4 years on, why does learning from the COVID-19 pandemic still matter?

As the UK emerged from its first lockdown in July 2020, I was on a plane to the Central African Republican (CAR) for Médecins Sans Frontières (MSF). After the mandatory 2-week quarantine, I arrived at Bangassou regional hospital, where MSF had been operating since 2014. With the onset of COVID-19, MSF had set up a large isolation zone for COVID-19 patients, set up handwashing stations at the main entrance and integrated COVID-19 prevention messages into its health promotion activities in the community.

To my knowledge, not a single COVID patient was ever identified in that region, and the isolation zone sat empty. The handwashing stations, used religiously by the international staff, were largely ignored by national staff, patients and visitors. COVID-19 was the least of their concerns.

A mere fortnight after my departure in December 2020, tension in CAR reached boiling point. Amid a hotly contested election on December 27th, there was a renewed outbreak of violence across the country. By January 3rd, Bangassou had been taken over by armed groups. Thousands of the town’s residents fled across the Mbomou river to DRC to escape the violence. My international colleagues messaged to say that they were locked in the safe room of the compound, listening to the sound of machine guns.

The COVID-19 isolation zone quickly became a refuge zone; a place to shelter less severely unwell patients while staff attended to the influx of wounded people. In the weeks that followed, MSF began helping those who had fled to DRC. If COVID-19 had been a low priority before, by now, it was bottom of the list.

Since leaving CAR and joining ALNAP, I’ve had the opportunity to look at the COVID-19 pandemic through a different lens. I’ve reviewed over 80 evaluations from across the sector for a forthcoming evaluation synthesis of the humanitarian response to COVID-19, and pondered questions such as, how did humanitarians understand the challenge of COVID-19? How did humanitarians prioritise and shape a response to COVID-19 amid other urgent needs? And how did they engage with communities? My thoughts keep returning to that isolation zone in Bangassou, and everything it represents about what went well and what went poorly in the pandemic response.

'A health crisis is never just a health crisis'

Our research shows that across the sector, humanitarians acted fast to prevent further spread of COVID, and reinforce health systems to cope with increased admissions and treat COVID-19 patients – just as MSF did. The pandemic was primarily understood as a health emergency, and while humanitarian efforts made a considerable contribution to global pandemic efforts, other needs were largely sidelined. This was unfortunate as humanitarians already knew, from previous experience with disease outbreaks such as cholera and Ebola, that a health crisis is never just a health crisis.

Without doubt, it was a gruelling task for humanitarian agencies to weigh the risk to life presented by COVID-19 in humanitarian settings. As a new pathogen, governments, public health officials, and humanitarians were all faced with the challenge of mounting an appropriate response while learning on the go. Limited testing capacity in humanitarian settings made that task even harder. Fearing that the virus could potentially tear through some of the world’s most vulnerable communities, many agencies decided to act on the basis of ‘no-regrets’. They chose to launch activities using best guesses and rough predictions, rather than risking loss of life by waiting for more data to become available. We now know that roughly one quarter of global deaths due to COVID-19 occurred in humanitarian contexts.

But there is also strong evidence that insufficient attention was given to addressing existing needs from before the pandemic, and the wider effects of public health measures were underprioritised. The loss of employment was a major concern of local communities, who emphasised that assistance was generally insufficient to cover their essential needs. Protection of women and girls was sorely lacking, despite soaring rates of sexual and gender-based violence. For many, access to treatment for malaria, malnutrition, and HIV, and maternal health services was a greater concern than COVID-19. By July 2022, WHO and UNICEF reported that 25 million infants had missed out on lifesaving vaccines for diphtheria, tetanus and pertussis – with the UNICEF Executive Director calling it ‘a red alert for child health’. The fact that many existing programmes had to be suspended or cancelled, led communities and humanitarians alike to wonder whether funding was being diverted towards the COVID-19 response.

Perennial problems in the international humanitarian architecture

Without the health systems support offered by humanitarian agencies, it’s possible that COVID-19 deaths in humanitarian settings may have been even higher. But the disparity between ‘Global North’ anxieties about COVID-19 and the lived experience of communities in humanitarian settings was striking. My experience in CAR was the norm, not the exception.

This echoes what we already know about the international humanitarian system: that despite global commitments to enhance locally-led response and accountability to affected populations, humanitarian response tends to be top-down and local voices and priorities are crowded-out. Of course, lockdowns and other public health measures meant community engagement was more difficult to maintain during COVID. But this defence rings rather hollow, given the long-standing dominance of humanitarian ‘experts’ was a known issue.

There are many aspects of the COVID-19 pandemic that a lot of us would like to try to forget. But today, on the 4th anniversary of the declaration of the pandemic by WHO, it’s important to recognise why learning from COVID-19 still matters for the humanitarian system. The ability to recognise the intersectional nature of vulnerability is key to relevant response design, but the sector tends to focus myopically on a limited set of needs. The pandemic showed how far the sector still has to go to achieve the ambitions it has set for itself, to put local actors and affected communities in the driving seat. And as budgets are being increasingly squeezed, many agencies are currently facing tough decisions on where to allocate resources. The question of who gets to decide what’s important, and how, has never been more relevant.