key: cord-0836030-jnmpyovl
authors: Broadbent, Alex; Streicher, Pieter
title: Can you lock down in a slum? And who would benefit if you tried? Difficult questions about epidemiology's commitment to global health inequalities during Covid-19
date: 2022-05-23
journal: Glob Epidemiol
DOI: 10.1016/j.gloepi.2022.100074
sha: 998671ffcc858a311175d3fdb23d58a8a9564624
doc_id: 836030
cord_uid: jnmpyovl

The initial response to the Covid-19 pandemic was characterised by swift “lockdowns,” a cluster of measures defined by a shared goal of suppressing Covid-19 and a shared character of restricting departure from the home except for specific purposes. By mid-April 2020, most countries were implementing stringent measures of this kind. This essay contends that (1) some epidemiologists played a central role in formulating and promulgating lockdown as a policy and (2) lockdowns were foreseeably harmful to the Global Poor, and foreseeably offered them little benefit, relative to less stringent measures. In view of the widespread commitment to reducing global health inequalities within the profession, this should prompt reflection within the epidemiological community and further work on pandemic response measures more appropriate for the Global Poor.

Introduction It has been widely reported that the impact of Covid-19 on population health varies by socioeconomic factors, with poorer, less privileged, marginalised, and racial minority groups suffering significantly greater health burdens [1] [2] [3] [4] . However, these findings primarily concern high-income countries. Furthermore, some of them fail to distinguish the direct effect of Covid-19 from the effect mediated by public health interventions, which becomes an important distinction if lockdown presents a high health cost but has low effectiveness.

In this essay, we make a case for the following two claims.

(1) Epidemiologists made essential contributions to the formulation of lockdown as a policy, and its endorsement as a universal precautionary measure, in lowincome settings.

(2) Lockdown was foreseeably inappropriate for the Global Poor, defined in relation to any reasonable international poverty line.

"Lockdown" has come to refer to a bundle of measures with two principle characteristics:

 The goal of suppressing Covid-19;

 The character of requiring reasons to leave one's home, which are then specified in a list that is more or less restrictive and usually excludes items such as trade, socialising and education.

Because specific regulations differ by jurisdiction, attempts have been made to place lockdowns on a percentage stringency scale (higher being more stringent) 5 . By the middle of April 2020, only a handful of countries remained below 50% on this index, with many countries in the 90-100% range for at least a few weeks. This policy was endorsed by influential institutions. The World Health Organisation (WHO) did not make an explicit recommendation global lockdown, but implicitly endorsed it in various ways, for example, by praising leaders of low-income countries who had locked down, by making global recommendations about the standards that should be met before governments relaxed restrictions (implying a presumption in favour of restrictions) 6 , by participating in the production of scientific policy advice and reports 7,8 , and simply by not saying anything to the contrary. This changed, and in October 2020 the WHO's Special Envoy on Covid-19, David Nabarro, said: "We really do appeal to all world leaders: stop using lockdown as your primary control method" 9 .

WHO's name appeared) 7,8 . While these reports are famous for the projections of their models, some of which have been heavily criticised, our interest here is not in their accuracy but in the policy response framework that was created in one of them (Report 9), and then projected globally, with a focus on low-income countries (Report 12).

Between these two reports, the following four claims were established.

1. Regulations intended to reduce social contact are the primary non-pharmaceutical intervention by which governments may suppress or mitigate the spread of Covid;

2. There is, in effect, a binary distinction between suppressing the spread of Covid and mitigating it;

3. Suppression is the only way to avoid unacceptably high mortality (and conversely, mitigation will lead to very high mortality); and 4. Claims 1-3 apply globally. Report 12 is particularly motivated by preventing Covid-19 mortality in low-income countries. The report does acknowledge various international differences, predicting "lower incidence of disease, hospitalisation and deaths in lower income settings" and acknowledging that "we do not quantify the wider societal and economic impact of such intensive suppression approaches; these are likely to be substantial" 8 . However, the report argues that of "those countries pursuing mitigation, lower-income settings are likely to experience a higher degree of excess mortality due to health system failure" 8 . The Report also asserts that that lower income countries are likely to exhibit more co-morbidities, and that they are less likely to be able to implement alternative, and non-distancing measures such as contact This is a global policy recommendation, obviously intended as such, and bound to be interpreted as such by politicians and their advisors. The recommendation is: that every country in the world should respond to Covid-19 by implementing broadly similar regulatory packages designed to dramatically reduce social contact.

