Bolivia is Incredibly Heterogeneous – Let’s Take Advantage of That When Fighting COVID-19

By: Lykke E. Andersen, Ph.D.*

 

“The only way to avoid ‘groupthink’ and blind spots is to ensure representatives with diverse backgrounds and expertise are at the table when major decisions are made.”
Devi Sridhar, Chair of Global Health at the University of Edinburgh Medical School

 

Bolivia is an amazingly diverse and heterogeneous country in every way. Within a million square kilometers we find both steamy Amazon jungle, large modern cities, mosquito infested swamps, melting glaciers, huge salt flats, and picturesque cloud forests. Some people live pretty much as their ancestors did hundreds of years ago, while others enjoy all the luxuries of the most advanced countries. According to our upcoming Municipal Atlas of the SDGs in Bolivia, the differences between municipalities within Bolivia are larger than the differences between all the countries in the world in terms of the Sustainable Development Index (SDI). And as within countries, there are also large inequalities within each municipality in Bolivia.

In this blog, I will argue that we should take advantage of this heterogeneity to reduce the mortality rate of COVID-19 in Bolivia.

 

Good News of the Week

About a month ago, the World Health Organization (WHO) came out with a worrying statement saying that “there is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection” [1]. If this were true, it would be very bad news for the many countries, including Bolivia and its neighbors, that have failed at containing the virus, have no test-trace-and-quarantine capacity, and whose only option to get through this pandemic therefore is to achieve herd immunity.

The good news out of the Korean Center for Disease Control (KCDC) last week was that the 263 people in Korea who tested positive for the disease a second time after previously being declared recovered and virus-free, was not due to re-infection nor re-activation of the SARS-CoV-2 virus. Rather, it was due to the PCR tests picking up old, inactive, and harmless virus RNA still present in the body a couple of months after the original infection. According to KCDC, the process in which COVID-19 produces a new virus takes place only in the cytoplasm of the host cells and does not infiltrate the nucleus. This means it does not cause chronic infection or recurrence, unlike viruses like HIV [2].

Thus, it seems that the herd immunity strategy might be viable after all. Once 60-70% of the population has become immune, the virus will die out, as it becomes difficult for it to find new hosts in which to multiply. The question now is how to apply that strategy with the least number of deaths and collateral damage possible.

 

Optimizing the Herd Immunity Strategy

I previously estimated that we will likely “end up with an Infection Fatality Rate (IFR) of around 1% for Bolivia (meaning anywhere between 0.3% and 2%, given the still high uncertainty). If 60% of 11.6 million people get infected, and 1% of those die, we would end up with about 70 thousand COVID-19 deaths in Bolivia” [3]. While this is an awful lot of deaths, the 1% IFR is a realistic estimate considering the age distribution of the population, underlying health conditions, the quality of the health care system, typical housing and work conditions, in addition to the level of education and trust in the population. It looks like the most likely outcome if we let the virus burn slowly through the population (through appropriate physical distancing measures) in a random way until reaching herd immunity after 12-18 months, and if we don’t actively make things worse than they have to be.

However, the IFR can be lowered considerably if we take advantage of the fact that the population is not homogeneous. Some people have far lower risk of dying from COVID-19 than others, so if we could secure that the first 60% to get infected are the ones least likely to suffer severe complications, then we could potentially reduce the total number of deaths considerably.

In the rest of this blog I will outline the main dimensions to consider when optimizing the herd immunity strategy.

 

1. The Demographic Dimension

The evidence from all over the world shows unequivocally that the risk of death from COVID-19 is higher in older people. In Italy, for example, until May 18th, only 4 people under 20 years of age had died, while the number of deaths of people over the age of 50 was almost 30,000 (see Figure 1).

Figure 1: COVID-19 deaths in Italy as of May 18, 2020, by age group


Source:
Istituto Superiore di Sanità (via Statista 2020).

 

There is also overwhelming evidence that men are almost twice as likely to die from COVID-19 compared to women. Figure 2 shows the case fatality rates observed in Italy to date, disaggregated by age and gender.

 

Figure 2: COVID-19 death rates in Italy as of May 2020, by gender and age group


Note:
The case fatality rates in this figure do not reflect the real Infection Fatality Rates, as there are errors
in both the nominator (un-counted COVID-19 deaths) and denominator (un-identified COVID-19 cases).
However, the overall pattern by age and gender is likely to reflect the actual differences in IFRs by age and gender.
Source: Istituto Superiore di Sanità (via Statista 2020).

 

Given this pattern, and similar patterns from all other countries with age and gender disaggregated COVID-19 death statistics, we can make the following rough demographic risk classification:


If we apply this classification to the population pyramid of Bolivia, it looks as shown in Figure 3.

