Krishna D. Rao
Director IPSI, and Associate Professor, Johns Hopkins Bloomberg School of Public Health
Pandemics are highly inequitable. They impose a disproportionate burden of morbidity and mortality on countries and people at the lower end of the income distribution. Moreover, as in the case of COVID-19, control efforts through social distancing and population lockdowns have brought additional deprivations on vulnerable populations. In low- and middle- income countries (LMIC) and elsewhere, the slowdown in economic activity has resulted in rapidly rising unemployment, particularly in the informal sector, where the majority of workers are employed and without adequate social safety nets. The effects of COVID-19 and population lockdowns will have short and long term effects on health, human capital, and income of vulnerable populations. It is now increasingly clear that economically vulnerable groups are being forced to sacrifice disproportionately more for the better health of society. To mitigate the deprivation due to COVID-19 it is necessary for government safety net programs to provide long term support focused on specific vulnerable populations.
The association between pandemics and poverty is well known. The 1918 Spanish flu left around 500 million people infected and at least 50 to 100 million deaths worldwide. Poor countries bore the brunt of the pandemic. Between 1918 and 1920, India, which at that time was under British rule, had an estimated loss of 18 million lives or 6% of the population, the highest anywhere. In contrast, the United States, where the flu might have originated, experienced only 675,000 deaths. Similar, social inequities are seen in the current COVID-19 pandemic. In New York City COVID-19 related mortality is disproportionately higher among Latino’s and blacks. Deaths and illness due to COVID-19 are both an emotional and economic shock. Deaths, particularly of earning family members, represent a huge financial loss to vulnerable households, which can take a long time to recover from. Further, those who are unable to work due to contracting COVID-19 will experience substantial income losses; this will be particularly challenging for daily wage earners and poor households. Such productivity losses have been reported to be as large as half the income of the poorest households. While inequities in COVID-19 morbidity and mortality are yet unknown in low and middle-income countries, given that the social conditions there are much more conducive to epidemic spread, the pandemic will likely disproportionately affect economically vulnerable households.
Pandemics affect the economic well-being of survivors long after they are over. Studies from several low and middle-income countries and elsewhere have reported that exposure to tropical diseases and poor nutrition in-utero or during early childhood have long lasting effects on future cognition, educational achievement, and adult income. A study on the Spanish flu in the United States reported that individuals who were in-utero during the pandemic, as adults displayed reduced educational attainment, increased rates of physical disability, lower income, and greater dependence on social security payments, compared with birth cohorts just before and after the pandemic. For example, children born to infected mothers were 15% less likely to graduate from high school, their annual wages were approximately 5–9 percent lower, and disability rate was 20% higher at age 61, compared to birth cohorts not affected by the flu. Importantly, these effects were greater in socially vulnerable populations such as women and non-whites. The long term inter-generational effects of the flu will affect the economically vulnerable disproportionately. As such, relief programs need to have a long time horizon.
Irrespective of the extent to which COVID-19 inflicts financial hardship on vulnerable households, it is certain that COVID-19 control measures such as social distancing and population lockdowns will profoundly affect their economic well-being and health. Globally, so far, around 2.6 billion people have been put on lockdown due to COVID-19 control measures. In LMICs, like elsewhere, the collapse of economic activity has affected employment and livelihoods on a massive scale. The International Labor Organization estimates that more than 25 million jobs will be lost globally, a large share being in LMICs. The workforce in LMICs is largely in the informal sector with limited access to paid or sick leave, or social safety nets. The loss of employment is already playing out in dramatic ways – in India thousands of migrant workers started fleeing cities because they found themselves without any income after the lockdown was announced; in Bangladesh, 1 million garment workers have lost their jobs due to the population shut down. Large scale unemployment is also seen in more prosperous countries such as the United States, and Spain.
The loss of livelihoods due to COVID-19 control measures will affect the health of economically vulnerable populations in both the short and long term. For poor households, the health effects due to loss of livelihood will result in greater emotional stress, lower food and health care consumption. Further, the closing of schools due to the lockdown has deprived many children of their only nutritious meal through school-feeding programs. The health effects on pregnant women and children are particularly important because of their long term effects.
Governments in LMICs have announced a range of social protection measures to address the economic hardship faced by vulnerable households. These limited-time interventions have relied on existing safety nets and typically include – providing free or subsidized food, direct cash transfers, extending unemployment insurance for those in the formal sector, providing microfinancing loans or restructuring existing loans. The effectiveness of these safety nets will depend on the adequacy of the relief package, how well they reach the poorest groups, and efficiencies in delivery system. It is important to note that these measures are one-off measures intended only for a short period of time. However, the economic and health deprivation caused by COVID-19 will have long term effects. Addressing the long term health and economic effects of COVID-19 is much more challenging. It will require extending relief measures for a longer duration to at least a few years and expanding the benefit package. To prevent human capital deprivation in the future, both long and short term relief measures will need to target specific populations like pregnant women and young children. As noted in studies on the effect of 1918 Spanish flu and tropical diseases more broadly, exposure to infectious disease and poor nutrition during pregnancy and early childhood affect children’s future cognitive ability, educational attainment, productivity, and income. Protecting vulnerable households from the short and long term consequences of COVID-19 will be expensive and require sustained political commitment.
Pandemics affect the economic well-being of survivors long after they are over. The COVID-19 outbreak will affect economically vulnerable populations in LMICs in multiple ways in both the short and long term. Recent government actions in this direction are helpful but they are focused on the short-term. As such, governments need to take a long term view of mitigating the many economic and human capital effects of COVID-19 and its control measures.