Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Congressional research reportMay 14, 2020
Ask Donna
What actually matters in this document.
Text
Novel Coronavirus 2019 (COVID-19): Q&A on
Global Implications and Responses
Tiaji Salaam-Blyther, Coordinator
Specialist in Global Health
Updated May 14, 2020
Congressional Research Service
7-....
www.crs.gov
R46319
SUMMARY
Novel Coronavirus 2019 (COVID-19): Q&A on
Global Implications and Responses
R46319
May 14, 2020
Tiaji Salaam-Blyther,
In December 2019, hospitals in the city of Wuhan in China’s Hubei Province began seeing cases
Coordinator
Specialist in Global Health
of pneumonia of unknown origin. Chinese health authorities ultimately connected the condition,
-re-acte--@crs.loc.gov
later named coronavirus disease 2019 (COVID-19), to a previously unidentified strain of
coronavirus. The disease has spread to almost every country in the world, including the United
For a copy of the full report,
States. WHO declared the outbreak a Public Health Emergency of International Concern on
please call 7-.... or visit
January 30, 2020; raised its global risk assessment to “Very High” on February 28; and labeled
www.crs.gov.
the outbreak a “pandemic” on March 11. In using the term pandemic, WHO Director-General
Tedros Adhanom Ghebreyesus cited COVID-19’s “alarming levels of spread and severity” and
governments’ “alarming levels of inaction.” As of May 14, 2020, WHO had reported more than 4.2 million COVID-19 cases,
including almost 300,000 deaths, of which more than 40% of all cases and 55% of all deaths were identified in Europe, and
more than 30% of all cases and nearly 30% of all deaths were identified in the United States. Members of Congress have
demonstrated strong interest in ending the pandemic domestically and globally. To date, Members have introduced dozens of
pieces of legislation on international aspects of the pandemic (see the Appendix).
Individual countries are carrying out not only domestic but also international efforts to control the COVID-19 pandemic, with
the WHO issuing guidance, coordinating some international research and related findings, and coordinating health aid in lowresource settings. Countries are following (to varying degrees) WHO policy guidance on COVID-19 response and are
leveraging information shared by WHO to refine national COVID-19 plans. The United Nations (U.N.) Office for the
Coordination of Humanitarian Affairs (UNOCHA) is requesting almost $7 billion to support COVID-19 efforts by several
U.N. entities. International financial institutions (IFIs), including the International Monetary Fund (IMF), the World Bank,
and the regional development banks, are mobilizing their financial resources to support countries grappling with the COVID19 pandemic. The IMF has announced it is ready to tap its total lending capacity, about $1 trillion, to support governments
responding to COVID-19. The World Bank can mobilize about $150 billion over the next 15 months, and the regional
development banks are also preparing new programs and redirecting existing programs to help countries respond to the
economic ramifications of COVID-19.
On January 29, 2020, President Donald Trump announced the formation of the President’s Coronavirus Task Force, led by
the Department of Health and Human Services (HHS) and coordinated by the White House National Security Council (NSC).
On February 27, the President appointed Vice President Michael Pence as the Administration’s COVID-19 task force leader,
and the Vice President subsequently appointed the President’s Emergency Plan for AIDS Relief (PEPFAR) Ambassador
Deborah Birx as the “White House Coronavirus Response Coordinator.” On March 6, 2020, the President signed into law the
Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020, P.L. 116-123, which provides $8.3
billion for domestic and international COVID-19 response. The Act includes $300 million to continue the U.S. Centers for
Disease Control and Prevention’s (CDC) global health security programs and a total of $1.25 billion for the U.S. Agency for
International Development (USAID) and Department of State. Of those funds, $985 million is designated for foreign
assistance accounts, including $435 million specifically for Global Health Programs. On March 27, 2020, President Trump
signed the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), P.L. 116-136, which contains emergency
funding for U.S. international COVID-19 responses, including $258 million to USAID through the International Disaster
Assistance (IDA) account and $350 million to the State Department through the Migration and Refugee Assistance (MRA)
account (P.L. 116-127).
The pandemic presents major consequences for foreign aid, global health, diplomatic relations, the global economy, and
global security. Regarding foreign aid, Congress may wish to consider how the pandemic might reshape pre-existing U.S. aid
priorities—and how it may affect the ability of U.S. personnel to implement and oversee programs in the field. The pandemic
is also raising questions about deportation and sanction policies, particularly regarding Latin America and the Caribbean and
Iran. In the 116th Congress, Members have introduced legislation to respond to the COVID-19 pandemic in particular and to
address global pandemic preparedness in general. This report focuses on global implications of and responses to the COVID19 pandemic, and is organized into four broad parts that answer common questions regarding: (1) the disease and its global
prevalence, (2) country and regional responses, (3) global economic and trade implications, and (4) issues that Congress
might consider. For information on domestic COVID-19 cases and related responses, see CRS Insight IN11253, Domestic
Public Health Response to COVID-19: Current Status and Resources Guide, by Kavya Sekar and Ada S. Cornell.
Congressional Research Service
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Contents
Introduction ..................................................................................................................................... 1
What are coronaviruses and what is COVID-19? ............................................................... 1
How is COVID-19 transmitted? ......................................................................................... 2
What are global COVID-19 case fatality and hospitalization rates? .................................. 2
Where are COVID-19 cases concentrated? ........................................................................ 4
COVID-19 Responses of International Institutions......................................................................... 5
International Health Regulations ............................................................................................... 5
What rules guide COVID-19 responses worldwide? .......................................................... 5
How does WHO respond to countries that do not comply with IHR (2005)? .................... 6
How does the Global Health Security Agenda (GHSA) relate to IHR (2005) and
pandemic preparedness? .................................................................................................. 6
Multilateral Technical Assistance .............................................................................................. 7
What is WHO doing to respond to the COVID-19 pandemic? ........................................... 7
How are international financial institutions responding to COVID-19? ............................ 8
What is the U.N. humanitarian response to the COVID-19 pandemic? ............................. 9
U.S. Support for International Responses ...................................................................................... 11
Emergency Appropriations for International Responses ......................................................... 12
U.S. Department of State ........................................................................................................ 13
How does the State Department help American citizens abroad?..................................... 13
What are the authorities and funding for the State Department to carry out
overseas evacuations? .................................................................................................... 14
How many evacuations have been carried out due to the COVID-19 pandemic? ............ 15
U.S. Agency for International Development (USAID) ........................................................... 16
Where is USAID providing COVID-19 assistance? ......................................................... 16
What type of assistance does USAID provide for COVID-19 control? ........................... 16
How do USAID COVID-19 responses relate to regular pandemic preparedness
activities? ....................................................................................................................... 17
U.S. Centers for Disease Control and Prevention (CDC) ....................................................... 18
What role is CDC playing in international COVID-19 responses? .................................. 18
How do CDC COVID-19 responses relate to regular pandemic preparedness
activities? ....................................................................................................................... 19
U.S. Department of Defense (DOD) ....................................................................................... 20
What is the DOD global COVID-19 response? ................................................................ 20
Emergency Appropriations for DOD Responses .............................................................. 20
To what extent is COVID-19 affecting United States security personnel? ....................... 21
Regional Implications of and Responses to the COVID-19 Pandemic ......................................... 22
Asia ......................................................................................................................................... 22
What are the implications for U.S.-China relations? ........................................................ 22
What are the implications in Southeast Asia? ................................................................... 24
What are the implications in Central Asia? ....................................................................... 25
What are the implications in South Asia? ......................................................................... 26
What are the implications in Australia and New Zealand? ............................................... 27
What are the implications for U.S. withdrawal from Afghanistan? .................................. 28
What COVID-19 containment lessons could be learned from Asia? ................................ 29
Europe ..................................................................................................................................... 33
How are European governments and the European Union (EU) responding? .................. 33
Congressional Research Service
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
How is the pandemic affecting U.S.-European relations? ................................................ 35
Africa ...................................................................................................................................... 36
How are African governments responding? ...................................................................... 36
How is the Africa CDC responding?................................................................................. 38
Middle East and North Africa ................................................................................................. 38
How are Middle Eastern and North African governments responding? ........................... 38
What are the implications for U.S.-Iran policy? ............................................................... 41
Canada, Latin America, and the Caribbean ............................................................................. 42
How is the Canadian government responding?................................................................. 42
How are Latin American and Caribbean governments responding? ................................. 43
International Economic and Supply Chain Issues ......................................................................... 44
What are the implications of the pandemic in China’s economy? .................................... 44
How is COVID-19 affecting the global economy and financial markets? ....................... 45
How is COVID-19 affecting U.S. medical supply chains? .............................................. 47
Issues for Congress ........................................................................................................................ 48
Figures
Figure 1. Confirmed COVID-19 Cases: May 7-13, 2020 ............................................................... 2
Figure 2. COVID-19 Hospitalizations, Intensive Care Unit (ICU) Admissions, and Deaths
by Age Group in the United States ............................................................................................... 3
Tables
Table 1. Top 10 Countries with Confirmed COVID-19 Cases and Deaths ..................................... 4
Table 2. COVID-19 Cases and Deaths, by WHO Region ............................................................... 5
Table 3. United Nations COVID-19 Appeal: April-December 2020 ............................................. 11
Table 4. USAID Global Pandemic Preparedness Funding: FY2017-FY2021 Request ................. 18
Table 5. CDC Global Pandemic Preparedness Funding: FY2017-2020 Enacted .......................... 19
Table A-1. Report Authors ............................................................................................................ 56
Appendixes
Appendix. Supplemental Information ........................................................................................... 50
Contacts
Author Contact Information .......................................................................................................... 57
Congressional Research Service
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Introduction
In December 2019, a new disease, later called COVID-19, emerged in China and quickly spread
around the world. The disease presents major consequences for global health, foreign relations,
the global economy, and global security. International institutions and country governments are
taking a variety of responses to address these challenges. In the 116th Congress, Members have
introduced legislation to respond to COVID-19 in particular and to address global pandemic
preparedness in general that are now occurring on a global scale. This report focuses on global
implications of and responses to the COVID-19 pandemic, and is organized into four broad parts
that answer common questions regarding: (1) the disease and its global prevalence, (2) country
and regional responses, (3) global economic and trade implications, and (4) issues that Congress
might consider. For information on domestic COVID-19 cases and related responses, see CRS
Insight IN11253, Domestic Public Health Response to COVID-19: Current Status and Resources
Guide, by Kavya Sekar and Ada S. Cornell.
What are coronaviruses and what is COVID-19?1
Coronaviruses that typically infect humans are common pathogens, which can cause mild
illnesses with symptoms similar to the common cold, or severe illness, potentially resulting in
death of the victim. Prior to COVID-19, two “novel” coronaviruses (i.e., coronaviruses newly
recognized to infect humans) have caused serious illness and death in large populations, namely
severe acute respiratory syndrome (SARS) in 2002-2003 and Middle East Respiratory Syndrome
(MERS), which was first identified in 2012 and continues to have sporadic transmission from
animals to people with limited human-to-human spread.2
The origin of COVID-19 is unknown, although genetic analysis suggests an animal source.3 The
World Health Organization (WHO) first learned of pneumonia cases from unknown causes in
Wuhan, China, on December 31, 2019. In the first days of January 2020, Chinese scientists
isolated a previously unknown coronavirus in the patients, and on January 11, Chinese scientists
shared its genetic sequence with the international community. (See CRS Report R46354, COVID19 and China: A Chronology of Events (December 2019-January 2020), by Susan V. Lawrence.)
The virus is now present in most countries (Figure 1). For the purposes of this report, CRS refers
to COVID-19 as the virus and the syndrome people often develop when infected.4
1 Written by Tiaji Salaam-Blyther, Specialist in Global Health, and Sara Tharakan, Analyst in Global Health.
2 CDC, “Human Coronavirus Types,” accessed February 14, 2020, https://www.cdc.gov/coronavirus/types.html.
3 For background on COVID-19, see the CDC, “Coronavirus Disease 2019 (COVID-19): Situation Summary, Updated
April 19, 2020; and WHO, “Q&A on coronaviruses (COVID-19),” Q&A, April 8, 2020.
4 The International Committee on Taxonomy of Viruses initially named the virus novel coronavirus (2019-nCoV), and
WHO later dubbed it severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), see
https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirusdisease-(covid-2019)-and-the-virus-that-causes-it. The virus can cause disease in humans called coronavirus disease
2019 (COVID-19).
Congressional Research Service
1
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Figure 1. Confirmed COVID-19 Cases: May 7-13, 2020
Source: World Health Organization, COVID-19 Situation Report 114, May 13, 2020.
How is COVID-19 transmitted?5
Health officials and researchers are still learning about COVID-19. According to the U.S. Centers
for Disease Control and Prevention (CDC), the virus is thought to spread mainly from person-toperson between individuals who are in close contact with each other (less than six feet), through
respiratory droplets produced when an infected person coughs or sneezes.6 Health officials and
researchers are still determining the virus’s incubation period, or time between infection and
onset of symptoms. CDC is using 14 days as the outer bound for the incubation period, meaning
that the agency expects someone who has been infected to show symptoms within that period.
The CDC has confirmed that asymptomatic cases (infected individuals who do not have
symptoms) can transmit the virus, though “their role in transmission is not yet known.”7 A study
of the 3,711 passengers on the Diamond Princess cruise ship found that 712 people (19.2% of the
cruise ship passengers) tested positive for COVID-19. Almost half (331) of the positive cases
were asymptomatic at the time of testing.8
What are global COVID-19 case fatality and hospitalization rates?9
The COVID-19 case fatality rate is difficult to determine; milder cases are not being diagnosed,
death is delayed, and wide disparities exist in case detection worldwide. In addition, the case
fatality rate in any given context may depend on a number of factors including the demographics
of the population, density of the area, and the quality and availability of health care services.
5 Written by Tiaji Salaam-Blyther, Specialist in Global Health.
6 CDC, “Transmission—2019 Novel Coronavirus,” accessed March 22, 2020.
7 CDC, “Healthcare Professionals: Frequently Asked Questions and Answers – Transmission,” updated March 30,
2020, accessed March 31, 2020.
8 Leah F. Moriarty et al., "Public Health Responses to COVID-19 Outbreaks on Cruise Ships Worldwide, FebruaryMarch 2020," Morbidity and Mortality Weekly Report, vol. 69, March 23, 2020.
9 Written by Tiaji Salaam-Blyther, Specialist in Global Health, and Sara Tharakan, Analyst in Global Health.
Congressional Research Service
2
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Scientists are using different methods to estimate case fatality and estimates range. One study of
those diagnosed with COVID-19 estimated case fatality rates for Wuhan, China and other parts of
China at 1.4% and 0.85%, respectively.10 Another estimated 3.6% within China and 1.5% outside
the country,11 with a third recommending using a range of 0.2%-3.0%.12
Current data suggest the elderly and those with preexisting medical conditions (including asthma,
high blood pressure, heart disease, cancer, and diabetes) are more likely to become severely
sickened by COVID-19. One study in China showed that 80% of those killed by the virus were
older than 60 years and 81% of surveyed COVID-19 cases were mild.13 Another study showed
that 87% of all hospitalized COVID-19 patients in China were aged between 30 and 79 years,
though the study did not further disaggregate the data by age.14 Whereas the CDC found that the
elderly had higher death rates, more than half (55%) of reported COVID-19 hospitalizations
between February 12 and March 16, 2020, were of individuals younger than 65 years (Figure
2).15
Figure 2. COVID-19 Hospitalizations, Intensive Care Unit (ICU) Admissions, and
Deaths by Age Group in the United States
(February 12-March 16, 2020)
Source: CDC COVID-19 Response Team, “Severe Outcomes Among Patients with Coronavirus Disease 2019
(COVID-19)—United States, February 12-March 16, 2020,” Morbidity and Mortality Weekly Report, vol. 69, March
18, 2020.
10 Joseph T. Wu et al., “Estimating clinical severity of COVID-19 from transmission dynamics in Wuhan, China,”
Nature Medicine, March 19, 2020.
11 David Baud et al., “Real estimates of mortality following COVID-19 infection,” The Lancet Infectious Diseases,
March 12, 2020.
12 Nick Wilson et al., “Case-Fatality Risk Estimates for COVID-19 Calculated by Using a Lag Time for Fatality,”
Emerging Infectious Diseases, Vol. 26, No. 6, June 2020.
13 Zhang Yanping, “The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID19) in China,” Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and
Prevention, Chinese Journal of Epidemiology, vol. 41, 2020.
14 Zunyou Wu and Jennifer McGoogan, “Characteristics of and Important Lessons from the Coronavirus Disease 2019
(COVID-19) Outbreak in China,” JAMA Network, February 24, 2020.
15 Ibid.
Congressional Research Service
3
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Notes: Hospitalization status was missing or unknown for 1,514 cases, ICU status was missing or unknown for
2,253 ICU admissions. The illness outcome (including death) was also missing or unknown for 2,001 cases.