 

 Figure 3: Population Pyramid for Bolivia, with risk categories


Source:
Author´s elaboration based on data from PopulationPyramid.net 

 

Based on just these basic demographic factors, 77% of the Bolivian population is at Low Risk of dying if contracting COVID-19; 16% is at Medium Risk; and 7% is of High Risk.

But there are more risk dimensions to take into consideration.

2. The Geographic Dimension

While age and gender are important determinants of risk, there are factors in the surrounding community that can either amplify or moderate the risk for each individual.

  • It is safer to live in a disperse rural area where you interact with few different people, than to live in a dense urban area touching public surfaces that thousands of other people touch every day.
  • It is safer to live alone, rather than in a three-generation extended household.
  • It is safer to live in a place that is not simultaneously plagued by other health threats, such as Dengue, Malaria, Tuberculosis and HIV.
  • It is safer to live in an area where there are basic water and sanitation services available.

In last week’s blog we developed a Municipal Vulnerability Index to COVID-19 [4], and while it is a continuous indicator, we can roughly divide it into Low, Medium and High Risk municipalities, with some admittedly arbitrary cut-offs. If we consider all municipalities with a Vulnerability Index higher than 36.7 High Risk, and lower than 31.7 Low Risk, then we get a municipal risk list as shown in Figure 4.

 

Figure 4: Municipal level COVID-19 Vulnerability Index, with risk categories.


(Click here to see details)
Source: Between a Wall and a Nasty Virus [4].

 

This Vulnerability Index only considers structural variables, and not actual infection rates, which would also be important to consider, but these suffer daily changes, and due to the limited testing capacity, many cases go undetected.

 

3. Occupational Dimension

Even for people of the same age and gender, living in the same municipality, risk will vary substantially depending on the kind of activities each of them engages in. The risk will be extremely high if you work as a dentist, but extremely low if you collect Brazil nuts alone in the forest.

In general, solitary outdoor activities are much safer than working indoors with lots of different people cramped together. The highest risk occupations would be those where you must be very close to many different, potentially infected people every day, such as dentists, doctors, and nurses. If you work at, or frequent, indoor locations where people are singing, screaming or breathing heavily, such as night clubs, karaoke places, churches, and gyms, you are also at high risk, as the virus spreads very effectively in this kind of places.

 

4. Individual Risk Factors

Apart from all the above mentioned risk variations, there will be additional personal risks that can be either permanent or temporary. For example, anyone who suffers from high blood pressure, diabetes or asthma would automatically and permanently move to a higher risk category than the one suggested by their age, gender, location, and occupation.

Likewise, anybody who presents COVID-19-like symptoms, irrespective of their age, gender, location, and occupation, should immediately consider themselves at High Risk and take every precaution to protect themselves and others.

Individual risk factors should also take into account other people in the same household. One individual might be young and healthy, but if they live together with a High Risk person, their risk category increases, because their actions might carry risks not to themselves, but to their loved ones.

 

Central Planning is Unlikely to Work

From the analysis above it is obvious that risks vary by several orders of magnitude from place to place and from person to person. This makes centralized decisions extremely difficult, and uniform rules will likely be both inefficient and harmful.

The initial strict quarantine measures have served to educate people about the dangers of this virus and about the hand-washing and physical distancing measures that can help control contagion. But these strict measures are clearly not sustainable over the many months that this pandemic is likely to last [5], and it is time for a more nuanced approach.

 

Decentralization of Decisions and Responsibilities

If our goal is to reach herd immunity with the least number of deaths and collateral damage possible, then we need to decentralize decisions considerably. Each department, each municipality, each business, each school, and each family need to analyze their strengths and weaknesses in this new global context, and make a plan on how to get through the following 24 months with the slightest possible damage. Damage not only includes COVID-19 deaths, but also loss of education, income, freedom, agency, joy, and happiness; so everybody needs to engage in quite a holistic analysis, which is not easy. It will take patience, communication, collaboration, and many iterations.

The need for decentralization of decisions and responsibilities is even greater now that the central government is facing a precipitous decline in revenues from all sources (especially IDH, IVA, IT, IUE, ICE, and RC-IVA), and thus will have much fewer funds available for distribution to departments, municipalities, and individuals.

We need to recognize that there are no right answers. Nobody knows the best way to get through this, and there is no one-size-fits-all solution. Nobody knows what the world is going to look like on the other side. This is a good time to be flexible, think out-of-the-box, and try out new ways of learning, working, and living.

Learning quickly is more important than ever, and learning is only possible if we try different strategies and learn from their different results. The best way to do that is to let municipalities pursue different strategies and record results more or less in real time.

