In poor countries, focus on protecting the elderly from Covid-19
By Joelle M. Abi-Rached and Ishac Diwan[1]
Following in the footsteps of China, most governments around the world are by now pursuing what we might call a “strategy of extinction” to try to contain the Covid-19 pandemic. Given the high rates of infection (Ro>2), and the fact that 15–20% of those infected need to be hospitalized, of which 5% in intensive care, “flattening the curve” quickly arose as the only strategy in the countries most affected, even when some considered choosing the alternative strategy of “herd immunity.” Very quickly, the focus shifted towards expanding the capacity of the health care system. In parallel, social distancing measures have been imposed in various forms, from extreme lockdowns to more reliance on citizens’ responsibility (like in some Nordic countries), in order to reduce the pressure on overwhelmed hospitals.
What is becoming rapidly clear, however, is that poor countries will be unable to follow the extinction strategy effectively when/if the pandemic gets out of control. We argue in this short piece that instead of trying to imitate the experience of richer countries, poor countries should focus their efforts on a particular form of social distancing that emphasizes the protection of their elderly and at-risk populations besides expanding as much as possible their health care system and social safety nets.
In a recent opinion piece, the economists Debraj Ray and Sreenivasan Subramanian have broken the taboo by noting that India cannot afford to let people lose their livelihood and simply die of famine. Their argument is not built on a dubious value of life logic. Rather, they argue that given the generally low case fatality rate (CFR) among the young, it is reasonable to allow them to work while measures are taken to reduce inter-generational transmission.[2]
Since then, we find looser arguments for alternative strategies in the developing world. Some pundits have started to argue that a total lockdown strategy is not realistic when governments do not have the means, either fiscal or bureaucratic, to support large populations by financing their confinement. As a result, where government safety nets barely extend to the sprawling informal sector, people will break the law to get a livelihood. In the worst-case scenario, a lockdown enforced by force could lead to hunger, violence, more lost lives, and increased morbidity.
We find that Ray and Subramanian’s argument extends well beyond India to countries where lockdowns are either not feasible or more likely to lead to more rather than fewer fatalities. Besides similarities with India in terms of state capacity (undeveloped and understaffed) and fiscal space (the state cannot finance all the poor during lockdowns), we argue that demography, more specifically, favors this type of targeted response.
The case fatality rates attributed to Covid-19 that are emerging from affected countries show clearly that deaths are very much concentrated among senior populations and those with certain comorbidities (especially, cardiovascular, severe obesity, hypertension, and diabetes).[3] In Italy and China, CFR is only 0.2–0.4% for those below age 50; 1.3% for those aged 50–60; 3.6% for those aged 60–70; 8% (China) vs. 12.8% (Italy) for those aged 70–80; 14.8% (China) vs. 20% (Italy) for those over age 80.[4] While the denominator is contested and imprecise, it is nevertheless clearly the case that CFR rises very fast with age.
There is, of course, no guarantee that those CFRs would not be higher in poorer environments where hospital capacity is very limited. ICU beds are scarce in poor countries (15 in Burkina Faso, 55 in Uganda, 80 in Senegal, 130 in Kenya), and ventilators are even scantier (11 in Burkina Faso, 20 in Ivory Coast, 80 in Senegal, 400 in Nigeria).[5] And so, it remains of crucial importance in any strategy to focus on expanding medical capacity.
Isolating the elderly is an important way of reducing the burden on hospitals. A recent study in The Lancet, has shown that the hospitalization rate of those confirmed to be infected with Covid-19 rises very sharply with age (even more sharply than death rates), but still the hospitalization rate among those age 30-50 was on average 4%, which is not negligible.[6] Therefore, by isolating the elderly not only does mortality decrease significantly, but the lives of many younger people who will eventually be hospitalized can be saved.
In sum, where social distancing measures are imperfect, focusing the effort on the protection of the elderly and those with high comorbidity risks is probably the best way to lessen the social impact of this pandemic until a vaccine is found.
On this count, poor countries have advantages and constraints compared to richer ones. The good news is that they have a small elderly population, as a result of their more recent demographic transition. While the senior population represents about 25% of the population in richer countries (Italy 30%, Germany 28%, France 26%, Spain 25.3%, Hong Kong 23%, United States 21.5%, South Korea 20%), this proportion is much lower in the poorest countries with an average below 5% in Africa (Ethiopia 5.3%, Liberia 4.9%, Sierra Leone 4.2%, Chad 4%, Uganda 3.3%). The share of seniors is around 10% in middle-income countries (India 9%, Brazil 12%, Chile 13%), with China being an exception with a large aging population (16%).[7]
It is therefore more feasible in theory to isolate the seniors in poorer countries on account of their numbers. But isolation can turn out to be more difficult because they tend to live much more often in large households. Here, the situation is reversed. In the Netherlands and Germany, for example, nearly 90% of the senior populations live alone or with their spouse (Italy 65%, Spain 55%).[8] In poor African countries the proportion falls to about 10%.
