In early March, $6,500 could buy you and three friends a round of golf on an island in Charleston, South Carolina, accompanied by a former NFL quarterback or maybe even Chris Tomlin. When the sun sank behind moss-draped live oaks and blackwater marshes, you could retire to a country club for cool drinks and a private show with Grammy-nominated band Needtobreathe.


And in the surreal psychology of philanthropic events, you could have done all this in solidarity with some of the world’s poorest people, your fee going to improve health care in places where a bite from the wrong mosquito or a sip from the wrong faucet can end your life. At least that’s how OneWorld Health, a Christian medical nonprofit, was marketing its big spring fundraiser.


By the middle of March, however, no amount of money could secure you a berth at a charity golf tournament or gala or silent auction anywhere in the country. Virtually all of them were being canceled. COVID-19 was burning its way across the globe and, for all anyone knew, it was just waiting to press the flesh in VIP circles at such gatherings.


OneWorld Health called off its Needtobreathe Classic on March 13. “It was an easy decision to make, the right decision,” said executive director Michael O’Neal. “But it certainly leaves a hole in terms of operational funds.”


The economic impact of the coronavirus pandemic threatens to decimate nonprofit groups. Churches, forced to livestream or outright cancel worship services, wonder what will happen when offering plates cannot be passed. Missions groups, forced to halt international travel, ask how long they can survive without sending workers into the field. Everyone worries how big donors will respond as investments dissolve and business profits disappear.


But the pandemic is a two-front war for organizations like OneWorld Health, which operates a dozen medical facilities in Central America and East Africa. Their fundraising efforts are being pummeled just as they scramble to get ahead of an anticipated onslaught of virus-related cases in the countries they serve. “We’re trying to prepare ourselves,” O’Neal said. “But we’re all going to see giving decline in the next 18 to 24 months.”


Global-health experts are particularly concerned about COVID-19’s impact in the developing world, where health care systems are already strained and, in many places, nonexistent. Millions could die. If a nation as powerful and as spread out as the United States has failed to get a handle on the virus, signs are not good for regions with high population densities, cultures of communal living, and deficient water and sanitation systems.


O’Neal knows. He and his wife moved to Uganda to help OneWorld Health open its first medical center there in 2011. “It’s going to have a huge effect,” he said. “There are 55 ICU beds in a country of 36-plus million people.” Doctors in other countries wish they had it that good. Martie Wahl works in a private medical practice in Windhoek, the capital of Namibia, and minced no words: “Our health system will not be able to cope with a large number of people who need ventilation,” she said. “It will collapse within days.”


For months, international groups have issued crescendoing calls to help poorer nations prepare for the worst. As early as February, countries including the UK began earmarking millions in special aid to help those with fragile health systems fight the outbreak. The United Nations released $15 million in early March and asked for $2 billion in additional assistance. Other groups like the International Monetary Fund and the G20 have followed suit with proposals of their own.


The concern is obvious: Wealthy countries, once they’ve beaten back the inferno in their own backyards, may be too exhausted to run toward smoke on the horizon. In a firestorm, it’s only human, even prudent, to worry about your own house and your next-door neighbor’s house. But the lesson of pandemics in a globalized era is that there are no clear boundaries between neighborhoods; flames don’t just jump streets, they jump continents.


“In global health, we know with diseases like this, you’re only as strong as your weakest link,” said Ed O’Bryan, who cofounded OneWorld Health and is a physician and director of global health at the Medical University of South Carolina. Taming COVID-19 in China and the US and all of Western Europe won’t matter if it’s still raging and potentially mutating in Africa or Russia, he said. “It’s going to come back around.”


In Namibia, the government has mandated social distancing, but Wahl doubts that will be possible for one of her employees who lives with five siblings and their children in a tiny house in a poor part of town. In Liberia, where there is no ambulance service, a missionary surgeon says he worries how the sick will even get to the hospital since public transit has been restricted. Street selling, which many depend on for income, has been banned, and formal markets may be scrutinized next.


