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The pandemic in countries with humanitarian crises: What’s happened so far and what’s coming next? A conversation between Mark Lowcock, United Nations Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, and Bruce Jones

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A conversation between Mark Lowcock, United Nations Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator, and Bruce Jones, Director of the Project on International Order and Strategy, Brookings Institution

Brookings Institution, Washington D.C., 7 December 2020 (virtual)

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What was your introduction to COVID and why is now a good moment to take stock?

On January 6, just after the holidays, Antonio Guterres called a meeting of a few senior colleagues including the Director General of the World Health Organisation and me for a discussion on pandemics. A new report had just flagged the world’s potential vulnerability to a deadly new airborne disease, or, in the technical jargon, a respiratory pathogen, with the potential not just for large-scale loss of life but also huge consequences for the world economy. Like previous reports, this one said the world was not very well prepared. In the meeting, we agreed a series of measures to take, including advancing readiness across the UN itself by conducting a major simulation exercise in which the Secretary-General would be a key participant. At the end of the meeting, Mike Ryan, the experienced, energetic, ebullient Irish doctor who is the head of emergencies at WHO and who I have worked with very closely in recent years, including on Ebola, said his team were currently gathering information about a new virus in China, which they did not yet know much about but which looked as though it could potentially be significant. That was my introduction to the year of COVID.

The main thing I would like to discuss with you today is where we are now in the pandemic in countries with humanitarian problems, and what we are going to have to deal with in 2021 – and probably beyond.

I offer what follows in all humility. COVID has been the biggest problem the world has faced for more than fifty years. A deadly airborne pandemic caused by a new virus is intrinsically difficult to cope with. At the outset the most important information is unknowable: how the virus is transmitted, the symptoms it causes, how long it takes for those symptoms to appear and disappear, what sort of people are most vulnerable, who will recover and who won’t. And, above all, how it can be tackled. The virus therefore has a huge head start, and responders inevitably risk mistakes while playing catch up. In many ways, the most surprising thing about the COVID experience so far is not how bad the response has been, but how good – not least in the speed of development of vaccines.

The nature of the problem is that it cannot realistically be fully forestalled by preparation alone, and when it arises it will inevitably have a huge impact.

While in the rich world, progress with vaccines means we can now see the light at the end of the tunnel, we are still in the middle of the crisis, and I’m a bit wary of the risk of coming across like the surgeon who wakes the patient up halfway through her operation and asks her how she thinks it is going.

At the same time, there are important things we have already learned and lessons to be applied in what we do next.

While parts of the response have been successful, mistakes have been made. I am sure, in due course, the COVID experience will come to be one of the most evaluated and scrutinized episodes in human history. But while we are still in the midst of it, there are very important choices the policy community and decision makers everywhere are making now on what to do next. Those choices are unavoidably happening in the midst of continuing uncertainty. But it is clear enough now that there are some bad choices available as well as good ones. I want to set out an agenda for the next steps for countries with ongoing humanitarian crises towards the end of our session.

What can we learn from previous pandemics?

In preparing for our meeting today, my team reminded me of humanity’s previous encounters with pandemics. There have been plenty of them, going back more than 5000 years to the dawn of agriculture when greater human contact with animals facilitated the transmission of new diseases.

The bubonic plague still seems to hold the prize for the largest contribution to human death. Fifteen hundred years ago, as wars raged across the Roman empire and harvests failed, Constantinople was forced to import large quantities of grain from Egypt. Unfortunately, they unwittingly imported plague-carrying rats in the process.

Once introduced the bubonic plague reverberated periodically around Europe for centuries. The worst episode, the Black Death, which seven hundred years ago spread rapidly across the continent through trade routes, killed between one-third and two-thirds of the entire population. One important insight we still rely on now was generated through this experience: that the disease was contagious and could be mitigated by quarantine.

A further important insight arose from the spread of cholera epidemics in the middle of the 19th century: that countries by collaborating could mitigate the damage. The first International Sanitary Conference took place in Paris in 1851.

