet know exactly what the collateral damage will be in shifting resources away from other infectious diseases now — or in the years to come. But public health experts say it’s clear that there could be lasting damage.
“We cannot afford to sacrifice the progress we have made on mitigating other infectious diseases in order to mitigate this one,” Ingrid Katz, of the Harvard Global Health Institute and the Center for Global Health at Massachusetts General Hospital, wrote to Vox. “It is imperative that we continue to fight against all infectious diseases alongside the fight against Covid-19.”
Here’s what we know about how the coronavirus pandemic is hurting the efforts to quell other infectious diseases — and why that puts everyone more at risk.
How Covid-19 is hurting essential vaccination and preventative treatment
After Covid-19 began spreading globally earlier this year, many people chose to skip routine health care appointments — including vaccinations, like those that protect children against measles, a highly contagious virus that can occasionally cause neurological damage and death.
In the US, for example, routine vaccines for children began to drop off in mid-March, as the pandemic was declared a national emergency. By mid-May, a report by the Centers for Disease Control and Prevention found there had been a “substantial reduction” in pediatric vaccines in the US.
“This will likely lead to higher rates of vaccine-preventable disease in the next year,” Bruce Ribner, medical director of Emory University Hospital’s Serious Communicable Diseases Unit, who was not involved in the research, wrote Vox in an email.
Current physical distancing practices are keeping other infectious diseases (along with Covid-19) from spreading as much as they normally would. With summer camps and schools closed, rates of contagious childhood illnesses are likely to stay low.
But that is temporary.
“As social distancing requirements are relaxed, children who are not protected by vaccines will be more vulnerable to diseases such as measles,” the CDC report authors wrote. For measles, we need vaccination rates of 90-95 percent to prevent outbreaks. But another recent CDC study found that the rate of measles vaccination coverage for May 2020 in one state (Michigan) had dropped to about 71 percent. The study authors urge health care providers and caretakers to ensure any missed vaccines are obtained as quickly as possible to ensure best protection — and to protect others, such as infants, who are not able to get some vaccines, including one for measles.
Many other countries rely on mass-vaccination events, such as those at schools or at community centers, to help fight measles and other infectious diseases — including deadly parasites that are still endemic in many places.
For example, Standley notes, in some countries affected by the parasite that causes schistosomiasis (which is still endemic in 52 countries), a preventative drug typically gets distributed to children at school. But now that schools have been closed due to the pandemic, the parasite will not only cause additional infections and deaths, but the closures will also lead to a larger setback in efforts to eliminate it entirely, she says.
Even many country-wide disease campaigns have been canceled altogether. Since the pandemic started, 27 countries have suspended their measles campaigns, and 38 have suspended polio campaigns, Katz notes. Millions of children have now missed their polio vaccines and are thus currently unprotected against the paralyzing illness.
In addition to missing vaccines, people around the world have been hesitant to seek other care, including tests for TB and HIV, at medical facilities because they are worried about catching Covid-19. “These fears are not unfounded,” Standley says.
But this is extremely problematic for disease detection, which can be crucial for stopping transmission. It “may result in many treatable conditions going undiagnosed” and in additional illness and death, Standley says.
This is especially crucial in places where these infectious diseases were still spreading frequently before the pandemic. “I worry about countries with high rates of tuberculosis, like India, Kenya, and Ukraine,” Katz says. For example, in early April, India saw an 80 percent drop in TB reporting, she says.
The July 13 study in The Lancet Global Health (which was funded in part by the Bill and Melinda Gates Foundation), notes that in places where TB, malaria, and HIV are common, additional deaths from these diseases could be “of the same order of magnitude as the direct impact from Covid-19.”
“The Covid-19 pandemic and actions taken in response to it could undo some of the advances made against major diseases,” Timothy Hallett, a global health researcher at the Imperial College London and one of the study co-authors, said in a statement. “Even short-term disruptions [in control and treatment] could have devastating consequences for the millions of people who depend on programs.”
