COVID-19: containment, poverty and population health

THE mass containment strategy has been a key part of the world’s response to stop the spread of COVID-19 and limit its impact. At best, containment can prevent a pandemic and protect a country, especially an island nation such as Australia, from a dangerous pathogen.

However, COVID-19 has been declared a pandemic by the World Health Organization and few experts would believe we can prevent widespread infections in Australia. It has been estimated that COVID-19 will eventually infect between 20% and 60% of the population and possibly become endemic. In this context, containment still plays a very important role in flattening the peak of the pandemic and, therefore, avoiding overloading or overwhelming public health facilities and, in particular, the capacity for life-saving ICU admissions. Therefore, containment can and will save lives and those who are quarantined, like me, should follow the advice of our public health officials.

Despite the public health potential of containment, there are obviously dramatic, if not catastrophic, costs to the economy. The world economic downturn has been dramatic with a global recession now seeming inevitable. This is not, however, a result of COVID-19 or of death from virus, but it is seemingly due to the response and reaction to it. It is the containment, associated mass quarantining, closure of childcare and school facilities, closure of restaurants, curtailment of travel and resultant disruption of trade, supply lines and productivity that are primarily responsible for the economic downturn (with fear and investor panic perhaps aggravating this effect).

What we seem not to be considering is the real impact of the economic downturn on global poverty rates and the impact of that on the poorest. The most recent economic downturn that is similar to the size of the current downturn was the 2007–08 Global Financial Crisis (GFC) and it is informative given its impact on poverty and health. For example, as a result of the GFC, it was estimated that in Bangladesh and the Philippines the excess poverty rate would be between 1.2% and 1.5 %. In 2009, Ravaliian and Chen modelled that in the 2 years following the GFC an extra 73 million people would be living on under $1.25 a day and an extra 91 million under $2 a day by 2010.

Such a financial crisis worsens population health and increases poverty, malnutrition and infant mortality. During the GFC, people earned less, ate less (and worse) foods and withdrew children from school. The impact in low- and middle-income countries is more dramatic and those in poverty are more inclined to fall ill and not be able to afford health care. During the GFC, for example, deaths from cancer rose by an estimated 500 000 as the ill could not afford or access the necessary treatment. Even in the US the suicide rate increased by about 10 000 people. These are just two examples of how poverty can kill and many others have been documented such as malnutrition, alcohol usage, and violence.

Although the extent of the economic downturn associated with containment and quarantine measures is not yet fully known, we can estimate that it will push many millions into poverty and result in excess mortality.

Yet, in the current scenario, the increased poverty level and its flow-on effect to population health seems to have been totally overshadowed by the focus on the direct mortality from COVID-19. Every death resulting from the virus is significant and concerning, and the total will almost certainly surpass the annual influenza toll of up to 650 000. Containment measures have, are, and will play an important role in limiting the number of deaths from the virus.

However, it is difficult to predict with accuracy the number of lives saved from the extensive and strict containment.  It is even more difficult predict the number of lives lost from economic downturn and they are largely hidden and difficult to see. The assumption, and our hope, is that the benefit of lives saved from mass containment will outweigh the cost of lives lost.  Yet, there is no simple cost-benefit scenario because some will benefit more from containment (probably high-income island countries like Australia) and some will pay a higher cost (such as poorer people who are at risk of falling below the poverty line).  It is probable that the poorer will differentially bear the greatest burden from the economic cost of containment.  To further consider this cost-benefit question, more complex economic and population health modelling would be required.

Containment actions are necessary and citizens should comply with state directives, as I am this week.  But we should also be considering the cost and asking how extensive, severe and long lasting the containment and subsequent mitigation responses should be?  For example, does it do more harm or good for one country with extensive community spread to ban all travel from another which also has extensive community spread?  Or could there be more focus on encouraging home isolation for high-risk groups such as the elderly whilst slightly loosening other bans over time? How flat does the curve need to be? The economic effect of containment, and in turn the effect on population health and more specifically on the health of the most vulnerable, needs also to be considered.

Associate Professor Nathan Grills (DPHIL, DPH, MBBS, MPH), is a Public Health Physician at the Nossal Institute for Global Health, University of Melbourne. He works on non-communicable diseases, community health mobilisation, and disability largely in low and middle income settings. His DPhil explored the response to HIV in India and his DPH focused on the role of partnerships in public health practice. Nathan coordinates the Victorian Public Health Medical Training Scheme which is delivered through the Melbourne Consortium.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.