Although some low- and middle-income countries (LMICs) seem to have so far escaped lightly from the health impacts of the COVID-19 pandemic that are devastating many wealthier countries, both the current reality and potential future are not rosy. For a start, the low number of cases is highly likely to be the result of under-reporting, and inadequate surveillance and detection systems. In particular, COVID-19 can cause symptoms similar to other diseases that are endemic to tropical climates, and this could lead to cases going under-recognised and unreported. For example, COVID-19 can cause fever and muscle ache, much like malaria, or coughing and fever, like respiratory syncytial virus. Diagnostic testing, that allows COVID-19 cases to be distinguished from other infectious diseases, has ramped up quickly in many LMICs but is not being done as frequently as in many high-income countries.

Moreover, some researchers are predicting that LMICs are yet to see the peak of disease transmission. SARS-CoV-2, the virus that causes COVID-19, appeared in many LMICs later than in high-income countries, so it has had less time to spread. In addition, a greater proportion of LMIC populations live in rural areas, which may have contributed to the virus spreading more slowly, as may have the introduction of physical distancing and other measures that many countries have put into place. Demographics may also be a factor, with relatively young populations in some regions, such as sub-Saharan Africa where a third of the population are children.

However, even if some LMICs do end up having fewer COVID-19 cases and deaths than countries like the USA, the UK or Italy, many poorly resourced countries are already suffering social and economic devastation from responding to the pandemic.

Collateral damage from COVID-19

Lockdowns and quarantines implemented by many countries to stop the spread of the new coronavirus have had disastrous impacts on even the strongest economies, by halting social and economic activity. However, in wealthier countries, many more people are able to work remotely or online, compared with informal or manual labour markets in LMICs, where people often depend upon hourly or daily salaries that ended the instant lockdowns or curfews were enforced. Social safety nets in wealthier countries are also much more extensive.

Unfortunately, the lockdowns in Africa and Asia have affected vulnerable and marginalised communities the most. For example in India, the 400 million workers in the informal sector - 80% of India’s non-agricultural workforce - are at risk of falling into poverty. Many can no longer find work in cities and have had to travel back to their home villages, causing considerable hardship. UNDP estimates that half of all jobs would be wiped out in Africa as a result of the pandemic. In other low- and middle-income countries, the informal economy contributes to a significant portion of their GDP.

Access to healthcare has been widely disrupted as well, with many routine immunisation programmes disrupted and preventive vaccination campaigns temporarily halted in many parts of the world in a bid to stop the spread of COVID-19.

Data collected by Gavi, UNICEF and others suggests that 80 million children under the age of one are at risk of diseases like measles and diphtheria because of disruptions related to the COVID-19 response. More than half (53%) of 129 countries saw moderate or total suspension of immunisation services in March and April.

This abrupt stop in routine immunisation risks taking the world back to the bleak times of the late 1990s where in poor countries 30 million children every year were not fully immunised. In the last two decades, thanks to enormous effort, funding and commitment from Gavi and partners, more than 760 million additional children have now received vaccinations. But this progress could roll back rapidly if measures aren’t taken swiftly to ease the delay in the transport of vaccines and increase the amount of personal protective equipment health workers in these countries have, to ensure that immunisation can continue. It will be critical to make sure that any children who have not received vaccines due to the COVID-19 response receive them as soon as possible.

Access to HIV and TB treatment has been challenging too. A World Health Organization and UNAIDS analysis showed that a six-month interruption in health services and supplies because of the pandemic could lead to half a million extra deaths from AIDS-related illnesses. For example, in sub-Saharan Africa the number of tuberculosis cases could double over the next year.

Scientists have warned that unless the response to the pandemic is balanced by ensuring access to other healthcare continues, there is a very real risk that more people will die from other, potentially preventable conditions than from COVID-19.

Pandemic responses are not generalisable

No-one can predict how long we will have to live with COVID-19, but infectious disease specialists predict that we will see continued outbreaks of the disease over the coming months, and potentially, years.

One potential reason for the relatively low case count in LMICs is that they have not yet reached the peak of transmission. South Africa expects to see its transmission peak only in September.

This suggests a need to think carefully about containment measures that are suited to LMICs, and ones that don’t come with devastating socioeconomic consequences.

The UN has issued a stark warning that “the economic lockdown necessary to save lives will immediately increase poverty, hunger and destitution”. What’s more, girls and women are likely to be disproportionately affected as they more often work in the informal sector or other economic sectors affected by physical distancing rules. Halting education will greatly affect girls, who already struggle to have equal access to schooling; this will impact their future in the medium- to long-term.

Avoiding tunnel vision in addressing a pandemic and acknowledging the wider socioeconomic and health inequities is likely to be critical in ensuring that the pandemic response doesn’t deepen social and economic inequities and cause more loss of life than it prevents.

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