The Spanish flu of 1918-19 reinforced cooperation. It infected and killed a much higher proportion of the global population than COVID has done so far. Because of its scale, and because people could see how easily and quickly it had become a global not just local problem, the Spanish flu prompted the establishment of the Health Organisation of the League of Nations. It also prompted states to recognise a governmental responsibility for public health rather than relying on private or voluntary efforts. This was also, incidentally, roughly the time when something else we have all got used to this year started – the wearing of face masks, which originated in China and Japan.

While pandemics have always been part of the human experience, the risk appears to have grown recently. In the last 40 years we have seen SARS, H1N1, MERS, Zika and Ebola. The frequency and diversity of outbreaks of new diseases seems to have increased steadily since 1980.

Why is that? The global population is bigger – approaching five times the size of a hundred years ago. It is older. It is more urban. It is more mobile: ports and border crossings counted 1.5 billion international arrivals last year. (A disturbing number of them were me). Human encroachment into animal habitats is leading to more transmission of infections from animals to people. And once that happens, the nature of today’s globalized societies makes it very difficult and expensive to prevent spread. That is especially true for those infectious viruses some of whose carriers develop symptoms either slowly or not at all.

Given the history and the risks, how effective were preparations and how did different countries respond?

I want now to say a few things about preparedness and planning for response. This is going to be the subject of a huge amount of work and discussion once we get through the pandemic as people turn their attention to how to handle the growing risks better in future. As Bill Gates has put it, what we have now is Pandemic 1. How do we prepare better for Pandemic 2?

There was no shortage of experts and reports warning of the risk we have just encountered. The World Bank, the G20 and the World Economic Forum all conducted simulations. At the beginning of my remarks, I mentioned the meeting we had in the UN on 6 January. That was in the wake of the new Global Preparedness Monitoring Board report which said, “There is a very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50-80 million people and wiping out nearly 5% of the world’s economy. The world is not prepared.” Quite prescient, as it turned out.

Many of the warnings have of course been borne out. One problem, though, was that too many of these preparedness initiatives were not well enough vested in the reality of how different societies actually work and how people behave.

The standard mix of measures for dealing with diseases spread through human contact all aim to reduce damaging interactions: hence the focus on handwashing, physical distancing, face masks, reducing socializing, including at work and especially where large groups of people gather, trying through testing and tracing to identify who might be carrying the virus, and introducing quarantines and isolation.

There are practical, legal, political, institutional and social constraints to implementing all these measures, even before considering the huge economic costs they imply. The constraints vary considerably between countries. Levels of preparation and past experience also help determine what is feasible and realistic in different societies.

By the end of March, the virus had reached essentially every place on the planet. Everyone was having to deal with it. That created quite a number of different responses to look at. Analysts have observed a variety of different response models over the last eight months.

A first category, those countries with recent experience of SARS, H1N1 and MERS, which were mostly in Asia, were alert to the danger, had invested in public health systems, and had governments which enjoyed levels of trust facilitating broad voluntary compliance with severe restrictions (or in some cases had authoritarian systems through which compliance could be ensured). These countries tended to act early and relatively effectively.

A second group of countries, including many in Europe and north America, had relatively large and effective medical systems (as distinct from public health systems), but less recent relevant exposure. In some cases, like the UK, they had disinvested in public health institutions as part of the austerity measures following the 2008-09 financial crash. Some of these countries tended to overestimate their capacity, underestimate the risk and had leaders high in confidence but limited in relevant experience. Typically, they acted slower, later and more weakly.

A third group, those at the forefront of the Ebola and HIV crises, including a number of African countries, knew their capacity to act was weak but at least had relevant recent experience. They acted early and decisively, taking the limited measures feasible for them – and they may also have benefitted from having younger populations less threatened by the virus and, being less urbanised, living conditions less conducive to its spread.

