Global health experts question why COVID-19 research is not becoming policy for the older population in low and middle-income countries (LMICs)
Current guidance on coronavirus “largely ignores” the implications for public health and clinical responses in light of those most at risk, according to an international group of global health experts.
Writing in the British Medical Journal, researchers from the University of East Anglia (UEA), London School of Hygiene & Tropical Medicine (LSHTM) and Samson Institute for Ageing Research (SIFAR), Cape Town, lead calls for an age perspective to be included explicitly in national and global planning on COVID-19 research. These academics also suggest the urgent formation of an expert group on older people to support with guidance and response to the virus.
Where could the most older people die?
In their editorial, Prof Peter Lloyd-Sherlock of UEA, Prof Shah Ebrahim and Prof Martin McKee of LSHTM, and Dr Leon Geffen at SIFAR note that the largest numbers of deaths will occur among older people in low and middle-income countries.
These countries contain 69% of the global population aged 60 and over, and health systems which are less extensive and less focused on the needs of older people than in high-income countries.
Whilst much media attention has focused, with good reason, on the price of medical bills in North America, the situation of LMICs is flying under the global radar. In South Africa, a COVID-19 test costs roughly £60, which is over the financial limit that governments have for spending on one person.
For instance, in Bangladesh, the government will spend £28 on an individual which is barely half of the price of one COVID-19 test. In Benin, this imposed spending limit is £24, whilst in Haiti it is £31. This would leave an immense amount of older people without any kind of testing, as these global health experts remind us – many older people in LMIC countries are unable to read or write. So how can they access the appropriate information? And financially, how can they access the test?
Prof Lloyd-Sherlock, professor of social policy and international development at UEA, said:
“The global response to coronavirus must be directed towards those groups who will face the most devastating consequences. So far, this has not happened. We are facing an unprecedented and enormous wave of mortality among older people in these countries.”
In LMICs the risk of infection for older people will be high because living arrangements are often cramped and overcrowded. Increasing numbers of older people in LMICs live in nursing homes or similar facilities, where conditions are often poor and regulation weak.
Do social distancing policies make sense?
The researchers say social distancing policies must consider the already precarious existence of many older people, particularly those living alone or dependent on others for care and support. These people may face barriers to obtaining food and other essential supplies if quarantine conditions become more widespread.
In some places, these people do not have the ability to self-isolate – communities can be crammed together, especially in their experiences of poverty.
As in high-income countries, the risk of dying from COVID-19 in LMICs increases sharply with age and the vast majority of deaths observed are in people over the age of 60, especially those with chronic conditions such as cardiovascular disease.
Can an LMIC handle the economic realities of COVID-19?
The capacity of health systems in LMICs to screen, let alone treat, the virus will be very limited: In South Africa each test costs around US $75 -this exceeds total annual government per capita health spending in many LMICs. Even before COVID-19 emerged, older people already faced significant barriers of access to health services and support, including affordability, and age based discrimination.
The researchers add:
“It will not be easy to deal with these problems, especially in settings where there is often weak public health infrastructure, a lack of gerontological expertise at all levels of the health system, and limited trust in government.
“However, a first step would be to recognise that these problems exist. An age perspective should be included explicitly in the development of national and global planning for covid-19, and a global expert group on older people should be formed to support with guidance and response to the virus in both residential facilities and home settings.
“As new knowledge emerges, this group can identify and evaluate cost effective therapies and interventions that respond to the particular needs of older people in LMICs living in challenging settings, where formal health service infrastructure is limited.”
global health priority setting is institutionally ageist.
They conclude: “Previously, some of the authors have argued that global health priority setting is institutionally ageist. COVID-19 offers an opportunity to prove us wrong.”
‘Bearing the brunt of COVID-19: older people in low and middle-income countries’ is published in the British Medical Journal.