Where are COVID-19 cases concentrated?16
As of May 13, 2020, national governments reported to the WHO more than 4 million cases of
COVID-19 and almost 300,000 related deaths worldwide. Ten countries accounted for over 70%
of all reported cases and almost 80% of all reported deaths (Table 1). The pandemic epicenter has
shifted from China and Asia to the United States and Europe. China and Belgium are no longer
among the 10 countries with the highest number of deaths, and Russia and Brazil joined the
ranks. Almost 90% of all reported cases were identified in the WHO Americas and Europe
regions (Table 2).17 Cases are continuing to rise in the Americas, where 88% of all cases were
found in the United States (74%), Brazil (9%), and Canada (4%). In Europe, the cases are more
widely distributed, and seven countries comprise 77% of all cases: Russia (14%), Spain (13%),
United Kingdom (13%), Italy (12%), Germany (10%), Turkey (8%) and France (8%).
Table 1. Top 10 Countries with Confirmed COVID-19 Cases and Deaths
(as of April 19, 2020)
Cases
Deaths
% of
All
Cases
1,320,054
79,634
31.6
27.7
Russia
242,271
2,212
5.8
0.8
Spain
228,030
26,920
5.5
9.4
United Kingdom
224,467
32,692
5.4
11.4
Italy
221,216
30,911
5.3
10.8
Germany
171,306
7,634
4.1
2.7
Brazil
168,331
11,519
4.0
4.0
Turkey
141,475
3,894
3.4
1.4
France
138,161
26,948
3.3
9.4
Iran
110,767
6,733
2.7
2.3
Top 10 Total
2,968,078
229,097
71.2
79.7
Grand Total
4,170,424
287,399
100.0
100.0
Country
United States
% of All
Deaths
Source: WHO, Coronavirus Disease 2019 (COVID-19) Situation Report 114, May 13, 2020.
Notes: Numbers include domestic and repatriated cases.
16 Written by Tiaji Salaam-Blyther, Specialist in Global Health and Sara Tharakan, Analyst in Global Health and
International Development.
17 See WHO web page on WHO regions at https://www.who.int/chp/about/regions/en/, accessed on April 6, 2020.
Congressional Research Service
4
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Table 2. COVID-19 Cases and Deaths, by WHO Region
(as of May 14, 2020)
Cases
Deaths
% of All
Cases
% of All
Deaths
Europe
1,780,316
159,799
42.7
55.6
Americas
1,781,564
106, 504
42.7
37.1
Western Pacific
163,201
6,578
3.9
2.3
Eastern Mediterranean
284,270
9,259
6.8
3.2
Southeast Asia
110,932
3,746
2.7
1.3
Africa
49,429
1,500
1.2
0.5
712
13
0.0
0.0
4,170,424
287,399
100.0
100.0
WHO Region
Diamond Princess
Total
Source: WHO, Coronavirus Disease 2019 (COVID-19) Situation Report 114, May 13, 2020.
Note: WHO regions at https://www.who.int/chp/about/regions/en/, accessed on April 6, 2020.
COVID-19 Responses of International Institutions
Individual countries carry out both domestic and international efforts to control the COVID-19
pandemic, with the WHO issuing guidance, coordinating some international research and related
findings, and coordinating health aid in low-resource settings. Countries follow (to varying
degrees) WHO policy guidance on COVID-19 response and leverage information shared by
WHO to refine national COVID-19 plans. The United Nations (U.N.) Office for the Coordination
of Humanitarian Affairs (UNOCHA) is requesting $6.7 billion to support COVID-19 efforts by
several U.N. entities (see “Multilateral Technical Assistance” section).18
International Health Regulations19
What rules guide COVID-19 responses worldwide?
WHO is the U.N. agency responsible for setting norms and rules on global health matters, including
on pandemic response. The organization also develops and provides tools, guidance and training
protocols. In 1969, the World Health Assembly (WHA)—the governing body of WHO—adopted
the International Health Regulations (IHR) to stop the spread of six diseases through quarantine
and other infectious disease control measures. The WHA has amended the IHR several times, most
recently in 2005.20 The 2005 edition, known as IHR (2005), provided expanded means for
controlling infectious disease outbreaks beyond quarantine. The regulations include a code of
conduct for notification of and responses to disease outbreaks with pandemic potential, and carry
the expectation that countries (and their territories) will build the capacity, where lacking, to comply
with IHR (2005). The regulations mandate that WHO Member States
build and maintain public health capacities for disease surveillance and response;
18 UNOCHA, Global Humanitarian Response Plan COVID-19: United Nations Coordinated Appeal April – December
2020, March 2020.
19 Written by Tiaji Salaam-Blyther, Specialist in Global Health.
20 For more information on the IHR, see the IHR (2005) web page at https://www.who.int/ihr/about/en/.
Congressional Research Service
5
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
provide or facilitate technical assistance to help low-resource countries develop
and maintain public health capacities;
notify WHO of any event that may constitute a Public Health Emergency of
International Concern (PHEIC) and respond to requests for verification of
information regarding such event; and
follow WHO recommendations concerning public health responses to the
relevant PHEIC.
Per reporting requirements of the IHR (2005), China and other countries are monitoring and
reporting COVID-19 cases to WHO. Observers are debating the extent to which China is fully
complying with IHR (2005) reporting rules (see “Asia” and the Appendix).
How does WHO respond to countries that do not comply with IHR (2005)?
IHR (2005) does not have an enforcement mechanism. WHO asserts that “peer pressure and
public knowledge” are the “best incentives for compliance.”21 Consequences that WHO purports
non-compliant countries might face include a tarnished international image, increased morbidity
and mortality of affected populations, travel and trade restrictions imposed by other countries,
economic and social disruption, and public outrage.
China’s response to the COVID-19 outbreak may deepen debates about the need for an IHR
enforcement mechanism. On one hand, questions about the timeliness of China’s reporting of the
COVID-19 outbreak and questions about China’s transparency thereafter might bolster arguments
in favor of an enforcement mechanism. On the other hand, some have questioned whether the
WHA would vote to abdicate some of its sovereignty to provide WHO enforcement authority.
How does the Global Health Security Agenda (GHSA) relate to IHR (2005) and
pandemic preparedness?
IHR (2005) came into force in 2007, with signatory countries committing to comply by 2012. In
2012, only 20% of countries reported to the WHO that they had developed IHR (2005) core
capacities, and many observers asserted the regulations needed a funding mechanism to help
resource-constrained countries with compliance. In 2014, the WHO launched the Global Health
Security Agenda (GHSA) as a five-year (2014-2018) multilateral effort to accelerate IHR (2005)
implementation, particularly in resource-poor countries lacking the capacity to adhere to the
regulations. The GHSA appeared to advance global pandemic preparedness capacity; more than
70% of surveyed countries reported in 2017 being prepared to address a global pandemic.22
Regional disparities persisted, however; about 55% of surveyed countries in the WHO Africa
region reported being prepared for a pandemic, compared to almost 90% of countries surveyed in
the WHO Western Pacific region. In 2017, participating countries agreed to extend the GHSA
through 2024. For more information on the GHSA, see CRS In Focus IF11461, The Global
Health Security Agenda (GHSA): 2020-2024, by Tiaji Salaam-Blyther.
21 WHO, Frequently asked questions about the International Health Regulations (2005), 2009.
22 See WHO, Global Health Observatory (GHO) Data, IHR Core Capacities Implementation: Preparedness, at
https://www.who.int/gho/ihr/monitoring/preparedness/en/, accessed on March 30, 2020.
Congressional Research Service
6
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Multilateral Technical Assistance
What is WHO doing to respond to the COVID-19 pandemic?23
In February 2020, WHO released a $675 million Strategic Preparedness and Response Plan for
February through April 2020. WHO aims to provide international coordination and operational
support, bolster country readiness and response capacity—particularly in low-resource
countries—and accelerate research and innovation. As of May 8, private donors and 26 countries
have contributed $536.5 million towards the plan, including $30.3 million from the United
States.24 Countries have pledged an additional $198.5 million towards the plan. As of April 22,
WHO has used the funds to
purchase and ship personal protective equipment (PPE) to 133 countries,
including
2,566,880 surgical masks and masks,
1,641,900 boxes of gloves,
184,478 gowns,
29,873 goggles, and
79,426 face shields;
supply 1,500,000 diagnostic kits to 126 countries;
develop online COVID-19 training courses in 13 languages; and
enroll more than 100 countries in WHO-coordinated trials to accelerate
identification of an effective vaccine and treatment, which include
1,200 patients,
144 studies, and
6 candidate vaccines in clinical evaluation and 77 in preclinical evaluation.25
In April 2020, the WHO issued an updated plan that provided guidance for countries preparing
for a phased transition from widespread transmission to a steady state of low-level or no
transmission, among other things.26 The update did not include a request for additional funds.
Also in April 2020, the WHO hosted a virtual event with the President of France, the President of
the European Commission, and the Bill & Melinda Gates Foundation where heads of state, the
G20 President, the African Union Commission Chairperson, the U.N. Secretary General and
leaders from a variety of nongovernmental organizations, including Gavi, the Vaccine Alliance,
and the Coalition for Epidemic Preparedness and Innovation (CEPI), pledged their commitment
to the Access to COVID-19 Tools (ACT Accelerator).27 The participants, and other partners who
23 Written by Tiaji Salaam-Blyther, Specialist in Global Health.
24 WHO web page on funding for the COVID-19 response plan, https://www.who.int/emergencies/diseases/novel-
coronavirus-2019/donors-and-partners/funding, accessed on April 13, 2020. The U.S. contributions were provided
before President Donald Trump announced on April 15, 2020, that he is “placing a hold on all funding to the WHO
while its mismanagement of coronavirus pandemic is investigated.” See White House, “President Donald J. Trump is
Demanding Accountability from the World Health Organization,” Fact Sheet, April 15, 2020.
25 WHO web page on funding for the COVID-19 response plan, https://www.who.int/emergencies/diseases/novelcoronavirus-2019/donors-and-partners/funding, accessed on April 13, 2020.
26 WHO, COVID-19 Strategy Update, April 14, 2020.
27 WHO, “Global leaders unit to ensure everyone everywhere can access new vaccines, tests and treatments for
Congressional Research Service
7
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
have since joined the effort, committed to “work towards equitable global access” to COVID-19
countermeasures (including vaccines and therapies). A pledging conference, hosted by the
European Union (EU), took place on May 4 to support the effort. As of May 6, donors have
pledged $7.4 billion for the ACT Accelerator and other global COVID-19 responses. The United
States neither participated in the launch nor provided funding for the ACT Accelerator.
Debates about whether health commodities are a public good are long-standing and have
intensified in recent years. For decades, countries have willingly donated virus samples to the
WHO for international research. During a 2005-2007 H5N1 avian flu outbreak, however,
Indonesia refused to share samples of the virus, asserting that companies were selling patented
vaccines created from the donated samples at a price Indonesians could not afford.28 The WHO
and its Member States, through the WHA, have not yet developed an agreement that satisfies
poor countries concerned about affordability and wealthier countries (where most global
pharmaceutical companies are based) concerned about recapturing research and development
costs. The WHO has sought to negotiate prepurchasing agreement during each major outbreak
since the H5N1 debacle. French officials, for example, have characterized any COVID-19
commodity that might be developed as a “public good,” and they have criticized statements by a
French pharmaceutical company on committing to provide the U.S. government first access to a
COVID-19 vaccine that the company produces.29 The WHO has established the Solidarity Trial to
coordinate international COVID-19-related research and development. Participating parties,
including countries, pharmaceutical companies, and nongovernmental organizations, agree to
openly share virus information and commodities developed with donated specimens.30 The EU
and its Member States, and nine other countries, have drafted a resolution to be considered at the
upcoming World Health Assembly on a unified international COVID-19 response, including on
“the need for all countries to have unhindered timely access to quality, safe, efficacious and
affordable diagnostics, therapeutics, medicines and vaccines ... for the COVID-19 response.”31
How are international financial institutions responding to COVID-19?32
The international financial institutions (IFIs), including the International Monetary Fund (IMF),
the World Bank, and specialized multilateral development banks (MDBs), are mobilizing
unprecedented levels of financial resources to support countries grappling with the health and
economic effects of the COVID-19 pandemic.33 About 100 countries—more than half of the
COVID-19,” press release, April 24, 2020.
28 Kenan Mullis, “Playing Chicken with Bird Flu: Viral Sovereignty, the Right to Exploit Natural Genetic Resources,
and the Potential Human Rights Ramifications,” American University International Law Review, (2009); and Laurie
Garrett and David Fidler, “Sharing H5N1 Viruses to Stop a Global Influenza Pandemic,” PLoS Medicine, vol. 4, no. 11
(November 2007).
29 Sylvie Corbet, “Sanofi walks back after saying US would get vaccine first,” Associated Press News, May 14, 2020;
and Henri-Pierre André and Matthias Blamont, “Sanofi CEO pledges virus vaccine for all after French backlash,”
Reuters, May 14, 2020.
30 WHO webpage on the Solidarity Trials, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/globalresearch-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments, accessed on May 14, 2020.
31 Draft Resolution on a WHA73: “Covid-19 Response,” May 18, 2020.
32 Written by Rebecca Nelson and Martin Weiss, Specialists in International Trade and Finance. For more information,
see CRS Report R46342, COVID-19: Role of the International Financial Institutions, by Rebecca M. Nelson and
Martin A. Weiss.
33 International Monetary Fund, IMF Makes Available $50 Billion to Help Address Coronavirus, March 4, 2020; World
Bank, World Bank Group Announces Up to $12 Billion Immediate Support for COVID-19 Country Response¸ March 3,
2019.
Congressional Research Service
8
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
IMF’s membership—have requested IMF loans, and the IMF has announced it is ready to tap its
total lending capacity, about $1 trillion, to support governments responding to COVID-19.34 In
April 2020, the World Bank pledged to mobilize about $160 billion through 2021, and other
multilateral development banks committed about $80 billion over the same time period.35 MDB
support is expected to cover a wide range of activities, including strengthening health services
and primary health care, bolstering disease monitoring and reporting, training front-line health
workers, encouraging community engagement to maintain public trust, and improving access to
treatment for the poorest patients. In addition, at the urging of the IMF and the World Bank, the
G-20 countries in coordination with private creditors have agreed to suspend debt payments for
low-income countries through the end of 2020.
Policymakers are discussing a number of policy actions to further bolster the IFI response to the
COVID-19 pandemic. Examples include changing IFI policies to allow more flexibility in
providing financial assistance, pursuing policies at the IMF to increase member states’ foreign
reserves, and providing debt relief to low-income countries. Some of these policy proposals
would require congressional legislation. Through the stimulus legislation (P.L. 116-136),
Congress accelerated authorizations requested by the Administration in the FY2021 budget for
the IMF, two lending facilities at the World Bank, and two lending facilities at the African
Development Bank.
What is the U.N. humanitarian response to the COVID-19 pandemic?36
Outside of the WHO, other U.N. entities and their implementing partners are considering how to
maintain ongoing humanitarian operations while preparing for COVID-19 cases should they
arise.37 On March 17, 2020, the International Organization for Migration (IOM) and the U.N.
High Commissioner for Refugees (UNHCR) announced they were suspending global resettlement
travel for refugees due to the COVID-19 travel bans.38 Cessation of resettlement may reinforce
population density in refugee camps and other settlements, which might further complicate efforts
to address COVID-19 outbreaks in such settings.
Many experts agree that even prior to the COVID-19 pandemic, the scope of current global
humanitarian crises was unprecedented.39 The U.N. Office for the Coordination of Humanitarian
Affairs (UNOCHA) estimated that in 2020, nearly 168 million people in 53 countries would
require humanitarian assistance and protection due to armed conflict, widespread or
indiscriminate violence, and/or human rights violations.40 The 2020 U.N. global humanitarian
annual appeal totaled an all-time high of more than $28.8 billion, excluding COVID-19
responses.41 The appeal also focused on the needs of displaced populations, which numbered
34 IMF Managing Director Kristalina Georgieva, Remarks to the G20 Finance Ministers, April 15, 2020.
35 World Bank President David Malpass, “Remarks to G20 Finance Ministers,” April 15, 2020.
36 Written by Rhoda Margesson, Specialist in International Humanitarian Policy.
International Monetary Fund, “IMF Makes Available $50 Billion to Help Address Coronavirus,” March 4, 2020;
World Bank, “World Bank Group Announces Up to $12 Billion Immediate Support for COVID-19 Country
Response¸” March 3, 2019.
38 U.N. News, “COVID-19: Agencies Temporarily Suspend Refugee Resettlement Travel,” March 17, 2020.
39 UNOCHA, Global Humanitarian Overview 2020, December 2019.
40 U.N. Office for the Coordination of Humanitarian Assistance (UNOCHA), Global Humanitarian Overview 2020,
December 2019.
41 The United States is the largest humanitarian assistance donor, consistently providing nearly one-third of total global
contributions. It also often takes the lead in coordinating humanitarian policy and diplomacy.
