As we write, COVID-19 has killed more than 850,000 people. It has plunged the world into a recession that is likely to get worse. And many countries are bracing for another surge in cases.
In past editions of the Goalkeepers Report—almost every time we have opened our mouths or put pen to paper, in fact—we have celebrated decades of historic progress in fighting poverty and disease.
But we have to confront the current reality with candor: This progress has now stopped. In this report, we track 18 indicators included in the United Nations' Sustainable Development Goals (SDGs). In recent years, the world has improved on every single one. This year, on the vast majority, we've regressed.
And so this essay has two goals. First, we analyze the damage the pandemic has done and is still doing—to health, to economies, and to virtually everything else. Second, we argue for a collaborative response. There is no such thing as a national solution to a global crisis. All countries must work together to end the pandemic and begin rebuilding economies. The longer it takes us to realize that, the longer it will take (and the more it will cost) to get back on our feet.
Global Impact - Covid-19 Affects Every Aspect of Society
The prefix "pan" in the word "pandemic" means the disease exists all over the world. It might as well also mean that it affects every aspect of society. An article about the 1918 influenza pandemic in India referred to that experience as "a set of mutually exacerbating catastrophes." In the blink of an eye, a health crisis became an economic crisis, a food crisis, a housing crisis, a political crisis. Everything collided with everything else.
In other words, we've been set back about 25 years in about 25 weeks.
"Mutually exacerbating catastrophes" is an apt description for the COVID-19 pandemic, too. First, there was the disease itself. Then, governments moved resources to try to manage it and people stopped seeking health care to avoid being infected: building blocks of a comprehensive health catastrophe. Consider vaccine coverage, which is a good proxy measure for how health systems are functioning. Our data partner, the Institute for Health Metrics and Evaluation (IHME), found that in 2020 coverage is dropping to levels last seen in the 1990s. In other words, we've been set back about 25 years in about 25 weeks. One of the most important questions the world now faces is how quickly low-income countries can catch back up to where they were and start making progress again. The hardest-hit will need support to make sure that what should be temporary reversals don't become permanent.
MEASLES IN THE TIME OF COVID‑19
When it first hit, COVID‑19 presented countries with many urgent questions but few clear answers.
Meanwhile, the catastrophes continued to pile up. As governments implemented necessary policies to slow the spread of the virus and people changed their behavior to limit their exposure, global supply chains started to shut down, contributing to an economic catastrophe. Schools closed, and hundreds of millions of students are still trying to learn on their own at home, an educational catastrophe. (Data from the Ebola epidemic in West Africa suggests that, when schools open again, girls are less likely to return, thereby closing off opportunities for themselves and for their future children.) People in high- and low-income countries alike report skipping meals, a nutritional catastrophe that will make the others worse.
All these catastrophes are undermining the progress we've made—and still need to make—toward equality. At the same time, they have made it crystal clear how much progress we still need to make. In our country, for example, the pandemic is hurting people of color the most: They are getting sick and dying from COVID-19 and suffering its economic consequences at much higher rates than white people. According to the U.S. Census Bureau, 23 percent of white Americans said they were not confident they could make rent in August, a frightening enough statistic. Among Black and Latinx Americans, though, the number was double that: 46 percent didn't think they could pay for the roof over their head.
The economic catastrophe
The widest-ranging catastrophe—the one that has spread to every country regardless of the actual spread of the disease—is economic. The International Monetary Fund projects that, even with the US$18 trillion that has already been spent to stimulate economies around the world, the global economy will lose US$12 trillion, or more, by the end of 2021.
That amount of money is impossible to fathom. Historical comparisons help: For example, in terms of global gross domestic product (GDP) loss, this is the worst recession since the end of World War II, when war production stopped in an instant, one entire continent and parts of another were destroyed, and 3 percent of the world's pre-war population was dead. In those same terms, the COVID-19 financial loss is twice as great as the "Great Recession" of 2008. The last time this many countries were in recession at once was in 1870, literally two lifetimes ago.
HOW BIG IS THIS RECESSION?
In some countries, spending on emergency stimulus and social protection has kept the absolute worst from happening. But these countries are not randomly determined. They are countries wealthy enough to raise billons and trillions by borrowing huge amounts and expanding the money supply.
By contrast, there are inherent limits to what lower-income countries are able to do to backstop their economies, regardless of how effectively those economies have been managed. On average, the economies of sub-Saharan African countries grew faster than the rest of the world every single year between 2000 and 2015, but sub-Saharan Africa is still the lowest-income region in the world. Most countries there can't borrow the money they need to minimize the damage, and their central banks don't have the range of options available to the European Central Bank and the U.S. Federal Reserve.