The Global Fund, an international health funding organization, has found that, as of mid-June, Covid-19 has disrupted 85 percent of HIV programs, 78 percent of TB programs, and 73 percent of malaria programs in over 106 countries in which it supports disease-fighting programs. These programs include prevention, treatment, and testing. As the fund notes, “if people aren’t diagnosed, they can’t be put on treatment and could continue to infect others. For example, a person with active TB can infect 10-15 other people in a year.”
“The scale is daunting,” Peter Sands, executive director of the Global Fund, wrote in a July 13 commentary in The Lancet Global Health. His group has been working on ways to help countries adapt their local programs, for example, buying motorcycles and more PPE for volunteers so that they can distribute mosquito nets to individual households rather than having people congregate at a central location to pick them up.
In areas where resources, like ventilators or ICU beds, are limited, people might also worry that care will be rationed and saved for the otherwise healthiest people. A TB diagnosis, for example, could, in theory, make someone lower priority for Covid-19 treatment should they become critically ill from the novel virus. So, Standley notes, this might give them a reason to avoid seeking care or diagnosis for another illness — even one like TB that is usually treatable and could otherwise spread to others.
Can we afford to fight other infectious diseases right now? Can we afford not to?
In the midst of the global pandemic, it’s hard to allocate limited resources — whether that is trained health care workers or basic medical equipment, like masks or testing machines. For now, in most places, Covid-19 is getting priority for what resources can be mobilized.
In Africa, the WHO coordinates a network of polio testing laboratories across 15 countries. The network has now dedicated half of its capacity to running Covid-19 tests instead of those for polio. In Pakistan, many workers who usually focus on polio eradication are now being deployed to do in-person contact tracing for Covid-19. (And thousands of other polio workers there have simply been laid off).
International philanthropies are also being pulled in two directions. The Bill and Melinda Gates Foundation has, for decades, put much of its work toward fighting infectious diseases around the world. But now, speaking of the pandemic, Bill Gates told the Financial Times, “This has the foundation’s total attention.”
“We’ve taken an organization that was focused on HIV and malaria and polio eradication, and almost entirely shifted it to work on this,” he said. (The Gates Foundation is also the second-largest funder — after the United States — of the WHO.)
“The pandemic is affecting all areas of our work, and we cannot deliver on our mission without addressing it,” a spokesperson for the foundation told Vox in an email. But, they noted, the foundation is still working on other diseases — and the more than $350 million it has pledged for Covid-19 response has not been pulled from other areas.
That is important, says Standley. “These [new] efforts cannot come at the expense of other health programming, or we will just be shifting the burden of morbidity and mortality,” she says.
The Global’s fund $1 billion they have committed so far to help HIV, malaria, and TB programs during the pandemic “only mitigates a small part of the problem,” Sands wrote. By their calculation, it will take close to $28.5 billion to “fund an effective response to Covid-19 and prevent a potentially devastating impact on HIV, tuberculosis, and malaria in [just] the highest-burden countries.”
In some cases, funding might dry up altogether, putting everyone at greater risk.
The US provided about 15 percent of the WHO’s total funding last year (including a pledge of $158 million to help eradicate polio). The WHO has spent decades helping to bring down the rates of HIV infection, tuberculosis, and malaria, as well as contributing to many other improvements in global health. “Many low- and middle-income countries rely on the WHO for many aspects of infection disease control, including testing, data collection, medical supplies, and more,” Katz says.
“By pulling out of the WHO, the US is hampering these countries’ ability to respond to disease outbreaks,” she says. This, in turn, further “increases the risk of infectious disease outbreaks in the United States.” Because contagious diseases don’t stay put.
Other experts agree. As Ribner notes, “We should have learned long ago that infections occurring overseas do not stay overseas,” he says. “We can choose to be prepared and minimize the impact of these outbreaks, or we can choose to be reactive and allow unnecessary illness and suffering. Hopefully we will learn that advance preparation is the most effective, and most efficient use of resources.”
