COVID-19 spreads to the world’s poorer countries

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As COVID-19 spreads to the world’s poorer countries, there are reasons why the coronavirus could have a greater or lesser impact than in the richer world. More detailed information is needed from all possible sources – virus testing programmes, health surveillance and surveys, and hospital and death records – to assess the current burden of COVID-19 in poorer countries, and to anticipate the effects of the coronavirus on global health in the coming months and years.

How have poor countries been affected by COVID-19 so far?

The COVID-19 pandemic has so far had a greater impact on richer countries than poorer ones. Around seven million cases of COVID-19 have now been reported globally with a death toll approaching 500,000.[1] North America and Western Europe accounted for more than two-thirds of these deaths. Africa has reported nearly 7,000 deaths, while the death toll in Asia is presently close to 44,000 and in Latin America around 70,000.[1] Brazil has reported 45,000 deaths and the number is quickly rising.

However, comparisons between countries are hampered by differences in the number of individuals tested for coronavirus: New Zealand has tested more than 53 in every 1,000 people, but in India and Indonesia just 2.05 and 0.64 in every 1,000 people have been tested respectively.[2] The proportion of positive tests also differs between countries: there were 0.23 positives per thousand tested in New Zealand, and 0.09 and 0.08 in India and Indonesia respectively.[2] This might signal lower rates of transmission currently in India and Indonesia, or it could reflect differences in the type of people being tested.

Another possible reason for these differences is that countries with apparently low numbers of infections are at an earlier stage of their epidemics, implying that worse is yet to come. There are already signs that transmission of the virus is gathering pace: countries in Africa are seeing an increase of infections beyond capital cities to rural areas, at the same time as an acceleration in overall case numbers across the continent.[3]

Because low- and middle-income countries account for more than half of the world’s population, resolving these uncertainties is of vital importance for global health.

How could the experience of COVID-19 differ between countries?

Even in countries with well-organised health systems, the response to COVID-19 has largely focused on ‘flattening the curve’: that is, keeping the daily number of cases at a level that can be managed by health services – especially the number of people who need intensive care. This is harder to accomplish in countries with fewer hospital beds, fewer health workers and less medical equipment. Switzerland, for example, has 4.7 hospital beds per 1,000 population, compared to 0.55 in India, and 0.9 in Nigeria.[4] If the virus is equally infectious in rich and poor countries, the number of COVID-19 deaths arising simply from a lack of access to life-saving medical care could run to millions.[5]

The pressure COVID-19 puts on health systems could also be higher in populations with high rates of other diseases, such as type 2 diabetes, cardiovascular disease and hypertension, which appear to be associated with more severe COVID-19 illness.[6] About 4 out of 5 people with diabetes live in low- and middle-income countries; the same is true of cardiovascular disease.

Preventing transmission of the virus is also more difficult in communities without access to clean water for hand washing, or where cramped living conditions make physical distancing almost impossible. The population of Hyderabad, India, is similar to that of London, but Hyderabad has four times as many people living in each square kilometre. The risk of transmission is particularly high in cities with crowded urban slums, such as Lagos in Nigeria or Karachi in Pakistan.

There are, on the other hand, some factors that are expected to mitigate the impact of COVID-19 in low- and middle-income countries: these countries typically have young populations, and the risk of severe illness or death is relatively low in children and young adults.[7] So, even if these countries suffer more cases of COVID-19, a smaller proportion will die.

Control programmes in poorer countries

Many poorer countries have introduced ‘lockdown’ strategies like those in eastern Asia and Europe: closing land borders, banning international and domestic flights, limiting commercial activity to essential services, and imposing restrictions on movement, including curfews. Several countries in Africa, like those in Asia and now Europe, have made face-masks mandatory in public spaces, a measure that is likely to reduce transmission.

Some exceptional local efforts have curbed the burden of illness and mortality. In the Indian state of Kerala, control measures were implemented early in the COVID-19 pandemic, based on the state’s famously strong health infrastructure, coupled with experience of previous outbreaks, such as Nipah virus in 2018.[8] Kerala carried out the essentials of outbreak control: testing and isolating patients, and contact tracing with quarantine. Kerala was the first state in India to experience COVID-19 and, although health records are unlikely to be complete, has so far reported fewer than 20 COVID-19 deaths in a population of 35 million.

What are the implications of COVID-19 for health care in poorer countries?

Efforts to tackle COVID-19 could divert resources away from other disease control programmes, such as those for HIV, tuberculosis and malaria.[9] The consequences were clear during the 2014 Ebola epidemic in West Africa, which was followed by a substantial increase in malaria because of disruption to malaria control efforts. It could also hamper vaccination programmes: already, Gavi, the Vaccine Alliance, has reported delays to vaccination campaigns and routine introductions which could leave at least 13 million people in the world’s least developed countries without protection against measles, polio and human papillomavirus (HPV).[10]

What next for COVID-19 in poorer countries?

There are many unanswered questions about the current status and potential impact of COVID-19 in low- and middle-income countries, and large gaps in data bases need to be filled. Nevertheless, the information already available from virus testing in clinics, from symptomatic surveillance and health surveys, and from hospital and death records can, when used in combination, give strong clues about the burden and trends of COVID-19, and the effectiveness of control programmes.

You may also be interested in


  1. COVID-19 situation update worldwide, as of 18 June 2020. European Centre for Disease Prevention and Control. 2020 Jun.

  2. Hasell J, Mathieu E, Beltekian D, et al. Coronavirus (COVID-19) Testing. Our World in Data. 2020 Jun.

  3. COVID-19 in the WHO African Region. World Health Organization Regional Office for Africa. 2020 Jun.

  4. Hospital beds (per 1,000 people). The World Bank Data. 2020 Jun.

  5. Walker PGT, Whittaker C, Watson OJ, et al. The impact of COVID-19 and strategies for mitigation and suppression in low- and middle-income countries. Science. 2020 Jun. DOI: 10.1126/science.abc0035.

  6. Chen Y, Gong X, Wang L, Guo J. Effects of hypertension, diabetes and coronary heart disease on COVID-19 diseases severity: a systematic review and meta-analysis. medRxiv. 2020 Mar. DOI: 10.1101/2020.03.25.20043133.

  7. Verity R, Okell LC, Dorigatti I, et al. Estimates of the severity of coronavirus disease 2019: a model-based analysis. The Lancet Infectious Diseases. 2020 Jun;20(6):669-677. DOI: 10.1016/s1473-3099(20)30243-7.

  8. Vijayan S. 4 lessons from Kerala on how to effectively control COVID-19. PATH. 2020 May.

  9. Hogan AB, Jewell B, Sherrard-Smith E, et al. Report 19 - The Potential Impact of the COVID-19 Epidemic on HIV, TB and Malaria in Low- and Middle-Income Countries. MRC Centre for Global Infectious Disease Analysis. 2020 May.

  10. COVID-19: massive impact on lower-income countries threatens more disease outbreaks. Gavi: The Vaccine Alliance. 2020 Apr.

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