37
Congressional Research Service
9
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
more than 70 million people, including 25.9 million refugees, 41.3 million internally displaced
persons (IDPs) and 3.5 million asylum seekers.42 In addition, natural disasters are also key drivers
of displacement each year.43
Humanitarian experts agree that the conditions in which vulnerable, displaced populations live
make them particularly susceptible to COVID-19 spread and present significant challenges to
response and containment.44 Overcrowded living spaces and insufficient hygiene and sanitation
facilities make conditions conducive to contagion.45 In many situations, disease control
recommendations are not practical. Space is not available to create isolation and “socialdistancing,” for example, and limited access to clean water and sanitation make regular and
sustained handwashing difficult.46 In addition, low or middle-income countries that are likely to
struggle to respond effectively to the pandemic host 85% of refugees worldwide.47 So far,
relatively few COVID-19 cases have been reported among the displaced and those affected by
conflict or natural disasters, although there is a widespread lack of testing.48
On March 25, 2020, the United Nations launched a $2.01 billion global appeal for the COVID-19
pandemic response to “fight the virus in the world’s poorest countries, and address the needs of
the most vulnerable people” through the end of the year.49 According to the United Nations, as of
early May, donors had so far provided $923 million toward the initial appeal and contributed
$608 million outside the plan.50 On May 7, 2020, the United Nations announced it had tripled the
appeal to $6.7 million and expanded its coverage to 63 countries as it became clear that COVID19’s “most devastating and destabilizing effects will be felt in the world’s poorest countries.”51
While the United Nations does not expect the pandemic to peak in the world’s poorest countries
for another three to six months, already there are reports of “incomes plummeting and jobs
42 Refugees are distinct from migrants because of their specific status and protections under international law. While
economic migrants, which numbered approximately 272 million in 2019 (approximately 3.5% of the global
population), move voluntarily often to leave poverty and unemployment to seek better opportunities or family
reunification, increasingly vulnerable migrants are forced to flee, which only compounds global displacement
challenges. International Organization for Migration (IOM), World Migration Report, 2020, November 27, 2019.
43 UNOCHA, Global Humanitarian Overview 2020, December 2019; Internal Displacement Monitoring Center, Global
Report on Internal Displacement 2019, May 10, 2019; International Rescue Committee, “Climate Change: Climate
Change Displacement is Happening Now,” March 19, 2019; UNHCR, “Climate Change and Displacement,” October
15, 2019.
44 Kurtzer, Jacob, “The Impact of COVID-19 on Humanitarian Crises,” CSIS: Critical Questions, March 19, 2020;
Colum Lynch and Robbie Gramer, “The Next Wave: U.N. and Relief Agencies Warn the Coronavirus Pandemic Could
Leave an Even Bigger Path of Destruction in the World’s Most Vulnerable and Conflict-riven Countries,” Foreign
Policy, March 23, 2020; Roald, Høvring, “Ten Things You Should Know About Coronavirus and Refugees, Norwegian
Refugee Council, March 16, 2020.
45 For example, this includes displaced populations caught in conflict in northwest Syria, crowded camps such as those
in Bangladesh and the Dadaab camp in Kenya, and a highly vulnerable population in Yemen that is on the brink of
famine and facing cholera outbreaks.
46 The New Humanitarian, “Behind the Headlines: How will COVID-19 impact crisis zones?” Live Stream, March 19,
2020.
47
UNHCR, Global Trends in Forced Displacement, June 19, 2019 (data for 2018, which is the latest available.)
48 Low or middle-income countries host 85% of refugees worldwide. UNHCR, Global Trends in Forced Displacement,
June 19, 2019 (data for 2018, which is the latest available.) See also, CDC, “Coronavirus Disease 2019 (COVID-19),
World Map: Locations with Confirmed COVID-19 Cases, by WHO Region,” March 24, 2020.
49 UNOCHA, Global Humanitarian Response Plan COVID-19: United Nations Coordinated Appeal April – December
2020, March 25, 2020.
50 UNOCHA, Global Humanitarian Response Plan COVID-19: United Nations Coordinated Appeal April-December
2020, May update, May 7, 2020.
51 Ibid.
Congressional Research Service
10
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
disappearing, food supplies falling and prices soaring, and children missing vaccinations and
meals.”52 The updated plan brings together humanitarian appeals from other U.N. agencies in an
effort to coordinate emergency health and humanitarian responses (see Table 3).
UNOCHA will coordinate the U.N.-wide response, but most of the activities will be carried out
by specific U.N. entities, non-governmental organizations, and other implementing partners. U.N.
guidance for scaling up responses in refugee and IDP settings includes addressing mental health
and psychological aspects, adjusting food distribution, and developing prevention and control
mechanisms in schools.53 Some experts recommend incorporating COVID-19 responses within
existing humanitarian programs to ensure continuity of operations and to protect aid personnel
while facilitating their access in areas where travel has been restricted.54
Table 3. United Nations COVID-19 Appeal: April-December 2020
(current U.S. $ millions)
Type of Response Plan
Health
Nonhealth
Total
0.0
0.0
1,010
1,300
2,180
3,490
Regional Refugee Response Plans
265
729
994
Regional Refugee and Migrant Response Plan
132
306
439
Other plans
92
65
157
New plans
235
394
629
2,024
3,674
6,708
Global support services
Humanitarian Response Plans
Total
Source: UNOCHA, Global Humanitarian Response Plan COVID-19: United Nations Coordinated Appeal April –
December 2020, May Update, May 7, 2020.
Notes: Each U.N. agency’s role in implementing the plan is described briefly on pp. 40-43 of the above cited
report.
U.S. Support for International Responses
On January 29, 2020, President Donald Trump announced the formation of the President’s
Coronavirus Task Force, led by the Department of Health and Human Services (HHS) and
coordinated by the White House National Security Council (NSC).55 On February 27, the
President appointed Vice President Michael Pence as the Administration’s COVID-19 task force
leader, and the Vice President subsequently appointed the head of the President’s Emergency Plan
for AIDS Relief (PEPFAR), Ambassador Deborah Birx, as the White House Coronavirus
52 UN News, “COVID-19: UN and partners launch $6.7 billion appeal for vulnerable countries,” press release, May 7,
2020.
53 Inter-Agency Standing Committee, COVID-19 Outbreak Readiness and Response, accessed March 24, 2020.
54 The New Humanitarian, “Behind the Headlines: How will COVID-19 impact crisis zones?” Live Stream, March 19,
2020; Colum Lynch and Robbie Gramer, “The Next Wave: U.N. and Relief Agencies Warn the Coronavirus Pandemic
Could Leave an Even Bigger Path of Destruction in the World’s Most Vulnerable and Conflict-riven Countries,”
Foreign Policy, March 23, 2020.
55 White House, Statement from the Press Secretary Regarding the President’s Coronavirus Task Force, Washington,
DC, January 29, 2020.
Congressional Research Service
11
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Response Coordinator.56 International COVID-19 response efforts carried out by U.S. federal
government departments and agencies, including those in the Task Force, are described below.57
Emergency Appropriations for International Responses58
On March 6, 2020, the President signed into law P.L. 116-123, Coronavirus Preparedness and
Response Supplemental Appropriations Act of 2020, which provides $8.3 billion for domestic and
international COVID-19 response.59 The Act includes $300 million to continue the CDC’s global
health security programs and a total of $1.25 billion for the U.S. Agency for International
Development (USAID) and Department of State. USAID- and Department of State-administered
aid includes the following:
Global Health Programs (GHP). $435 million for global health responses (see
“U.S. Agency for International Development (USAID)”), including $200 million
for USAID’s Emergency Reserve Fund (ERF).60
International Disaster Assistance (IDA). $300 million for relief and recovery
efforts in the wake of the COVID-19 pandemic.
Economic Support Fund (ESF). $250 million to address COVID-19-related
“economic, security, and stabilization requirements.”
The Act also provides $1 million to the USAID Office of Inspector General to support oversight
of COVID-19-related aid programming.
On March 27, 2020, President Trump signed P.L. 116-136, Coronavirus Aid, Relief, and
Economic Security Act, which contains emergency funding for U.S. international COVID-19
responses, including the following:
International Disaster Assistance (IDA). $258 million to “prevent, prepare for,
and respond” to COVID-19.
Migration and Refugee Assistance (MRA). $350 million to the State
Department-administered MRA account to “prevent, prepare for, and respond” to
COVID-19.
56 White House, Remarks by President Trump, Vice President Pence, and Members of the Coronavirus Task Force in
Press Conference, Washington, DC, February 27, 2020. White House, Vice President Pence Announces Ambassador
Debbie Birx to Serve as the White House Coronavirus Response Coordinator, Washington, DC, February 27, 2020.
57 Members of the Task Force include: Dr. Deborah Birx, White House Coronavirus Response Coordinator; Secretary
Alex Azar, HHS; Robert O’Brien, Assistant to the President for National Security Affairs; Dr. Robert Redfield, CDC
Director; Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at NIH, Deputy
Secretary Stephen Biegun, Department of State, Ken Cuccinelli, Acting Deputy Secretary Department of Homeland
Security, Joel Szabat, Acting Under Secretary for Policy, Department of Transportation; Matthew Pottinger, Assistant
to the President and Deputy National Security Advisor; Rob Blair, Assistant to the President and Senior Advisor to the
Chief of Staff; Joseph Grogan, Assistant to the President and Director of the Domestic Policy Council; Christopher
Liddell, Assistant to the President and Deputy Chief of Staff for Policy Coordination; and Derek Kan, Executive
Associate Director, Office of Management and Budget (OMB).
58 Written by Sara Tharakan, Analyst in Global Health.
59 This section focuses on funds specified by Congress for international activities. Funds from other sources, such as the
Infectious Disease Rapid Response Reserve Fund (IDRRF), may be made available for international responses.
60 Congress authorized the ERF through the Consolidated Appropriations Act of 2017, P.L. 115-31, “to enable the
United States and the international public health community to respond rapidly to emerging health threats.”
Congressional Research Service
12
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
U.S. Department of State61
How does the State Department help American citizens abroad?
Section 43 of the State Department Basic Authorities Act of 1956 (P.L. 84-885; hereinafter, the
Basic Authorities Act) requires the State Department to serve as a clearinghouse of information
on any major disaster or incident that affects the health and safety of U.S. citizens abroad.62 The
department implements this statutory responsibility through its Consular Information Program
(CIP), which provides a range of products, including but not limited to country-specific
information web pages, Travel Advisories, Alerts, and Worldwide Cautions. Travel Advisories
range from Level 1 (Exercise Normal Precautions) to Level 4 (Do Not Travel).
On March 31, 2020, the State Department issued an updated Level 4 Global Health Advisory
advising U.S. citizens to avoid all international travel due to the global impact of COVID-19.63
Level 4 Travel Advisories do not constitute a travel ban. Instead, they advise U.S. citizens not to
travel because of life threatening risks and, in some cases, limited U.S. government capability to
provide assistance to U.S. citizens.64 The State Department’s Level 4 Global Health Advisory
notes that because the State Department has authorized the departure of U.S. personnel abroad
who are “at higher risk of a poor outcome if exposed to COVID-19,” U.S. embassies and
consulates may have more limited capacity to provide services to U.S. citizens abroad.65
CIP products are posted online and disseminated to U.S. citizens who have registered to receive
such communications through the Smart Traveler Enrollment Program (STEP). The Assistant
Secretary for Consular Affairs is responsible for supervising and managing the CIP. 66 State
Department regulations provide that when health concerns rise to the level of posing a significant
threat to U.S. citizens, the State Department will publish a web page describing the health-related
threat and resources.67 The Bureau of Consular Affairs has developed such a web page for the
COVID-19 pandemic.68 Additionally, the State Department has created a website providing
COVID-19-related information and resources for every country in the world.69 Furthermore, on
March 24, 2020, the State Department began publishing a daily COVID-19 newsletter, developed
for Members of Congress and congressional staff, intended to “dispel rumor, combat
misinformation, and answer any outstanding questions regarding the Department’s overseas crisis
response efforts.”70
61 Written by Cory Gill, Analyst in Foreign Affairs.
62 See 22 U.S.C. §2715.
63
U.S. Department of State, “Global Level 4 Health Advisory – Do Not Travel.”
64 U.S. Department of State, “7 FAM 042 Appendix A: Travel Advisory Information,” Foreign Affairs Manual.
65 U.S. Department of State, “Global Level 4 Health Advisory – Do Not Travel.”
66 U.S. Department of State, “7 FAM 000 Appendix A: Consular Information Program,” Foreign Affairs Manual.
67 U.S. Department of State, “7 FAM 057.1 Appendix A: Health Information Definition,” Foreign Affairs Manual.
68 U.S. Department of State, “Current Outbreak of Coronavirus Disease 2019.”
69 U.S. Department of State, “COVID-19 Country Specific Information.”
70 U.S. Department of State, “Coronavirus Congressional Information.”
Congressional Research Service
13
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
What are the authorities and funding for the State Department to carry out
overseas evacuations?
The Omnibus Diplomatic Security and Antiterrorism Act of 1986 (P.L. 99-399) authorizes the
Secretary of State to carry out overseas evacuations. Section 103 of this law requires the
Secretary to “develop and implement policies and programs to provide for the safe and efficient
evacuation of United States Government personnel, dependents, and private United States
citizens when their lives are endangered.”71 In addition, the Basic Authorities Act authorizes the
Secretary to make expenditures for overseas evacuations. Section 4 of this law authorizes both
expenditures for the evacuation of “United States Government employees and their dependents”
and “private United States citizens or third-country nationals, on a reimbursable basis to the
maximum extent practicable,” leaving American citizens or third-country nationals generally
responsible for the cost of evacuation, although emergency financial assistance may be available
for destitute evacuees.72 Furthermore, the Basic Authorities Act limits the scope of repayment to
“a reasonable commercial air fare immediately prior to the events giving rise to the evacuation.”73
In practice, even when the State Department advises private U.S. citizens to leave a country, it
will advise them to evacuate using existing commercial transportation options whenever possible.
This is reflected in the State Department’s current Level 4 Global Health Advisory, which states
that “[i]n countries where commercial departure options remain available, U.S. citizens who live
in the United States should arrange for immediate return.”74 In more rare circumstances, when the
local transportation infrastructure is compromised, the State Department will arrange chartered or
non-commercial transportation for U.S. citizens to evacuate to a safe location determined by the
department. Following the outbreak of COVID-19, the State Department has made such
arrangements for thousands of U.S. citizens throughout the world, initially those in Wuhan, China
and, shortly thereafter, U.S. citizen passengers who were quarantined on the Diamond Princess
cruise ship in Yokohama, Japan. As demand for repatriation surged, the State Department
leveraged new options to evacuate U.S. citizens, including “commercial rescue flights.” To
facilitate these flights, the department worked with the airline industry to help them secure the
needed clearances to carry out evacuation flights in high-demand countries.75 The State
Department said that these flights enabled it to focus its own resources to send chartered flights
where “airspace, border closures, and internal curfews have been the most severe.”76 While
evacuations are still ongoing, the department estimated in late April that around 40% of U.S.
citizens who were evacuated for reasons related to COVID-19 returned to the United States on
commercial rescue flights.77
71 See 22 U.S.C. §4802.
72 See 22 U.S.C. §2671
73 See 22 U.S.C. §2671.
74 U.S. Department of State, “Global Level 4 Health Advisory – Do Not Travel.”
75 U.S. Department of State, “Briefing With Dr. William Walters, Deputy Chief Medical Officer for Operations, Bureau
of Medical Services; Deputy Assistant Secretary Hugo Yon, Bureau of Economic and Business Affairs; and Principal
Deputy Assistant Secretary Ian Brownlee, Bureau of Consular Affairs On COVID-19: Updates on Health Impact and
Assistance for American Citizens Abroad.”
76 U.S. Department of State, “Briefing on COVID-19: Updates on Health Impact and Assistance for American Citizens
Abroad, April 3, 2020.”
77 U.S. Department of State, “Briefing with Dr. William Walters, Deputy Chief Medical Officer for Operations, Bureau
of Medical Services, and Principal Deputy Assistant Secretary Ian Brownlee, Bureau of Consular Affairs, on COVID19: Updates on Health Impact and Assistance for American Citizens Abroad.”
Congressional Research Service
14
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Congress authorizes funding for the evacuation-related activities through the Emergencies in the
Diplomatic and Consular Service (EDCS) account, which is part of the annual Department of
State, Foreign Operations, and Related Programs (SFOPS) appropriation. For FY2020, Congress
appropriated $7.9 million for this account.78 Congress typically funds this account through noyear appropriations, thereby authorizing the State Department to indefinitely retain funds.79 The
State Department is able to further fund emergency evacuations using transfer authorities
provided by Congress. In recent SFOPS appropriations, for example, Congress has authorized the
State Department to transfer and merge funds appropriated to the Diplomatic Programs, Embassy
Security, Construction, and Maintenance, and EDCS accounts for emergency P.L. 116-123,
evacuations.80
In addition to the funds and transfer authorities provided in annual appropriations legislation,
Congress appropriated an additional $588 million for State Department operations (including
$264 million appropriated through P.L. 116-123 and $324 million appropriated through P.L. 116136) to “prevent, prepare for, and respond to coronavirus,” including by carrying out evacuations.