A fourth category includes those with limited relevant capabilities and no relevant recent experience. They included both some middle-income countries – including in Latin America. But they also included most of the world’s poorest, conflict-affected and fragile countries, often with significant refugee and displaced populations. That’s why back in March many people thought these countries, which are where humanitarian agencies mostly work, would be hit worst of all. That has turned out to be true. But not, as some people expected, through the direct impact of the virus and the disease itself, but as a result of the economic carnage it has wrought.

Overall, countries placing a large premium on individual freedoms, with limited relevant recent experience, with less strong public health systems than their overall level of development might have implied, where trust in government has been falling and who had leaders less well personally equipped for such a crisis, underperformed. Some of these countries did though have two huge compensating advantages: they could cope better with the economic contraction, and they had the scientific and industrial capabilities to develop vaccines and treatments faster than anyone else.

In the March-April period, governments, businesses and many families and individuals took decisions the effects of which were temporarily to close down substantial parts of the world economy, with the goal of slowing the spread and impact of the virus and buying time to find solutions – especially vaccines and treatments.

This remarkable approach to handling the problem – never previously adopted – was feasible only because the better-off economies were able to protect their citizens from the worst effects of the economic lockdown. They threw out the fiscal and monetary policy rule books, and introduced a vast array of furlough schemes, business loans, social payments, tax holidays, asset purchases through central banks, wage subsidies and other extraordinary measures. The measures were not formally coordinated across the major economies, but they all did the same sorts of things in a synchronized way, which reinforced the impact. The cost, running into tens of trillions of dollars, is dizzying and before long will need to be addressed. Nevertheless, this was the right thing to do.

What has been the impact of the pandemic in the poorest, most vulnerable countries?

My most severe criticism of how the crisis has been handled, however, is that the better-off countries failed to offer an adequate helping hand to the poorest countries who faced the same economic crunch but lacked the resources, institutions or access to markets to take similar measures.

The poorest countries have faced a collapse in their commodity earnings, tourism revenues and remittances from citizens working abroad, as well as the economic costs of global and in some cases nationally imposed lockdown measures.

While the better-off countries threw more than 20% of their national incomes at the protection of their own citizens, the poorest countries could access only 2% of their (much smaller) incomes. This is surprising because what needed to be done was pretty clear from the experience of the 2008-09 financial crisis. That was of course smaller: global GDP fell by 0.1% then, compared to the much bigger reduction of 4-5 % this year.

The obvious measures that were taken to support the most vulnerable countries during the 2008-09 financial crisis, including the issuing of Special Drawing Rights to all the IMF’s members, the recapitalisation of the multilateral development banks and generous replenishments for their soft lending arms have so far not been adopted. There has also so far been a failure adequately to address the debt burden the poorest countries face.

The cost to the richer countries, by which I mean those represented in the G20 and the OECD, of more generous measures would be minimal, especially in the short term. The fact that they have not been taken is a commentary on the current state of geopolitics. But it represents a governance failure in leading countries, who have in the past acted collaboratively for the wider benefit and in their own self-interest.

As a result, the economic and social consequences of the pandemic in countries where humanitarian agencies work are much worse than they need have been, had international action been better.

For the first time since the 1990s, extreme poverty will increase. By the end of 2021 up to 150 million people could fall back into extreme poverty (on the World Bank’s $1.90 a day measure), bringing the number to 736 million. That’s 9.4% of the world’s population, compared to 586 million, or 7.5% before COVID.

Health services in the poorest countries have been heavily compromised. Life expectancy will fall. The annual death toll from HIV, tuberculosis and malaria is set to double. The number of people facing starvation may also double. Women will suffer most.

There has been a lot of commentary recently on the reduction of mental well-being and psycho-social stress, going beyond people’s physical health, that the pandemic has caused in better-off countries. Lord O’Donnell, the former head of the British civil service, has drawn attention to that, and Larry Summers recently noted that putting a value on this suffering, and its associated impact on productivity, dramatically increases the overall cost of the pandemic.