 

The Need for Timely, Geographically Disaggregated Data on Deaths from All Causes

Since we have extremely limited testing capacity all over the world, and especially in Bolivia, reported COVID-19 cases and deaths rarely reflect reality. It is more feasible and useful to simply register the total number of deaths (by age and gender) per week from all causes, and compare that to the expected number of deaths per week in each territory.

According to INE, we expected 66,760 deaths in Bolivia this year without the COVID-19 pandemic [6], corresponding to 1,284 deaths per week in the whole country. This data can be disaggregated to the department level by applying the departmental crude deaths rates calculated by INE to the population of each department (see Table 1).

 

Table 1: Expected weekly deaths, 2020, by department


Source: INE and https://www.covid19bo.com/

 

According to this data, Beni is the only department in Bolivia that has a serious COVID-19 outbreak at the moment, probably because it is particularly vulnerable to a COVID-19 outbreak (due to high levels of obesity, low coverage of water and sanitation, crowded housing, simultaneous Dengue, Malaria, Tuberculosis, and HIV outbreaks, and low local government capacity), as we showed in our blog a couple of weeks ago [4]. However, the real number of COVID-19 deaths is likely far higher, since only people with a positive COVID-19 tests are counted. The dedicated COVID-19 cemetery in Trinidad (Beni), for example, a few days ago held 148 deceased, of which only 57 were confirmed COVID-19 deaths, while 91 were suspected [7].

In the table above, there are question marks in the last column concerning the number of deaths from all causes. This information is currently not available from any government entity in Bolivia. My recommendation to the National Statistical Institute of Bolivia (INE) would be to quickly build up a system to record number of deaths in each municipality each week by age and gender.

Weekly, geographically disaggregated information on all deaths by age and gender is necessary to carefully monitor local outbreaks and take adequate precautions in the right places [8].. A fine-tuned, decentralized response to this pandemic, requires timely disaggregated data. It is well worth the effort to set up the information gathering and reporting system, as it can save tens of thousands of lives and avoid a lot of unnecessary economic costs and human suffering.

—-

Footnotes:

[1] https://time.com/5827450/who-coronavirus-antibodies-reinfection/

[2] http://m.koreaherald.com/view.php?ud=20200429000724. See John Campbell’s video for an easy-to-understand interpretation of the findings: https://www.youtube.com/watch?v=uATMbGK__Tg&t=1200s. See MedCram for a much more detailed, intracellular, explanation of the same thing: https://www.youtube.com/watch?v=01Rftnxbi6w.

[3] https://www.sdsnbolivia.org/en/english-forty-days-of-quarantine-what-have-we-learned/

[4] https://www.sdsnbolivia.org/en/entre-la-pared-y-un-terrible-virus/

https://live.worldbank.org/coronavirus-impact-pandemic-women-and-girls?cid=ecr_fb_worldbank_en_EXTP&fbclid=IwAR0chR9dC6VBVWSzd1M0qkZWKTg0yYjghbeKR1vYKh0aFabdT7o_SIN4GaA

[5] The World is still in the very early phases of this pandemic, with even hard-hit countries still having a long way to go before reaching herd immunity.  By early May, it was estimated that Belgium was the country closest to herd immunity, with 6.4% of the population having been infected, while in other European countries the immune population is still less than 5%. In certain hot-spots, like Madrid, the rate is much higher, but still nowhere near immunity (https://www.ft.com/content/f7d08906-b5c5-4210-b2c6-0ec95d533bc6).

[6] https://www.ine.gob.bo/index.php/censos-y-proyecciones-de-poblacion-sociales/#

[7] This page by Our World In Data provides a collection of sites monitoring excess mortality (https://ourworldindata.org/excess-mortality-covid). The Economist, Financial Times, the New York Times and EUROMOMO all provide excellent examples of how this data can be presented in user-friendly ways.

* SDSN Bolivia.

The viewpoints expressed in the blog are the responsibility of the authors and do not reflect the position of their institutions. These posts are part of the project “Municipal Atlas of the SDGs in Bolivia” that is currently carried out by the Sustainable Development Solutions Network (SDSN) in Bolivia.

Nuestro aporte en tiempos de COVID-19

Durante el actual contexto de la pandemia del COVID-19, enfermedad provocada por el virus SARS-CoV-2, SDSN Bolivia ha realizado una serie de presentaciones haciendo uso de los indicadores del Atlas Municipal de los ODS en Bolivia, para ayudar a entender mejor la situación de Bolivia ante esta amenaza. A continuación, se encuentran los detalles para dos presentaciones que están disponibles en línea.

 

Economics Research Workshop No. 38

El día 6 de mayo, la Directora Ejecutiva de SDSN Bolivia, Lykke E. Andersen, Ph.D, realizó la presentación “Usando el Atlas Municipal de los ODS en Bolivia para analizar la vulnerabilidad ante el COVID-19”, durante la cual explicó cómo estos indicadores pueden ayudarnos a entender la variación espacial en los potenciales efectos sobre la salud que pueden derivar de la propagación del virus SARS-CoV-2.