P.L. 116-123 also increased the amount of funding the State Department is authorized to transfer
from the Diplomatic Programs account to the EDCS account for emergency evacuations during
FY2020 from $10 million to $100 million.81
How many evacuations have been carried out due to the COVID-19 pandemic?
The State Department began arranging evacuations of U.S. government personnel and private
U.S. citizens in response to the COVID-19 pandemic on January 28, 2020, when the department
started evacuating over 800 American citizens from Wuhan, China. An additional 300 American
citizens who were passengers aboard the Diamond Princess cruise ship were subsequently
evacuated in February. When COVID-19 continued to spread and was declared a global pandemic
by WHO, the State Department accelerated its efforts to evacuate Americans amid actions by
countries to close their borders and implement mandatory travel restrictions. On March 19, 2020,
the State Department established a repatriation task force to coordinate and support these efforts.
As of May 11, 2020, the State Department had coordinated the repatriation of more than 85,000
Americans on 886 flights.82 The State Department’s current Level 4 Global Health Advisory
warns that while the department is “making every effort to assist U.S. citizens overseas who wish
to return to the United States, funds “may become more limited or even unavailable.”83 Some
Members of Congress have applauded the State Department’s efforts to scale up consular
assistance to U.S. citizens abroad during the COVID-19 pandemic. Other Members have
expressed concern that as COVID-19 spread worldwide, the State Department was slow to
communicate with and provide options to Americans abroad seeking repatriation.84
78 See Division G, Title I, of P.L. 116-94.
79 White House, Office of Management and Budget, “A Budget for America’s Future,” Appendix, p. 813. As a result,
the department has carried over large balances of unexpired, unobligated EDCS funds each year. Prior to the onset of
the COVID-19 pandemic, the Office of Management and Budget (OMB) estimated that the State Department would
carry forward $248 million in EDCS funds in FY2021.
80 See Section 7009(a) of P.L. 116-94.
81 See Section 403 of P.L. 116-123.
82 U.S. Department of State, “Department of State Coronavirus Repatriation Statistics.”
83 U.S. Department of State, “Global Level 4 Health Advisory – Do Not Travel.”
84 Sam Mintz, "Americans remain stranded abroad as State Department struggles to respond," Politico, March 25, 2020.
Congressional Research Service
15
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
U.S. Agency for International Development (USAID)85
Where is USAID providing COVID-19 assistance?
USAID is providing assistance to more than 100 affected and at-risk developing countries facing
the threat of COVID-19.86 USAID identified these countries through a combination of the
following criteria:
trend of increasing confirmed cases of COVID-19, especially with evidence of
local transmission;
imported cases with high risk for local transmission due to connectivity to a
hotspot;
low scores on the Global Health Security Index87 classification of health systems
and on the Global Health Security Agenda Joint External Evaluation, which
measures compliance with IHR (2005);
other vulnerabilities (unstable political situation, displaced populations); and
the existence of other U.S. global health programs that could be leveraged.
USAID is also providing funding to multilateral organizations, including the WHO, UNICEF, and
the International Federation of the Red Cross and Red Crescent Societies for COVID-19
assistance, and to facilitate coordination with other donors.
What type of assistance does USAID provide for COVID-19 control?
On February 7, 2020, USAID committed $99 million from the Emergency Reserve Fund (ERF)
for Contagious Infectious Diseases. USAID received $986 million from the first emergency
supplemental appropriation and an additional $353 million from the second. Examples of
activities to which USAID resources will be programed include
assisting target countries to prepare their laboratories for COVID-19 testing,
implementing a public-health emergency plan for points of entry,
activating case-finding and event-based surveillance for influenza-like illnesses,
training and equipping rapid-response teams,
investigating cases and tracing the contacts of infected persons, and
adapting health worker training materials for COVID-19.
As of May 1, 2020, USAID pledged to provide $653 million for international COVID-19
response, $215 million of which has been obligated.88 The pledged amounts include $99 million
85 Written by Tiaji Salaam-Blyther, Specialist in Global Health.
86 Countries include: Afghanistan, Albania, Angola, Armenia, Azerbaijan, Bangladesh, Belarus, Bosnia and
Herzegovina, Burkina Faso, Burma, Cambodia, Cameroon, the Caribbean, Central Africa Republic, Colombia, Cote
d’Ivoire, Democratic Republic of the Congo, Ethiopia, Georgia, Haiti, India, Indonesia, Iraq, Jamaica, Kazakhstan,
Kenya, Kosovo, Kyrgyzstan, Laos, Libya, Moldova, Mongolia, Morocco, Mozambique, Nepal, Nigeria, North
Macedonia, Pacific Islands, Pakistan, Papua New Guinea, Philippines, Rwanda, Senegal, Serbia, Somalia, South
Africa, South Sudan, Sri Lanka, Sudan, Syria, Tajikistan, Tanzania, Thailand, Timor Leste, Tunisia, Turkmenistan,
Ukraine, Uzbekistan, Venezuela, Vietnam, Zambia, Zimbabwe, and Regional Efforts in Asia. See U.S. Department of
State Fact Sheet “Humanitarian and Health Assistance Response to COVID-19” March 26, 2020.
87 For more information on the Global Health Security Index, see https://www.nti.org/about/projects/global-healthsecurity-index/.
88 USAID, COVID-19-Global Response, Fact Sheet #2, Fiscal Year 2020, May 5, 2020.
Congressional Research Service
16
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
from the ERF, $100 million from the Global Health Programs (GHP) account, $300 million in
humanitarian assistance from the International Disease Assistance (IDA) account, and $153
million from the Economic Support Fund (ESF).
How do USAID COVID-19 responses relate to regular pandemic preparedness
activities?
Congress appropriates funds for USAID global health security and pandemic preparedness
activities through annual State, Foreign Operations, and Related Programs appropriations (Table
4). From FY2009 through FY2019, the bulk of USAID’s pandemic preparedness activities have
been implemented through the Emerging Pandemic Threats (EPT) program. Those efforts
comprised USAID’s contribution towards advancing the Global Health Security Agenda (see
“International Health Regulations”) and are being leveraged for COVID-19 responses worldwide.
Key related activities include
strengthening surveillance systems to detect and report disease transmission;
upgrading veterinary and other national laboratories;
strengthening programs to combat antimicrobial resistance (AMR) in the public
health and animal-health sectors;
training community health volunteers in epidemic control and designing
community-preparedness plans;
conducting simulation exercises to prepare for future outbreaks; and
establishing or strengthening emergency supply-chain programs specially
designed to deliver critically needed commodities (e.g., personal protective
equipment) to affected communities during outbreaks.
The PREDICT project was a key part of the EPT program. According to USAID, the second
phase of the project, PREDICT-2 (2015-2019), helped nearly 30 countries detect and discover
viruses with pandemic potential. The project has
detected more than 1,100 unique viruses, 931 of which were novel viruses (such
as Ebola and coronaviruses);
sampled over 163,000 animals and people; and
provided $207 million from 2009 through 2019.
USAID has responded to 42 outbreaks through PREDICT-2, which ended in March 2020
(following a three-month extension). In May 2020, USAID announced that it will use the lessons
learned through PREDICT to inform its new STOP Spillover project. The STOP Spillover project
is aimed at building capacity in partner countries to stop the spillover of zoonotic diseases into
humans. USAID aims to “award the STOP Spillover project by the end of September 2020,
through a competitive process, as PREDICT sunsets as scheduled.”89
89 USAID, “USAID: Investments in Global Health Security By the U.S. Agency for International Development,” Fact
Sheet, May 7, 2020.
Congressional Research Service
17
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Table 4. USAID Global Pandemic Preparedness Funding: FY2017-FY2021 Request
(current U.S. $ millions)
Fiscal Year
Amount
FY2017 Enacted
72.5
FY2018 Enacted
72.5
FY2019 Enacted
100.0
FY2020 Enacted
100.0
FY2021 Requested
115.0
Source: Congressional budget justifications and appropriations legislation.
Notes: Excludes emergency appropriations for controlling the 2014-2016 Ebola outbreak in West Africa.
U.S. Centers for Disease Control and Prevention (CDC)90
What role is CDC playing in international COVID-19 responses?
CDC has staff stationed in more than 60 countries who have been providing technical support,
where relevant, and is receptive to bilateral requests for assistance or requests for assistance
through the Global Outbreak Alert and Response Network (GOARN). CDC is working with
WHO and other partners, including USAID and the Department of State, to assess needs and
accelerate COVID-19 control, particularly by helping countries to implement WHO
recommendations related to the diagnosis and care of patients, tracking the epidemic, and
identifying people who might have COVID-19.
Through supplemental appropriations (P.L. 116-123), Congress provided CDC $300 million for
global disease detection and emergency response. CDC plans to obligate $150 million of the
funds by the end of FY2020. Related efforts will focus on
disease surveillance,
laboratory diagnostics,
infection prevention and control,
border health and community mitigation, and
vaccine preparedness and disease prevention.
CDC is reportedly working closely with USAID and Department of State to ensure a coordinated
U.S. government approach to the COVID-19 pandemic. CDC is prioritizing countries based on
the current status of COVID-19 in country and future trajectory of its spread;
the ability to effectively implement activities given CDC presence, capacity and
partnerships in the country; and
the capacity to provide support to other countries in the region.
CDC staff are working with colleagues in partner countries to conduct investigations that will
help inform COVID-19 response efforts.
90 Written by Tiaji Salaam-Blyther, Specialist in Global Health.
Congressional Research Service
18
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
How do CDC COVID-19 responses relate to regular pandemic preparedness
activities?
Through the Global Health Protection line item of annual Labor-HHS appropriations, CDC works
to enhance public health capacity abroad and improve global health security, particularly through
GHSA (Table 5). CDC works to bolster global health security and pandemic preparedness in 19
countries by focusing on enhancing the core foundations of what CDC views as strong public
health systems—comprehensive disease surveillance and integrated laboratory systems, a strong
public health workforce, and capable emergency management structures.
Programs within CDC’s global health security portfolio include the following:
The Field Epidemiology Training Program (FETP) trains a global workforce
of field epidemiologists to increase countries’ ability to detect and respond to
disease threats, address the global shortage of skilled epidemiologists, and
deepen relationships between CDC and other countries. Over 70 countries have
participated in FETP with more than 10,000 graduates.
National Public Health Institutes (NPHI) help more than 26 partner countries
carry out essential public health functions and ensure accountability for public
health resources. The program focuses on improving the collection and use of
public health data, as well as the development, implementation, and monitoring
of public health programs.
Global Rapid Response Team (GRRT) is a team of public health experts who
remain ready to deploy for supporting emergency response and helping partner
countries achieve core global health capabilities. The GRRT focuses on fieldbased logistics, communications, and management operations. Since the GRRT’s
inception, more than 500 CDC staff have provided over 30,000 person-days of
response support. From January through March 2020, CDC staff has completed
more than 100 deployments for COVID-19 response. Core and surge members
support domestic deployments to quarantine stations and repatriation sites,
international deployments, WHO and country office operations, and the
Emergency Operations Center in Atlanta.
The Public Health Emergency Management (PHEM) program trains public
health professionals affiliated with international ministries of health on
emergency management and exposes them to the CDC Public Health Emergency
Operations Center. To date, the program has graduated 142 fellows from 37
countries (plus the African Union).
Table 5. CDC Global Pandemic Preparedness Funding: FY2017-2020 Enacted
(current U.S. $ millions)
Fiscal Year
Amount
FY2017 Enacted
58.2
FY2018 Enacted
108.2
FY2019 Enacted
108.2
FY2020 Enacted
183.2
Source: Correspondence with CDC, March 27, 2020.
Notes: In the Labor, HHS Appropriations, these activities are described as Global Public Health Protection. For
the purposes of this report, these activities are referred to as pandemic preparedness.
Congressional Research Service
19
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
U.S. Department of Defense (DOD)
What is the DOD global COVID-19 response?91
DOD is conducting medical surveillance for COVID-19 worldwide.92 Related activities entail
daily monitoring of reported cases, including persons under investigation (PUI), confirmed cases,
and locations of such individuals,93 as well as surveillance for COVID-19 at China’s southern
border.94 DOD is supporting the U.S. CDC with additional laboratory capabilities. The DOD
Laboratory Network, which includes military facilities in the United States and in certain
overseas locations, has made available to interagency network laboratories its “detection and
characterization capabilities … to support COVID-19-related activities across the globe.”95 The
Secretary of Defense also has directed geographic combatant commanders96 to “execute their
pandemic plans in response to the [COVID-19] outbreak.”97
Emergency Appropriations for DOD Responses98
The Families First Coronavirus Response Act (P.L. 116-127) became law on March 18, 2020.
Title II of Division A of the act included $82 million for the Defense Health Program to waive all
TRICARE cost-sharing requirements related to COVID-19.99
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136) became law
on March 27, 2020. Title III of Division B of the act included $10.5 billion in emergency funding
91 Written by Bryce H.P. Mendez, Analyst in Defense Health Care Policy.
92 DOD defines health surveillance as “regular or repeated collection, analysis, and interpretation of health-related data
and the dissemination of information to monitor health of a population and to identify potential risks to health, thereby
enabling timely interventions to prevent, treat, or control disease and injury.” DOD defines medical surveillance as
“ongoing, systematic collection, analysis, and interpretation of data derived from instances of medical care or medical
evaluation, and the reporting of population-based information for characterizing and countering threats to a
population’s health, well-being, and performance.” DOD Directive 6490.02, Comprehensive Health Surveillance,
updated August 28, 2017, p. 11.
93 Military Health System (MHS), “MHS prepared to support interagency coronavirus response,” February 6, 2020.
The Defense Health Agency’s Armed Forces Health Surveillance Branch is conducting the daily monitoring. For more
on this branch, see https://health.mil/Military-Health-Topics/Combat-Support/Armed-Forces-Health-SurveillanceBranch/Global-Emerging-Infections-Surveillance-and-Response.
94 Ibid. Naval Medical Research Unit-2 in Phnom Penh, Cambodia is performing this surveillance activity. For more on
the research unit, see https://www.med.navy.mil/sites/nmrca/SitePages/Home.aspx.
95 MHS, “MHS prepared to support interagency coronavirus response,” February 6, 2020. For more on the DOD
Laboratory Network and interagency network laboratories, see https://www.icln.org/about/index.html.
96 Combatant commanders lead U.S. military operations in certain geographic areas of responsibility. For more on
combatant commanders, see CRS In Focus IF10542, Defense Primer: Commanding U.S. Military Operations, by
Kathleen J. McInnis.
97 Certain military orders directing the planning or execution of military operations are often classified or not made
public. However, references are made to a “SECDEF-approved EXORD [execute order] that directs USNORTHCOM
to execute its pandemic plan 3551-13 and supporting geographic combatant commanders to execute their pandemic
plans in response to the NCoV outbreak” in U.S. Navy, Naval Administrative Message 039/20, “Updated DOD
Guidance for Monitoring Personnel Returning from China during the Novel Coronavirus Outbreak,” February 11,
2020. Also see, U.S. Marine Corps, Marine Corps Administrative Message 082/20, “U.S. Marine Corps Disease
Containment Preparedness Planning Guidance for 2019 Novel Coronavirus (2019 nCoV), February 11, 2020.
98 Written by Brendan W. McGarry, Analyst in U.S. Defense Budget.
99 DOD's Military Health System (MHS) offers health care benefits and services through its TRICARE program to
approximately 9.5 million beneficiaries composed of servicemembers, military retirees, and family members. For more
information, see CRS In Focus IF10530, Defense Primer: Military Health System, by Bryce H. P. Mendez.
Congressional Research Service
20
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
for DOD. Of the $10.5 billion, $4.9 billion (47%) is for the Defense Health Program (DHP),
according to the bill text. The DHP funding included $1.8 billion for patient care and procurement
of medical and protective equipment; $1.6 billion to increase capacity in military treatment
facilities; $1.1 billion for private-sector care; and $415 million to develop vaccines and to procure
diagnostic tests, according to a summary released by the Senate Appropriations Committee.100
H.R. 748 also provided
$2.5 billion for the defense industrial base, including $1.5 billion in defense
working capital funds and $1 billion in Defense Production Act purchases;
$1.9 billion in operations and maintenance (O&M) funding for the Services, in
part to support deployment of the hospital ships USNS COMFORT and USNS
MERCY to ease civilian hospital demand by caring for non-COVID patients; and
$1.2 billion in military personnel (MILPERS) funding for Army and Air National
Guard personnel deployments.
