School closures have denied more than 1.6 billion children in 199 countries access to traditional education; 370 million no longer receive school meals that they counted on. These are stark reminders that efforts to mitigate the catastrophic effects of the pandemic can exert their own tolls — not just in terms of money but also in lost educational opportunities, social isolation, the inability to provide for one’s family and sometimes death.
We desperately need more thoughtful and nuanced strategies for dealing with the pandemic in different regions, and not just because there are three ventilators in all of Liberia compared with roughly 170,000 in the United States. Someone surviving on $3 or less per day with no savings or social safety net — a description that applies to about a quarter of the world’s population, or 2 billion people — faces radically different priorities and trade-offs than their American or European counterparts.
Sheltering in place is a luxury that most of the developing world cannot afford: Without work, some people would be unable to buy food the very next day, throwing themselves and their households into immediate jeopardy. (Think, too, of all the refugees, migrants and homeless people who have no stable place to shelter at all.) While intelligently targeted social distancing makes sense everywhere, stricter measures such as broad shutdowns carry a much higher human price in the developing world. All nations face hard choices, but rational policies can ease the trade-offs.
Of course, it is imperative to pick at least the low-hanging fruit in all countries and thereby save millions of people from the novel coronavirus. Developing nations can and should support stringent personal hygiene: avoiding physical greetings, wearing homemade masks, covering the mouth when coughing or sneezing, and washing hands whenever possible. Other smart responses include temporarily banning large indoor gatherings such as religious services, and closing clubs and bars.
One striking feature of the developing world is its relative youth: In sub-Saharan Africa, for instance, only 3 percent of the population is over 65 — and more than 40 percent is under 15. One advantage of having fewer elderly citizens, given the higher fatality rates they face from covid-19, is that they can be more easily sheltered, and limited social resources can be more efficiently directed toward them. (As of Thursday, African nations reported 26,000 cases of covid-19, up from 16,000 the week before, out of a population of 1.3 billion.)
Even if strict social distancing is the most effective strategy in the global north — and some countries, notably Sweden, have controversially chosen a different approach — it is simply not possible in places like Bangladesh, where the population density of the entire country of 165 million people is more than twice that of the city of Nashville. The World Health Organization’s extensive guidance on responding to the pandemic — mainly focused on best practices for health systems and clinical care — does not discuss what must be done differently in low-income nations with limited infrastructure, constrained resources and very different baseline levels of health.
The United States responded to the pandemic-induced recession with a $2.2 trillion stimulus bill. But most countries can’t afford such measures (although international institutions such as the World Bank can mitigate economic disruption). They therefore must prevent their already-fragile economies from imploding, not least because it’s a mistake to think of “public health” and “the economy” as two competing concerns: The immiseration caused by job loss can lead to severe long-term health problems such as heart disease, depression and suicide. Financial loss doesn’t sit quietly in an accounting system somewhere; it transforms into deprivation, despair, damaged physical and social infrastructure, and ultimately death. That is true in wealthier nations but doubly so in poorer ones.
Policymakers everywhere may be tempted to focus on the immediate fatalities from covid-19 while eliding the equally real but more remote mortality from malnutrition, psychological distress, extreme poverty and sociopolitical unrest that lockdowns and economic disruption can cause. Yet the dangers of the latter are far sharper in the developing world. School closures, for example, are a high-profile and easily enforced intervention, but research suggests that they are surprisingly ineffective at reducing deaths from coronaviruses. In part, that’s probably because children tend to have smaller and overlapping social circles, so they don’t transmit diseases as widely, and in part because (especially for covid-19) they appear to far more rarely exhibit severe symptoms.
On the other hand, we know that school shutdowns come with awful costs, particularly in poorer countries: Sexual and other violence will increase (for some young people, school is a safer environment than home), as will teen pregnancies; many children, especially girls, will not return to school after it reopens. “Depriving a child of education, at any time up through adolescence, has lifelong negative consequences on health, cognition and earnings,” Donald Bundy, a professor of epidemiology and development at the London School of Hygiene and Tropical Medicine, told me.
Some wide-angle numbers may help clarify the choices that low-income countries face. Consider sub-Saharan Africa: If governments do nothing, the new coronavirus could spread across the continent and infect perhaps half of its 1 billion residents. Given the age distribution and recent estimated fatality rates, we would expect 0.2 percent of them — 1 million people — to die, three-quarters of them over age 60. Assuming a typical remaining life expectancy of about 10 years, this implies about 10 million years of life lost, a devastating number. That is why sustainable mitigation measures — masks, hand-washing, avoiding large crowds, minimizing nonessential travel, isolation if symptomatic — should be promulgated as soon and as widely as possible.
In comparison, malaria kills about 400,000 Africans annually, 80 percent of them under age 15. Given a remaining life expectancy of 60 years, this constitutes roughly 20 million years of life lost, year in and year out, from one easily preventable and treatable disease. Effective interventions can avert a malaria death for less than $2,000 on average. The response to the coronavirus must be robust, but it should not overshadow either existing commitments or potential opportunities for alternative and extremely cost-effective ways of saving lives.
Low- and middle-income countries must forcefully and intelligently fight this tragic pandemic — but they must also take into account local contexts and priorities. As wealthier nations slowly begin to reopen, and as we are inspired by the generous sacrifices for the greater good that so many citizens have willingly made, this is a timely opportunity to take stock and to ponder how each of us, wherever we live, can support those around the globe who are needlessly suffering. Our eyes have been opened to the havoc caused by public health catastrophes. Sadly, such catastrophes are far from rare outside our privileged bubbles. I hope we can remember that vision, and what we did about it, when covid-19 is yesterday’s news.