Of the world's 20 poorest states, the Democratic Republic of the Congo spends the least per citizen on health care — $19 per person annually.
And in Sierra Leone, the highest health spender among those states south of the Sahara, it's over triple — $66 per capita.
That's still just a fraction of how much the world's wealthiest countries spend on each of their residents' health. In the United States, the number is nearly $10,000. Half of the 20 richest countries spend at least $5,000 per person.
While experts warn that higher health spending doesn't necessarily lead to better outcomes, it helps in a pandemic.
These budgets fund hospitals. They pay for doctors and cover the cost of essential medical supplies and services, like intensive care beds, medication and ventilators.
Strapped health-care budgets and weak infrastructure imperil the coronavirus response and longer-term health outcomes in sub-Saharan Africa, where the world's poorest countries are clustered, but that's only part of the picture. For these countries, which have already battled other outbreaks – AIDs, Ebola and tuberculosis – the playbook has always looked different.
As confirmed cases of the virus mount across developing and underdeveloped countries previously spared by the virus, disparities in testing capacity mean current caseload estimates in low-resource countries likely undershoot the true scope of the disease, says Dr. Andrea Tenner, who oversaw isolation units in Sierra Leone during the 2014 Ebola outbreak and is helping to develop emergency care in Tanzania.
On top of this, poor record keeping of cases and deaths is making it even harder to fully measure the scope of the virus. Facing a dearth of reliable and consolidated national numbers, many governments are flying blind as they roll out a response to the outbreak.
"The documentation [of deaths] is mostly paper," Tenner recalls of her experience working in these countries. "It's hard to follow."
Also, sub-Saharan Africa, which is critically dependent on imported medicinal and pharmaceutical products, faces acute shortages in the supplies needed to treat COVID-19.
According to a report by the United Nations Commission for Africa, nearly 94 percent of Africa's total stock of pharmaceutical products are imported. And at least 71 nations have already imposed limitations or full bans on exports of essential COVID-19 supplies, forcing many of the poorest countries into bidding wars over highly urgent, highly priced medical products.
"What's going to happen to countries having to choose between supporting populations living with malnutrition or starvation or getting personal protective equipment for hospitals?" Tenner says. "And it's very hard to enforce these kinds of regulations with people [who are] ... eating what they earn every day. They can't stay home for two weeks and survive."
These inequities run deeper than any single medical resource: World Bank research in 2015 suggests that 54% of all deaths in low- and middle-income countries could have been prevented with adequate prehospital or emergency care.
Not all the challenges have to do with money or material resources. Many sub-Saharan countries must grapple with people not showing up to get medical care, especially during an infectious disease outbreak.
Peter Berman, the head of University of British Columbia's School of Public Health, says in Ethiopia, for instance, citizens are more reticent to seek medical care as coronavirus spreads. This could lead to an increase in mortality from other, often-preventable causes.
"People will drastically reduce their use of very important measures that are available to address other causes of disease and mortality," Berman said. "They will stop bringing their children for treatment for respiratory infection or diarrheal diseases. They will stop getting immunized because they're afraid to go to the clinic. They will stop getting more treatment for tuberculosis, malaria, [HIV] or other problems that are prevalent."
Yet, even in the face of cultural factors like these, research shows that having money isn't all it takes to keep people healthy anyway.
A 2019 report on global health security by researchers at the Nuclear Threat Initiative, the Johns Hopkins Center for Health Security and the Economist Intelligence Unit demonstrate major vulnerabilities for countries — poor and rich — when it comes to defense against a pandemic. Despite their wealth, some of the richest countries were less prepared to deal with a pandemic than researchers expected.
Jessica Bell, one of the report's leads, explains: Wealthier countries often didn't prioritize health systems and disease prevention in ways tantamount to their resource power.
That's why how a nation spends the money it does have can be more important than the dollar amount of a nation's wealth, regardless of whether there's a pandemic.
"Imagine that if we spend $100 per capita to build up very high-level hospitals which treat sophisticated diseases — that doesn't do much for the general population," Berman says. "If we spent that same money on assuring that everyone is immunized or treating these children's infections and so on, we could see a very significant drop in mortality at the population level."
When it comes to a pandemic, past experience helps these countries, too, says Krutika Kuppalli, an infectious diseases physician and vice chair of the Infectious Diseases Society of America's Global Health Committee. She cared for patients with Ebola in Sierra Leone and worked with HIV- infected patients and patients with tuberculosis in Ethiopia.
"You have the experience of standing up the infrastructure, having a health care workforce that has been deployed and working with those high-consequence pathogens. You have people, again, that are trained to do contact tracing, which is important," Kuppalli says.
Poor countries are used to leveraging extremely limited resources, Kuppalli and Tenner say, which is not something countries like the U.S. are used to. Tenner, who is now helping the city of San Francisco respond to COVID-19 outbreak, described drawing from her experience in Africa: she's begun giving patients nebulizer treatments in the open air rather than in buildings, to lower the risk that medical workers are exposed to the coronavirus.
"In the U.S., treating patients outside is not something we ever do," Tenner says. "In Ethiopia, I worked in a clinic where we saw a lot of [tuberculosis] patients and we saw all of them outside."
Despite these mitigating factors, Tenner is worried that the poorest countries may lose out to wealthier ones in the global grab for medical supplies — a devastating hit.
"They could be bidding against San Francisco, against New York or Seattle, or Dar es Salaam in Tanzania or Freetown [in Sierra Leone]," she says.
"When you're in those bidding wars, the highest price wins."