Densely populated, low- and middle-income: Coronavirus rips into regions previously spared

People wear masks inside a train in Cairo, Egypt, on May 31, 2020.
People wear masks inside a train in Cairo, Egypt, on May 31, 2020.PHOTO: EPA-EFE

CAIRO (NYTIMES) - For months, one enduring mystery of the coronavirus was why some of the world's most populous countries, with rickety health systems and crowded slums, had managed to avoid the brunt of an outbreak that was burning through relatively affluent societies in Europe and the United States.

Now some of those countries are tumbling into the maw of the pandemic, and they are grappling with the likelihood that their troubles are only beginning.

Globally, known cases of the virus are growing faster than ever, with more than 100,000 new ones a day. The surge is concentrated in densely populated, low- and middle-income countries across the Middle East, Latin America, Africa and South Asia.

Not only has it filled hospitals and cemeteries there, it has frustrated the hopes of leaders who thought they were doing everything right or who believed they might somehow escape the pandemic's worst ravages.

"We haven't seen any evidence that certain populations will be spared," said Natalie Dean, an assistant professor of biostatistics at the University of Florida. For those not yet affected, she said, "it's a matter of when, not if."

Several of the newly hit countries are led by strongmen and populists now facing a foe that cannot be neutralised with arrests or swaggering speeches. In Egypt, where the rate of new confirmed infections doubled last week, the pandemic has created friction between President Abdel-Fattah el-Sissi and doctors who have revolted over a lack of protective equipment and training.

In Brazil, the total death toll surpassed 32,000 on Thursday (June 4), with 1,349 deaths in a single day, dealing a further blow to the populist president, Jair Bolsonaro, who has continued to minimize the threat.

"We are sorry for all the dead, but that's everyone's destiny," he said on Tuesday.

In Bangladesh, natural disaster helped spread the disease. Cyclone Amphan, a deadly storm that tore through communities under lockdown there last month, helped drive cases up to 55,000.

This week Bangladeshi authorities reported the first death from Covid-19 in a refugee camp, a 71-year-old Rohingya man from Myanmar - an ominous sign for wider worries about the plight of vulnerable people huddled in hundreds of such camps in the world's most fragile countries.

The upswing marks a new stage in the trajectory of the virus, away from Western countries that have settled into a grinding battle against an increasingly familiar adversary, toward corners of the globe where many hoped that hot weather, youthful populations or some unknown epidemiological factor might shield them from a scourge that has infected 6.5 million people and killed almost 400,000, over a quarter of them in the United States.


Some countries now being overrun by the virus seemed to be doing the right thing. In Peru, where President Martín Vizcarra ordered one of the first national lockdowns in South America, over 170,000 cases have been confirmed, and 14,000 more deaths than average were recorded in May, suggesting there were many more virus fatalities than the official count of about 5,000.

South Africa, Africa's economic powerhouse, banned sales of tobacco and alcohol as part of a strict lockdown in March, yet now has 35,000 confirmed infections, the highest on the continent. Even so, President Cyril Ramaphosa eased the restrictions last week, citing economic concerns.

The pandemic's new direction is bad news for the strongmen and populist leaders in some of those countries who, in its early stage, reaped political points by vaunting low infection rates as evidence of the virtues of iron-fisted rule.

President Vladimir Putin of Russia, whose delivery of a planeload of medical aid to the United States in March was seen as a cocky snub, is grappling with the world's third-largest outbreak, with 440,000 cases that have enraged the public and depressed his approval ratings to their lowest in two decades.

For el-Sissi of Egypt, the outbreak has posed a rare challenge to his preferred narrative of absolute control.

Although Egypt's 30,000 cases are far fewer than those of several other Arab countries - Saudi Arabia has three times as many - it has by far the highest death toll in the region, and its infection rate is soaring.

Last Sunday the government recorded 1,500 new cases, up from about 700 just three days earlier. The next day the minister for higher education and scientific research warned that Egypt's true number of cases could be over 117,000.

