Médecins Sans Frontières/Doctors Without Borders (MSF)

Evidence to the House of Commons International Development inquiry on “Humanitarian Crisis Monitoring: Impact of Coronavirus”

Please find below our submission of evidence to the House of Commons International Development inquiry on “Humanitarian Crisis Monitoring: Impact of Coronavirus” from Médecins Sans Frontières/Doctors Without Borders (MSF).

MSF is an international medical humanitarian organisation, which provides assistance to populations in distress, and to victims of natural or man-made disasters and armed conflict. MSF do so irrespective of race, religion or political convictions. MSF observes neutrality and impartiality in the name of universal medical ethics and the right to humanitarian assistance, and claims full and unhindered freedom in the exercise of its functions. MSF teams provide medical and humanitarian assistance to people facing extreme hardship in over 70 countries. In 2018, we ran over 11 million outpatient consultations and assisted with over 300,000 births worldwide. MSF receives 95 per cent of its funding through private donations. We currently have preparedness and response operations responding to COVID-19 in more than 80 countries. These are mainly in our ongoing operational contexts, but MSF has also opened programmes in 12 additional countries, including across Europe and North America. MSF has for example opened new projects in response to COVID-19 in France, Switzerland, Belgium, Iraq, Syria, Afghanistan, South Africa, Zimbabwe, Sudan, Brazil and Venezuela, and is adapting all other existing projects so they can respond if cases are identified.

With this submission MSF will cover four crucial topics within the current COVID-19 pandemic and the response to it that are of concern to MSF. We are still potentially early in the response to the pandemic, so it is hard to provide evidence of how the response is going. At this stage of the response we will share our opinion on what should be done by states, including the UK, and key areas of concern and risk beyond just treating the disease.

The British Government, as a key international actor and donor, must lead and use both its influence and funding to ensure an effective international response to COVID-19. Whilst the focus is understandably drawn to the domestic situation, the UK still has a responsibility to support an international COVID-19 response, especially in fragile settings or areas of conflict where healthcare systems will be even less able to cope, for example in Yemen or Central African Republic.

We are very concerned by how the COVID-19 pandemic will affect people in countries with already fragile health systems. On any given day, staff in our medical programmes treat tens of thousands of patients for a variety of illnesses. In many areas where we work, there are few medical organisations in a position to respond to a large influx of patients. Now, more than ever, global solidarity is needed to overcome this pandemic.

We have included below our asks to DfiD. In addition to wanting to see commitments, our question would be how these commitments will be made into actions. 1) The indirect impacts of the outbreak

Non-COVID-19 Impact on Health When a pandemic hits, treating patients and stopping transmission of the virus are understandably the priority of the government and other responders. While crucially important, this narrow focus comes with the risk that other essential health programmes, such as mass vaccination campaigns,1 food and nutrition programmes and protection services, are scaled back or even stopped.2,3 Similarly, any reduction in the provision of non-health programmes (e.g. livelihoods, education and shelter) also will increase the risk factors for health issues. This is compounded by the fear of COVID-19 infection, which will affect people’s health-seeking behaviour and reduce the use of health services. Even without the threat of COVID-19, many people around the world lack access to life-saving care because of weak health systems, limited funding, fragile governance, displacement, violence and conflict. If their access to healthcare were to become further restricted it would have devastating consequences for wider population.

Prior disease outbreaks and humanitarian emergencies, such as the Ebola outbreaks in West Africa and Democratic Republic of Congo (DRC), have underscored the importance of maintaining essential services. In Liberia, health services deemed unrelated to the epidemic were discontinued, which led to a loss of life from non-Ebola related illnesses that far exceeded that of Ebola.4 These outbreaks saw the diversion of resources from regular programmes towards the Ebola response and a reduction of health services to limit the risk of transmission. They also saw a decrease in the number of health workers due to illness or death, and less demand for services from the community due to fear of contracting the disease and/or avoidance of routine healthcare.

While parallels can be drawn between Ebola and the current response to COVID-19, managing this pandemic has many additional layers of complexity. Firstly, the global scale presents an unprecedented challenge for modern public health, as almost every country in the world is affected.5 Health systems in some of the world´s most resource-rich countries are struggling to contain the outbreak and manage cases.

New estimates suggest that, under a scenario in which COVID-19 causes similar disruptions to services as was seen during the West Africa Ebola outbreak, almost 1.2 million children and 57,000 mothers could die in low- middle income countries over the next six months. This could represent a 45 per cent increase over existing child mortality levels6.

