There have been over 7,000,000 confirmed COVID-19 cases and 400,000 deaths globally, and given the high transmission rate of the disease, health officials predict millions of additional cases in the months to come. Although nearly every country has been affected by the pandemic, containing the virus presents a particular challenge for low- and middle-income countries (LMICs) where health care services are limited and social distancing measures are difficult to effectively implement.
Without an available vaccine or effective treatment for COVID-19, governments across the globe have implemented curfews, lockdowns, and other social distancing measures to compulsorily limit social contacts. Similar measures saved thousands of lives during the 1918 Spanish influenza pandemic by slowing the spread of the disease. However, despite intensive efforts to reduce social transmission, only select countries such as South Korea, New Zealand, and China have been able to effectively reduce contact rates and, subsequently, infection rates to near zero, allowing their populations to return to some level of socio-economic normalcy.
As was evident in 1918 as well as today, lockdowns are effective tools for slowing the spread of airborne disease. However, prolonged lockdown measures have stifled national economies. As a result of the novel coronavirus pandemic, the International Monetary Fund predicts a global cumulative output loss of 9 trillion dollars over the next two years. Extreme poverty is expected to rise for the first time since 1998, while an additional 135 million people will face acute food insecurity by the end of 2020 due to disruptions in supply chains and financial crises.
Given this economic impact, which has negative consequences for even basic health care provision, policymakers and health officials in LMICs face a major ethical dilemma: to commit to lockdown measures that can slow the spread of SARS-CoV-2 or to allow national economies to function as if business is running as usual. At one extreme is the possibility that everyone who dies from COVID-19 would have died regardless of the measures implemented. Lockdowns therefore may only delay inevitable mortality while at the same time causing severe economic hardship. On the other extreme, successful lockdowns, although harmful to national economies, can reduce disease transmission to near zero, delaying the spread of disease until therapies and vaccines become widely available. The reality certainly lies somewhere between these extremes, and the choices made by countries depend in part on their ability to realistically reduce the overall burden of disease mortality.
Reducing the burden on healthcare institutions prevents unnecessary deaths due to lack of available equipment or personnel, and, based on historical patterns from 1918, likely reduces overall mortality. However, these results are based on the experience of high-income countries. In most LMICs, health systems are overburdened and underdeveloped during the best of times. According to a recent analysis, there is less than one ICU bed per 100,000 people in 32 out of 54 African countries. Therefore, lockdowns to reduce mortality by reducing the burden on health facilities may not be as effective in LMICs as in developed countries as these health systems are already compromised. Moreover, when a vaccine becomes available, its availability and use may be limited in LMICs where immunization rates of routine vaccines, such as those for diphtheria, measles, and polio, remain low. These factors may mitigate the effectiveness of lockdowns. On the other hand, greater pollution, higher rates of Tuberculosis, HIV/AIDs, and malnutrition may make populations in LMICs more susceptible to disease increasing the risk of not reducing the spread of the disease.
Quantifying the benefits and risks of stringent social distancing measures is difficult but should be central to ethical decisions made in determining policies to extend lockdowns or to open economies worldwide. Compared to people in high-income countries, those living in LMICs face higher poverty rates, are more likely to earn an income from the informal sector and have a smaller social security net to provide aid. Across India and Africa, over 80% of people are employed in the informal sector, and as a result, short disruptions in employment due to curfew or lockdown can mean the difference between feeding one’s family or not, the difference, in many cases, between life and death.
As such, individuals face the difficult decision of providing for themselves and their families and potentially contracting SARS-CoV-2 or facing the legal repercussions of breaking curfew or lockdown. Although decisions to prolong or lift lockdowns will be made on a country-by-country or even city-by-city basis, the implications are global, as the virus does not respect global boundaries. Global aid to LMICs to manage the economic fallout of lockdowns is imperative to prevent unnecessary mortality, reduce the risk of societal collapse, and prevent increased spread of the disease. This assistance should take the form of increased food and medical aid, as it is a moral imperative to shift the decision-making such that attempts to mitigate COVID-19 are not seen as ultimately causing more harm than good.