Belfast — The COVID-19 pandemic has presented a difficult ethical choice to medics around the world. When you can't save everyone, who do you prioritise?
In several countries where healthcare systems risked becoming overwhelmed, authorities issued guidelines, such as these in Italy (translated by The Atlantic), "informed by the principle of maximising benefits for the largest number".
As a matter of course, public health authorities prioritise based on a utilitarian ethical framework: what brings the greatest good to the greatest number of people. In times of limited resources and excess needs, the logical move for national health ministries or the World Health Organisation is to choose to send staff and scarce medical equipment to where they can save the maximum number of lives in the shortest time.
War zones and areas with very vulnerable populations are not such a place. Providing healthcare amid conflict and other protracted crises is messy, expensive, dangerous, and inefficient: a large investment of scarce resources for a limited number of lives saved. The callous may argue that these people are more likely to die anyway.
Prioritising resources in easy-to-reach, densely populated areas like national capitals instead of more remote conflict areas or already vulnerable refugee camps is a rational and ethical choice from a public health point of view, in the interest of maximising benefits. But it's not the choice we should make.
If we are to be truly humanitarian in our decision-making, saving the greatest number of lives cannot be the only deciding factor. We should not sacrifice the most vulnerable for the greater good, even if it means we save fewer lives.
With cases now present in Yemen, in a Rohingya refugee camp in Bangladesh, in the giant Dadaab refugee camp in Kenya, in South Sudanese camps for displaced people, and in conflict zones in Afghanistan and northern Nigeria, this dilemma will only become more pronounced in the weeks to come.
Typically, international humanitarian responses help prioritise the most vulnerable in dangerous or difficult places, while governments serve the masses.
But many international humanitarian staff have returned to their homes in Europe and North America because either: they can't work during lockdown; they want to contribute to the COVID-19 response in their own countries; or they fear becoming vectors of the disease themselves. The decision by my organisation, Médecins Sans Frontières, to open projects in Italy and the United States caused tension internally, with many staff opposed to helping people in rich countries that are not the most vulnerable.
Humanitarian responses face further challenges: severe restrictions on aid agencies' ability to send staff and supplies due to closures of borders, ports, and airports; and lockdowns that keep national staff confined to their homes or restricted to travel inside their own countries.
Even where responses are possible, the UN-led $6.6 billion appeal to help vulnerable countries through COVID-19 is only 15 percent funded as donor nations concentrate on propping up their own economies.
Meanwhile, countries around the world are fighting over essential items like Personal Protective Equipment (PPE), and global shortages have prompted many governments to prioritise their own populations by imposing export restrictions.
On 15 March, the EU effectively blocked MSF (and others based in Europe) from sending certain items like PPE from our own warehouses to protect our own staff working abroad (after intense negotiations, the EU amended its restrictions one week later, granting exemptions for humanitarian purposes, albeit with strict procedures for each consignment still in place).
As The New Humanitarian recently reported, the United States imposed similar restrictions, forbidding NGOs they fund through their Agency for International Development (USAID) to use US money to buy medical masks and gloves "given the competing demands for some categories of medical supplies and commodities - including in the United States".
In Ecuador, Peru, and Brazil, where the pandemic now appears to be at its worst globally, health authorities are reportedly complaining of being outbid by richer nations on scarce medical supplies. According to Gzero Media, to date, 685 tests per million people have been conducted in Africa compared to 23,000 tests per million people in Europe.
The WHO has launched an Access to Covid-19 Tools (ACT) Accelerator initiative to counter such protectionism and ensure countries with less money and political weight can also access critical supplies as well as yet-to-be developed vaccines, treatments, and tests. They aim to ensure equitable global access for all.
But what about equitable distribution within conflict-affected countries, which have even fewer resources and greater needs?
Governments in Mali, Central African Republic, and the Democratic Republic of Congo are making utilitarian choices: focusing their resources on treatment centres in the cities, leaving smaller health centres in the conflict zones without protective equipment.
The politicisation of aid is noticeable too. Northwest Syria, controlled by the armed opposition running a parallel health authority, consequently gets no supplies from the capital, Damascus, at all, and has to rely entirely on special humanitarian supply lines from Turkey. Inevitably, with the state as one party to the conflict, national politics will influence decisions about what in-country equity means.
People trapped in conflict, already living perilous lives, find their situations manipulated and even more neglected because of this pandemic.
My plea is this: amid this unparallelled competition for resources - at both international and national levels, in both government health ministries and humanitarian headquarters - let's not limit our decisions to where we can save the most lives most easily.
Just as we assist the elderly in care homes in richer countries - even though it's more expensive and they are more likely to die - we should help refugees and those in conflict zones who are harder to reach, even if it means we save fewer lives overall.
Beyond mortality statistics, we have an obligation to stand up for the most vulnerable. In times of crisis, we must defend those individuals and populations that fall through the cracks, those most excluded and marginalised. Not only because the pandemic can only be controlled when all outbreaks are confronted everywhere, but also to defend our common humanity.