Policies imposed in rich countries to fight the coronavirus could have adverse effects in low-income nations—potentially endangering more lives than they save.
“It’s is unbelievably stupid to apply a modern model of an ageing wealthy population to a poor country with a young population with a miniscule of the fraction of Corona mortality that a typically first world country faces. This research is so obvious, yet to a world of ivory towered politicians and more affluent people it appears beyond comprehension. History has a rather delightful habit of celebrating the truth however uncomfortable that turns out to be. Scientific, economic and political stupidity will be in the limelight for decades to come and will form part of future think tanks about panic or if you insist pandemic models not to employ. Cinderella’s glass slippers do not fit everybody.” – Rubin Van Niekerk
In response to the coronavirus pandemic, varying levels of social distancing have been implemented around the world, including in China, Europe, and much of the United States. Hundreds of millions of people have accepted dramatic disruptions to their daily lives and substantial economic losses based on the reasoning that slowing the spread of the coronavirus can keep health care systems from becoming overwhelmed.
Epidemiological models make clear that the cost of not intervening in rich countries would be in the hundreds of thousands to millions dead, an outcome far worse than the deepest economic recession imaginable. In other words, social distancing interventions and aggressive suppression, even with their associated economic costs, are overwhelmingly justified in high-income societies.
But the logic of this response is built on the characteristics of the industrialized, relatively wealthy societies where the policy has emerged. Low- to middle-income countries, such as Bangladesh and Nigeria, are different and raise different questions, namely: Do the benefits of countrywide lockdowns also outweigh the costs in poor countries?
We see several reasons—including demographic composition, the source of people’s livelihoods, and institutional capacity—that suggest that the answer may be different than in the United States or Europe. To put it bluntly, imposing strict lockdowns in poor countries—where people often depend on daily hands-on labor to earn enough to feed their families—could lead to a comparable number of deaths from deprivation and preventable diseases.
It’s worth looking first at the likely impact of the disease on different countries. While the young are not safe, the coronavirus hits older people hardest, with an estimated fatality rate of 6.4 percent in people above the age of 60, increasing to 13.4 percent for people above the age of 80.
Low-income countries (where per capita income is less than $1,000 per year) have smaller proportions of people over 65 (3 percent) than wealthy low-fertility nations (17.4 percent), according to the World Bank.
As a result, the Imperial College COVID-19 Response Team’s influential epidemiological model estimates that the unmitigated spread of the new coronavirus would kill 0.39 percent of Bangladesh’s population and 0.21 percent of the sub-Saharan African population; that’s less than half the 0.8 percent mortality rate estimated for the United States and other OECD countries.
This model accounts for country-specific demographics, differences in health care capacity, and infection rates, and it projects higher mortality in rich countries despite the comparatively poor quality of health systems in poorer nations. The model, however, does not account for the greater prevalence of chronic illnesses, respiratory conditions, pollution, and malnutrition in low-income countries, which could increase the fatality rates from coronavirus outbreaks. That is an important limitation of these comparative projections.
To calculate the comparative benefits of imposing social distancing guidelines in rich versus poor countries, we combined these estimates of country-specific costs of mortality with epidemiological predictions of mortality from the spread of the virus to generate estimates for a range of countries. In research that is currently under peer review, we found significant differences in the value of social distancing across countries.
An equally effective social distancing policy is predicted to reduce coronavirus-related mortality by 1.3 million people in the United States and 426,000 in Germany. Such a policy would only save 182,000 people in Pakistan and 102,000 in Nigeria. The question is how many lives would such a policy endanger in those poor countries.
The very large social distancing benefits estimated for the United States and Western Europe leave no room for debate about the public health value of widespread lockdowns and stay-at-home orders in those regions. That’s why calls from U.S. President Donald Trump and others to not make the cure worse than the disease make little sense in a country like the United States. The quantitative picture is a lot less clear in low- or middle-income countries, however. Those citizens also want to be safe from illness, but they don’t want to be unemployed, impoverished, or hungry.
The net gains in welfare from saving lives by imposing coronavirus suppression policies is even larger in high-income countries relative to low-income ones, because social distancing lowers disease risk by limiting people’s economic opportunities. According to our recent research, poorer people are naturally less willing to make major economic sacrifices. Indeed, they place relatively greater value on their livelihood concerns compared to concerns about contracting the coronavirus.
Our estimates may even overstate the value of social distancing in poor countries, where such policies may also exact a heavier economic toll, especially on the poorest and most vulnerable. Workers in these countries are more likely to be employed doing hands-on work that cannot be conducted while social distancing. They are also likely to in the informal sector and rely on a daily cash wage—without access to a social safety net. In the short term, social distancing prevents them from working and generating an income; in the long term, this can lead to hunger, malnutrition, other non-coronavirus-related health problems, and death.
These are no longer merely hypothetical concerns. We started collecting systematic data last week from representative samples of individuals in rural Bangladesh and Nepal by conducting thousands of structured phone interviews, and we are learning that food insecurity and unemployment—not health and safety—are now the top concerns of the extreme poor in rural areas. Our research found that after Nepal’s lockdown was imposed, labor hours in rural areas have dropped 50 percent below even the limited number of labor hours that people are able to secure during the lean or so-called hungry season in the agricultural crop cycle.