Among G20 countries, stimulus funding averages about 22 percent of GDP. Among sub-Saharan African countries, that average is just 3 percent—and of course their GDPs are much less. In short, theirs is a much smaller slice of a much smaller pie, and it's not enough.
HOW MUCH SAFETY NET CAN COUNTRIES AFFORD?
Under these constraints, many low- and middle-income countries are innovating to meet the challenges they face. Vietnam's contact-tracing system is a global model: With a population of more than 100 million, the country has seen just 1,044 confirmed cases and 34 deaths from COVID. Ghana started pooling tests, instead of testing people individually, to conserve scarce resources while still tracking the spread of the disease.
In Nigeria, more than 100 private-sector partners, including corporations and individuals, created the Coalition Against COVID and have raised $80 million (so far) to bolster the government's response. The Africa Centres for Disease Control and Prevention, the UN Economic Commission for Africa, the African Export-Import Bank, and dozens of other partners launched the African Medical Supplies Platform to ensure that countries on the continent have access to affordable, high-quality, lifesaving equipment and supplies, many of which are manufactured in Africa.
Many developing countries are doing especially impressive work on digital cash transfers that put money directly in people's hands. According to the World Bank, 131 countries have either implemented new programs or expanded existing ones since February, reaching 1.1 billion people. India, which had already invested in a world-class digital identity and payment system, was able to transfer cash to 200 million women almost immediately once the crisis hit. This not only reduced COVID-19's impact on hunger and poverty but also advanced India's long-term goal of empowering women by including them in the economy. Other countries facilitated new cash transfer systems with nimble policy changes.
The eight members of the West African Economic and Monetary Union, for example, allowed people to open accounts by text message or telephone and follow up later to verify their identity in person. More than 8 million West Africans signed up for accounts while their countries were in lockdown.
Even so, there is a cap on how much money many governments are able to spend on the safety net, and people are suffering. IHME estimates that extreme poverty has gone up by 7 percent in just a few months because of COVID-19, ending a 20-year streak of progress. Already in 2020, the pandemic has pushed almost 37 million people below the US$1.90 a day extreme poverty line. The poverty line for lower-middle-income countries is US$3.20 a day, and 68 million people have fallen below that one since last year. "Falling below the poverty line" is a euphemism, though; what it means is having to scratch and claw every single moment just to keep your family alive.
HOW ARE THE MOST VULNERABLE EXPERIENCING THE CRISIS?
These newly impoverished people are more likely to be women than men. One reason is that women in low- and
In Africa, the earnings of informal workers declined more than 80 percent in the first month of the pandemic.
middle-income countries work overwhelmingly in the informal sector, which tends to operate in now-inaccessible spaces (like people's homes and public markets) and provides less access to government support. In Africa, the earnings of informal workers declined more than 80 percent in the first month of the pandemic.
Another reason is the avalanche of unpaid care work—like cooking, cleaning, caring for children and sick relatives—women are expected to do. Women already did most of it; now, with children at home instead of school, many men at home instead of at work, and many sick people at home instead of at health clinics, there is much more unpaid care work to be done, and the early evidence suggests that the distribution is growing more lopsided, not less.
Understanding Women's Lives
We support a multidisciplinary design-anthropology project called Pathways, in which locally embedded researchers observe and participate in the lives of women in Kenya and other countries, getting to know them over the span of two years. This deep knowledge can provide the context that is sometimes missing from the design of health and development programs. When COVID-19 struck, Pathways researchers spoke to women they had come to know well to learn about the mutually exacerbating impacts of the pandemic in their lives. Sylvia, Faith, and Agnes shared details of their lives with us. Out of respect for their privacy, we don't show their faces or other identifying details, but we use photographs and their words to welcome you into their homes, just as they welcomed us.
A GOOD ROLE MODEL
Sylvia, who was born with HIV, learned how to get by on her own in her teens, when both her parents died from HIV-related complications and she gave birth to her daughter Gift. She's outgoing and self-confident; she built up a network of family, friends, neighbors, and the staff at the health clinic where she goes for treatment. "My doctors," she said, "think I am a good role model to discuss HIV and support the cause"—so good, in fact, that they invited her to be a peer counselor for other HIV-positive mothers. Soon after the pandemic started, though, the facility ran out of money to pay her a stipend for her counseling—and ran out of Septrin, an antibiotic she takes with her HIV treatment to prevent pneumonia.