DOD has not detailed how much of the emergency funding may be used to support international
activities related to COVID-19, though DOD has stated it is working with the Department of
Health and Human Services and the Department of State to provide support in dealing with the
pandemic.101 As part of missions that began in March, Air National Guard C-17 cargo aircraft
have transported hundreds of thousands of coronavirus testing swabs from Italy to the United
States.102 The swabs have been distributed to medical facilities around the country at the direction
of the Department of Health and Human Services.103
To what extent is COVID-19 affecting United States security personnel?104
The degree to which U.S. security operations around the world may be affected due to personnel
becoming infected has yet to be determined.105 Numerous media reports suggest that various parts
of the U.S. military have seen a significant number of servicemembers contract or die from
COVID-19 related symptoms. Citing operational security concerns, on March 30, 2020 the
Department of Defense (DOD) directed military service commanders not to share the number of
personnel affected by the COVID-19. In justifying this policy the DOD stated, “We will not
report the aggregate number of individual service member cases at individual unit, base or
Combatant Commands. We will continue to do our best to balance transparency in this crisis with
operational security.”106 Also, as of April 1, 2020, reportedly the Department of Homeland
Security had nearly 9,000 employees whose exposure to COVID-19 that has taken them out of
100 U.S. Congress, Senate Committee on Appropriations, “Shelby Urges Swift Passage of Comprehensive Coronavirus
Bill,” press release, March 25, 2020.
101 Department of Defense, Coronavirus: DOD Response website, accessed April 17, 2020.
102 Department of Defense, Department of the Air Force, Air National Guard, Tennessee Air National Guard, “Two
Memphians bring much-needed supplies home,” press release, April 3, 2020.
103 Ellen Mitchell, “Air Force moves 500K coronavirus test swabs from Italy to US,” The Hill, March 18, 2020.
104 Written by John Rollins, Specialist in Terrorism and National Security.
105 The section of the paper focuses on personnel-related issues as it pertains to conducting normal operations. Another
significant concern, not addressed in this section, entails the possible redirection of personnel and financial and
equipment resources redirected from traditional security missions to address COVID-19 concerns.
106 Ellen Mitchell, “Pentagon orders military bases to stop releasing specific COVID-19 numbers,” March 30, 2020.
Congressional Research Service
21
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
the workforce,107 and deployed U.S. Naval vessels, such as the USS Theodore Roosevelt, have
had their operational effectiveness called into question.108
Regional Implications of and Responses to the
COVID-19 Pandemic
Asia
What are the implications for U.S.-China relations?109
U.S.-China relations were fraught well before the outbreak of COVID-19, with the two
governments engaging in a bitter trade war, competing for influence around the globe, and
clashing over such issues as their activities in the South China Sea, China’s human rights record,
and China’s Belt and Road Initiative. The pandemic appears to have increased the acrimony. On
February 3, when the COVID-19 outbreak was at its peak in China, a spokesperson for China’s
Foreign Ministry blasted the United States for its response to the crisis there. “The U.S.
government hasn’t provided any substantive assistance to us, but it was the first to evacuate
personnel from its consulate in Wuhan, the first to suggest partial withdrawal of its embassy staff,
and the first to impose a travel ban on Chinese travelers,” the spokesperson charged. “What it has
done could only create and spread fear.”110 Days later, Secretary of State Michael R. Pompeo
announced the United States would make available up to $100 million in existing funds “to assist
China and other impacted countries,” and that the State Department had facilitated the delivery to
China of 17.8 tons of personal protection equipment and medical supplies donated by the private
sector.111
As COVID-19 transmission has accelerated in the United States, the Trump Administration has
stepped up criticism of China’s early response to the outbreak. Secretary Pompeo told an
interviewer on March 24, “unfortunately, the Chinese Communist Party covered this up and
delayed its response in a way that has truly put thousands of lives at risk.”112 Spokespeople for the
State Department and China’s Foreign Ministry have traded COVID-19-related accusations on
Twitter. On March 12, a Chinese spokesperson tweeted, “It might be US army who brought the
epidemic to Wuhan.”113 Secretary Pompeo accused China of waging a disinformation campaign
107 Molly O’Toole, “Coronavirus has sidelined roughly 9,000 Homeland Security employees, internal report shows,” April
1, 2020.
108 Lucy Craymer, “Virus Grounds a U.S. Aircraft Carrier as Crew Quarantined in Guam,” The Wall Street Journal,
April 1, 2020.
109 Written by Susan V. Lawrence, Specialist in Asian Affairs.
110 Ministry of Foreign Affairs of the People’s Republic of China, “Foreign Ministry Spokesperson Hua Chunying's
Daily Briefing Online,” February 3, 2020.
111 U.S. Embassy and Consulates in China, “The United States Announces Assistance to the COVID-19,” February 7,
2020.
112 U.S. Department of State, “Secretary Michael R. Pompeo with Tony Perkins of Washington Watch,” March 24,
2020.
113 Tweet by Zhao Lijian, March 12, 2020. Zhao was alluding to a conspiracy theory that a U.S. military athlete
participating in the October 2019 World Military Games in Wuhan could have brought the virus to China. For
discussion, see Renée DiResta, “For China, the ‘USA Virus’ Is a Geopolitical Ploy,” The Atlantic, April 11, 2020.
Congressional Research Service
22
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
“designed to shift responsibility,” and President Trump for several days referred to COVID-19 as
“the Chinese virus.”114
On April 17, in announcing his decision to withhold U.S. funding from the World Health
Organization, President Trump accused the multilateral institution of having “pushed China’s
misinformation about the virus, saying it was not communicable and there was no need for travel
bans.”115 Administration officials have also repeatedly suggested that a Chinese research
institution may have been the source of the virus.116 On April 30, 2020, when asked if he had seen
anything “that gives you a high degree of confidence that the Wuhan Institute of Virology was the
origin of the virus,” the President replied, “Yes, I have.”117 The same day, the Office of the
Director of National Intelligence stated that the intelligence community would continue efforts
“to determine whether the outbreak began through contact with infected animals or if it was the
result of an accident at a laboratory in Wuhan,” indicating continuing uncertainties about the
virus’s origin.118
China has pushed back against U.S. allegations, including in a “Reality Check” document tweeted
by a Chinese Foreign Ministry spokesperson responding to 24 U.S. allegations, which the
spokesperson calls “lies.”119 (The document argues, for example, that the Wuhan Institute of
Virology “does not have the capability to design and synthesize a new coronavirus, and there is
no evidence of pathogen leaks or staff infections in the Institute.”) Chinese spokespeople have
gone on the offensive in criticizing the U.S. response to COVID-19 and have doubled down on
spreading a conspiracy theory that the virus could have originated in the United States. On May 8,
a Chinese Foreign Ministry spokesperson tweeted, “The #US keeps calling for transparency &
investigation. Why not open up Fort Detrick & other bio-labs for international review? Why not
invite #WHO & int’l experts to the U.S. to look into #COVID19 source & response?”120
Some U.S.-based analysts have expressed alarm about the downward spiral in bilateral relations.
Some see neither the United States nor China helping to coordinate a global response to the
pandemic, and argue, “U.S.-China strategic competition is giving way to a kind of ‘managed
enmity’ that is disrupting the world and forestalling the prospect of transnational responses to
transnational threats.”121 Others suggest, “There will be time later to assess the early mistakes of
China and others in greater detail, but the virus is out there now and we should be tackling it
114 U.S. Department of State, “Secretary Michael R. Pompeo's Remarks to the Press,” March 17, 2020; and The White
House, “Remarks by President Trump, Vice President Pence, and Members of the Coronavirus Task Force in Press
Briefing,” March 18, 2020.
115 The White House, “Remarks by President Trump in Press Briefing,” April 14, 2020,
https://www.whitehouse.gov/briefings-statements/remarks-president-trump-press-briefing/.
116 See, for example, U.S. Department of State, “Secretary Michael R. Pompeo with Hugh Hewitt of The Hugh Hewitt
Show,” April 17, 2020, https://www.state.gov/secretary-michael-r-pompeo-with-hugh-hewitt-of-the-hugh-hewitt-show3/.
117 The White House, “Remarks by President Trump on Protecting America’s Seniors,” May 1, 2020,
https://www.whitehouse.gov/briefings-statements/remarks-president-trump-protecting-americas-seniors/.
118 Office of the Director of National Intelligence, “Intelligence Community Statement on Origins of COVID-19,”
April 30, 2020, https://www.dni.gov/index.php/newsroom/press-releases/item/2112-intelligence-community-statementon-origins-of-covid-19.
119 Tweet by Hua Chunying, “24 LIES & FACTS about #COVID19,” May 10, 2020,
https://twitter.com/SpokespersonCHN/status/1259376944400891904. “Reality Check of US Allegations Against China
on COVID-19,” Xinhua, May 10, 2020, http://www.xinhuanet.com/english/2020-05/10/c_139044103.htm.
120 Tweet by Hua Chunying, May 8, 2020, https://twitter.com/SpokespersonCHN/status/1258780531707109377.
121 Evan A. Feigenbaum, “Why the United States and China Forgot How to Cooperate,” April 28, 2020,
https://carnegieendowment.org/2020/04/28/why-united-states-and-china-forgot-how-to-cooperate-pub-81673.
Congressional Research Service
23
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
together.” Some have called for cooperation in vaccine development and distribution, and in
addressing the economic crisis the virus is causing in the developing world.”122
Writing in The Washington Post, China’s Ambassador to the United States suggested on May 5
that China would still be open to cooperation. “Blaming China will not end this pandemic,” he
wrote. “On the contrary, the mind-set risks decoupling China and the United States and hurting
our efforts to fight the disease, our coordination to reignite the global economy, our ability to
conquer other challenges and our prospects of a better future.”123 In a May 14, 2020, Fox News
interview, President Trump said, however, that he had no desire to speak to China’s leader Xi
Jinping. He suggested that to punish China, “we could cut off the whole relationship.” Apparently
referring to the U.S. trade deficit with China, which was $378.6 billion in 2019, the President
added, “You’d save $500 billion if you cut off the whole relationship.”124
Several Members of Congress have introduced legislation criticizing China’s response to the
COVID-19 pandemic (see Appendix).
What are the implications in Southeast Asia?125
Southeast Asia was one of the first regions to experience COVID-19 infections and the outbreak
could have broad social, political, and economic implications in the months ahead and possibly
years ahead. The region’s countries are deeply tied together through trade and the movement of
labor, links that could be reshaped if the outbreak leads to broad policy changes. Their economies
have already been affected by disruptions to these links, and broad economic networks and
supply chains could be reshaped if the outbreak leads to broad policy changes.
As an example, Malaysia banned overseas travel on March 18, affecting approximately 300,000
Malaysians who work in neighboring Singapore. Malaysia, however, changed tack on April 14
and allowed Malaysians in Singapore to return if they agreed to be tested and placed in
quarantine. In Singapore, widespread outbreaks among migrant laborers, mostly from South Asia,
who live in crowded dormitories, have led to the region’s largest number of COVID-19
infections.
Other regional issues include the following:
Indonesia and the Philippines, the region’s two most populous nations, appear to
be experiencing widening outbreaks and may have a significantly larger COVID19 case count than their public health systems are able to detect and address.126
Malaysia and Thailand, which have undergone substantial political turmoil in
recent years, have relatively new governments that could face legitimacy
122 Thomas J. Christensen, “A Modern Tragedy? COVID-19 and U.S.-China Relations,” May 2020,
https://www.brookings.edu/research/a-modern-tragedy-covid-19-and-us-china-relations/.
123 Cui Tiankai, “Chinese Ambassador: Ignoring the Facts to Blame China Will Only Make Things Worse,” May 5,
2020, https://www.washingtonpost.com/opinions/chinese-ambassador-cui-tiankai-blaming-china-will-not-end-thispandemic/2020/05/05/4e1d61dc-8f03-11ea-a9c0-73b93422d691_story.html.
124 “Trump on China: ‘We Could Cut Off the Whole Relationship,” Fox Business, May 14, 2020,
https://www.foxbusiness.com/politics/trump-on-china-we-could-cut-off-the-whole-relationship.
125 Written by Ben Dolven, Specialist in Asian Affairs.
126 Y. Rusmana and H. Suhartono, “Indonesia has Recent Rise in Covid Cases, Taking Total to 2,738,” Bloomberg,
April 7, 2020; John McBeth, “Why Indonesia has the World’s Highest COVID-19 Death Rate,” Asia Times. March 20,
2020.
Congressional Research Service
24
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
questions based on their responses to the pandemic and as their economies begin
the process of opening.127
Some nations, including the Philippines and Cambodia, have taken actions that
raise concerns about human rights and freedoms. Philippine President Rodrigo
Duterte has imposed strict lockdown measures that one U.N. official criticized as
“highly militarized,” and these measures have resulted in more than 120,000
arrests, disproportionally affecting poor urban residents.128 Human rights groups
have criticized a draft emergency order by Cambodia’s government that would
give it greater control over traditional and social media.129
Some of the region’s poorest countries, including Burma and Laos, have reported
relatively few COVID-19 cases, highlighting questions about transparency in
nations that may be particularly vulnerable given their underdeveloped health
systems.
Much of the Southeast Asian diplomatic calendar, which drives regional cooperation on a wide
range of issues including trade and public health, has been cancelled or has moved to virtual
meetings. The International Institute for Strategic Studies (IISS) has cancelled this year’s iteration
of its annual Shangri-la Dialogue, slated for June 5-7, after consultations with the government of
Singapore.130
What are the implications in Central Asia?131
In Central Asia, the economic impacts of the pandemic may affect the roles of Russia and China
in the region. Given disruptions to trade and cross-border movement, the pandemic could reverse
recent progress on regional connectivity, a U.S. policy priority in Central Asia. The COVID-19
pandemic is placing significant economic pressure on Central Asian countries due to declines in
domestic economic activity, economic disruptions in China and Russia, and the fall in
hydrocarbon prices. China has cut the volume of natural gas imports from Central Asia due to
falling demand, and analysts speculate that Chinese investment in the region may also shrink.
Turkmenistan sends almost all of its gas exports to China and is particularly vulnerable, as the
Turkmen government uses gas exports to service billions of dollars of Chinese loans. The
economic impact of the pandemic will likely interrupt the flow of remittances from Russia, where
millions of Kyrgyz, Tajik, and Uzbek citizens work as labor migrants, accounting for significant
percentages of their countries’ GDPs.132
Some measures implemented to combat the spread of COVID-19 could provide governments in
the region with the means to suppress political and media freedoms. Human Rights Watch has
stated that Central Asian governments are failing to uphold their human rights obligations by
limiting access to information and arbitrarily enforcing pandemic-related restrictions. In
127 “Malaysia Reaches 131 New Coronavirus Case; 3,793 in Total with One New Death,” The New York Times, April 6,
2020.
128 UN News, “’Toxic Lockdown Culture’ of Repressive Coronavirus Measures Hits Most Vulnerable,” April 27, 2020.
129 Human Rights Watch, “Cambodia: Emergency Bill Recipe for Dictatorship,” April 2, 2020.
130 International Institute for Strategic Studies, Update on the 2020 IISS Shangri-La Dialogue: Asia Security Summit,
March 27, 2020.
131 Written by Maria Blackwood, Analyst in Asian Policy.
132 Maximillian Hess, “Central Asia’s Force Majeure Fears: Impact of COVID-19 Outbreak on China’s Natural Gas
Supply Demands,” Foreign Policy Research Institute, March 16, 2020; Bruce Pannier, “Analysis: Do Oil Price Cuts
Signal Bad Economic Times Will Return to Central Asia?” Radio Free Europe/Radio Liberty, March 14, 2020.
Congressional Research Service
25
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Kazakhstan, authorities have detained government critics and journalists on suspicion of
“disseminating knowingly false information during a state of emergency,” a charge that can be
punished by up to seven years in prison. Kyrgyz authorities restricted the ability of independent
media outlets to report for over a month using provisions in the country’s state of emergency. The
government of Tajikistan has been suppressing information on the pandemic, refusing to answer
media questions and blocking a website that crowdsources information on COVID-19 fatalities in
the country.133
What are the implications in South Asia?134
The seven countries of South Asia are home to about 1.8 billion people, nearly one-quarter of the
world’s population. In most South Asian countries, per capita spending on health care is relatively
low and medical resources and capacities are limited.135 Dense populations and lack of hygiene
are facilitating factors for pandemics, and with medical equipment needed to address the crisis in
short supply, South Asia nations are likely to face serious risk.136 As of May 1, 2020, the United
States had provided nearly $6 million in health assistance to help India slow the spread of
COVID-19 and nearly $15 million to assist Pakistan’s response.137
The COVID-19 crisis has put a broad hold on activities related to U.S.-India and regional
multilateral security cooperation, as well as delayed sensitive negotiations on U.S.-India trade
disputes. The postponement of a planned March visit to New Delhi by Secretary of Defense Mark
Esper had led to worries by some of inertia in bilateral defense relations.138 With India and
Pakistan still engaged in a deep-rooted militarized rivalry, any generalized South Asian crisis,
especially in the disputed region of Kashmir, could lead to societal breakdowns and/or open
interstate conflict between these two nuclear-armed countries.
