key: cord-0695123-haqsclcs
authors: Hummel, Calla; Knaul, Felicia Marie; Touchton, Michael; Guachalla, V Ximena Velasco; Nelson-Nuñez, Jami; Boulding, Carew
title: Poverty, precarious work, and the COVID-19 pandemic: lessons from Bolivia
date: 2021-01-25
journal: Lancet Glob Health
DOI: 10.1016/s2214-109x(21)00001-2
sha: 7852ec66cde52251c45874dc595c1b160c526287
doc_id: 695123
cord_uid: haqsclcs

nan

The Bolivian Government announced a postconfinement phase on Sept 1, 2020, and subsequently all departments began to relax containment strategies. A national mask mandate, nightly curfew, school closure, event ban, and border closure were maintained while allowing most workplaces and transportation to open with restricted hours and distancing protocols. Departments differed with regard to opening hours of businesses, the level of intermunicipal transportation, the size of gatherings, and local enforcement. The relaxation of restrictions in some departments coincided with the nationwide surge in COVID-19 deaths in June and July, 2020. However, deaths declined in September and October, 2020, despite the post-confinement relaxation.

Informality, inequity, and overlapping health disparities and pre-existing conditions of specific groups are systemic and persistent issues that amplified the impact of the pandemic and explain outcomes observed across the country. In the poorest departments, deaths in July, 2020, were more than seven times higher than that in July, 2019. 2 In comparison, the peak of deaths in the wealthiest departments were only two times higher than that in the same period in 2019.

More than 70% of working Bolivians do not have employment contracts or employer-based social security 3 making strict containment especially difficult to achieve. National and departmental containment laws designated market, transportation, and agricultural labourers as essential workers, 4 despite informal, openair, street markets being identified as sites of contagion. Employment in these sectors continued amid a shortage of personal protective equipment (PPE) and testing. Departmental and municipal governments implemented mask and glove mandates, but these low-income workers were expected to source and purchase their own PPE and tests. COVID-19 cases were concentrated in these informal workplaces. In Cochabamba, market and transportation workers and their families account for 40-50% of confirmed COVID-19 cases despite low levels of testing among these groups. 5 The national government expanded benefits for existing cash transfer programmes in late March, 2020, and extended income transfers to previously unprotected workers. 6 Although such programmes represent a welcome anti-poverty policy, electronic distribution was impossible, benefits were collected in-person, and crowds formed at the distribution sites. The absence of strict social distancing protocols further increased health risk.

Bolivia highlights the importance of labour market structures for understanding the spread of SARS-CoV-2 (panel). Non-salaried, unprotected workers and their families have been disproportionately affected by the COVID-19 pandemic. These groups are vulnerable for multiple reasons: their work requires close contact with the public and each other without PPE; their living spaces are overcrowded without access to clean water; and most workers do not have health and unemployment insurance. 6 Informal workers' organisations could be a crucial route for the government to respond to workers' shortterm needs while addressing larger systemic issues. 7 Bolivia has previously used these groups for health policy enforcement, advocacy for workers' needs, and distribution of PPE. However, to date, Bolivia has missed an important opportunity to partner with workers' unions and civil society organisations to deliver health services, implement non-pharmaceutical interventions, and reach vulnerable populations.

Bolivia, despite being a relatively small country with a population of around 11 million, mirrors the dynamics of COVID-19 in larger countries including Mexico, Brazil, Canada, and the USA: variation in subnational nonpharmaceutical intervention is key to understanding a country's response to the pandemic. 8, 9 Understanding such variation might also provide essential insight with regard to the evolution of COVID-19 since subnational non-pharmaceutical intervention might be both a cause of, and a reaction to, deaths from COVID-19.

Similar to Bolivia, many low-income and middleincome countries face the combined, structural challenges of poverty, inequity, and precarious work that require a syndemic approach. 10 Governments struggle to provide employment-based crisis relief and enforce health policy when most people work informally. This has been a challenge throughout Latin America to which few countries have responded with effective income supports, non-pharmaceutical intervention implementation, or strategies for re-opening. Subnational policy making, combined with effective national testing and vaccination strategies, will be key to outbreak management, safe re-opening of the economy, and relief from pandemicinduced poverty. 

The approaches used in Bolivia to deal with the COVID-19 pandemic are instructive for several reasons, and can be applied to many countries around the world, especially lowincome countries.

A high proportion of the Bolivian population are affected by unequal, precarious working conditions and poverty, which creates multiple, overlapping vulnerabilities and systemic issues that exacerbate the impact of the pandemic and complicate public policy responses. Similar to many other low-income and middle-income countries, these overlapping issues require a syndemic approach.

In Bolivia, non-pharmaceutical interventions were combined with income supports targeted at workers at risk of impoverishment, but the safe delivery of such interventions was challenging. Although income support is a crucial part of pandemic relief, their delivery must be carefully orchestrated and organised in ways that do not further endanger health-eg, through electronic delivery of funds that do not require beneficiaries to be present in-person.

Policy making at the subnational level has been a crucial aspect of the pandemic response in Bolivia and many other countries around the world. Ideally, local ministries of health should operate under the umbrella of effective national stewardship of public health policy to ensure a robust response to COVID-19. Where national responses are slow or inadequate, local governments must act quickly in the absence of federal support to implement or maintain non-pharmaceutical intervention where they have jurisdiction.

Bolivia has a long history of delivering public services in cooperation with workers' unions and other civil society groups, yet the Bolivian Government has not engaged these groups to reach vulnerable populations during the COVID-19 pandemic. Governments should apply a multisectoral, interinstitutional approach that harnesses all available formal and informal networks and non-governmental actors to protect their citizens and combat the COVID-19 pandemic.

Decreto Supremo 4179. Gaceto Oficial de Bolivia

Reflexiones sobre la pandemia en Bolivia" IISEC-UCB N. 6 impactos del Covid-19 en la economía informal

COVID-19 and Latin America: social impact, policies and a fiscal case for an emergency social protection floor

Disobedient markets: street vendors, enforcement, and state intervention in collective action

COVID-19 observatory: observatory for the containment of COVID-19 in the Americas

Characterizing early Canadian federal, provincial, territorial and municipal nonpharmaceutical interventions in response to COVID-19: a descriptive analysis

Offline: COVID-19 is not a pandemic