By Jerome Amir Singh
Since WHO declared COVID-19 a Public Health Emergency of International Concern in late January 2020, the organisation has recommended that people practice “physical distancing” to slow the spread of COVID-19 and reduce mortality. Since then, governments, globally, have advised physical distancing, and taken measures to prohibit gatherings. While guidance differs from country to country on what constitutes a “safe distance” between people, WHO recommends that people keep at least 1 meter away from others. In settings such as England, authorities recommend a distance of at least 2 meters away from others. WHO has also recommended other preventative measures, such as thorough handwashing and self-isolation, as well as eating fresh and unprocessed foods, and drinking adequate water.  While such advisories and measures are important to mitigate the spread and impact of COVID-19, they are difficult to reconcile with the reality of life for billions of poor and vulnerable people living in fragile contexts, and in countries affected by conflict, poor governance, and natural disasters. With the world’s attention squarely focused on the plight of affluent countries affected by COVID-19 – such as Italy, Spain, and the United States – the plight of poor and vulnerable communities at considerable risk of COVID-19 infection, elsewhere, have received scant attention.  With COVID-19 cases rising in low and middle income countries, it’s time we put them back on the radar.
According to the United Nations, more than 700 million people, or 10% of the world population, live in extreme poverty and struggle to fulfil the most basic needs like health, and access to water and sanitation. Employment does not inoculate against poverty, with approximately 8% of employed workers and their families, globally, living in extreme poverty. Women, children, and those who live in rural areas are disproportionately affected by extreme poverty. More than 50% of the extremely poor live in Sub-Saharan Africa. In such settings, poor and vulnerable communities typically live in high-density shanty towns, makeshift shelters, and communal homesteads, while millions more live on the streets. Those incarcerated are typically confined in grossly overcrowded facilities, while internally displaced persons, refugees, asylum-seekers, and migrants, face deplorable conditions whilst on the move, and/or in cramped detention centres or transit camps. In such fragile settings, ablution facilities, if they are functional or even exist at all, are in a deplorable state. They are communal in nature and access is characterised by long queues. Hundreds, if not thousands, of people, have no other choice but to use such facilities. They touch the same door handles and typically have no access to water or soap to wash their hands thereafter. Worst off, perhaps, are the victims of trafficking and forced labour, who have to endure inhumane conditions, without access to sanitation or adequate ventilation. For all such communities, “physical distancing”, access to personal protective equipment, hygiene, and access to adequate food and water, is not a lifestyle choice. It’s a practical impossibility.
Every major disease outbreak in recent times — Ebola, SARS, and Zika — has profoundly affected the economies of affected countries, as measured by direct outlays, lost productivity, loss from death, and the impact of avoidance. The global economic impact of the COVID-19 pandemic is no different, and will have an unprecedented impact on health and food security, globally. To contain their respective COVID-19 outbreaks, many countries have instituted curfews or lockdowns. While these may be necessary containment measures and in the interests of public health, they have exacerbated the plight of the poor and vulnerable. With people forced to stay indoors, physical distancing and self-isolation is all but impossible where habitation comprises a one bedroom shack or tent in a refugee camp. Domestic abuse rates will foreseeably increase, everywhere.
Even before the arrival of COVID-19, over 800 million people faced chronic undernourishment and over 100 million people were in need of lifesaving food assistance.  But the COVID-19 pandemic has disrupted global supply chains, undermining the efforts of humanitarian and food security organizations. With billions globally unable to earn an income because of COVID-19 containment measures, the poorest amongst us, are particularly vulnerable. We don’t want to save people from the COVID-19 infection, only to see them die of starvation. Country authorities cannot afford to wait for donor assistance. They must do all they can, now.
Authorities need to address food insecurity precipitated by their COVID-19 containment measures. They must introduce universal COVID-19 testing to the poor and vulnerable as soon as reasonably possible to understand COVID-19 incidence and prevalence in these vulnerable communities. They must mitigate the risks faced by those who access water and sanitisation communally. They must take proactive measures to address spikes in domestic abuse. And they must act with urgency and empathy in reciprocating the sacrifices being made by the poor and vulnerable for the greater good. History will judge them harshly if they don’t.  
Acknowledgments JAS is supported by the Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa.  The author is also supported by the HIV Prevention Trial Network, and the Bill and Melinda Gates Foundation. No specific funding was received for writing this article. The views of the writer do not necessarily reflect the views of his funders or employers.


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