Andersen presentó los avances del Atlas y mostró, en un ejercicio interactivo con los participantes, cómo los datos pueden ser usados para analizar la vulnerabilidad al COVID-19. La presentación se dio en el Economics Research Workshop No. 38, coorganizado por UPB, SEBOL, INESAD y ABCE, en colaboración con la Fundación Solydes.

Como resultado del aporte de los participantes, se eligieron los principales indicadores para analizar esta situación (vea el informe completo aquí).

La presentación se encuentra disponible en el siguiente enlace: https://youtu.be/ohkCEM5yls0?t=201 o en el reproductor:

 

 

WEBINAR |Bolivia: Pobreza y Desigualdad en el entorno del #COVID19

El 14 de mayo, Lykke E. Andersen realizó la presentación “Variación espacial de los impactos del COVID-19 en Bolivia” a través de la cual se intentó dar una respuesta a las siguientes interrogantes:

  • ¿Quién es más vulnerable a los impactos directos del virus SARS-CoV-2?
  • ¿Quién es más vulnerable a las medidas de mitigación del virus?
  • ¿Qué estrategias podemos implementar para evitar grandes aumentos en pobreza y desigualdad?

En análisis se realiza tomando en cuenta tres dimensiones: geográfica, demográfica y sectorial. Le invitamos a conocer las respuestas a estas interrogantes siguiendo el enlace: https://youtu.be/VPotFSyg_iU?t=1635 o en el reproductor:

 

 

El webinar fue moderado por Oscar Molina Tejerina, Ph.D, Vicerrector Nacional de la Universidad Privada Boliviana, y Presidente de la Sociedad de Economistas de Bolivia, y contó con tres conferencistas internacionales: María Eugenia Dávalos, Ph.D (Economista Senior – Banco Mundial), Lykke E. Andersen, Ph.D (Directora Ejecutva – SDSN Bolivia) y Maria Alejandra Gonzalez-Perez, Ph.D (Profesora Titular – Universidad EAFIT).

 

Entradas de Blog:

 

Entre la espada y la pared: el dilema del COVID-19

Por: Lykke E. Andersen, José Acuña y Luis Gonzales | Publicado el 12 de mayo de 2020

Cuarenta días de cuarentena: ¿qué hemos aprendido? 

Por: Lykke E. Andersen | Publicado el 01 de mayo de 2020

Between a Wall and a Nasty Virus

By:
Lykke E. Andersen*,
José Acuña**,
and Luis Gonzales***

 

 

During the present COVID-19 pandemic, most countries in the world have failed at implementing precise measures of testing, contact tracing and quarantining of sick and infectious people. Instead they have implemented the rather crude and desperate strategy of locking everybody up for many weeks.

The latter is obviously not a sustainable strategy, and many countries are beginning to let people out of their homes, knowing full well that the virus is still out there, so opening up will inevitably lead to higher infection rates and more deaths. They just hope to keep severe cases at manageable levels. It is a big balancing act that requires good information in real time, and that is incredibly scarce.

Ideally, we should first let out the people who are least likely to get infected, least likely to infect others, and least likely to die from COVID-19. The idea is to gradually build up herd immunity over the next 12 months with the least number of COVID-19 deaths possible and the lowest collateral damage. That is, we are aiming to minimize total damage from this pandemic.

Who can most safely get out and resume work, education, and leisure activities? The relevant probabilities have three main dimensions: geographic, demographic, and sectoral, and they interact in complicated ways.

In this blog we will provide some empirical evidence to inform strategies to gradually get out of the extremely strict lockdowns in Bolivia.

 

Geographic variations in risk

Once the virus arrives to a new location, it can have very different impacts depending on a variety of factors. If it arrives to a sparsely populated region with young, healthy, well-informed people practicing good hygiene, the virus will spread slowly, and the vast majority of infected people will likely have either mild symptoms or none at all. But if it hits a densely populated area with malnourished and frail people already suffering from other diseases and without adequate access to water, soap, and sanitation (such as a refugee camp), the impacts could be devastating.