How other infectious diseases could make the Covid-19 fight much worse
The pandemic has hobbled even wealthy countries like the US and UK as they fail to stop an infectious disease outbreak, struggling to supply personal protective equipment or roll out testing and contact tracing. Now, as other diseases gain steam in the shadow of the coronavirus, they could lead to even more untenable strain.
“Any country that has a health system unable to meet the health needs of all its citizens — and I include the United States in that description — is at risk of multiple simultaneous disease outbreaks that hamper the fight against any one disease,” Kristina Talbert-Slagle, director of Yale College Global Health Studies Program, told Vox in an email.
For months we were running short on basic supplies, like masks, to protect health care workers in the US just from Covid-19. Some far more resource-poor countries, though, are already fighting outbreaks of more than one infectious disease, and the situation is dire.
In the Democratic Republic of Congo, in addition to Covid-19, their measles outbreak has already killed more than 6,700 people there (mostly children) since 2019, and Ebola has caused more than 2,200 deaths since 2018. With an already-strained health care system, the country runs an even larger risk of losing even more lives to those diseases — and of not being able to contain them.
Throughout all of this, some infectious diseases also add to the difficulty in diagnosing Covid-19. In Brazil, for example, where there has been an outbreak of Dengue fever, doctors have missed cases of Covid-19, mistaking them for the mosquito-borne virus.
And many of the infectious diseases that are poised to start creeping back up might also make people even more vulnerable to severe Covid-19 and death. Preliminary findings, which have not yet been peer reviewed, suggests that HIV infection as well as current — and even previous — TB infections makes people substantially more likely to die from Covid-19.
How more disease will worsen existing inequities
The pandemic has underscored persisting inequities in health care in the US and around the globe. And an increased infectious disease burden threatens to make them even worse.
“It’s most likely that the poorest communities, who suffer the most from other preventable, treatable, or otherwise controllable diseases, will bear most of [the burden]” brought by pandemic-driven setbacks, Standley says.
In high-income countries, according to a 2018 report from the WHO, only one of the top 10 causes of death is infectious (lower respiratory infections, such as pneumonia) — and it is sixth on the list, just above colorectal cancer.
For low-income countries, half of the top 10 causes of death are infectious diseases, including the top two (lower respiratory infections and diarrheal diseases, respectively). The other three are: HIV/AIDS (fourth), malaria (sixth), and tuberculosis (seventh), which are all likely to increase as a result of the pandemic.
And there are even more people who are sickened by these diseases but survive. In the process, they often lose wages or are unable to care for others, and many suffer lasting disability.
The pandemic setbacks do not end with contagious illnesses that can threaten lives and livelihoods. As Talbert-Slagle notes, if anyone is not getting routine care and normal screenings, they end up more at risk for “not just infectious diseases, but also non-infectious diseases, like diabetes, mental illnesses, cancer, chronic respiratory disease, and cardiovascular disease,” she says. All of these can put further (and preventable) strain on precious resources, personal and, when seen on a large scale, national.
This observation echoes familiar and persistent health care patterns here in the US, where marginalized communities have long received poorer care and seen worse health outcomes. The pandemic has made these inequities even more apparent, with black Americans much more likely to die from Covid-19 than white Americans.
As Marya T. Mtshali, a lecturer in studies on women, gender, and sexuality at Harvard University, wrote for Vox: “This can snowball into even larger problems that compound health care inequities… [And] can translate into a reluctance for Black people to engage with these institutions in times of need or to give up in frustration… This, of course, then further results in poorer health outcomes.”
This is a final and perhaps even more insidious threat that will creep along behind the pandemic for years to come, at home and abroad. “Lack of trust in health services can persist after the outbreak is over, especially if populations feel their needs were not addressed during the outbreak or they were otherwise marginalized,” Standley says.
Or, as Talbert-Slagle puts it, the pandemic has fueled “an outbreak of distrust in expertise.” This threatens not only the fight against Covid-19 but also just about every arena of public health, from seeking care when you’re sick to getting your children vaccinated against measles on time.
Katherine Harmon Courage is a freelance science journalist and author of Cultured and Octopus! Follow her on Twitter at @KHCourage.
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