All these features are evident in the most fragile countries too. The plague of violence against women and girls particularly demands attention. The fear, stress and anxiety the pandemic has triggered, as well as the fact that many people have been cooped up in cramped conditions for long periods of lockdown, has unfortunately taken its toll on the behavior, especially, of men. In some countries, calls to dedicated helplines have increased by over 700%. Support services are overwhelmed. Alongside this, we are receiving disturbing reports of cases of sexual exploitation and abuse, which we are acting on in a number of countries right now.

While all countries have of course suffered, and there are daunting problems in middle income as well as better-off countries, the human carnage is concentrated in the poorest, most vulnerable countries.

As Bill and Melinda Gates’ Goalkeepers report put it in September, the last 25 weeks threaten to unravel 25 years of progress in some key development activities, like immunisation.

It’s worth remembering what many poor countries were like 25 years ago. I was working in a country then where a quarter of children never saw their fifth birthday, most never went to school and one woman in 18 died in childbirth.

It is also important to recognise that the problems now brewing have the potential to come back to bite everyone.

All the poverty, hunger, sickness and suffering will fuel grievances, hopelessness and despair. And in their wake will come conflict, instability, migration and refugee flows, all giving succour to extremist groups and terrorists.

The consequences will reach far and last long.

There is a serious risk of a grand reversal of the substantial global progress over the last 50 years in reducing poverty, increasing life expectancy, improving literacy and access to education and reducing hunger.

How have humanitarian agencies responded?

I am going to turn now to the things humanitarian agencies, including my office and I, have particular responsibility for, and what we have been trying to do to support the most fragile countries through the pandemic.

The last major international trip I took was at the end of February into early March. I went to Fiji, New Zealand, Australia, through Dubai to Saudi Arabia, then to Turkey down to the border with Syria and then back to New York. Everywhere I went people were talking about the virus and how to cope with it – though in most places there were few, if any, cases.

In February, before there were any recorded cases in any of the countries my office is active in, we took our first practical action, to provide a grant to WHO and UNICEF from the UN’s Central Emergency Response Fund, to help them start public information campaigns and get testing kits and protective equipment to as many countries as possible.

The public information issue is crucial. One of the main problems in the modern world is that too many people believe things that are not true, and don’t believe things that are true. That is exacerbated by one of the world’s biggest growth industries: fake news and misinformation. This is all potentially catastrophic in the highly charged atmosphere of the early stages of a pandemic, where fear, anxiety and myths abound, and correct information is limited.

We recognised, in the UN, that there was an important role for us to play here. One of our assets is that people trust us. The Edelman Trust Barometer, a respected annual survey, reports growing trust globally in the UN over recent years, and that many people in much of the world put significantly higher levels of trust in what we say than in governments or parts of the media.

So, one of the things we tried to do was ensure that every person on the planet knew a few basic facts about the virus and what they could do to protect themselves. The UN’s ‘Verified’ campaign, launched in the first months of the pandemic and delivered with the help of more than 110,000 volunteers in 100 countries, spotted and reported dodgy claims that needed correcting, reaching more than a billion people in multiple languages. Those efforts were greatly facilitated by collaboration from responsible media organisations around the world.

On 11 March, WHO declared COVID a pandemic. There ensued a frantic two weeks of activity in which we prepared, and then launched on 25 March what became our largest ever response plan: the Global Humanitarian Response Plan for COVID-19. The heads of all the world’s major humanitarian agencies – the UN, the Red Cross family and leading NGOs , which I bring together in something the member states of the UN imaginatively called the Inter-Agency Standing Committee – who normally meet twice a year - had weekly meetings to coordinate the response. We raised a billion dollars in the first few weeks. We have now raised $3.8 billion.

What have we done with the money?

Well, first we set clear objectives, which – luckily or otherwise - turned out, in my opinion, to be the right ones.