Treatment for the some of the top three causes of death from infectious diseases (HIV, TB and malaria) risks being interrupted, delayed or reduced. Resources, such as lab equipment used to detect TB, may be diverted towards COVID-19. Promoting proactive approaches, such as community-based preventative malaria treatment and LLIN distribution (mosquito net impregnated with insecticide), home-based TB services and dispensing multi-month treatment, will be crucial to protect vulnerable populations from COVID-19 infection, while ensuring access to care and reducing mortality.

Although there are a lot of unknowns about how the coronavirus will behave in sub-Saharan Africa, there is a risk that in some contexts the COVID-19 peak may also coincide with the seasonal malaria and malnutrition peaks. Modelling studies predict that Central and Eastern African countries´ malaria seasons will overlap with their peaks in COVID-19 infections. For countries in the Sahel and West Africa, which have some of the highest rates of malaria transmission, if the COVID-19 outbreak lasts for the next six months there will be a significant overlap.7

1 https://apps.who.int/iris/bitstream/handle/10665/331590/WHO-2019-nCoV-immunization_services-2020.1-eng.pdf?ua=1. 2 https://reliefweb.int/sites/reliefweb.int/files/resources/20200319_covid_sop_food_assistance.pdf 3 https://apps.who.int/iris/bitstream/handle/10665/331590/WHO-2019-nCoV-immunization_services-2020.1-eng.pdf?ua=1. 4 https://www.ajtmh.org/content/journals/10.4269/ajtmh.16-0702 5 https://www.internationalhealthpolicies.org/wp-content/uploads/2020/04/Corona-in-sSA-questions-and-reflections-v4.pdf 6 https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3576549

7 Unpublished modelling study – PATH/BMGF  The UK must protect ongoing and future humanitarian efforts by committing to continue funding and encouraging others to do the same.  The UK must use its influence and financial contributions to key global health providers (WHO, WFP, UNICEF and GAVI) to ensure that decisions to prioritise or deprioritise programmes and mechanisms are made transparently, accounting for wider health needs.  The UK must ensure that they have a clear mitigation mechanism and monitoring framework to judge the indirect impacts of COVID-19 in their programmes, which are either funded directly by the UK or through a pool fund.  On Programmes:  Continue ongoing emergency health interventions, in particular epidemic responses, e.g. measles in DRC and CAR. Epidemiological surveillance of other illnesses should also be maintained and strengthened. It is crucial to maintain routine immunisation programmes and ensure rapid disbursement of resources should an outbreak occur.  Malaria prevention and case management must be maintained, with adapted strategies. In high burden areas, prevention is the best way to avoid overloading the healthcare system and avoid malaria-linked mortality. Beyond hospital care, provide long-lasting insecticide- impregnated nets, indoor residual spraying, community case management, IPTp (intermittent preventive treatment in pregnant women) and IPTi (intermittent preventive treatment in infancy). Seasonal Malaria Chemoprophylaxis (SMC) should also be considered.  People with TB and those with HIV that lack effective viral load suppression are at a higher risk of COVID-19 and are vulnerable to interrupted treatment. An adapted follow-up scheme is needed so patients can avoid health facility visits, such as for DOTS (Directly observed treatment) and routine lab examinations. Provide multi-month drug pick-ups, community provision of medicines, harness prevention interventions, specific screening for TB patients, and community and peer support from a distance.  Help to ensure that access to essential care is provided free of charge to patients.  Maintain essential reproductive health and sexual violence services, including the four essential elements that must remain available: emergency obstetric and newborn care, safe abortion and post-abortion care, contraception, and care for survivors of sexual violence. (Note: in some states safe abortion care is not classed as an essential service.)

Borders and supply At a time when international solidarity is most needed, countries around the world are closing their borders, shutting down airports and airspaces, and restricting the movement of people. Commercial aviation activities, including medical evacuation services, are being curtailed. MSF is facing challenges to continuing our operations in a context where the procurement of medical equipment, transport of supplies and movement of staff are impeded by shortages and border closures in response to the COVID-19 pandemic. These limit our ability to respond to the requests for assistance we are receiving from countries where MSF does not already operate. To maintain routine medical programmes, along with essential preparedness and response activities in relation to COVID-19, we must be able to export medical supplies. We are concerned about continued access to care for many of the populations we serve.

 The UK must support and facilitate urgent exemptions for humanitarian organisations so they can continue existing operations and maintain capacity to respond to the pandemic. This includes:  Flight exemptions to allow humanitarian and COVID-19-related supply deliveries, ensuring that life-saving medical supplies can be transported without disruption.  Procurement and distribution service provider exemptions as included on lists of critical staff, including adequate protections to ensure sufficient staffing to continue operations.  Travel exemptions for humanitarian workers to and from countries of operation. Allowing for 14-day self-quarantining, preferably under MSF supervision before starting work.  NOTE: DHSC have granted a humanitarian exemption for the ban on some parallel exports of medicines (https://www.gov.uk/guidance/parallel-export-and-hoarding-of-restricted- medicines ).  The UK must ensure that its own resettlement schemes from within and outside the EU continue during this outbreak, knowing that the conditions that millions of refugees are living in leave them exposed and vulnerable to this outbreak.