In this section we will present a municipal level analysis of differences in the likely impact of the arrival of SARS-CoV-2 to different municipalities in Bolivia. We considered several dozen potentially relevant indicators from the upcoming Municipal Atlas of the SDGs in Bolivia, and grouped them into the following three broad categories:

 

  1. Risk of rapid spread
    • Number of main roads entering the municipality
    • Centrality of migration (an index reflecting how many other municipalities each municipality is connected with through recent migration)
    • Percentage of population living in urban areas
    • Percentage of population living in crowded homes (more than 2 persons per room)
    • Public transportation intensity
  2. Underlying health situation
    • Obesity level
    • Chronic malnutrition level
    • Incidence of Dengue, Chagas, Malaria, Tuberculosis and HIV
    • Percentage of population older than 60 years
  3. Response capacity
    • Water and sanitation coverage
    • Electricity, Phone and Internet coverage
    • Share of population who do not speak Spanish
    • Education inequality
    • Local government budget execution capacity
    • Public investment per capita
    • Number of doctors per 10,000 inhabitants.

 

Each variable was converted into an index from 0 to 100, and these indices were aggregated together using weights derived from an online consultation process [1]. The Vulnerability Index reported in this blog uses the 15 indicators that more than 50% of participants agreed had a strong effect on the probability of dying from COVID-19, and equal weights were given to each of them. The 15 indicators chosen were equally distributed between the three groups and they are highlighted in italics in the list above [2].

Table 1 shows the Vulnerability Index for the 339 municipalities of Bolivia ranked from the most vulnerable to the least vulnerable.

Table 1: Vulnerability Index to COVID-19 (based on 15 indicators)
Click on image to expand.

Source: Authors’ elaboration.
Note: The 9 state capitals + El Alto are highlighted in bold.

 

Map 1 shows the spatial distribution of the same Vulnerability Index.

 

Map 1: Vulnerability Index to COVID-19 (based on 15 indicators)

Source: Authors’ elaboration.

 

Demographic variations in risk

Within each municipality there is considerable variation in risk between different population groups.

It is clear from studies carried out in areas that were infected by SARS-CoV-2 early on that Infection Fatality Rates (IFR) increase exponentially with age and are considerably higher for men than for women [3]. In addition, people with one or more underlying health problems, especially hypertension, obesity, and diabetes, are much more likely to die [4]. Both in the UK and the US, racial differences in IFRs have been observed. Even after controlling for socio-economic and occupational factors, people with darker skin are more likely to die than people with lighter skin [5], possibly due to vitamin D deficiencies that weaken the immune system [6]. This is unlikely to be a significant factor in Bolivia, as long as everybody can get out in the sun every day.

Fortunately, children rarely get seriously ill from COVID-19. Of more than 27 thousand COVID-19 deaths in Italy to date, only 3 were under the age of 18 [7]. There is also some emerging evidence that infected children may not spread the virus as much as adults [8]. Thus, many countries are starting to reopen schools, with increased hand-washing and social distancing efforts, daily disinfection and cleaning of school surfaces, and careful monitoring of the results [9].

 

Sectoral variations in risk

For people of similar demographic characteristics within the same municipality, risk will vary depending on what kind of activities they carry out. In general, solitary work outdoors is much less risky than working indoors with exposure to lots of different people. Thus, agriculture and construction are relatively safe, while working in a supermarket, a hospital or a dentist office is of high risk [10]. Similarly, solitary outdoor leisure activities, like hiking, golf or tennis, are much safer than indoor team sports like volleyball, basketball or handball. Potentially super-spreading places include night clubs and karaoke bars, among others.

Some high-risk activities are essential and must remain functional even during the strictest lockdowns. In these cases, implementing measures to reduce risk as much as possible is important. Mask wearing in supermarkets, banks, and public transportation is a highly effective way of preventing the virus spread from asymptomatic people to others. Extended opening hours and staggered work schedules reduce crowding and facilitate physical distancing. Switching to online services and home delivery is also possible in many cases. Even many medical services have been successfully transformed and turned into much safer and more convenient telemedicine systems.

 

Recommendations for loosening the lockdown in Bolivia

A total and uniform lockdown turns out to be inefficient given the large geographic, demographic, and sectoral variations in COVID-19 risk. It is also highly damaging to people’s mental, physical and economic health, and clearly unsustainable.

Given that a vaccine is very unlikely to become available at a global scale until late next year at the earliest [11], and given that we have failed at eradicating the virus even after 50 days of the strictest lockdown that could possibly be enforced in Bolivia, the only remaining option to get through this pandemic is to let the virus burn through most of the population in a controlled fashion over the next 12 to 24 months [12].

If we abandon all precautionary measures, infection rates will skyrocket and we will end up with many more daily deaths than we can physically and psychologically handle. Instead we should continue rational precautionary measures and carry out a gradual reopening, starting with the municipalities, the demographic groups, and the sectors with the lowest risk.