First, and most difficult, to contain the spread and decrease mortality and morbidity.

Second, to stem the deterioration in human rights, social cohesion, food security and livelihoods.

And third, to protect the people who we feared might turn out to be the most vulnerable of all – including refugees, people displaced inside their own country, normally because of conflict, migrants and the host communities for all these groups.

We have provided cash transfers worth $1.7 billion to vulnerable people who have lost incomes across more than 60 countries. We have assisted 33 million refugees, displaced people and vulnerable migrants. We have improved water, sanitation and hygiene for more than 70 million people. We have delivered essential health services to 75 million, and community-based mental health and psychosocial support also to 75 million.

We have also had to innovate to cope with the unique circumstances we have faced. In March and April commercial airlines mostly disappeared, especially in the places we work. Through the Nobel Peace Prize-winning World Food Programme, we created a new air service which over the following months transported 25,000 humanitarian workers from nearly 400 organisations, many of them NGOs, to and from the humanitarian frontline, as well as vaccines, medicines and other supplies.

Many NGOs faced a real financial crunch as some of their traditional supporters found they could no longer contribute. From the Central Emergency Response Fund, we provided $25 million in grants direct to some of those agencies to keep them going.

We have also provided $25 million from the Central Emergency Response Fund to support women-led organisations to respond to violence against women and girls.

I am conscious I have used the word “we” a lot in the last few minutes. What does that actually mean? For the UN, it means the 50,000 colleagues we have working on the front line in humanitarian crises. The vast majority are nationals of the countries in which they serve, working to help their fellow citizens. The NGOs we work with and support have even larger numbers of staff. All these people - and the overall numbers have been sustained through the pandemic so far - have stayed and delivered, often at personal risk and in conditions which are really tough.

We are, though, very conscious of what we have not been able to do. While we have raised $3.8 billion for our COVID response plan, we were really after $10 billion. The best that can be said is that things would have been even worse in the absence of what we did, which is obviously less than a ringing endorsement.

What next in humanitarian contexts?

So, what are the priorities in terms of international support for the countries with the biggest humanitarian crises in the months ahead? Here are five of them.

First, sustain ongoing humanitarian programs in the 56 countries dealing with the biggest crises. Last week at another virtual event here in DC we launched the Global Humanitarian Overview for 2021. It is the most comprehensive, authoritative and evidence-based assessment of humanitarian need available. We forecast that more than 235 million people will need assistance to survive next year – a 40% increase on 2020, almost entirely due to COVID. The UN and the NGOs we work with have developed plans to meet the needs of 160 million of those people, for which we will need $35 billion.

One of the most critical things those plans do is set out the actions necessary to stave off multiple imminent famines, including in Yemen, South Sudan, parts of the Sahel and elsewhere. I studied famines as a graduate student, and my first job was dealing with the famine that cost a million people their lives in Ethiopia in the mid-1980s. One of the most remarkable achievements of recent history has been to confine this extreme and brutal example of human failure – which in the past was ubiquitous across the planet - to the dustbin of history. Famines are now back. Not because of a shortage of food: in fact, there has never been as much food available per person around the world as there is now. But because of the depth of crises especially in places affected by conflict and climate change. It will be a horrible stain on humanity for decades to come if we become the generation to oversee the return of such a terrible scourge. This is still avoidable.

The second priority is to act, finally, to do the obvious, cheap and effective things to ease the economic and financial pressure on the most fragile and conflict-affected countries. Their powerful shareholders really must now take the necessary decisions to allow the international financial institutions to step up.

  • Agree a substantial issue of Special Drawing Rights for all the IMF’s members, and cut a deal to allow the allocations for countries that don’t need them to be recycled straight away to the most vulnerable, who do.

  • Populate the debt treatment framework agreed at last month’s G20 meeting, both for rescheduling and write downs, and in a way that covers all the major creditors. That means both official and private creditors – and those trying to dodge their responsibilities by hovering somewhere in between.

