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Brussels, Belgium, 28 April 2020 —  Alarming new analysis by the ̽����ѡ (̽����ѡ) reveals that without swift action in coming weeks to mitigate the spread of Covid-19, the world could see up to 1 billion infections [1] and 3.2 million deaths due to COVID-19 over the course of the pandemic in 34 crisis-affected countries served by the ̽����ѡ [2], including warzones like Afghanistan, Syria, and Yemen.

David Miliband, President and CEO of the ̽����ѡ, said: “These numbers should serve as a wake-up call: the full, devastating and disproportionate weight of this pandemic has yet to be felt in the world’s most fragile and war-torn countries. We are still in the critical window of time to mount a robust preventative response to the early stages of COVID-19 in many of these countries and prevent a further perpetuation of this epidemic globally.” 

Preliminary estimates compiled by ̽����ѡ are based on epidemiological modelling and data produced by  This model takes into account the age structure, household size, and social contact patterns of different countries, as well as mortality patterns from the early outbreak in China. ̽����ѡ’s calculations for the 34 countries in which we work highlight the extent of the burden on fragile countries of the COVID-19 outbreak, and the importance of immediate actions in coming weeks to influence the trajectory of the epidemic.

Scientists are still studying the drivers of the pandemic in lower-income contexts, including factors such as population health risks which may drive infection rates up, or others such as younger population age structure which may drive mortality rates down; these figures are nevertheless sufficient to spark significant alarm on the international trajectory of COVID-19. However, three significant limitations of the current data suggest that estimates for fragile countries may be conservative at best: 

1. Healthcare capacity and virus reproductive rate (R0): The ICL/WHO model uses the best available mortality data, from China, which pre-supposes that levels of medical care available therein would be available elsewhere.   fragile states have nowhere near the healthcare capacity provided in China. In Venezuela alone, the long-standing economic and humanitarian crisis has forced more than half of doctors to leave the country and 90% of hospitals already faced shortages of medicine and critical supplies. In addition, refugee camps in countries included in the analysis like Syria, Greece and Bangladesh represent some of the most densely-populated areas in the world -- up to 8.5 times more , where transmission of the virus was up to four times faster than in Wuhan, China [3]. Beyond demonstrating the infeasibility of extreme social distancing in these contexts and the scarcity of basic health capacity, this suggests that the reproduction rate of the virus in significant pockets of these states are likely to be far higher than the current projections suggest.
2. Pre-existing humanitarian vulnerability: These mortality figures do not account for excess deaths caused by underlying humanitarian vulnerability (including co-morbidity due to pre-existing health issues such as malnutrition) or by the economic and political instability which constitute a “double emergency” for fragile contexts. While strict lockdowns and social distancing will unquestionably save lives in wealthier nations, direct consequences such as market closures and income losses (without robust social safety nets) risk driving impoverishment, hunger, and domestic violence in humanitarian settings. Without sufficient social safety nets or relief packages in place to prevent people from spiralling further into poverty and hunger, these same measures risk harming populations already caught in weak states or unstable humanitarian contexts. 
3. Disruptions to humanitarian aid delivery: Movement restrictions and disruptions to supply chains are already impacting the ability of agencies like the ̽����ѡ to deliver life-saving humanitarian aid to people in need. South Sudan, a country with only 4 ventilators and 24 ICUs and where almost 65% of the population relies on humanitarian assistance, may for instance face famine with a toxic mix of restricted movement, economic instability, reduction in agricultural labour and pre-existing high levels of malnutrition and chronic food insecurity. 

It is clear that the impact of COVID-19 in these settings will be different than in the developed countries first hit by the pandemic - and a “one-size-fits-all” model based on measures in countries hit first by COVID-19 is unrealistic and potentially counterproductive. In order to identify the bespoke measures that are not only appropriate but necessary for crisis-affected states, ̽����ѡ has released a new report,  detailing the risks and possible solutions required to combat COVID-19 in fragile settings - and to avoid exacerbating humanitarian suffering.

David Miliband, President and CEO of the ̽����ѡ, continues, “The key now is for donors to urgently put flexible funding behind frontline efforts, already positioned to scale up and serve the most vulnerable. This requires consistent access to personal protective equipment, testing and isolation of all suspected cases, isolation units and handwashing stations. Donors, response actors and governments must work together to remove any impediment to humanitarian assistance- adapting restrictions to ensure access to COVID-19 supplies and equipment, food and other basic goods, as well as health, protection and livelihoods services. The ̽����ѡ is implementing a comprehensive response strategy that aims to mitigate the spread of COVID-19 and treat patients, but also focuses on meeting our clients’ other health and economic needs and expanding our protection services for women and girls. Without immediate international action that supports the needs and unique challenges faced by people in these countries in the face of COVID-19, the consequence will be the loss of life and livelihood on an appalling scale.”

The ̽����ѡ has launched a US $30 million appeal to help us mitigate the spread of coronavirus among the world’s most vulnerable populations, with a focus on mitigating and responding to the spread in vulnerable communities, protecting our staff and ensuring continuation of life-saving programming.

As part of ̽����ѡ’s COVID-19 response, ̽����ѡ’s research and innovation team is helping create context-appropriate and cost-effective solutions to respond to this pandemic. The preliminary estimates of the burden of COVID-19 are a first step in supporting response planning, and further collaborative research is planned to improve pandemic models for low-income and conflict-affected states.

Editors Notes: 

[1]: Based on an R0 of 3.3 and response scenarios “Basic Mitigation” and “Suppression, 1.6 deaths per 100,000 trigger”, as laid out in the model and data set published by ICL / WHO’s March 26 Global Impact Study.

[2]: Afghanistan, Burundi, Bangladesh, Burkina Faso, Chad, Cameroon, CAR, Chad, Colombia, Côte d’Ivoire, DRC, El Salvador, Ethiopia, Greece, Iraq, Jordan, Kenya, Lebanon, Liberia, Libya, Mali, Myanmar, Niger, Nigeria, Pakistan, Sierra Leone, Somalia, South Sudan, Syria, Tanzania, Thailand, Uganda, Venezuela and Yemen.

[3]: Refugee camps are at particular risk due to overcrowding and paltry sanitary conditions: Bangaldesh’s Cox’s Bazar (40,000 per km2), Greece’s Moria camp (203,800 per km2), and Al Hol, Syria (37,570 per km2), all far exceed the density of the Diamond Princess cruise (24,400 per km2).