Responding to COVID-19 As we have seen in several previous epidemics, such as Ebola, the response to COVID-19 will have to be tailored to each setting and community, and will have to reflect local capacities. This will need to be done with the safety of healthcare workers as a top priority in every and all types of healthcare facility. This is crucial to keep services running with enough staff and without them falling sick, and to prevent them from spreading the virus further within their facilities and communities. Infections of healthcare staff can happen easily in facilities that are overwhelmed by large numbers of patients. This is compounded by limited supplies of personal protective equipment (PPE) for staff and the likelihood of a reduced workforce as increasing numbers of healthcare staff become unwell. Global shortages of PPE pose a grave threat to all. The success of public health interventions remains rooted in popular acceptance and engagement, whereas security interventions are rooted in deterrence, forced compliance and punishment. A dependence of government public health interventions on security forces almost always increases mistrust and negatively influences perceptions of the response and responders, alienating communities from what must be a collective effort to overcome COVID-19. Where public health can be used as grounds for limiting certain rights if the state needs to take measures ‘aimed at preventing disease or injury or providing care for the sick and injured’, any restrictions must meet standards of legality, evidence-based necessity, proportionality and gradualism, as per criteria of the Siracusa Principles.8 Measures taken in the name of public health must be grounded in these principles: 1. They should be proportionate to the public health aim and be the least restrictive means possible 2. They should be are carried out in accordance with the law, be neither arbitrary nor discriminatory and must be explained clearly to those whose rights are restricted 3. They must be subject to regular review and reconsideration.

 The UK must ensure that within the programmes that it funds, both bilaterally and through pool mechanisms, equal energy and resources are placed on preventive actions that facilitate behaviour change and empower individuals or households to take control over their health and reduce their own risks.  The UK must publicly support the global vigilance and opposition to the use of force or coercive measures in the form of verbal or physical pressure to oblige patients, their families or loved ones to adhere to public health measures, particularly in conflict zones and ‘fragile’ states.  The UK must to ensure that PPE can still be purchased and exported for use in humanitarian programmes.

Ensuring access to forthcoming COVID-19 drugs, tests and vaccines

MSF is deeply concerned about access to any forthcoming drugs, tests and vaccines for COVID-19 in the places where we work and in other countries affected by this pandemic. The United Kingdom stands out as one of the largest investors in research and development (RnD) for global health—particularly in the face of global epidemics, and now pandemic response efforts. The UK government is majority donor to two of the world’s leading global health institutions for vaccine development (CEPI – the Coalition for Epidemic Preparedness and Innovation) and delivery (GAVI – the Global Vaccine Alliance) and has committed up to £744m to global COVID response efforts since their inception, including £388m for vaccines, treatments, tests.

The UK government is also one of the founding partners involved in the creation of the new “Access to COVID Tools Accelerator”9,10 launched collectively with the help of the UK on April 24th, 2020. A landmark global

8 https://www.icj.org/wp-content/uploads/1984/07/Siracusa-principles-ICCPR-legal-submission-1985-eng.pdf collaboration for the accelerated development, production, and equitable global access to new COVID-19 essential health technologies. Other key participants in this initiative include the abovementioned actors: CEPI and GAVI, but also the Global Fund to fight AIDS, TB, and Malaria (GFATM)—to which the UK is also a strong donor. Research, technology, and innovation that arises from the above investments are UK public contributions, and the government should ensure that any products developed with its support remain accessible and affordable to those who need them. Guaranteeing that public health priorities drive the production of any new COVID-19 vaccine.

MSF knows too well what it means to not be able to treat people in our care because an essential drug is just too expensive or not available. High prices and monopolies lead to the rationing of COVID-19 medicines, tests and vaccines, which will only serve to prolong this pandemic. Without safeguards there is a real danger that pharmaceutical companies may gain exclusive rights to a new vaccines and medical tools, which in turn could lead to price gouging and unaffordable costs for millions of people. They could also create barriers for researchers that wish to build on new knowledge and technologies that arise from publicly funded research. Removing patents and other barriers is critical to help ensure that there are enough suppliers selling medicines, tests, and vaccines at prices everyone can afford.

