On May 15th, 2020, there were 450,000 confirmed cases of COVID-19 and more than 25,000 related deaths in Latin America and the Caribbean. In the absence of a cure or a vaccine, countries in the region have resorted to lockdowns and physical distancing to reduce the rate of infection and avoid overwhelming national health systems.
But the challenge of addressing the pandemic in the public health sphere go far beyond those measures. There are chronic and deep-seated problems of disease, poverty, and education in the region that complicate both the immediate response to the crisis and the eventual lifting of restrictions.
A study of more than 5,000 patients hospitalized in the New York City area shows that the most common comorbidities of COVID-19 are hypertension, obesity and diabetes. A systematic review of the literature suggests that these risk factors are more prevalent for severely affected patients compared with non-severely affected ones.
Using data from the Global Burden of Disease Study, a worldwide research program, Andrew Clark of the London School of Hygiene and Tropical Medicine and colleagues estimate that 137 million people in Latin America and the Caribbean, or 21% percent of its population, have at least one factor that put them at higher risk of severe COVID-19 disease. The prevalence of one or more conditions was approximately 48% for those 50 and older and 74% for those 70 and older.
This vastly complicates the public health problem. According to recent data from nationally representative health surveys in Argentina, Brazil, Ecuador, Guyana, Mexico, Peru and Uruguay, the prevalence of obesity, hypertension and high cholesterol in people older than 20 is staggering, at more than 30% in most countries, and over 40% in others.
The size of this at-risk population will be a serious challenge for governments as they seek to ease lockdown restrictions and eventually distribute a vaccine when it becomes available.
Another cause for concern is that COVID-19 is likely to place a greater health burden on the poor than the rich. First, the incidence of risks factors such as diabetes, hypertension and obesity is generally higher among the poor. For example, in Argentina and Uruguay the prevalence of some of these risk factors is between 5 and 8 percentage points higher in people with low levels of education (completed primary education or less) than among the more educated. Moreover, poor people are more likely to have comorbidities (more than one risk factor) that increase the risk of severe COVID-19 disease.
Second, a large share of the population is unaware that they suffer from a risk factor. For example, in Argentina 33% of adults who think their blood pressure is not an issue actually have high blood pressure. Less educated people are also less likely (by 6 percentage points for high blood pressure in Argentina) to be aware of underlying health issues. That is probably because they are more likely to work in the informal sector and have worse health insurance coverage and poorer access to health services.
As we move from universal to targeted lockdowns it is important to bear in mind that those who do not know their underlying risk may fail to take the required preventive measures. This is especially significant given that poorest people in the region often have jobs that can’t be done from home. Because quarantine policies cause them the greatest financial strain, they also are the most eager to return to work.
Third, the disease might spread faster within and among the poorer households who, because of deficient housing conditions, may find it harder to quarantine. These factors may increase the transmission of the disease in slums, as is already seemingly the case throughout the region.
Finally, there is the issue of how underlying conditions that affect the severity of COVID-19 are managed during the pandemic. The pandemic disproportionately exposes the poor to economic hardship and, in the process, may force some households to spend their limited financial resources on food rather than medicine.
In this environment, governments must consider providing medicine for free to the poor with underlying chronic conditions. They must also consider the possibility of expanding primary care services, and the testing and monitoring of risk factors among their people.