 

Our recommendations for the immediate future are the following:

  1. Everywhere, we should maintain the following simple measures to limit the infection rate:
    • No kissing, hugging or handshaking, except with your closest circle of family members and loved ones;
    • No unnecessary gatherings of a lot of people, meaning no sports events, no concerts, no carnivals, no festivals, no graduation events, and no religious gatherings;
    • Maintain a 2-metre distance from strangers, interact with as few different people as possible, and wear a mask if you have to be close to them (in supermarkets, public transportation, banks, etc.);
    • Avoid touching surfaces that a lot of other people touches, and wash your hands thoroughly after touching a potentially infected surface;
    • Work and study from home as much as possible, and limit interactions to as few different people as possible.
    • When working from home is not possible, implement flexible working hours and staggered work schedules to reduce peak occupancy in public transportation systems and workplaces.
  1. Everywhere, outdoor work and leisure activities should be permitted, as long as physical distancing is possible. Indeed, people should be encouraged to get fresh air, sunlight and moderate exercise in order to optimize their immune systems. Masks should not be compulsory when exercising outdoors, because they limit the optimal oxygen intake.
  2. In the vast majority of municipalities, children can get back to school if adequate hygiene facilities are available. It would be safest if teachers are female, under the age of 60, and generally healthy. Teachers with high risk of a severe COVID-19 reaction (older males with high blood pressure, diabetes, or other risk factors) should not get into contact with children. WHO has guidelines on how to reduce risk in schools [13].
  3. In the vast majority of municipalities, most shops can reopen, as long as clients can maintain adequate physical distancing. Risks would be lowest if shops are attended by young women. Opening hours should be expanded rather than reduced, in order to reduce crowding.

 

On the other hand, the most vulnerable municipalities need to prepare for a major impact of COVID-19. In all the variations of our Vulnerability Index, Riberalta jumps out as the most vulnerable municipality in Bolivia. It is a big urban municipality (about 100,000 inhabitants) with lots of connections to other municipalities through recent migration, and it provides health services for many surrounding municipalities in the departments of Beni, La Paz and Pando. However, it has a very low coverage of water and sanitation, and high levels of obesity, malnutrition, Dengue, Malaria, Tuberculosis, and HIV. It is a ticking bomb. But for some reason, the government’s index does not flag it as high risk.

Finally, since this is going to take many months to get through, we should use this opportunity to get universal coverage of electricity, telecommunications, and online services. Now is the time for AGETIC to really push forward with electronic government services.

Footnotes:

[1] See recording of webinar held on the 6th of May 2020, and this PDF of the polling results.

[2] We are working on a working paper with much more details and which includes a sensitivity analysis, since there are many possible ways of aggregating the indicators. But the results presented here are highly correlated with the other aggregate indices analyzed.

[3] In Germany, for example, the death rate for men between 50 and 80 years is at least double the death rate for women in the same age group (https://www.statista.com/statistics/1105512/coronavirus-covid-19-deaths-by-gender-germany/). In Italy, Spain, China, Peru and Greece, the gender difference is even more pronounced (https://www.businessinsider.com/men-women-coronavirus-death-rates-by-country-worldwide-health-habits-2020-4)

[4] See, for example, Richardson, S., Hirsch, J. S., Narasimhan, M., et al. (2020). “Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized with COVID-19 in the New York City Area.” JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775 ( https://jamanetwork.com/journals/jama/fullarticle/2765184)

[5] https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020

[6] https://link.springer.com/article/10.1007/s40520-020-01570-8, https://www.bmj.com/content/356/bmj.i6583, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3571484

[7] https://www.statista.com/statistics/1105061/coronavirus-deaths-by-region-in-italy/

[8] https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/

[9] https://www.sciencemag.org/news/2020/05/should-schools-reopen-kids-role-pandemic-still-mystery

[10] https://www.weforum.org/agenda/2020/04/occupations-highest-covid19-risk/

[11]See this article for a discussion of what it takes to develop, test, produce and distribute a new vaccine: https://unherd.com/2020/04/when-we-get-the-covid-19-vaccine/?tl_inbound=1&tl_groups[0]=18743&tl_period_type=3

[12] See https://www.sdsnbolivia.org/en/english-forty-days-of-quarantine-what-have-we-learned/.

[13] See https://www.who.int/docs/default-source/coronaviruse/key-messages-and-actions-for-covid-19-prevention-and-control-in-schools-march-2020.pdf?sfvrsn=baf81d52_4

* Executive Director, SDSN Bolivia

** Economic Research at Centro Latinoamericano de Políticas Económicas y Sociales – Pontificia

Universidad Católica de Chile – CLAPES-UC.

*** Head of Energy, Environment and Economics at Centro Latinoamericano de Políticas Económicas y

Sociales –Pontificia Universidad Católica de Chile – CLAPES-UC

 

* SDSN Bolivia.