If Claims 1-4 are accepted, policy-makers have little choice but to take maximal efforts to reduce social contact: in short, to lock down. There was no opportunity to replicate or even thoroughly evaluate the reports, since both reports emphasised the importance of time. In Report 12, the difference between locking down at 0.2 deaths per 100,000 population per week and doing so at 1.6 is the difference between 1,858,000 and 10,452,000 deaths globally over 250 days. Replication in such circumstances is not feasible, even in those relatively few countries with the scientific capacity to do so.

None of this analysis shows that one team of infectious disease epidemiologists is solely responsible for the spread of lockdowns through the world in first half of 2020. What it shows, rather, is that the core ideas behind this spread had an articulation and justification in influential parts of the scientific community. Even if the recommendations came from a fairly small corner of the wider epidemiological discipline, the remainder of the discipline largely allowed itself to be represented as supportive of these recommendations; there were some widely-publicised "head on" confrontations but most epidemiologists either tacitly supported the general strategy or kept their dissent quiet. The effect on education is obvious, and a link between health and education is wellestablished, mediated by a variety of mechanisms operating in both short and long term.

Some education systems also include school feeding programmes which would create a foreseeable detriment to child nutrition.

In short, it was entirely foreseeable that the effect of lockdowns on the Global Poor would be negative. However, the important question is whether these effects were outweighed by even more negative effects of not locking down, based on evidence available at the time. Putting it equivalently but less awkwardly, the question becomes: what were the foreseeable health benefits of lockdown for the Global Poor?

In early 2020, the justification for locking down came from comparing mortality in scenarios with different degrees of social contact. This line of thinking obviously assumes that it is possible to reduce social contact to the levels specified in the model. However, for J o u r n a l P r e -p r o o f the Global Poor, it was foreseeable that reductions of social contact to the extent modelled, e.g., reductions of the order of 75% 7 , would be impossible. There were two reasons for this: overcrowding and unavoidable non-compliance.

If too many people share dwellings, then a lockdown will not reduce social contact by the necessary levels, even if it is complied with. For example, in Accra, over 50% of the population lives in a single-room dwelling 12 . In such a context, if departures from the home are greatly restricted, social contact will remain high due to the number of people in each home. According the NGO Habitat for Humanity, one in seven people lives in a slum, and overcrowding is one of the defining characteristics of a slum 13 . In developing countries, 1 in 3 urban residents live in slums, and in some countries 90% of the population live in a slum.

Estimates for global slum population vary considerably from 900 million to 1.6 billion 14 . It could not have been reasonably imagined that any of these populations would satisfy any model of lockdown, and thus even assuming perfect compliance and perfect model accuracy, it was foreseeable that lockdown would offer minimal benefit to those of the Global Poor living in slums. This is academic, however, since compliance was in any case never likely. The threats posed to livelihoods have already been described and these would inevitably force people from their homes, and further force them to engage with each other in economic activity such as trade. Government feeding programmes and grants inevitably mean long queues and these cannot be expected to remain socially distanced in conditions of extreme stress. In addition, the need for water and sanitation, and extreme heat in some cases, would be obvious causes for people to leave their homes. These contextual factors mean that compliance with lockdown regulations could never have been a reasonable expectation.

To put these points another way, the relevance to a slum of a model projecting the benefits of a 75% reduction in social contact is no greater than the relevance to a wealthy J o u r n a l P r e -p r o o f Journal Pre-proof suburb of a model projecting 100% reduction. In both cases, these reductions would not be achieved even if people stayed home all the time. And in both cases, compliance is in any case impossible.