LESS ROOM FOR MANEUVER
The good news is that Sylvia can buy Septrin at the local pharmacy—but it costs 30 shillings (about 28 U.S. cents) a dose, which over the course of the month adds up to twice her rent. Her landlord, an old family friend, is usually understanding if she needs to pay late, but now he's worried about making ends meet, so he's asking to be paid on time. Sylvia washes clothes and braids hair for a living, but her customers can't pay her. Meanwhile, her sister, who sold mandazies (fried bread) at a school that closed, can no longer send money. In short, expenses are up, income is down, and there's less room for maneuver.
CARING FOR GIFT
Gift, who is 4, is especially bright, so Sylvia enrolled her in school in January; it closed almost immediately. Neighbors used to watch Gift when Sylvia had to work, but that's become harder with social distancing. When Sylvia goes to the hair salon to braid hair, she now brings Gift along. When she's washing clothes in the neighborhood, she lets Gift play on her own—and trusts that she'll come to find her mother when she's hungry.
Skipping meals, a money-saving strategy employed by many women, is an especially risky option for Sylvia because she shouldn't take her HIV medication on an empty stomach. Nearby Lake Victoria has been overfished for years, and the rains have been unusually heavy in recent years, so fish is harder to get and more expensive. Sylvia still buys omera (small sardines) from time to time but relies on maize flour. "My daughter is used to porridge," she says. "Even if you give it to her without sugar, she'll take it."
A BRAVE MOVE
Last year, Faith did one of the bravest things a woman can do: She left her abusive husband and took her two children to live with her mother at her grandfather's home. Then COVID-19 destroyed her mother's vegetable business: It was hard to get to the market, the operating hours kept changing, and good produce became scarce. Faith was also having trouble finding casual work, and the bills started piling up. To relieve the financial pressure on the household, Faith's grandfather asked her to leave.
With nowhere else to go, Faith had to go back to her husband and his family. She'd originally left when she'd gone into premature labor after one of his beatings, and her child died after three days. Faith says that her husband hasn't been violent since she moved back but admits that "sometimes I can see he is this close to punching me." She also talks about the constant emotional abuse she suffers from his family, particularly his mother, who blames Faith for her own financial problems.
When her children were in school, she knew they'd get lunch every day. If she couldn't afford to pay for it, the teacher would advance her money for a few days. Now, if she's short, they don't eat. Her 8-year-old son, now constantly exposed to his stepfather's explosive temper, has started pushing back against his mother and refusing to do his homework.
HARVESTS OF RAIN
In Kiambu, the price of maize shot up (from 90 to 140 shillings), so Faith and her children eat whatever she can grow. "This past Sunday," Faith said when she was interviewed, "we almost slept hungry. … I just boiled some kale for the children and they ate it by itself." Her in-laws don't share food with her or her children. They can't afford to buy tanks of water, so they're harvesting rainwater instead.
Agnes, the eldest child in her family, has felt an obligation to provide for the rest of the family ever since her parents passed away when she was 12. Before COVID-19, Agnes lived in Kawangware, an informal settlement in Nairobi, with her three children (15, 12, and 6), her younger sister Yvette, and Yvette's two children (6 and 1). She washed windows at Nairobi hotels while Yvette and the older children cared for the younger children. Yvette, who also worked odd jobs in the neighborhood, had a long history of respiratory illnesses due, according to Agnes, to "doing laundry for people where we're always in water." In April, when her symptoms flared up, Yvette worried that given her trouble breathing, if she went to a health facility she'd be put in quarantine, which she couldn't afford. Finally, it got bad enough that she checked into a private hospital, where she died three days later of undiagnosed diabetes.
Agnes cannot pay the enormous hospital bill of 130,000 shillings (approximately US$1,200). In good times, she can earn 200 shillings a day. She was hoping her chama (investment group) could help, but that option "fell through." The day before she was interviewed in May, she had gone "to look for prominent people who can assist me with the hospital bill." Her biggest concern is raising money for a proper funeral for her sister—including taking her body to their maternal home in a hearse—but Agnes cannot claim the body until she pays the hospital bill.
WORKING FOR THE STOMACH
Earning enough money to buy enough food to keep her family alive has always been Agnes's priority. "I work for the stomach" is how she put it during her first interview last year. When asked whether COVID-19 has changed the family's diet, she answered, "It has changed drastically because we have no food in the house." While the children may miss breakfast and lunch, and have lost weight, Agnes tries to "hustle to make sure that at least there's food for supper." Ultimately, she wants to teach her children, she says, "to program themselves," to learn how to cope in case she's not there.