The viewpoints expressed in the blog are the responsibility of the authors and do not reflect the position of their institutions. These posts are part of the project “Municipal Atlas of the SDGs in Bolivia” that is currently carried out by the Sustainable Development Solutions Network (SDSN) in Bolivia.

Forty Days of Quarantine – What Have We Learned?

By: Lykke E. Andersen, Ph.D.*

 “There are lies, damn lies, and COVID-19 statistics”
Johan Norberg

 

 

The term quarantine comes from a venetian word meaning “forty days” which was the number of days in which ships and people had to be isolated before being admitted to the Republic of Venice in Medieval times in order to be sure that they were not infected by deadly infectious diseases, such as the Plague, Cholera, Syphilis, or Yellow Fever.

In Bolivia we are nearing our forty days of “reverse quarantine” (keeping the healthy people locked up, in order to prevent them from getting infected by an external threat).

This reverse quarantine has bought us some time to get to understand the novel SARS-CoV-2 virus (Severe Acute Respiratory Syndrome Corona Virus No. 2), and the COVID-19 disease it is causing. Initial data out of China and Italy was so scary that it was worth the high costs to buy us some time to formulate a strategy on how to deal with the threat, and prepare the population and the health system to manage it as well as possible. We have very little data from Bolivia, but since this is a global pandemic, we can learn a lot from other countries, despite extremely flawed data.

A few basic things have become clear:

  • The SARS-CoV-2 virus has infected people in pretty much every country and territory on the planet, so suppression and eradication of the virus is unfortunately no longer a realistic option (1);
  • Many people who catch the virus have no symptoms, which is why this virus has managed to spread so easily across the globe (2).
  • There is no previous immunity, nor any treatment available (3), so the virus will not go away until we have achieved herd immunity, either through vaccination, or by 60-70 percent of the population having been infected (4);
  • Although many potential vaccines have been developed in record time, they have to be tested for safety and efficacy, which means that vaccines at a global scale will not be available for at least another 12 months. By the time a safe and effective vaccine becomes available for billions of people, it may not be needed any more (5);
  • The Infection Fatality Rate (IFR) is likely to be somewhere between 0.1% and 10%, depending on the health of the population, the age composition of the population, the quality of the health care system, the policies enacted to confront the problem, and possibly the type of the virus that dominates, because there seem to be different strains circulating already (6). It is clear that men are more likely to die than women, older people are far more likely to die than younger people, and people with underlying health problems, especially hypertension, obesity and diabetes, are more likely to die (7).

Given these facts, it is clear that we are facing some difficult decisions. Short of simultaneously locking up everybody on the planet for many months, there is no way we can prevent that millions of people will die from COVID-19. In the absolute best case scenario (IFR like the common flu at 0.1% and 60% of the world population getting infected), we will see 4.2 million people die from this disease, and we should consider ourselves very lucky if that is the number we converge towards over the next 24 months. More likely, there will be at least 5 times more deaths than that, meaning at least 20 million people will die. So far, only about a quarter of a million have died, so the world is still in the very early stages of the pandemic (98% still to come).

 

How are we doing in Bolivia?

In Bolivia, we have barely started the process, because we locked down early and thoroughly. To date we have only 62 confirmed COVID-19 deaths, out of a minimum of 7,000 and a maximum of 800,000 to be expected. That is a frustratingly large range, and it is difficult to make wise decisions until we narrow down the likely path of this epidemic. The whole point of locking down is to obtain more information and figure out which end of the range is most likely, and thus which kind of policies are appropriate to get us through this pandemic.

In a normal year, about 24,100 people die from all causes in Bolivia. In the absolute best case scenario, this virus would kill off 6,600 old and frail people who would have died from other causes this year anyway, thus implying no excess mortality. Unfortunately, we already know that this best case scenario will not play out, because among the first to die of COVID-19 in Bolivia were a pregnant nurse, and several otherwise healthy people below 70 years of age.

 

How bad is it going to be?                                                                                       

We have waited for 40 days in order to rule out the worst case scenario, which would be a 10% IFR. The original data coming out of Wuhan suggested that 20% of infected people would need hospital care in order to survive, and that almost 4.9% of infected people died anyway. Also, of more than 1 million closed cases to date worldwide, 18% have died (8). However, recent antibody tests carried out in California (9), Germany (10), Denmark (11), and the Netherlands (12) suggest that many people have been infected without any symptoms, which means that the true number of infections is several times higher than the confirmed cases, implying that the IFRs are much lower than the official Case Fatality Rates (CFR = Deaths/Confirmed Cases) suggest.

In the USA, the New York State recently carried out random anti-body testing on 3,000 individuals to figure out how many people had really been infected, and they found that 13.9% of the population, or about 2.7 million people in the state, had already been infected at a time when “only” 19,453 COVID-19 deaths had been registered. This suggests an IFR in New York state of around 0.72%, or a little bit higher, since some of these infected people are still critically ill and more will unfortunately die (13).