In contrast to the urban and peri-urban poor, the rural poor do not live in large conurbations, and overcrowding is rarer. Nonetheless, small multiple occupancy dwellings are obviously common. Low compliance is to be expected for parallel reasons as those already discussed. Agriculture is a common livelihood (including subsistence agriculture) and requires constant activity. Amenities such as piped water are largely absent implying frequent departures from the home and subsequent mixing. Isolated communities may have no effective access to healthcare due to large distances, no transport, and clinics with no relevant capacity (no ventilators, no ICU, etc.), meaning that there is also no effective benefit of preserving hospital capacity by reducing incidence of Covid-19. The penetration of any government welfare schemes in rural areas is likely to be very limited. Enforcement is also likely to be minimal.

For all these reasons, it was foreseeable that the beneficial effectiveness of lockdown would be minimal in many of the contexts in which the Global Poor lived. This does not mean that there were no available non-pharmaceutical interventions, however. Restrictions on large gatherings, some restrictions on travel between regions, the use of masks (initially pronounced ineffective by the World Health Organisation), hand-washing, and other familiar non-pharmaceutical interventions were available. It was, however, not reasonable to expect additional benefit of stay-at-home orders designed with entirely different living contexts in mind.

Additionally, it was evident from very early on that Covid-19 was considerably more dangerous for the old than for the young. There is a very strong correlation between age and wealth. The median age in Europe is 43.9, but 19.7 in Africa. Thus it never appeared that J o u r n a l P r e -p r o o f

Covid-19 would be a public health problem among almost half the population of that continent, even considering the prevalence of other health issues. Africa is the second most populous continent, with 1.3 billion inhabitants-more than North America and Europe (including Russia) combined.

Moreover, the relative threat posed by Covid-19 in relation to other causes of mortality differs with context. This means that the relative benefit offered by measures designed to combat it will differ, compared to the benefit of directing the same resources to other causes of mortality. In short, the optimal health policy for a region will vary depending on the causes of mortality in that region. It was never likely that the same policy would be appropriate for all regions and countries, given what was already known about the fatality of Covid-19 and the age-profile.

For all these reasons, it was foreseeable that lockdowns would offer minimal benefits to the Global Poor.

If these points were foreseeable, then why were they not made in the early days of the pandemic? The answer is that these points were being made, starting as early as March 2020 [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] , but that they did not attract widespread attention or apparently influence policy. It was not long before empirical evidence began to confirm many of these fears 11, 12, 15, [17] [18] [19] 22, 26, [29] [30] [31] [32] [33] [34] [35] [36] [37] , but this did not prompt, and still has not prompted, the degree of reflection one might have expected. There may have been a general sense that the early measures were precautions taken in a period of great uncertainty. However, a precaution is only a precaution if it can be reasonably expected to work; seatbelts are not a precaution when a boat strikes a rock.

Moreover, as pointed out, there was in fact great certainty in all the relevant areas.

These concerns were known but were not salient, presumably because Covid-19 poses the J o u r n a l P r e -p r o o f most serious infectious disease threat that wealthy countries have faced for some time.

UNICEF reports that in 2020, 5 million children globally died under the age of 5 38 . In the same year, 1.88 million Covid-19 deaths were reported 39 

In the first part of 2020, most of the world entered stringent lockdowns.

Epidemiologists played a central role in formulating the policy of lockdown and in recommending it globally, through global health institutions, notably the WHO. However, it was foreseeable at the time that these recommendations would pose much more significant health costs to the poor than to the rich, and that it would bring the poor minimal health benefits. It was also predictable that the logical endpoint of lockdown, namely vaccine availability, would be much delayed for the Global Poor. Considering all these points, the unfortunate but unavoidable conclusion is that, through global lockdown recommendations, some within the discipline of epidemiology contributed to an increase in global health inequalities, and that this was foreseeable. This is a point for reflection within the epidemiological community, and a spur for empirical work on the health impact of lockdown on the Global Poor with a view to developing better pandemic response measures for the future.

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