And everywhere in societies where elders occupy special places of honor, people dread a virus that preys largely on the aged. “Often the unfortunate case is that the grandparents are the breadwinners and caregivers of the grandchildren,” Wahl said. “We would have a lot of orphaned children, more than we already have.”


If the COVID-19 pandemic has hammered wealthy nations, it’s arriving in many poorer ones like a demolition crew. Foreign investment is fleeing, revenue from oil and tourism has vaporized, and unemployment has risen to perilous levels. All this in places where most people have little or no savings to cushion their fall. Days before Pakistan’s prime minister, Imran Khan, ordered his 210 million countrymen into their homes, he lamented that it would “save them from corona at one end, but they will die from hunger on the other side.”


For missionaries and aid workers, it’s a foregone conclusion that surging desperation and malnutrition crouch just around the corner.“It’s said, ‘When the US sneezes, Latin America gets pneumonia,’” missionary Kevin Abegg, who oversees ministry in that region for United World Mission, wrote to donors. “The sheer scale of the US economy and resources available provide significant protections that are not available in the Central American countries where we and our fellow missionaries serve.”


The developing world is not a monolith; some quarters are better equipped than others to fight the virus that has breached nearly every geopolitical border. In low-income countries outside of Southeast Asia, fewer daily flights were emptying bellyfuls of passengers from infection hot spots. That gave some leaders time to watch the rest of the world react to the pandemic. Sudan closed schools and banned large gatherings after reporting only two COVID-19 cases. Haiti closed its airports after announcing its debut pair of infections.


Across parts of Africa, fresh memories of previous epidemics like Ebola primed many countries to respond swiftly and forcefully. Liberia’s first positive test for COVID-19 was at 4 a.m., and by 10 a.m. that day, the president was shuttering schools.


The mood here “is pretty tense,” said Rick Sacra, a missionary physician at ELWA hospital in Monrovia, Liberia, who survived Ebola after contracting it in 2014. He reassured his colleagues that COVID-19 is not like Ebola, which killed half of everyone it infected. “Some of the staff, just like during Ebola, they tried to put on the personal protective equipment and felt all claustrophobic and just couldn’t cope with it.”



But responses have varied starkly. On the opposite side of Africa, Tanzania had already reported 12 cases when President John Magufuli smiled calmly and promised a cheering congregation that he would not close houses of worship because COVID-19 “cannot survive” there; “it will burn.” Across the Atlantic, while much of the world was shut indoors, thousands of Nicaraguans marched in the streets in a government-orchestrated show of support for coronavirus victims. (Nicaragua reported its first infection three days later on March 18.) Farther south in Brazil, President Jair Bolsonaro was dismissing the virus as a “measly cold” while the nation’s reported number of infections blew past 2,000.


“There are some things, from a public health standpoint, that are very scary for us,” said OneWorld’s O’Neal. His organization runs multiple medical centers in Nicaragua.


In most countries, doctors told CT, governments are taking the lead in testing for COVID-19 and preventing its spread. But nearly everyone in scrubs, whether employed by hospitals or by NGOs, is bracing for overwhelming numbers of coughing, feverish patients. “We’re going to be hard-hit when it picks up,” Sacra said.


That’s in no small part because, while COVID-19 has become almost the singular focus of the global health community, more-menacing diseases like tuberculosis and infectious diarrhea continue to prowl. So do less sensational illnesses like pneumonia, the world’s leading killer of children, which claims more than 800,000 lives under age five every year. “Just because you’re battling this, malaria doesn’t go away,” O’Neal said.


COVID-19 has left ample mysteries as it sweeps the globe, and doctors don’t know exactly how it will behave in the developing world. Maybe it will be less lethal among Africa’s young-skewing population. Maybe the virus faces headwinds in tropical climates, if the possibility that it doesn’t like warmer temperatures holds true. Maybe, in some tragic twist, all of these advantages are nullified in malnourished bodies.


What countries will probably never be certain of is a death toll. However scarce testing supplies become in the US, O’Bryan said, count on far less in poor countries. “You’re going to see higher mortality rates, but they may not necessarily be attributed to coronavirus. You’re going to see a lot of patients die of ‘unknown respiratory illness.’”

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