  • Ask the institutions to be more aggressive now in using their balance sheets in supporting the vulnerable, recognising the balance sheets may later need strengthening.

  • And agree how to provide further support through IDA, the World Bank’s most important vehicle for the poorest countries.

Third, we need to think clearly now about vaccine deployment. For understandable reasons, the new vaccines will be rolled out first in the countries whose scientists, pharmaceutical companies and taxpayers have done most to develop them. But they will quickly be available for others too. How that gets managed will matter a lot.

Hopefully there will be more vaccines beyond the three which seem to be most advanced, those developed by Moderna, Pfizer/BioNTech and the Oxford-Astra Zeneca collaboration. Some vaccines may be cheaper and easier than others to deploy in the most fragile countries, given varying cold chain and other requirements. The COVAX facility, co-led by the Global Alliance on Vaccines and Immunisation, the Coalition for Epidemic Preparedness Innovations and WHO has an important role to play in working out the best approach and will need to be well financed.

I want to mention two particular challenges that will need to be managed. The first is ensuring that COVID vaccines do not get financed for the very poorest countries at the expense of other activities which may save more lives in those countries. It would be perverse, and probably in fact increase loss of life, to pay for the COVID vaccine by cutting funding for things like food security and routine immunisation against diseases like measles.

The second challenge relates to the limitations of the vaccine delivery system in fragile and conflict- affected countries. There have been unhappy previous experiences with donors chopping and changing priorities as a result of delivery difficulties: I recall a ten year period in northern Nigeria, for example, with successive bursts of enthusiasm for polio eradication, then malaria control and then the discovery that they were being pursued at the expense of routine immunisation. It will be a real challenge to add delivery of the COVID vaccine to the to-do list of weak health systems without doing unintended damage to other important objectives.

Thinking about all these issues now, before we have the vaccines ready for the poorest countries, will help minimize problems later.

The fourth priority I want to mention relates to the needs of women and girls. The most stomach-churning experiences I have had in this job, which takes me to the location of every humanitarian horror story on the planet, have been listening to women and girls describe the brutality and abuses – and sometimes just the ignorance or carelessness – they experience, mostly at the hands of men. I implore the donors genuinely to put their money where their mouths are in financing more work – which many humanitarian agencies are desperate to do – to deal with this.

Fifth and finally, some sort of shake-out among international NGOs and locally led organisations responding to crises looks to me, however undesirable, to be inevitable. A survey of more than a thousand African civil society organisations found that the majority had already lost funding and cut programs. In the UK, barely half of NGOs believe they will be operating two years from now. The funders would be well-advised to do what they can to enable the best organisations, and those with the greatest potential to play important roles in future, to survive. Good institutions are central to progress, hard to build and easily lost.

And what will be the wider consequences of the pandemic?

It is obviously too early to be clear what things will look like in three or five years. It would not surprise me if the recovery in better-off countries is brisk, though the economic chickens will come home to roost. In the poorest countries, on the other hand, I think the COVID hangover is likely to be long and harsh, especially if there is no improvement in international help.

The biggest economic and social effect of the pandemic, when measured over the long term, may turn out to be that arising from the disruption to the education of hundreds of millions of children. The effects of that may not be very visible, but they will be there just the same.

The countries that can afford to will invest more in public health, and scientific and technological research to prepare for Pandemic 2. There will probably be some permanent reorganisation of sensitive supply chains. The sharp expansion we have seen in digitalisation of all sorts, including digital medicine, will be locked in and amplified further, with lasting and for the most part positive effects all over the world.

There is bound to be a lot of soul-searching about the future role of shared, multilateral institutions. Everyone I know in the leadership of multilateral organisations is keen to learn lessons and work out what we can do better in future. Logically, collaboration against shared threats should be in everyone’s interests, but whether logic will prevail in the current geopolitical context remains to be seen.

UN Office for the Coordination of Humanitarian Affairs
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