India. Several U.S. and Indian firms are cooperating on research for a coronavirus vaccine.139
India is home to several major vaccine manufacturers and is the world’s leading producer of
hydrocholoquine, an anti-malarial drug President Trump has touted as a potential treatment for
COVID-19. In April, the U.S. President suggested that the United States might retaliate against
India if New Delhi bans export of the drug and fails to fulfill an existing large-scale U.S.
purchase order. India has agreed to allow limited exports.140
The COVID-19 crisis has led to more acute questioning of the political leadership in India, where
since last year Prime Minister Narendra Modi has faced mass protests over new citizenship laws
and persecution of Muslims. Reports indicate that the health pandemic is fueling greater
oppression and persecution of Indian Muslims, with that community coming under blame for the
133 Human Rights Watch, “Central Asia: Respect Rights in Covid-19 Responses,” April 23, 2020; Manshuk Asautai,
“Podpiska o nerazglashenii dannykh sledstviia—sredstvo davleniia?” Radio Azattyq, May 4, 2020; Aida Dzhumashova,
“Sredstvam massovoi informatsii razreshili rabotat’ s 11 maia,” 24.kg, April 29, 2020; Bakhmaner Nadirov, “V
Tadzhikistane zablokiroali sait po sboru informatsii o pogibshikh COVID-19,” ASIA-Plus, May 11, 2020.
134 Written by K. Alan Kronstadt, Specialist in South Asian Affairs, and Bruce Vaughn, Specialist in Asian Affairs.
135 For example, according to the WHO, India has 8 physicians per 10,000 residents and Pakistan has nearly 10,
compared to 41 in Italy and 26 in the United States.
136 Angel Martinez Cantera, “Can India Keep Up With COVID-19?,” Diplomat (Tokyo), March 23, 2020.
137 See the State Department release at https://go.usa.gov/xvHpH.
138 Vikram Singh, “Can US-India Defense Progress Continue to Surge Through COVID-19?” (op-ed), Financial
Express (Noida), May 8, 2020.
139 “How India Will Play a Major Role in a Covid-19 Vaccine,” BBC News, April 27, 2020.
140 “India Allows Limited Exports of Anti-Malaria Drug After Trump Warns of Retaliation, Reuters, April 7, 2020.
Congressional Research Service
26
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
pandemic from some quarters. Accusations also have arisen that the New Delhi government is
using the pandemic as a cover for increased efforts to limit press freedoms. India’s Jammu and
Kashmir territory—which came under a strict security lockdown in August 2019 and lost
statehood in November—reportedly faces a “double lockdown” with the pandemic and resulting
severe physical and psychological hardships. The New Delhi government may be using the
pandemic as cover to further consolidate its grip on the disputed Kashmir Valley.141
In Pakistan, Prime Minister Imran Khan was already dealing with widespread disaffection
related to his government’s performance and legitimacy. In late March, the powerful military
“stepped in and sidelined” the civilian leadership after the Khan government’s national pandemic
response was criticized for perceived indecisiveness. By some accounts, the Pakistan government
has also “caved in to the demands of clerics” regarding lockdown regulations.142
In Bangladesh, social distancing is difficult for many living in densely populated areas. In
addition, over 1 million displaced Rohingya reside in overcrowded and unsanitary camps along
Bangladesh’s border with Burma. Of these Rohingya, approximately 630,000 live in the
Kutupalong camp, which may be the world’s largest refugee camp. The population density in the
camps—104,000 people per square mile in Kutupalong—poses challenges for social distancing,
quarantine, and isolation. Any COVID-19 transmission in the camps would likely quickly
overwhelm medical facilities and services, and because of the camps’ porous perimeters, risk
spreading into neighboring Bangladeshi towns and villages.143 Bangladesh reportedly quarantined
a number of Rohingya on Bhansan Char island to prevent the spread of COVID-19.144
What are the implications in Australia and New Zealand?145
In both Australia and New Zealand, relations with China have been further strained by the
COVID-19 pandemic. In April 2020, Australia expressed its support for an international
investigation into the origins and spread of the pandemic, a call that raised sensitivities in the
PRC.146 China’s Ambassador Cheng Jingye in an Australian newspaper interview warned “that
pursuing an inquiry could spark a Chinese consumer boycott.”147 Opposition Foreign Affairs
spokesperson Penny Wong has signaled Labor’s support of the government on the issue. In the
view of one commentator, such attempts at “intimidation” and “economic coercion” make it “now
plain for all to see that the CCP is waging political war on Australia, using trade as a weapon.
This is Australia’s moment of clarity.”148
141 “In India, Coronavirus Fans Religious Hatred,” New York Times, April 12, 2020; “India Uses Pandemic to Try to
Muzzle Media, Press Freedom Advocates Say” (interview), NPR (online), April 30, 2020; Tariq Mir, “India is Using
the Pandemic to Intensify Its Crackdown in Kashmir” (op-ed), Washington Post, April 30, 2020.
142 “Pakistan’s Imran Khan Sidelined by Military During Coronavirus Outbreak,” Financial Times (London), April 24,
2020; Madiha Afzal, “Pakistan’s Dangerous Capitulation to the Religious Right on Coronavirus,” Washington Post,
May 1, 2020.
143 “Panic Grips Rohingya Refugee Camps in Bangladesh Over Coronavirus Concerns,” Radio Free Asia, March 20,
2020; Bertil Lintner, “Rohingya Refugee Camps a Covid-19 Time Bomb,” Asia Times, March 20, 2020.
144 Ashley Westerman, “Bangladesh Sends 28 Rohingya Refugees to Cyclone Prone Island Over COVID-19 Fears,”
May 4, 2020.
145 Written by Bruce Vaughn, Specialist in Asian Affairs.
146 Karen DeYoung, “U.S., Australia Call for Global Probe of Early Response,” The Washington Post, April 24, 2020.
147 Rod McGuirk, “China Warns Australia it Could Face Boycotts Over Call for an Independent Inquiry Into
Coronavirus,” Time, May 1, 2020.
148148 Peter Hartcher, “China’s Man in Canberra Has Unmasked the Regimes True Face,” The Sydney Morning Herald,
April 28, 2020.
Congressional Research Service
27
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
In May, China berated New Zealand for supporting Taiwan’s participation at the World Health
Organization.149 New Zealand Foreign Minister Winston Peters stated, “[w] e have to stand up for
ourselves” when asked about China’s response to New Zealand’s position on Taiwan.150
What are the implications for U.S. withdrawal from Afghanistan?151
The presence and spread of COVID-19 in Afghanistan is adding new confusion to the Afghan
peace process, already complicated by an extended political crisis in Kabul. The February 29,
2020 agreement signed by U.S. and Taliban negotiators commits the United States to withdraw
about 3,500 of the 12,000 troops it has in Afghanistan by mid-June 2020 (with commensurate
drawdowns of international forces). There have since been conflicting reports about how the
COVID-19 pandemic is impacting that timeline. Most notably, the United States announced on
March 18 that it is pausing the movement of personnel into and out of theater due to concerns
about COVID-19.152 More recent reports indicate that the withdrawal is proceeding apace, if not
ahead of schedule, and NBC News reported in April 2020 that President Trump has called for
further accelerating the withdrawal of U.S. troops out of Afghanistan because of the pandemic.153
The U.S.-Taliban agreement also called for negotiations between the Taliban and Afghan
government representatives to begin by March 10, but thus far no formal negotiations have taken
place or been scheduled. Some limited engagements were held over Skype, due to the pandemic,
but talks are chiefly held up by a disputed prisoner exchange.154
Further spread of COVID-19 in Afghanistan could present opportunities for compromise and
intra-Afghan cooperation. For example, Afghan government representatives have expressed
support for Taliban efforts to combat the virus in areas they control.155 In addition, while the
Taliban have reportedly targeted health workers in the past, a Taliban spokesman announced that
the group “assures all international health organizations and WHO of its readiness to cooperate
and coordinate with them in combatting” COVID-19, a commitment they appear to have
upheld.156 At the same time, some observers dismiss the Taliban’s response as a propagandistic
attempt to undermine the legitimacy of the Afghan government, and charge that the Taliban’s
dramatic escalation of violence since February 2019 is the main factor impeding the country’s
response to the pandemic.157 Afghanistan may be at particularly high risk of a widespread
COVID-19 outbreak, due in part to its weak public health infrastructure and its porous border
with Iran, a regional epicenter of the pandemic where up to three million Afghan refugees live.
More than 277,000 Afghans have returned to Afghanistan from Iran since January 1, 2020.158
149 “China Berates New Zealand Over Support for Taiwan at WHO,” The New York Times, May 11, 2020.
150 “New Zealand Backs Taiwan Joining the WHO Despite China Rebuke,” The Guardian, May 12, 2020.
151 Written by Clayton Thomas, Analyst in Middle Eastern Affairs.
152 Thomas Gibbons-Neff and Julian Barnes, “Coronavirus Disrupts Troop Withdrawal in Afghanistan,” New York
Times, March 18, 2020.
153 Kylie Atwood and Ryan Browne, “US troop drawdown in Afghanistan running ahead of schedule,” CNN, April 30,
2020; Carol E. Lee and Courtney Kube, “Trump tells advisors U.S. should pull troops as Afghanistan COVID-19
outbreak looms,” NBC News, April 27, 2020.
154 Sayed Salahuddin, “Skype call reconnects Taliban and Afghan officials,” Arab News, March 24, 2020.
155 Ruchi Kumar, “Taliban launches campaign to help Afghanistan fight coronavirus,” Al Jazeera, April 6, 2020.
156 Abdul Qadir Sediqi and Orooj Hakimi, “Coronavirus makes Taliban realise they need health workers alive not
dead,” Reuters, March 18, 2020.
157 See Ashley Jackson, “For the Taliban, the Pandemic is a Ladder,” Foreign Policy, May 6, 2020, and “The Taliban
are joining Afghanistan’s fight against covid-19,” Economist, May 9, 2020.
158 International Organization on Migration, Return of Undocumented Afghans Weekly Situation Report, May 3-9,
2020. See also, Jaffer Shah et al., “COVID-19: the current situation in Afghanistan,” The Lancet, April 2, 2020.
Congressional Research Service
28
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
What COVID-19 containment lessons could be learned from Asia?
Asian governments outside mainland China were the first to deal with COVID-19. Five
jurisdictions, in particular, have received wide praise for their COVID-19 control approaches:
Taiwan, Hong Kong, South Korea, Australia, and New Zealand. Singapore was also praised for
its initial actions to control the virus, although a large “second wave” of infections has pointed to
vulnerabilities that even jurisdictions perceived as well-run still face. All of these jurisdictions
have drawn on their experiences in addressing previous public health emergencies, including
outbreaks caused by SARS, swine and avian flu, and MERS. Those experiences fostered
bureaucratic and public attentiveness to public health challenges and prompted governments to
develop active protocols for screening, testing, isolating infected individuals, and tracing their
contacts. Prior experience may also have conditioned people in those places to follow standard
infection control measures (frequent hand-washing, mask-wearing, and social distancing) and to
more readily accept quarantines and movement restrictions. Some of these jurisdictions have
begun the process of loosening restrictions related to COVID-19, which may provide lessons for
the United States and others.
Taiwan.159 Taiwan (which officially calls itself the Republic of China, or ROC), is located just 81
miles off the coast of mainland China. On December 31, 2019, the same day China notified the
WHO China Office of pneumonia cases of unknown origin, Taiwan officials had begun to board
planes arriving from Wuhan to evaluate passengers who had fever or pneumonia symptoms.160
Travel alerts, routine passenger screenings, and directives to self-quarantine soon followed, and
by early February, Taiwan barred residents of mainland China from entry. Taiwan also extended
indefinitely a suspension of cross-Strait flights from all but five airports in mainland China,
previously set to expire at the end of April.161 On January 20, Taiwan both confirmed its first
COVID-19 case and activated a Central Epidemic Command Center (CECC) to lead and
coordinate the government’s response to the COVID-19 crisis.162 The CECC is part of the
National Health Command Center, a 24/7 central command headquarters created in 2004
following the SARS outbreak.163 The government also integrated its national health insurance,
customs, and immigration databases to facilitate case identification and tracking.164 The
concentration of public health expertise among Taiwan’s top leaders likely contributed to the
government’s attentive response. Taiwan’s vice president, vice president-elect, vice premier, and
minister of health are all public health experts.165
The government has also issued strict and transparent guidance to contain the spread of the virus,
which its citizens largely appear to have followed. Taiwan has tested widely for the virus,
159 Written by Caitlin Campbell, Analyst in Asian Affairs.
160 C. Jason Wang et al., “Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive
Testing,” Journal of the American Medical Association, May 3, 2020.
161 Taiwan Center for Disease Control, “Starting from February 6, 2020, China (including Hong Kong, Macau) to be
listed as Level 2 Area or above; Chinese residents to be prohibited from entering Taiwan,” February 5, 2020; Taiwan
Centers for Disease Control, “CECC extends restrictions on direct cross-strait flights and ban on passenger transits,”
April 23, 2020.
162 C. Jason Wang et al., “Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive
Testing,” Journal of the American Medical Association, May 3, 2020.
163 Other parts of the NHCCC include: the Biological Pathogen Disaster Command Center, the Counter-Bioterrorism
Command Center, and the Central Medical Emergency Operations Center.
164 C. Jason Wang et al., “Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive
Testing,” Journal of the American Medical Association, May 3, 2020.
165 Winston Wen-yi Chen, “Lessons on handling the COVID-19 outbreak from Taiwan,” iPolitics, March 17, 2020.
Congressional Research Service
29
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
including mandatory tests for certain groups and tests for patients with respiratory illnesses that
tested negative for the flu.166 Directives to conduct “self-health management” or self-quarantine
have been enforced by harnessing cellphone location data and punishing violators with steep
fines.167 The government’s daily press conferences and frequent broadcasts of public service
announcements have heightened public awareness and facilitated compliance with best
practices.168 Taiwan also created informational apps, to help citizens track the spread of the virus
and locate supplies of masks.169 In February and March, the government announced economic
relief and stabilization measures, including approximately USD$2 billion to assist Taiwan
industries affected by the outbreak, and payments totaling $465 to individuals who were
quarantined or providing care for the quarantined.170
Hong Kong.171 Initially, the government of Hong Kong, a Special Administrative Region
(HKSAR) of the People’s Republic of China, resisted taking aggressive measures to prevent a
COVID-19 outbreak. Public criticism of what many considered an insufficient and inconsistent
initial response appears to have contributed to the government’s subsequent decision to act. A
newly formed union of doctors and nurses working for the Hong Kong Hospital Authority held a
strike on February 3, 2020, demanding the HKSAR government close the city’s border with
mainland China, for example.172 The HKSAR government closed all but two of the land crossings
with mainland China the next day. The government implemented a mandatory 14-day quarantine
for all arrivals to Hong Kong on March 17, 2020, which remains in effect.173 The HKSAR
government has also indefinitely closed Hong Kong’s borders to all non-resident arrivals (except
people from Mainland China, Macau and Taiwan who have not been to another country in the
previous 14 days).174 The government has also developed an extensive range of public service
announcements, web pages, and other modes of informing the public about COVID-19.175
Although the HKSAR government may have hesitated, Hong Kong’s public quickly adopted
social distancing and anti-contamination behaviors developed during previous viral outbreaks.
Similarly, medical professionals quickly implemented anti-viral protocols.176
166 Taiwan Centers for Disease Control, “To strengthen community-based surveillance, groups with foreign travel or
contact history or other groups of potential risks included in COVID-19 testing procedure,” February 16, 2020; Kathrin
Hille and Edward White, “Containing coronavirus: lessons from Asia,” Financial Times, March 16, 2020.
167 Laws and Regulations Database of the Republic of China, “Communicable Disease Control Act,” June 19, 2019;
Cindy Sui, “What Taiwan can teach the world on fighting the coronavirus,” NBC News, March 10, 2020.
168 Anders Fogh Rasmussen, “Taiwan Has Been Shut Out of Global Health Discussions. Its Participation Could Have
Saved Lives,” Time, March 18, 2020.
169 Winston Wen-yi Chen, “Lessons on handling the COVID-19 outbreak from Taiwan,” iPolitics, March 17, 2020.
170 Executive Yuan, “Executive Yuan Approves Special Budget to Fund COVID-19 Response,” Press Release,
February 27, 2020; “CECC Announces Compensation for COVID-19 Quarantine,” Taiwan Today, March 12, 2020.
171 Written by Michael F. Martin, Specialist in Asian Affairs.
172 "Coronavirus: Hong Kong hospital staff strike to demand closure of China border," BBC, February 3, 2020.
173 Rachel Wong, “Closure of checkpoints with China a ‘speedy’ response to virus outbreak, says Hong Kong’s Carrie
Lam,” Hong Kong Free Press, February 4, 2020; Rachel Wong and Jennifer Creery, “Coronavirus: 14-day quarantine
for all arrivals to Hong Kong except from China, Macau, Taiwan,” Hong Kong Free Press, March 17, 2020.