Medical staff intubating a patient in the isolated ward for the coronavirus patients in Cairo, on April 25, 2020. PHOTO: AFP

Some hospitals are overflowing, and doctors are up in arms over shortages of protective equipment that, they say, has resulted in the deaths of at least 30 doctors. Outrage crystallised last week around the death of Dr Walid Yehia, 32, who had been denied emergency treatment at the overwhelmed Monira general hospital where he worked.

Fellow doctors at the hospital went on strike for a week to protest his death. The main doctors union issued a statement accusing the government of "criminal misconduct" and warning that Egypt was veering toward "catastrophe" - strong words in a country where el-Sissi has jailed tens of thousands of opponents.

Last week, el-Sissi railed on Twitter against unspecified "enemies of the state" who attacked government efforts to combat the virus. Earlier, Egypt's public prosecutor warned that anyone spreading "false news" about the coronavirus faced up to five years of imprisonment.

Doctors at several hospitals said they had been threatened by el-Sissi's feared security apparatus for daring to complain. The doctors interviewed for this article spoke on condition of anonymity out of fear of reprisal or arrest.

When doctors at the Mansheyat el Bakry hospital threatened to strike last month to protest the lack of training and protective equipment, they received a warning from a hospital senior manager: Anyone who failed to turn up for work the following day would be reported to the National Security Agency, which human rights groups have accused of torture and other abuses.

Reached by phone, the manager, Dr Hanan el-Banna said the message was part of "normal disciplinary measures." Then she denied that she had sent it.

A spokesman for Egypt's Health Ministry did not respond to questions about the message or other complaints from doctors.

The power of the virus was brought home to el-Sissi in the early stages of the pandemic, when two senior generals died from Covid-19. Yet his government has frequently seemed determined to put a Panglossian spin on how well it is being handled.

Last week the Health Ministry published a promotional video that showed coronavirus patients in a hospital praising their care and hailing el-Sissi.

"I can't believe this, President Abdel-Fattah el-Sissi," says one masked patient. "I can't believe what he's doing for our sake."

A very different picture emerges on Facebook, where desperate patients or their relatives have posted videos pleading for help.

In one widely circulated recording, a weeping woman says that her ailing father was refused treatment at several hospitals. In another, a man with coronavirus symptoms remonstrates with hospital security guards who turn him away.

"Take your complaint to the police," they tell him.

Even if Egypt's doctors were not muzzled by their government, Western-style social distancing would be nearly impossible in a chaotic, densely populated city of 20 million people like Cairo, where many families survive on day jobs. Mosques, churches and airports remained closed, but the decision to relax a night curfew during the holy month of Ramadan - ostensibly to allow people to break their daily fast together - may have accelerated the spread of the virus, experts say.

Many low- and middle-income countries, now grappling with surging cases, are also struggling to balance public health against the realities of poverty-stricken societies, said Ashish Jha, professor of global health at the Harvard T.H. Chan School of Public Health.

"At some point the lockdown becomes intolerable," he said. "The human cost to day laborers, many of whom are already barely surviving, is enormous."

The hopes of some countries that they could somehow avoid the pandemic are likely to be dashed, he added.

"In the early days, people were seeing patterns that were not really there," he said. "They were saying that Africa would be spared. But this is a highly idiosyncratic virus, and over time the idiosyncrasy goes away. There is no natural immunity. We are all, humanitywise, equally susceptible to the virus."


Experts say that el-Sissi's obsession with showing that he is beating the pandemic may have encouraged some Egyptians to drop their guard - a phenomenon similar to that in the United States, where some Americans have taken comfort in President Donald Trump's breezy reassurances.

Unfortunately, such heedlessness can have dire consequences.

In March, Mohammed Nady, 30, an employee at the Sheraton hotel in central Cairo, posted a video to Facebook dismissing the virus as an American-engineered conspiracy to humiliate China.

A few weeks later, he posted a second video from the hospital announcing that he had contracted the coronavirus.

A third clip showed him in bed, struggling to breathe.

"I am dying," he said. "I am dying."

He died in April, three days before his father also died from the disease.