Agnes will raise Yvette's young children as her own. She has decided not to tell the 6-year-old about her mother's death. "For now," she says, "I'll let her enjoy her childhood a bit." Agnes's 15-year-old son is unlikely to go back to school after the pandemic; he will probably join the hustle economy in Kawangware to help her support the family. Her 12-year-old daughter is even more at risk. Last year, Agnes talked at length about the struggles of young girls in Kawangware, and how girls her daughter's age are sniffing glue regularly, engaging in transactional sex to pay for basics, and sometimes getting pregnant. With the family deep in debt, Agnes worries what the future may hold for her daughter.
A Collaborative Response
The US$18 trillion in economic stimulus proves that the world understands how massive the COVID-19 crisis is. But it's not just different in degree; it's also different in kind. Every person on the planet shares this crisis. We need to share solutions, too.
We see this difference every day in our communities. We cannot keep ourselves safe from coronavirus by ourselves. We have to rely on one another—to keep distance, wash our hands, wear a mask. So far, some governments have been able to contain the disease effectively; some have been able to cushion the economic shock; some have been able to do both. No matter where you live, though, whether your government is rich or poor, your country will never be able to meet this challenge alone.
It is impossible to inoculate a national economy against a global economic catastrophe.
The COVID-19 pandemic has taught us that just as everything collides into everything else, everywhere collides into everywhere else. No matter how good any individual place is at testing, contact tracing, and quarantining, a person who has no idea they are contagious can still get on an airplane and be in another place in a few hours.
These collisions deepen the economic crisis, too. In this century of sophisticated interconnections, no country's economy can be fully healthy if the global economy is sick. Consider the fact that 66 percent of the European Union's GDP is export- and import-related. Or that the economy of New Zealand, with extremely low case numbers, is shrinking. It is impossible to inoculate a national economy against a global economic catastrophe.
Our foundation has focused for years on global health equity. We concentrate especially on what some have called "residual pandemics"—infectious diseases like malaria and tuberculosis that barely exist in high-income countries but still kill millions (and trigger mutually exacerbating catastrophes) in many others. We try to bring attention to these diseases because they aren't top of mind for everyone.
COVID-19 is top of mind for everyone. The danger now is that the countries already dealing with residual pandemics will be sent permanently to the back of the line for solutions to this one. This would be a heartbreaking injustice. It would also go against the self-interest of the countries at the front of the line.
We have our work cut out for us in the years to come. We need a strong coalition of businesses, governments, and development banks—the entire international financing system—to come together to mount a global response equal to the challenge we've been describing in this essay.
But before the world can really begin to address the damage this set of mutually exacerbating catastrophes has caused, we need to stop the inciting one: the pandemic that is currently getting worse, not better, in many countries. We cannot rebuild health systems, economic systems, educational systems, and food systems—to say nothing of making them better than they were when this year began—until the virus that is tearing them all down is under control.
To get it under control, to end the pandemic, the world should collaborate on three tasks as quickly as possible:
Develop diagnostics and treatments to manage the pandemic in the short term and vaccines to end it in the medium term.
Manufacture as many tests and doses as we can, as fast as we can.
Deliver these tools equitably to those who need them most, no matter where they live or how much money they have.
The key to developing new vaccines, especially in the early stages, is to pursue as many candidates as possible. Some countries have started making deals with pharmaceutical companies to reserve doses of a given vaccine candidate in the event that it eventually succeeds. This is not a bad thing. Governments have a responsibility to protect the health of their people, and these investments help jump-start important R & D, pay for new manufacturing facilities, and bring the world closer to delivering a vaccine.
Yet the steady trickle of headlines about promising early-stage clinical-trial results obscures the fact that R & D is inherently very high risk: the probability of success is 7 percent in early stages and 17 percent once candidates move on to human testing. Governments are essentially placing long-shot bets on the vaccine candidates they hope will "win"—but most will lose. One way to minimize this risk is for countries to invest jointly in a large portfolio of candidates.
Manufacturing is one of the most under-the-radar challenges the world faces: Once we find a vaccine or vaccines that work, we will need to manufacture billions of doses as quickly as possible. Right now, we don't have anywhere near enough manufacturing capacity to do this—and no individual country has the incentive to scale up on its own. Yet every dose of vaccine that the world fails to manufacture quickly means a longer pandemic, more deaths, and a longer global recession.