To date the government has yet to enact safeguards or place conditions on the use of its funding for Global COVID RnD efforts to ensure end products are truly treated as a “global public goods”. MSF is a signatory to open letters written to the European Commission and Parliament and to the UK Government by a wide group of international aid and development organisations. We also support a letter written by Philippa Whitford MP on behalf of the APPG on “Vaccinations For All”, which urges the UK to lead the world in ensuring access for all to COVID-19 health technologies, including diagnostics, treatments and vaccines. We strongly recommend that institutions and national governments such as the UK incorporate collective, pro-public safeguards regarding public contributions, accessibility and affordability clauses, and non-exclusive licences for exploitation of end-result products into current and future funding calls and investments.

Urgent steps are needed to define how COVID-19 medical tools can really be “global public goods”

 The UK and other governments must recognise how many lives are on the line and use their powers to make diagnostics, treatments and vaccines available, accessible and affordable for everyone.  We urge the UK Government to prepare to suspend or override patents for COVID-19 medical tools by issuing compulsory licenses.  Public interest conditions should be implemented as safeguards for all UK funding committed to the development of COVID-19 diagnostics, treatments and vaccines.  The UK should support global coordination to improve decentralised public vaccine production capacity.

Example of contexts of concern We have highlighted four examples of contexts of concern below.

Greece In Greece, the conditions in the reception centres and migrant camps provide a perfect storm for an outbreak of COVID-19, with disastrous impacts, especially for the people most at risk. In order to avoid a public health emergency, people, especially vulnerable people, need to be evacuated immediately from the islands. The UK has not yet agreed to take any additional children from the Greek islands above those included in the Dublin and Dubs agreements, as other European states have done.11 In Greece, as in other migration contexts, saving lives and public health interventions must not be sacrificed to or overridden by migration and immigration policies. Evacuation of squalid Greek camps more urgent than ever over COVID-19 fears

9 https://www.who.int/who-documents-detail/access-to-covid-19-tools-(act)-accelerator 10 https://ec.europa.eu/commission/presscorner/detail/en/ip_20_797 11 https://www.theguardian.com/world/2020/apr/08/migrant-children-in-greek-island-camps-to-be-relocated-across-eu Nigeria If we consider contexts like north-east Nigeria (Borno, Adamawa and Yobe states), where access to healthcare is already extremely limited due to the ongoing conflict, where vaccination coverage is alarmingly low (eight per cent in some areas), where malaria is the biggest cause of mortality, where 2.7 million women and children need nutrition support and 310,000 children suffer from severe acute malnutrition (SAM),12 and where there are already confirmed cases of COVD-19, this paints a worrying picture. The lack of preventive measures means that the risk of contracting vaccine-preventable diseases, malnutrition or malaria will increase. If with a response to COVID-19 leads to a reduction in primary healthcare services, there is an increased risk that these conditions will likely progress to severe forms that require hospitalisation and may result in death. This may be at a time when hospitals are already overwhelmed with COVID-19 patients. Other diseases will not relent in Borno state during COVID-19 pandemic

Yemen Without a sustained ceasefire and ensured access for coordinated provision of aid, the impact of a COVID-19 outbreak amid the worst humanitarian crisis in the world will be catastrophic. Years of conflict and blockades means that operational healthcare facilities in Yemen are few and far between. Many Yemenis have no option but to travel long distances to access healthcare. The facilities that are operational, including the 12 hospitals in which MSF operates, are under constant threat of indiscriminate attacks by various armed actors. Those who do opt to seek care can face fatal consequences travelling over land that is in the grip of active conflict. The sheer extent of malnutrition in Yemen is a prominent concern for increasing vulnerability, as is the annual expected increase in cholera cases. Both are ongoing issues that will require continued support and increase the risk for many to develop severe COVID-19. Authorities in Yemen must do all they can to facilitate COVID-19 response

Bangladesh Almost 850,000 Rohingya refugees live in just 26 square kilometres of land in Cox’s Bazar. It is two years since a major influx of Rohingya from Myanmar created one of the largest refugee settlements in the world, and access to potable water, hygiene products and other essential services remains sub-standard. Refugees still depend on communal distributions for drinking water, food and fuel, which means they must wait for hours in large groups. In places, the water provided is barely adequate for drinking, cooking and bathing. Physical distancing in this kind of densely populated environment is nearly impossible. Capacity within the health sector has reduced, with efforts redirected to deal with the spread of the coronavirus. The wider humanitarian response has also been significantly reduced. However, mothers will continue to give birth, children will get sick with diarrhoea and chronic patients will need their medications. It is crucial that these essential, life-saving activities are maintained. Bangladesh: Preparing for COVID-19 in the world’s largest refugee camp

12https://www.who.int/news-room/feature-stories/detail/who-and-partners-take-on-malaria-the-top-killer-in-north-eastern- nigeria