Second wave of COVID-19: Lessons from Latin America

While many countries that have contained COVID-19 now face the prospect of a second wave, a number of countries in Latin America are yet to contain the first wave.

In a recent working paper, we reviewed the responses of Ecuador, Brazil, Peru, Chile and Colombia to the pandemic. We showed that these five countries adopted containment strategies that were similar to those followed by other countries, but their efficacy in containing the disease was limited by a range of factors.

Why have containment strategies failed?

Measures adopted globally following the World Health Organisation’s guidelines included public health campaigns to encourage citizens to wash hands and maintain social distancing, border closures, curfews and dynamic lockdowns. By and large, all these measures were introduced early at the onset of the disease in all five countries as demonstrated by their relatively high rank in terms of Oxford stringency index in the early phase.

However, despite the early adoption, cases have continued to grow in the five countries and only recently the number of new cases and death has decreased in Chile and Peru.

In the working paper, we explored several possible explanations for the measures not having worked as expected, including compliance, the socio-economic context of the most affected areas, and “pandemic management” (including the governments’ communication strategies).

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The relationship between compliance and the socio-economic context is key to understand why containment strategies failed. In particular, high informality rates, dependence on the “cash economy”, overcrowding and poverty characterise many of the most affected areas across the five countries. The notion that individuals in these areas can work from home or stay at home is clearly not realistic.

For example, informality reaches 90% in Colombia’s Amazon region, with overcrowding and poverty levels of 16% and 35%, respectively, of the population. Not surprisingly, this region has had one of the highest rates of incidence and mortality in the country.

In Chile, low socio-economic municipalities such as Independencia, San Ramon and La Granja experienced increases between 100% and 300% in the number of daily cases during lockdown. During the same period, the number of daily cases decreased between 50% and 100% in the higher income municipalities of Vitacura, Lo Barnechea, Las Condes and Ñuñoa.

In a similar fashion, the mortality rate reached over ten deaths per million in low socio-economic areas, whereas the rate reached 4.9 and 4.3 per million in Vitacura and Lo Barnechea, respectively, two of the counties with Chile’s highest per capital income.

In Brazil, large metropolitan areas such as Rio de Janeiro and São Paulo were the most affected. These cities have high levels of crowding and poverty, characteristics that are evidenced as determinants of the impact of COVID-19 in the country.

While income support was introduced by all five countries, its delayed implementation and limited penetration in the informal sector meant that staying home was simply not an option for many workers. For example, income support measures have been piecemealed in Chile, with three main cash transfer programs increasing in size and population reach.

Table: Days until selected income support measures were introduced

*(Note: * Number of days since the first restrictions were introduced in Rio de Janeiro. ** Number of days from lockdown in the first “low income” municipality.)*

Mobility data confirms that lockdowns did not work. For example, data for Ecuador shows that mobility was reduced by 40% in April during the lockdown. In Chile, movement decreased unevenly between high and low-income municipalities.

Las Condes saw a reduction of nearly 60% in movement, while in Puente Alto, El Bosque and La Pintana, this numbers varied between 20 and 30%. The target was a reduction in mobility of 60%.

The governments’ mismanagement of the pandemic also played a role in reducing the efficacy of the containment measures. In Brazil, there was a lack of a centrally co-ordinated public health response, lack of data transparency and a government that sent mixed signals to the population. Brazil’s President dismissed COVID-9 as a “mere cold”, refused to wear a mask in public and did not follow his government’s social distancing guidelines.

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In Chile, the return to a “new normality” announced around 20 April, which included the opening of a landmark shopping centre and the return to work for public servants, was halted after an increasing number of new cases forced the lockdown of most of Santiago’s metropolitan region. In Ecuador, restrictions were eased while ICU beds were still nearly fully utilised in some areas, as in the province of Pichincha.

There have also been inconsistencies in data reporting, with numbers being changed in a non-transparent way. Easing of restrictions seemed to follow political rather than public health criteria. It is telling that Brazil, Ecuador and Chile have had changes in the Minister of Health during the pandemic. In Brazil, there have been two changes and the current acting minister is an army general.

What is missing from their response?

There are four essential elements that are missing from the response of the five countries: extensive testing, tracing (where feasible), isolation and early treatment. For example, with the exception of Chile, testing has fallen well behind international standards.

Table: Tests per 100,000

There have only been attempts at tracing in Chile and Colombia. Tracing in Chile began around three months after the first case, when the active cases surpassed 50,000. Tracing in Colombia only occurred in Medellín (Colombia), which has a low level of cases and deaths.

As the virus arrived in the region much later than in Europe, the five Latin American countries had more time to scale up the response capacity of their inadequate health systems. For example, the number of beds per 1,000 population on a simple average of the five countries equals 1.84 while the OECD average is 4.7.

However, Chile, Ecuador and Peru (for which there is available data) have seen their health systems collapse, with high occupancy rates of ICU beds. In Brazil, there has been a flurry of corruption investigations into the alleged misuse of public money allocated for COVID-19 emergency procurement.

The current situation

Peru and Chile have seen a reduction to around 100 and 150 new cases per million population, respectively, down from nearly 200 cases in early June (Peru) and 530 cases (15 June), while deaths as of mid-July were around 5–5.5. On the other hand, the number of new cases per million population continues to increase in Ecuador, Brazil and Colombia (lowest incidence rate in terms of cases and deaths).

*(Source: own elaboration based on Ourworldindata. Note: The data for Ecuador was revised to show negative rates, which were replaced by zeros in the figure above.)*

The lack of compliance, the socio-economic context and the governments’ inability to implement effective health policy responses have limited the tools available to contain the disease. Indeed, in Chile, flattening of the curve was achieved through an increase in the restrictions in the freedom of movement (people can leave home only twice a week now) and strict enforcement measures, together with improved economic support measures.

The experience of these five Latin American countries offers some insights to countries that are now facing a potential second wave. First, overcrowding and poverty make containment difficult. Isolation measures have been studied to be cost-effective in these cases. The impact of overcrowding on transmission seems obvious. Indeed, the new hotspots in Victoria can be linked to highly-crowded public housing.

Poverty in the five Latin American countries means less access to health services, but also makes compliance with staying at home directions harder and highlights the need for adequate income support policies. These insights suggest that a combination of localised lockdowns and appropriate income support programs may become key to address the trade-off between the economic consequences and public health concerns.

Dr Francesco Paolucci is Professor of Health Economics & Policy at the Faculty of Business & Law, University of Newcastle and the School of Economics & Management, University of Bologna.

Josefa Henriquez is an economist currently working as a Research Fellow at the University of Bologna in Italy on the European Horizon 2020 funded MCDS Therapy economic research group.

Flavio Menezes is a Professor of Economics at the University of Queensland School of Economics.

Alejandra Benitez has been a research assistant at the Centro de Estudios Publico, Chile, since May 2018.