Responding to COVID-19 in the Developing World

As of April 20, 2020, there were over 130 countries around the world that had reported at least 100 cases of COVID-19, with the total number of known cases crossing 2.36 million worldwide. A global pandemic of these proportions merits a global response—and indeed, by the beginning of April, approximately a third of the world’s population was under some form of lockdown as governments across the world scrambled to contain the spread of the virus.  

Yet while the pandemic has hit both developing and developed countries, the former have not yet seen the sorts of galloping case counts of the worst-hit countries, which (apart from China) have so far been in Europe and North America. As of April 20, 1.86 million of the 2.36 million confirmed cases worldwide were in high-income countries, compared with around 0.49 million in middle income countries, and a mere 4,695 cases in low-income countries

It may of course be that these differences are merely artifacts of lower rates of testing in poorer countries, but it is also possible that developing countries are on an earlier part of the transmission curve. Nevertheless, developing countries may have a small (and possibly shrinking) window of opportunity to develop and fine-tune their policy response to COVID-19.

While speed is of the essence, haste—and a disregard for the economic and social realities of the developing world, the nature and limits of state capacity, and their likely behavioral responses to any measures taken to contain the virus—will handicap the chances of success of any actions, particularly if the goal is to minimize harm to already vulnerable people. This means the actions developing countries take will have to be carefully tailored to their specific circumstances. Advice that can seem grounded in “universal” human tendencies must be careful not to ignore the context in which it is applied—something we all must remember. This may seem obvious, but experience suggests that these basic facts can be overlooked—particularly when action is urgent.

The actions that developing countries take will have to be carefully tailored to their specific circumstances. Advice that can seem grounded in “universal” human tendencies must be careful not to ignore the context in which it is applied.

Take, for example, the idea of a lockdown. Painful even in Europe or the United States—consider the soaring unemployment figures in the latter—such measures, if implemented without consideration for economic realities and likely behavioral responses, are likely to fail and may in fact exacerbate the problem they are designed to solve. In India, the government imposed a nationwide lockdown on March 24 with only four hours’ notice. While sheltering in place may be possible, even if onerous, in Italy or France, it proved impossible for a large fraction of the estimated 100 million Indians who toil in the informal or semiformal sectors of the country’s major cities.

These workers don’t just live paycheck to paycheck—they survive on daily wages. The complete shutdown of the country’s economy meant that the equivalent of 16 New York City’s worth of people found themselves with no option but to walk hundreds of miles back to their hometowns. The human cost aside (several dozen are known to have perished on their perilous journeys), this predictable behavioral response could end up spreading COVID-19 into the country’s vast rural hinterland, worsening the problem the lockdown was aimed at solving. Lockdowns will have similar problems in any country with a large informal sector and widespread rural-urban and seasonal labor migration. Worse, such reverse migration means that industries supplying essential goods may face a shortage of workers to make, load, and transport these goods when the lockdown ends, lengthening COVID-19’s adverse economic impact.

What then is the alternative, given the importance of preventing transmission?

Should lockdowns be necessary, they would need to be accompanied by carefully thought-out ways to ensure that those left without work are supplied with food and other essentials in a way that allows them to stay where they are, rather than return to places where they may feel safer. Indeed, even in India, some states have done a better job of enabling people to stay home than others, using existing food distribution systems to supply people with essentials while staying home. With sufficient planning and coordination, developing countries may in fact be able to leverage existing networks of street vendors and food suppliers and information about places where migrant workers congregate to make it easier for people to stay in place. Lockdowns in developing countries would also need to account for people (especially poorer people) lacking the infrastructure to store large amounts of perishables at home and work to minimize exposure rather than insist on unviable rules. 

We need to recognize that “keeping a safe” distance is simply not a possibility in crowded urban slums. Instructions and heuristics around distancing need to take account of these realities. 

Recognizing these realities might require governments to work to develop systematic ways of ensuring that people don’t need to congregate in large numbers to get what they need, perhaps by staggering or extending opening hours for shops, using networks of vendors and delivery agents to minimize need to go out, and so on. This may require governments to work with police and other local authorities to provide the right kind of identification, protective gear, and supply chain support to the people who work in these sectors—something of a radical departure for administrations who often regard these folks as more of a nuisance than the essential workers they are. And there may be merit to considering intensive case identification led by community health workers, as Nobel Laureates Abhijit Banerjee and Esther Duflo have suggested India could do, as well as local containment strategies, rather than blanket bans on movement. 

Next, consider “distancing.” Countries in the global North are encouraging people to maintain a degree of distance by staying at home and minimizing contact with those not in their immediate households. This may simply not be possible for the poor and lower middle classes in developing countries, many of whom live in extremely cramped conditions.

Some estimates put the population density of Kibera in Nairobi, Kenya—often called Kenya’s largest informal settlement—at as high as 300,000 people per square kilometer. Compare this with New York City, one of the rich world’s densest cities, which has about 30,000 people per square kilometer. At the very least, we need to recognize that “keeping a safe” distance is simply not possible in crowded urban slums, whether Dharavi or Kibera. Instructions and heuristics around distancing need account for these realities. Given the impossibility of true distancing, there may be creative ways to help people develop heuristics for which social interactions to minimize and how, and think through how to shield the most vulnerable in low-income settings, following an approach the London School of Hygiene and Tropical Medicine has developed.

In Kibera, poor sanitation and overcrowding make social distancing an impossible task, raising fears about the potential spread of the novel coronavirus.

Campaigns around handwashing and other hygiene measures will also need to adapt to the realities of people’s living conditions. It makes little sense to ask people who have no running water to wash their hands regularly unless provisions are also made to fix this structural problem, as has been attempted in Kibera. More broadly, behavioral science tells us that people are likely to disregard advice that appears to not be targeted at “people like them,” making it doubly important to tailor any instructions to people’s lived realities. Advice needs to be realistic—perhaps people could indeed be asked to wear masks, and existing networks of small tailors supported to make them quickly and cheaply—but recognizing the limits on what is possible in crowded, less-sanitary settings will be important (if necessarily sobering).

Beyond adapting measures to local circumstances, developing countries need to recognize the extreme financial vulnerability of a large fraction of their working population, who often have even less of a buffer than poor people in richer countries. Mitigating the economic impact of widespread losses of income thus becomes doubly critical. Governments need to put in place systems to quickly get cash assistance to vulnerable households and groups by utilizing existing mechanisms for the provision of cash or in-kind support, such as direct transfers to bank accounts opened under financial inclusion drives, leveraging beneficiary lists for seasonal cash-for-work public works programs, and so on.

It makes little sense to ask people who have no running water to wash their hands regularly unless provisions are also made to fix this structural problem.

Ultimately, a crisis like the present one only underlines the importance of having invested in systems—whether primary health care, food and cash distribution systems, or plain administrative capacity—in more benign times. Governments that have done the hard work of setting these systems up have a much better chance of being able to handle the fallout from COVID-19 without immense pain to their poorer citizens than those that have postponed these important tasks or neglected them altogether.

Disclosure: Saugato Datta is an employee of ideas42, which is a founding partner of the Behavioral Scientist.