The front lines in the battle to limit damage from the new coronavirus are expanding.

Covid-19, the disease caused by the virus, emerged in China and then blossomed in comparatively wealthy countries like Italy, South Korea, and the United States.

Now, the virus is spreading in poorer regions — in sub-Saharan Africa, South Asia, and parts of Latin America — where essential defensive measures against infectious disease are often missing.

Healthcare facilities in low- and middle-income countries are a potential weak link in the fight against Covid-19, health experts say. Hospitals and clinics in countries like Nepal and Tanzania often lack handwashing stations, proper waste disposal, hygienic equipment, and even running water.

“It’s huge,” said Maggie Montgomery about the role of water, sanitation, and hygiene in healthcare facilities. Montgomery is the World Health Organization technical officer for water, sanitation, and hygiene, also called WASH.

“Fundamentally, hand hygiene is the number one means of prevention,” Montgomery told Circle of Blue. “For a disease with no vaccine, no clear course of treatment, it’s even more important. Also, because there is a lack of personal protective equipment” — items like masks and gloves — “hand hygiene becomes the fundamental measure to interrupt disease transmission.”

Limited Resources

The World Health Organization says that “frequent and proper” handwashing is one of the most important bulwarks against spreading the virus. But in many healthcare facilities, it is difficult even to find soap.

Absent these basic precautions, global health experts worry that healthcare workers in developing countries could be a vector for spreading the virus.

“It is very vital to offer quality handwashing services and reduce cross infection,” Om Prasad Gautam, global hygiene lead for WaterAid, a charity that focuses on WASH, told Circle of Blue. “If those facilities are not there, workers will act as an epicenter of transmitting disease.”

Where handwashing facilities are limited, especially in countries in Africa and Asia, it may be very difficult to control the virus once it is established, Gautam added.

“If the virus started spreading in these countries, it may spread very fast,” Gautam said.

Underfunded and neglected, clinics in developing countries frequently see doctors tending to ill patients without minimum protections against disease transmission.

University of North Carolina researchers examined environmental conditions in healthcare facilities in 78 low- and middle-income countries. The results, published in 2018, paint a dismal picture. Only half of the nearly 130,000 healthcare facilities in the analysis had piped water. Thirty-nine percent did not have handwashing soap. One-third did not have satisfactory toilets. Nearly three-quarters did not have sterilization equipment. Only two percent of facilities had the complete package of water, sanitation, hygiene, and proper waste disposal.

“The statistics are quite alarming,” Gautam said.

Though alarming, the numbers alone may not tell the whole story, cautions Aaron Salzberg, the director of the Water Institute at the University of North Carolina, Chapel Hill. Data on Covid-19 transmission is limited and healthcare facilities are challenged by a host of other pressures in their efforts to treat and control the disease. Clinics may not have enough masks and gloves. Or their facilities may be cramped, putting ill people in close contact with each other.

“At this point, we have to be cautious stating that the lack of access to WASH services is a major pathway for transmission of Covid-19,” Salzberg, the former top official for water at the U.S. State Department, told Circle of Blue. “Many factors, including overcrowding, the lack of physical space, and the absence of supplies to protect healthcare workers may be bigger issues.”

‘A Story of Coping’

For WaterAid, some of those factors — population figures and potential overcrowding of hospitals — are informing its strategy to respond to the pandemic. The main transmission pathway for the virus is close, personal contact. It is spread mainly through coughs, sneezes, and handshakes. It can survive on surfaces: roughly four hours on copper, 24 hours on cardboard, and several days on steel and plastic. Thus the medical community’s recommendation for social isolation, disinfection of surfaces, and frequent handwashing.

Gautam said that WaterAid’s top-priority countries are those with a trio of risk factors. They have inadequate hygienic services in healthcare facilities, large populations, and have already recorded Covid-19 cases. Those countries are Bangladesh, Ethiopia, India, Nigeria, and Pakistan.

The number of confirmed cases in these countries is quite low as of March 18: 187 cases in Pakistan, 137 in India, eight in Bangladesh, five in Ethiopia, and two in Nigeria.

Low numbers of confirmed cases, however, are an incomplete indicator. Without widespread testing, there is no way to know how bad the situation is, said Lindsay Denny, health advisor to Global Water 2020, a WASH advocacy group.

The true number of cases is one of many unknowns. Other questions center on the environmental conditions that nurture the virus. The survival of similar coronaviruses is dependent on temperature and relative humidity, according to research from Lisa Casanova at Georgia State University.

Lower temperatures and low humidity are more favorable for survival. Higher temperatures kill the virus. Countries with the largest outbreaks to date are in the northern hemisphere, which is transitioning away from cooler winter temperatures.

“The picture of this virus is evolving very rapidly,” Casanova said on a conference call last week.

If there is a coming wave of infections in the southern hemisphere as it moves into autumn and winter, governments need to be prepared, said Michael Ryan, executive director of the health emergencies program at the World Health Organization.

Ryan said that while many countries in sub-Saharan Africa have fragile health systems, they are not helpless against viruses, having gained experience during the Ebola outbreak and with other diseases.

“I have worked with African colleagues and in Africa for many, many years, and what I see is a story of resilience, a story of coping, and an ability to overcome adversity through communities, by building on community intervention and building community acceptance,” Ryan said at a press conference. “If we can match community participation with good governance, then I believe that Africa can succeed. It has demonstrated that time and time again.”