174 Jennifer Creery, “Coronavirus: Hong Kong to ban all foreign visitors as 8,600 businesses barred from selling
alcohol,” Hong Kong Free Press, March 23, 2020; and The Government of the Hong Kong Special Administrative
Region, “Entry restriction on non-Hong Kong residents coming from overseas extended,” press release, April 6, 2020.
175 For example, the HKSAR has created a dedicated web page, https://www.coronavirus.gov.hk/eng/index.html, to
provide current COVID-19 information.
176 These protocols include mandatory masking in patient contact areas and establishing “dirty teams” to treat riskier
patients. According to a Hong Kong doctor contacted by CRS, medical professionals implemented these measures
Congressional Research Service
30
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
After 14 days without a confirmed local case of contagion and only a few “imported cases,” on
May 5, 2020, the HKSAR government began to selectively relax its restrictions, reopening
government offices and selective businesses while maintaining the requirement to wear masks in
public and prohibiting gatherings of more than eight people.177 The same day, it also announced
that it would provide every Hong Kong resident with a free reusable face mask that complies with
the American Society for Testing & Materials F2100 Level 1 Standard in terms of particle and
bacterial filtration efficiency.178 The HKSAR government, however, also noted that restrictions
may be reinstated if there is an increase in local cases.
Singapore.179 Singapore, a Southeast Asian city-state of 5.7 million people, has offered lessons
perceived as both positive and cautionary in its handling of the pandemic. Singapore was one of
the first nations outside China to report COVID-19 cases, with its first infection reported on
January 23. Public health experts have praised Singapore’s rapid early actions, including
extensive monitoring of cases and their contacts, temperature checks at building entrances, and
clear public messaging. Singapore health officials conducted detailed interviews of affected
individuals, requiring those who had come into contact with them to quarantine themselves. The
Health Ministry developed the capacity to test more than 2,000 individuals a day.180 Individuals
who come within two meters of an infected individual or spend 30 minutes with one are required
to undergo testing and to quarantine or be placed under observation. Individuals found to have
misled health officials are subject to criminal penalties including fines and the threat of
imprisonment.181 The Health Ministry issues daily updates on individual cases and the numbers of
people under care or protective quarantine, including details of where each individual who has
tested positive lives.
Despite its early successes curbing the spread, Singapore has experienced a significant “second
wave” of cases, leading authorities to close schools and most businesses, steps that they had
avoided earlier.182 Many of the new cases have come from crowded quarters where migrant
workers live, and the expansion has left Singapore with Southeast Asia’s largest number of
COVID-19 infections, as of May 11.183
South Korea.184 After cases were confirmed in South Korea in late January, authorities pursued
an aggressive testing regimen and public communication strategy. South Korea describes its
strategy as the three “T”s: tracking, testing, and treatment. By early May, the number of new
cases per day had fallen to 6.4.185 As of early May, nearly 660,000 citizens had been tested for the
before the Hospital Authority issued instructions to do so.
177 The Government of the Hong Kong Special Administrative Region, “Lifting of certain social distancing measures
under Prevention and Control of Disease Ordinance,” press release, May 5, 2020.
178 The Government of the Hong Kong Special Administrative Region, “Gov’t to distribute reusable masks,” press
release, May 5, 2020.
179 Written by Ben Dolven, Specialist in Asian Affairs.
180 Hannah Beech, “Tracking the Coronavirus: How Crowded Asian Cities Tackled an Epidemic,” The New York
Times, March 17, 2020.
181 Sribala Subramanian, “How Singapore Connected the Dots on Coronavirus,” The Diplomat. March 4, 2020.
182 “Singapore Reports 287 New Coronavirus Cases in Biggest Daily Jump,” U.S. News and World Report, April 9,
2020.
183 Hilary Leung, “Singapore Was a Coronavirus Success Story – Until an Outbreak Showed How Vulnerable Workers
Can Fall Through the Cracks,” Time. April 29, 2020.
184 Written by Emma Chanlett-Avery, Specialist in Asian Affairs.
185 “Korea’s Evolving Response to COVID-19,” Republic of Korea Ministry of Foreign Affairs, May 11, 2020.
Congressional Research Service
31
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
virus186—the highest rate of testing per capita in the world—at over 600 sites, including pop-up
facilities and drive-through sites.187 Results are generally provided within 24 hours.188 The case
fatality ratio (1.64% as of March 30) has also been low, which health officials attribute to early
detection and treatment, as well as universal health care.189 As of early May, South Korea has
been able to stabilize the outbreak without lockdowns or wholesale travel bans, in part, experts
argue, by being transparent and disseminating information about the virus’ spread, including
possible infections at the neighborhood level. President Moon Jae-in has stepped aside to allow
national health officials to take the lead in delivering twice-daily messages to the public. After
MERS killed 38 people in 2015, South Korea reformed its health policy by granting the
government greater powers to monitor and track individual patients and to allow private
companies to rapidly produce tests. Shortly after the COVID-19 outbreak hit, authorities were
able to test 10,000 patients daily.190 Authorities can now test over 20,000 patients per day.191
Australia.192 Observers believe that Australia’s mitigation efforts (including self-isolation,
movement restrictions, a two-week quarantine for those entering the country), the public’s
general adherence to rules, and widespread testing and tracing of contacts may be responsible for
a relatively successful effort to contain the pandemic in Australia.193 Australia reportedly has one
of the highest per capita testing rates in the world.194 In April 2020, the Australian government
launched “Covidsafe,” an application that traces every person running it with other application
users that have tested positive for COVID-19. Using Bluetooth, the app records others that have
been within 1.5 meters for 15 minutes or more who also have the app.195 Within three days of its
release, 3 million Australian had reportedly signed up for the app.196
New Zealand.197 New Zealand confirmed its first case of coronavirus on February 28, 2020. The
late date of the first outbreak, New Zealand’s relative isolation, swift early response, and
widespread testing all appear to have helped New Zealand to effectively deal with the virus.198 On
March 14, with only six confirmed COVID-19 cases in the country, Prime Minister Jacinda
Ardern announced that all entering New Zealand would have to self-isolate for two weeks and
that the existing travel ban for those coming from China and Iran would remain in place.199 From
March 19, the New Zealand border has been closed to almost all travelers, with only New
186 “Korea’s Fight Against COVID-19,” South Korea Ministry of Foreign Affairs, March 30, 2020.
187 “Korea’s Fight Against COVID-19,” South Korea Ministry of Foreign Affairs, March 30, 2020.
188 “How South Korea Put Into Place the World’s Most Aggressive Coronavirus Test Program,” The Wall Street
Journal, March 16, 2020.
189 “Coronavirus: South Korea seeing a ‘stabilising trend’” BBC News Video, March 15, 2020.
190 “How South Korea Scaled Coronavirus Testing While the U.S. Fell Dangerously Behind,” ProPublica, March 16,
2020.
191 “Korea’s Fight Against COVID-19,” South Korea Ministry of Foreign Affairs, March 30, 2020.
192 Written by Bruce Vaughn, Specialist in Asian Affairs.
193 Rosie Perper, “Australia and New Zealand Have Been Able to Keep Their Number of Coronavirus Cases Low,”
Business Insider, April 17, 2020.
194 “Australia’s Virus Testing Rate Leads World,” Financial Review, April 1, 2020.
195 Josh Taylor, “COVID Safe App,” The Guardian, April 27, 2020.
196 O. Patrick, “Millions of Australians Get App to Track Virus,” The Washington Post, April 30, 2020.
197 Written by Bruce Vaughn, Specialist in Asian Affairs.
198 Julia Hollingsworth, “How New Zealand ‘Eliminated’ COVID-19 After Weeks of Lockdown,” CNN, April 28,
2020.
199 Rt Hon. Jacinda Ardern, Major Steps Taken to Protect New Zealanders from COVID-19,” March 14, 2020.
Beehive.govt.nz.
Congressional Research Service
32
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Zealand citizens, residents, and their immediate families allowed to enter the country.200 This was
a significant move for the country, which has an estimated 4 million international visitors a
year,201 and where tourism accounted for approximately 5.8% of GDP for the year ending March
2019.202 Since April 9, arrivals have been placed in “managed isolation facilities,” and those
deemed to be high risk have been placed in quarantine facilities.203
New Zealand has moved from lockdown to an easing of restrictions in a relatively short period of
time. Prime Minister Ardern announced on March 23 that New Zealand would enter a level 4
lockdown204 on March 25, when it had less than 150 cases.205 New Zealand then moved to alert
level 3 on April 27. It subsequently moved to alert level 2 on May 13, under which most
businesses will be open, tertiary education will open, travel between regions of the country, and
gatherings up to 10 people will be allowed. Border controls and physical distancing requirements
will remain, wide scale testing will continue, and those unwell or who have been in contact with
the sick will be isolated.206 New Zealand and Australia have reached an agreement to lift travel
restrictions between their two countries and establish a Trans-Tasman COVID Safe Zone, or
travel bubble, as soon as it is safe to do so.207
Europe208
How are European governments and the European Union (EU) responding?
On March 13, 2020, WHO officials characterized Europe as the new global epicenter of the
COVID-19 pandemic, noting that more cases were being reported each day in Europe than were
reported in China at the height of its epidemic.209 As of May 15, about 1.2 million infections and
nearly 155,000 deaths had been reported across the 27-member European Union (EU) and United
Kingdom (UK).210 Italy, Spain, and the UK have been particularly hard hit, but infection rates
grew across Europe throughout the month of March. Ukraine, Russia, and other parts of the
former Soviet Union also reported a growing number of new COVID-19 cases.
Since mid-April, a growing number of European governments have expressed cautious optimism
that their countries have passed the peak of the crisis. Many European countries, including
France, Germany, Italy, and Spain, have announced and begun to implement staged “re-opening”
200 “Coronavirus Travel Restrictions Across the Globe,” The New York Times, May 8, 2020.
201 “PM Ardern’s Full Lockdown Speech,” www.newsroom.co.nz, and Anna Fifield, “New Zealand isn’t Just
Flattening the Curve its Squashing it,” The Washington Post, April 7, 2020.
202 “About the Tourism Industry,” www.tourismnewzealand.com.
203 “COVID-19 Key Updates,” www.immigration.govt.nz.
204 New Zealand has four COVID-19 Alert levels: Level 4 Lockdown: likely the disease is not contained; 3 Restrict:
high risk the disease is not contained; 2 Reduce: the disease is contained but the risk of community transmission
remains; and 1 Prepare: the disease is contained in New Zealand. “Alert Levels Summary,”
www.covid19.govt.nz/assets/resources/tables/COVID-19-aler-tlevels-summary
205 Eleanor Roy, “NZ Plans to ease Coronavirus Lockdown in a Week,” The Guardian, April 20, 2020.
206 “Alert Level 2,” www.covid19.govt.nz.
207 Katherine Murphy, “Morrison and Ardern Agree on Travel ‘Bubble’ Between New Zealand and Australia,” The
Guardian, May 5, 2020.
208 Written by Kristin Archick, Specialist in European Affairs, and Paul Belkin, Analyst in European Affairs.
209 “Coronavirus: Europe Now Epicentre of the Pandemic, Says WHO,” BBC, March 13, 2020.
210 “Coronavirus in Europe – Live Data Tracker,” Politico.eu, updated regularly at
https://www.politico.eu/article/coronavirus-in-europe-by-the-numbers/.
Congressional Research Service
33
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
plans, slowly rolling back some of the “lockdown” measures implemented in March. Government
officials caution, however, that reopening measures are strictly conditions-based and could be
halted if infection rates grow.
European leaders have characterized the pandemic as Europe’s biggest challenge since the
Second World War, with potentially severe economic consequences and far-reaching social and
political implications beyond the public health impact.211 European governments and the EU are
enacting an array of policy responses. Authorities in most European countries initially imposed
strict limitations on the movement of people and are undertaking significant fiscal and monetary
measures. Key measures taken in Europe to combat the pandemic include the following:
Initial “lockdowns” transitioning to cautious reopening. On March 9, Italy
became the first country to impose a nationwide quarantine, prohibiting “nonessential” movement within the country and closing all non-essential businesses;
France, Germany, the United Kingdom, and others followed with similar
restrictions. Almost all European countries closed schools and some types of
businesses and have restricted public gatherings to varying degrees. Numerous
European governments mobilized their military forces to assist response efforts,
including constructing makeshift hospitals. In some countries, government
authorities scaled back public transportation and introduced curfews.
In mid-April, some European countries began announcing plans for a gradual
reopening of their societies and economies in the coming months, but the pace of
reopening measures vary across Europe, and leaders caution that such measures
would be contingent on a clear reduction in infection rates. European
governments have generally stressed the importance of a staged approach to
reopening, allowing for regional differences depending on regional infection
rates and hospital and testing capacity. They also have sought to implement
widespread testing and contact tracing capacity.
Economic stimulus. Many analysts predict that the COVID-19 pandemic could
cause a financial crisis in Europe that might be several times worse than the 2008
global recession. European governments and the EU have announced an array of
measures to mitigate a severe economic downturn. Measures include loan
programs and credit guarantees for companies, income subsidies for affected
workers, tax deferrals, and debt repayment deferments. On May 14, the Italian
government announced a €55 billion (about $60 billion) stimulus plan. In France,
President Emmanuel Macron has pledged to provide unlimited budgetary support
to companies and workers, which the government says could cost upward of €45
billion ($48 billion). Germany has announced direct fiscal support of €236 billion
(about $256 billion) and a €500 billion ($536 billion) loan program.212 Other
countries have announced similar relief measures.
On March 18, the European Central Bank, which manages the EU’s common currency
(the euro), announced a Pandemic Emergency Purchase Program (PEPP) of about €750
billion ($803 billion) aimed at calming markets and stemming a debt crisis in the
Eurozone (the 19 EU member states that use the euro as their currency).213 On April 9,
Eurozone leaders agreed to a new financial assistance package of at least €540 billion
211 Liz Alderman and Jack Ewing, “Europe’s Big Economies Brace for Sharpest Drop Since World War II,” New York
Times, April 8, 2020.
212 “How European Economies Are Trying to Mitigate the Coronavirus Shock,” Financial Times, March 17, 2020.
213 Mehreen Khan, “Lagarde Bails Out Europe,” Financial Times, March 19, 2020.
Congressional Research Service
34
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
(roughly $590 billion). This package includes access to credit lines through the European
Stability Mechanism (ESM, the Eurozone’s “bail-out” fund) worth approximately €240
billion ($261 billion) for health-related costs, establishment of a European Investment
Bank fund to back up to €200 billion ($219 billion) in loans for businesses, and a €100
billion ($110 billion) unemployment benefit support plan. Reaching consensus on this
financial package was contentious and exposed divisions among EU member states. The
package does not include establishing common EU debt instruments (or “corona
bonds”)—one of the most controversial proposals supported by hardest-hit countries such
as Italy, Spain, and France—but EU leaders will likely continue to discuss this option and
other potential economic measures.214
Border closures. Numerous European governments have enacted national border
controls and some have restricted entry only to national citizens. These measures
have complicated efforts to maintain the free movement of goods, services, and
people (key elements of the EU’s single market) on which the EU’s highly
integrated economy depends. National border controls and closures within the
EU’s internal border-free Schengen Area215—in which individuals may travel
without passport checks among 22 EU member states and four non-EU
countries—resulted in long delays at several borders. On March 16, 2020, EU
leaders agreed to implement a temporary ban on “non-essential travel” into the
EU and the Schengen Area for most foreign nationals from outside countries
(including the United States), partly in an effort to preserve freedom of
movement within the EU. This ban on nonessential travel into the EU and the
Schengen Area is expected to remain in place until at least June 15. Many
analysts contend that the disparate national reactions to the COVID-19 pandemic
are endangering the EU’s single market and Schengen system, with possible
long-term implications for the EU’s future.216
How is the pandemic affecting U.S.-European relations?
Managing the spread of COVID-19 has added new tensions to already strained U.S.-European
relations. The EU—a frequent target of criticism from President Trump—expressed dismay with
the announcement from the Trump Administration on March 11, 2020 of a travel ban on foreign
nationals arriving in the United States from the Schengen Area. In a joint statement on March 12,
EU leaders noted that COVID-19 was a global crisis that “requires cooperation rather than
unilateral action” and expressed disapproval that the U.S. travel ban was imposed “without
consultation.”217 U.S. officials countered that the travel ban decision had to be taken quickly and
was based on the WHO’s assessment of sustained transmission in the Schengen Area.218 The
214 European Council, Eurogroup Report on the Comprehensive Economic Policy Response to the COVID-19
Pandemic, April 9, 2020, at https://www.consilium.europa.eu/en/press/press-releases/2020/04/09/report-on-thecomprehensive-economic-policy-response-to-the-covid-19-pandemic/.
215 For more information on the EU, including the Schengen Area, see CRS Report RS21372, The European Union:
Questions and Answers, by Kristin Archick.