Developing and manufacturing vaccines won't end the pandemic quickly unless we also deliver them equitably. Some governments that have made bets will win those bets, but if they use all the available vaccine to protect only their people, they will be extending the life of the pandemic everywhere. They will also be contributing to a much larger death toll. According to modeling from Northeastern University, if rich countries buy up the first 2 billion doses of vaccine instead of making sure they are distributed in proportion to the global population, then almost twice as many people could die from COVID-19.
How Many Lives Could Equitable Vaccination Save?
Northeastern University's Laboratory for the Modeling of Biological and Socio-technical Systems (MOBS LAB) has worked for years on modeling influenza transmission, which put them in a good position to model COVID-19. Because it is so difficult to predict the future, MOBS LAB ran counterfactual scenarios examining what would have happened if a vaccine had been available starting in mid-March. This allows the model to work with observed data related to events that have already taken place, instead of guesses about data related to events that might take place a year from now. Northeastern ran two scenarios. In one, approximately 50 high-income countries received the first 2 billion doses (out of 3 billion) of an 80 percent effective vaccine. In the other, all countries received the 3 billion doses proportional to their populations. The outcome of the simulations is rendered as the percentage of deaths averted in each scenario, compared to the actual scenario of no vaccine.
It is not yet clear precisely how the world will organize a collaborative response. In April, many partners came together to launch the Access to COVID-19 Tools Accelerator (ACT-A), the most serious collaborative effort to end the pandemic to date. The two main partners in ACT-A's vaccine strategy—the Coalition for Epidemic Preparedness Innovations (CEPI), which has nine COVID-19 vaccine candidates in its portfolio, and Gavi, the Vaccine Alliance, which has helped low- and middle-income countries deliver 750 million vaccines since it was founded in 2000—were built to solve problems like the one we're facing now. That is why our foundation supports ACT-A, and why we urge others to join us.
To be clear, funding these organizations and other key partners adequately will cost a lot of money—but not compared to the cost of a festering pandemic. Every single month, the global economy loses US$500 billion, and a collaborative approach will shave many months off of the world's timeline. Countries have already committed US$18 trillion to economic stimulus to treat the symptoms of the pandemic. Now they need to invest a small portion of that total to root out its cause.
The response to the COVID-19 pandemic has shown us some of the best of humanity: pathbreaking innovation, heroic acts by frontline workers, and ordinary people doing the best they can for their families, neighbors, and communities. In this report, we've focused on the threat before us. That's because the stakes are so immediate and so high. What the world does in the next few months matters a great deal.
Our tagline for Goalkeepers is "progress is possible but not inevitable"—and we stand by it. How bad the pandemic gets and how long it lasts is largely within the world's control. Ultimately, businesses and governments must really believe that the future is not a zero-sum contest in which winners win only when losers lose. It is a cooperative endeavor in which we all make progress together.
GLOBAL HEALTH AND DEVELOPMENT data usually involves a lag. It takes time (and a lot of work) to collect data on how many people have been vaccinated, who has been diagnosed with which diseases, or how people's income has changed. It takes even more time to standardize the data, fill in gaps and fix errors, validate it, analyze it, and share it.
This means that, with traditional methods, it would be 2021 before the impact of COVID-19 showed up in the data included in the Goalkeepers Report. The point of the report is to track (and promote) progress toward the Sustainable Development Goals, and the big thing standing in the way of that progress right now is the pandemic. So we decided not to wait the usual year-plus to try to quantify the impact of this disaster.
With this year's Goalkeepers, our data partner, the Institute for Health Metrics and Evaluation (IHME), worked together with many partners and used novel data collection methods to generate a set of contemporary estimates for how the pandemic has interrupted global progress on the SDGs. These estimates are not perfect (see below for some important caveats) and will likely need to be revised as more data becomes available.
IHME estimates break down into four time periods, each of which is informed by specific data and methods.
We started writing the Goalkeepers Report to track progress toward the Sustainable Development Goals (SDGs). We promised that, every year, we'd publish the most recent global data about the 18 indicators most closely related to the work our foundation does. This year, as we explain here, the estimates aren't perfect, but we believed it was important to try to quantify the impacts of COVID-19. As in previous years, the projections include better and worse scenarios. We are focused on the difference between the scenarios. It is up to world leaders to make the tough decisions to get as far away as possible from the worse scenario and as close as possible to the better one.
Go to Goalkeepers Report for the full, interactive version.