What about comorbidity? In developed countries, chronic conditions like diabetes, cardiovascular issues and other conditions known to increase Covid-19-related mortality are more prevalent in young adults than in poorer countries. In middle-income countries (like many countries in the Middle East and North Africa or Latin America), these important comorbid conditions might complicate an approach that mainly relies on demography. But in poorer countries, especially those with high food insecurity or large groups of refugees living in camps, it is communicable diseases (tuberculosis, malaria, and other infectious and parasitic diseases) that remain more common than chronic diseases.[9] We still do not know the role played by these communicable diseases in the mortality related to Covid-19, hence comorbidity implications of communicable diseases in poorer countries need to be urgently investigated.
This leaves us with the question of how to isolate the elderly. Even poor states should be able to afford whatever this may require in terms of financial help. But how to do it varies from place to place, depending on the particular living conditions (slums vs. rural housing), culture (patriarchy vs. matriarchy), equipment (masks) and health personnel, and even architecture (large houses vs. crowded and dense habitats). In most places, how to go about this isolation is probably best left to communities and households, supported by some state financing. But to make isolation successful, medical care, food, masks as well as psychological support must be provided until a vaccine is administered to these vulnerable populations, which in the best of circumstances will not be available before September 2021.
What would be most crucial, however, is the dissemination of information about the serious risk of death from Covid-19 among the elderly. Typically, the poorer the household, the less connected to public sources of information, and in many cases, the less trust in public information. There is a crucial role here for civil society organizations, religious institutions, and traditional chiefs in disseminating information about those risks. This effort must start immediately, well before the virus hits, in parallel to a scaling up of medical facilities.
For the poorest countries, and for most of the poor in middle-income countries, herd immunity is unfortunately not a matter of choice as much as a predicament they have to deal with as individuals and communities. These societies will have to make a special effort to preserve their elders during the difficult period when/if the virus will circulate in waves and blow across society. The good news is that this can be done, if proper efforts are expanded as soon as possible in finding workable ways. The main risk of imitating the rich and imposing harsh but unworkable lockdowns is that the effort would crowd out scarce public capacity that can be better put to use elsewhere where it can make a difference.
[1] J. M. Abi-Rached, MD PhD, is an invited researcher at the École normale supérieure and the École des hautes études en sciences sociales as well as Mellon Postdoctoral Fellow at the Society of Fellows in the Humanities, Columbia University. Ishac Diwan, PhD, is Professor of Economics at the École normale supérieure | Paris Sciences et Lettres.
[2] Debraj Ray and Sreenivasan Subramanian, “Covid-19: Is there a reasonable alternative to a comprehensive lockdown,?” Ideas for India, March 28, 2020, “https://www.ideasforindia.in/topics/macroeconomics/is-there-a-reasonable-alternative-to-a-comprehensive-lockdown.html?fbclid=IwAR21FkuUziKPBP9RaFWKJ9jX3Hj56HgqwvT87v0hYWMYxcsvPkaFegxSpCU
[3] Wei-jie Guan, et al., “Clinical Characteristics of Coronavirus Disease 2019 in China,” New England Journal of Medicine, February 18, 2020, https://www.nejm.org/doi/full/10.1056/NEJMoa2002032; Center for Disease Control and Prevention, “Groups at Higher Risk for Severe Illness,” 2020, https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html
[4] Graziano Onder, Giovanni Rezza, and Silvio Brusaferro, “Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy,” Journal of the American Medical Association, March 23, 2020. doi:10.1001/jama.2020.4683
[5] Olivier Marbot, et al., “Nombre de lits de réanimation et de respirateurs : où en est l’Afrique ? ,” Jeune Afrique, April 8, 2020, https://www.jeuneafrique.com/924087/societe/nombre-de-lits-de-reanimation-et-de-respirateurs-ou-en-est-lafrique/
[6] See Robert Verity, et al., “Estimates of the severity of coronavirus disease 2019: a model-based analysis,” The Lancet, March 30, 2020, https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext#%20
[7] United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Ageing 2017 — Highlights (ST/ESA/SER.A/397).
[8] Ibid.
[9] Philip Stevens, “Diseases of poverty and the 10/90gap,” International Policy Network, 2004 https://www.who.int/intellectualproperty/submissions/InternationalPolicyNetwork.pdf. On the rise of the global burden of chronic conditions in poor countries see, World Health Organization, “NCDs, poverty and development,” 2011, https://www.who.int/nutrition/topics/2_background/en/