216 David M. Herszenhorn, “Coronavirus Border Controls Imperil EU Freedoms,” Politico Europe, March 16, 2020;
Michael Peel, Sam Fleming, and Jim Brunsden, “EU Leaders Prepare to Close Bloc’s Borders,” Financial Times,
March 16, 2020; Benjamin Novak and Melissa Eddy, “Closed Borders Within Europe Unleash Congestion and Chaos,”
New York Times, March 18, 2020.
217 European Council, Statement by Presidents Charles Michel and Ursula von der Leyen with the Croatian Presidency
on US Travel Ban Related to COVID-19, March 12, 2020.
218 The White House, Proclamation – Suspension of Entry as Immigrants and Nonimmigrants of Certain Additional
Congressional Research Service
35
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Trump Administration subsequently extended the travel ban beyond the Schengen Area to the UK
and Ireland. Nevertheless, some analysts on both sides of the Atlantic asserted that the U.S. travel
ban was scapegoating the EU, threatened future U.S.-EU relations, and imperiled broader U.S.European political and security alliances. 219
Some European leaders and EU officials also object to certain elements of the U.S. international
response to the COVID-19 pandemic. Many European policymakers have criticized President
Trump’s decision to halt U.S. funding to the WHO pending a review of its role in allegedly
mismanaging the pandemic response. EU officials have expressed concern that U.S. economic
sanctions are blocking humanitarian supplies for hard-hit countries such as Iran and Venezuela.
Some European officials, including in Germany and France, have complained about U.S. efforts
to outbid them in the global marketplace for facemasks and other critical medical equipment.
Some critics have also bemoaned the lack of coordinated U.S.-European leadership in mobilizing
a global response to control the pandemic and address its wider societal and economic
consequences.
Africa220
How are African governments responding?
As of May 12, 2020, all countries in sub-Saharan Africa (“Africa”) except Lesotho had confirmed
COVID-19-cases. South Africa had 11,000-plus cases, 25% of Africa’s total. Most early cases
were imported, notably from Europe, or linked to such cases. Africa’s known COVID-19
caseloads have lagged those of more developed countries, and Africa’s per capita incidence of
COVID-19 remains very low in global comparison. Most countries in Africa, however, now have
confirmed local COVID-19 transmission chains, and in some countries cases are surging.
Prevention and mitigation strategies vary considerably in the region. Many governments have
sought to increase COVID-19 testing capacity (though some have inadequate access to testing
supplies), and to isolate confirmed and presumptive infected persons and trace their contacts.
Many have improved their capacities in these areas since the start of the pandemic (see next
section), in some cases building on lessons from past Ebola virus outbreak responses.221 Many
African health systems, however, have limited capacities. Per capita ratios of doctors and health
workers, rates of health spending, and hospital beds are some of the lowest globally, and supplies
of healthcare goods (e.g., drugs, ventilators, and oxygen supplies) are low.222 Socioeconomic
challenges also hinder prevention measures centering on hygiene (e.g., handwashing) and social
distancing. Many Africans lack access to clean water or sanitation facilities, and live in highdensity areas (e.g., informal urban settlements or displaced person camps). COVID-19 co-
Persons Who Pose a Risk of Transmitting 2019 Novel Coronavirus, March 11, 2020; The White House, “Remarks by
President Trump and Prime Minister Varadkar of Ireland Before Bilateral Meeting,” March 12, 2020.
219 James McAuley and Michael Birnbaum, “Europe Blindsided by Trump’s Travel Restrictions, With Many Seeing
Political Motive,” Washington Post, March 12, 2020; Erik Brattberg, “Trump’s Coronavirus Travel Ban Delivers a
Blow to Transatlantic Relations,” Carnegie Endowment for International Peace, March 13, 2020; Jeremy Shapiro, “A
View from Washington: The America First Pandemic,” European Council on Foreign Relations, March 19, 2020.
220 Written by Nicolas Cook, Specialist in African Affairs.
221 CRS Insight IN11285, Fostering Behavior Change During Disease Outbreaks: Insights from Ebola Response in
Africa, among others.
222 Katharine Houreld et al., “Virus exposes gaping holes in Africa’s health systems,” Reuters, May 7, 2020; and Johns
Hopkins Center for Health Security, et al., 2019 Global Health Security Index, among others.
Congressional Research Service
36
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
morbidity with other diseases widespread in the region (e.g., HIV and malaria) and/or chronic
health problems (e.g., diabetes and malnutrition) may increase the risk from COVID-19 in Africa.
Most countries have launched public outreach campaigns centered on personal hygiene
promotion, the use of facial masks, and social or physical distancing. Residential lockdowns,
business restrictions, prohibitions on large gatherings, and school and university closures have
been common. Some countries, however, have implemented only some of these various
responses, or implemented them in limited geographic areas.223 Governments in multiple
countries have authorized restrictive measures under pandemic national states of disaster or
emergency. In several countries, security forces enforcing lockdowns and other restrictions have
violated human rights, at times in the face of social unrest over the effects of these restrictive
measures. In some countries, observers fear that incumbent regimes may use their emergency
authorities to extend their powers or time in office, or, as some have, to restrict press freedoms or
opposition activity.224
Given that many Africans make a precarious hand-to-mouth living in the informal sector,
lockdowns have caused intense economic pain in the region, and governments have been eager to
permit normal commercial activity to resume. A number of African governments began easing
restrictive measures in late April, though in some countries, a spike in COVID-19 cases has
accompanied or followed such actions.225
Experts are concerned that the pandemic’s broader economic impacts could be particularly
devastating in Africa, where many countries rely on tourism and/or commodity exports, notably
to China.226 Both tourism and exports have declined sharply due to COVID-19-linked
interruptions and declines in world economic activity, trade, and travel. In food import-dependent
countries, food insecurity may also increase, due to these factors as well as lock-down linked
restrictions. Remittances from abroad also have dropped. Africa’s heavy reliance on imports of
consumer and industrial goods from China may also suffer, alongside business sectors tied to
these imports (e.g., digital technology and local retail sectors).227 Exports of mined and energy
commodities, which comprise roughly 75% of African exports by value, may be particularly
hard-hit. Africa’s oil export-dependent countries may face a double threat: a global oil price
collapse initially driven by a now-ended price war among selected producers and an ongoing
collapse in global oil demand.228 African airlines also are suffering steep losses. Multiple central
banks have acted to increase economy-wide liquidity and many governments are making resource
reallocations or are slated to receive international assistance to finance COVID-19 responses.229
223 AFP, “After head start on virus, Africa begins clampdown,” March 17, 2020; and David Pilling, Joseph Cotterill,
and Neil Munshi, “African countries move swiftly to head off coronavirus spread,” Financial Times, March 18, 2020.
224 BBC News, “Coronavirus in Africa: Whipping, shooting and snooping,” April 9, 2020; Simon Allison, “The Covid19 pandemic is a wildcard that will change politics as we know it,” Mail & Guardian, March 25, 2020; and Freedom
House, Heavy-Handed Pandemic Responses Could Fuel Unrest in Southern Africa, May 11, 2020, inter alia.
225 Christopher Giles and Peter Mwai, “Coronavirus: Why are some African states easing lockdowns?,” BBC News,
May 4, 2020.
226 Economist, “Africa is woefully ill-equipped to cope with covid-19,” March 26, 2020; and Landry Signé and
Ameenah Gurib-Fakim, “Africa is Bracing for a Head-On Collision with Coronavirus,” ForeignPolicy.com, March 26,
2020.
227 Baker McKenzie, The Impact of COVID-19 on African Trade, March 12, 2020, among others.
228 Reuters, “Sub-Saharan Africa faces pressure from oil price shock, pandemic rout,” April 3, 2020; Nikos Tsafos,
“Who is Prepared for an Oil Price War?,” CSIS, March 9, 2020; and Baker McKenzie, The Impact of COVID-19 on
Key African Sectors, March 10, 2020.
229 IMF, Policy Responses to COVID-19 and COVID-19 Emergency Financial Assistance; and World Bank, “Assessing
Congressional Research Service
37
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
How is the Africa CDC responding?
The African Union (AU) Africa Centres for Disease Control and Prevention (Africa CDC), at
times in partnership with the WHO and other international actors, is helping African governments
to enhance the capacity of their public health systems to detect and respond to COVID-19.230
Africa CDC support has centered on training personnel on disease detection and surveillance at
national laboratories and ports of entry, providing COVID-19 test kits and other health
commodities (e.g., personal protection equipment or PPE), and other health response capacitybuilding.231 The Africa CDC has provided COVID-19 detection training to at least 40 country
labs, almost all of which are now able to independently test for the disease. These labs are
supported by a regional COVID-19 specimen referral and verification system comprising expert
labs in Senegal and South Africa, with ten more planned region-wide.232 The Africa CDC also has
created a regional COVID-19 task force under a regional response plan, has activated its
Emergency Operations Center and Incident Management System, and is aiding information
sharing among AU member states.233 The Africa CDC also has trained epidemiologists in disease
event tracking and risk analysis, including through its Regional Collaborating Centres (RCCs),
and is providing COVID-19 medical and technical advice and pandemic briefings to AU member
states.234
Middle East and North Africa235
How are Middle Eastern and North African governments responding?
As of May 2020, all 17 countries in the Middle East and North Africa region, in addition to the
Palestinian territories, had confirmed local transmission of COVID-19.236 Iran was an early
the Economic Impact of COVID-19 and Policy Responses in Sub-Saharan Africa,” Africa Pulse, April 2020.
230 The Africa CDC was established in 2016, with U.S. and Chinese support. In February 2020, Trump Administration
officials reportedly warned that U.S. assistance might end should the AU agency accept a Chinese offer to build its
headquarters. An unnamed Administration official alleged that Chinese assistance would enable China to “steal … vast
amounts of genomic data” held by the Africa CDC and its regional affiliates. China has rejected such claims. Katrina
Manson and David Pilling, “US warns over Chinese ‘spying’ on African disease control centre,” Financial Times,
February 6, 2020; and China Ministry of Foreign Affairs, Daily Briefing, February 7, 2020, inter alia.
231 Information in this paragraph drawn from Africa CDC, Outbreak Brief #17: Coronavirus Disease 2019 (COVID-19)
Pandemic, May 12 2020, and prior regular Africa CDC 2020 COVID-19 outbreak briefs since January 2020.
232 One of these reference labs, Senegal’s Institute Pasteur, has partnered with Mologic, a British biotech firm, to
produce a rapid mobile COVID-19 test. DiaTropix, a Senegalese diagnostic testing innovation and production entity, is
to manufacture the test kits at cost, at roughly $1 per test. The effort is funded by the UK government and the Gates
Foundation. Yomi Kazeem, “A Senegalese innovation lab is helping the UK develop a 10-minute coronavirus test kit,”
Quartz, March 11, 2020; and William Worley, “Why the UK wants a new coronavirus test to be made in Senegal,”
Devex, March 17, 2020.
233 On February 22, 2020, AU Ministers of Health adopted a regional Africa Joint Continental Strategy for COVID-19
Outbreak. Africa CDC, Outbreak Brief #6: Novel Coronavirus (COVID-19) Global Epidemic, February 25, 2020.
234 RCCs support disease surveillance, lab networks, emergency preparedness and responses, and other public health
capacity building initiatives. Africa CDC, “Regional Collaborating Centres,” 2020.
235 Written by Carla Humud, Analyst in Middle Eastern Affairs and Kenneth Katzman, Specialist in Middle Eastern
Affairs.
236 For the purposes of this report, the Middle East and North Africa region (MENA), or what the State Department
calls “Near East” Affairs (NEA), is defined as an area stretching from Morocco in the west to the Persian/Arabian Gulf
in the east, excluding Turkey. It comprises Algeria, Bahrain, Egypt, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya,
Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, West Bank/Gaza, and Yemen. The World
Health Organization refers to this area as the Eastern Mediterranean Region (EMR), which it defines as 21 countries
Congressional Research Service
38
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
epicenter of the pandemic; as of May, Iranian cases represent roughly 40% of all confirmed cases
in the region. The six Arab Gulf states also have emerged as a focal point; as of May these states
(combined) also represent nearly 40% of the region’s confirmed cases.237 Observers and U.S.
government officials have expressed concern that some states have sought to downplay the extent
of the spread of the virus in their countries.238 Many countries in the region also lack the
capability to conduct comprehensive testing.
Starting in March, many countries suspended international and domestic passenger flights, closed
land and sea crossings with neighboring states, imposed curfews, and closed commercial,
educational, and religious sites. Some governments also passed emergency legislation and
expanded surveillance as part of their response to the pandemic. In some cases, observers argued
that these measures may have been designed in part to suppress political opposition.239
In Egypt, parliament expanded the country’s emergency law; Human Rights
Watch warned that most of the new authorities granted to the government are
unrelated to public health issues.240
In Algeria, the government of recently elected President Abdelmadjid Tebboune
banned all public gatherings of more than two people, including protest rallies,
which had been held weekly for political reforms since February 2019.241
In Israel, the government approved temporary emergency regulations for security
officials to monitor COVID-19 patients and potential victims via their mobile
phones.
Economies in the region have been hard hit by the collapse in global energy prices and tourism.
As in other regions, government efforts to contain the spread of the virus have also involved the
suspension of most public commerce and trade, resulting in a severe blow to economic activity
that is expected to generate increased unemployment. In April, the IMF projected that the region
comprising the Middle East, North Africa, Afghanistan, and Pakistan would contract by 3.1% in
2020, with oil exporters in the region contracting by 4.2%.242 Rising unemployment, particularly
concentrated among the youth, could have implications for political stability in the region. A
prolonged global economic slowdown associated with COVID-19 also could dampen global
demand for oil and natural gas resources exported from countries in the Middle East and North
Africa for a prolonged period, with corresponding diminishing effects on export revenues and the
fiscal health of some regional governments.
plus the Gaza Strip and West Bank. MENA and EMR countries largely overlap. However, EMR includes some
countries not covered by MENA (Afghanistan, Pakistan, Djibouti, Somalia, and Sudan). EMR does not include Israel,
which the WHO classifies under its Europe regional office.
237 Percentages based on official government figures as posted by the World Health Organization’s EMR office. These
figures are updated daily on Twitter @ WHOEMRO.
238
“Pompeo says Iran must ‘tell the truth’ on coronavirus.” AFP, February 25, 2020; “Egypt: rate of coronavirus cases
‘likely to be higher than figures suggest,’” Guardian, March 15, 2020.
239 “As covid-19 spreads, Arab states are clamping down,” Economist, March 26, 2020.
240 Human Rights Watch, “Egypt: Covid-19 Cover for New Repressive Powers,” May 7, 2020.
241 U.S. Embassy in Algeria, “COVID-19 Information: Country-Specific Information,” updated as of May 11, 2020. A
number of local activists had called for a temporary halt to protests prior to the new restrictions, citing public health
concerns.
242 IMF, “Press Remarks by Jihad Azour on the Economic Outlook for the Middle East and Central Asia,” April 15,
2020.
Congressional Research Service
39
Novel Coronavirus 2019 (COVID-19): Q&A on Global Implications and Responses
Starting in late April, some countries began lifting some internal restrictions on movement and
commercial activity—including Tunisia, where nationwide lockdown measures appeared to
contribute to a drop in new confirmed cases—and Lebanon, where cases appeared to spike
following the easing of restrictions.243 The WHO Eastern Mediterranean Regional (EMR) office
warned, “Without careful planning, and in the absence of scaled up public health and clinical care
capacities, [a] premature lifting of physical distancing measures is likely to lead to an
uncontrolled resurgence in COVID‑19 transmission and an amplified second wave of cases.”244
The WHO has highlighted the particular risks posed by the spread of the virus to states such as
Syria, Libya, and Yemen, noting that years of conflict, natural disasters, and previous outbreaks
have left these countries with weakened health systems, shortages in health workers, and
limited access to even the most basic medical care services. Millions of already vulnerable
people in these countries are also more prone to infectious diseases due to overcrowded
living conditions, weakened immunity due to years of food insecurity, and insufficient
treatment for other underlying medical conditions. Many of these countries are also
politically fragmented, resulting in limited humanitarian access to populations in some
areas, and challenges in the sharing of information between controlling parties and WHO
in a timely and transparent manner. 245
In addition, other areas of elevated risk in the region include the following:
The Gaza Strip. The Hamas-controlled Gaza Strip has reported 20 COVID-19
cases as of May 11, and officials from international organizations have voiced
concerns about a possible outbreak given the acute humanitarian challenges in
Gaza. The densely populated territory of nearly 2 million Palestinians has a weak
health infrastructure and many other challenges related to sanitation and
hygiene.246 On May 8, the U.N. Relief and Works Agency for Palestine Refugees
in the Near East (UNRWA) updated an emergency flash appeal from $14 million
to $93.4 million to prepare and respond to COVID-19-related needs for
Palestinian refugees in Gaza, the West Bank, Jordan, Lebanon, and Syria through
July 2020. The Trump Administration stopped U.S. contributions to UNRWA in
2018 and all bilateral aid to the West Bank and Gaza in 201
This text is long and has been trimmed here. Open the source document for the complete record.
This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.