Of course, New York is one of the richest places on the planet, so their IFR may not be relevant for Bolivia. Data from Peru is probably more relevant here, and fortunately Peru has somehow managed to carry out more than 300,000 tests, while Bolivia has only done around 6,000. In Peru, more than 37,000 people have been confirmed to have the virus, but only 2.8% of confirmed cases have died so far (8). However, Peru, like all other countries, has limited testing capacity, so in reality there will be many more infected, and thus the IFR will be a lot lower.

With the still very incomplete information available at the moment, I estimate that we will end up with an IFR of around 1% for Bolivia (meaning anywhere between 0.3% and 2%, given the still high uncertainty). If 60% of 11.6 million people get infected, and 1% of those die, we would end up with about 70 thousand COVID-19 deaths in Bolivia. The number could be lower if a vaccine becomes available before we reach herd immunity through infection, but I consider that unlikely (5). The good news is that more than 11 million Bolivians will not die from COVID-19.

 

Proportionate interventions

We are facing an undeniably difficult situation, like all other countries. What we definitely have to make sure is not to make things even worse than they have to be. 70,000 dead people is bad. But these people dying alone, shunned and isolated in designated COVID hospitals, without family, friends and funerals, seems much worse. If at the same time even more people are losing their livelihoods, their investments and their dreams due to quarantine, that would be awful. If children start dying from hunger because their parents are not allowed to work (14), it would be a full-blown disaster. If we lose our basic human rights and freedoms, and we cannot see and hug our loved ones for years (15), that is simply an unbearable thought.

Thus, we have to make sure our interventions are well thought through and based on the best evidence possible. We are lucky that our country got infected relatively late (first confirmed case on the 10th of March, 2020), and we managed to keep numbers low for the first couple of months through strict quarantine measures, which means we got the gift of time to enable us to learn from good and bad experiences in other countries, and from all the new scientific research that is coming out to help us understand our options better.

 

Flattening the curve is clearly necessary

I am not suggesting that we should flatten the curve so that our health care system does not get overwhelmed, because it got overwhelmed by the very first patient (16). But I do suggest we flatten the curve enough to make sure that we can physically, mentally and socially handle every diseased person in a dignified manner. If we do not spread our expected 70,000 deaths out as evenly as possible over at least a year, we will experience the horrors of dead bodies piling up in the streets, like we are seeing in Guayaquil in Ecuador (17). If we could spread our expected 70,000 deaths perfectly evenly over the next 12 months, we would have around 1,350 COVID-19 deaths per week. Hopefully some of these would have died from other causes anyway, but it is clear that we have to be prepared to increase our funeral capacity, because Bolivia is used to handle only about 1,300 deaths per week from all causes.

 

What does successful management of a global pandemic look like?

Ideally, we should have nipped this epidemic in the bud, like we managed to do with the first SARS outbreak in 2003, the MERS outbreak in 2012, the Ebola outbreak in 2014, and hopefully most future similar outbreaks. However, this time the world screwed up big time, and with millions of people being infected all over the globe, eradication is just not realistic anymore. A few rich island nations may be able to test, trace and isolate cases and keep it under control until a vaccine is available, but for most of the world’s countries, including Bolivia, that is just not a realistic aspiration.

My criteria for success are much less ambitious: If less than 0.6% of the population die from COVID-19 within the next 12 months, and if the unfortunate 0.6% die with loved-ones holding their hands, and family members and close friends get the opportunity to pay their respects and process their losses, and if the economy contracts less than 5% (a setback of less than 2 years), then I would consider that a successful management of an unescapable pandemic with no known cures available.

 

How do we successfully manage this epidemic?

The key is avoiding huge and unmanageable spikes in deaths. That will require carefully calibrated social distancing measures.

Some “easy” social distancing measures should be implemented by everybody at all times until this pandemic is over:

  • No kissing, hugging and handshaking, but try to be kind to everybody anyway;
  • No unnecessary gatherings of a lot of people, meaning no sports events, no concerts, no carnivals, no festivals, no graduation events, and no religious gatherings; but try to have fun in new creative ways;
  • Maintain a 2-metre distance from strangers, interact with as few different people as possible, and wear a mask if you have to be close to them;
  • Avoid touching surfaces that a lot of other people touches, and wash your hands thoroughly after touching a potentially infected surface;
  • Work and study from home as much as possible, and limit interactions to as few different people as possible.
  • When work from home is not possible, implement flexible working hours and staggered work schedules to reduce peak occupancy in public transportation systems and work places.

These simple measures substantially reduce infection rates, but they may not be enough. Even tougher measures may be necessary in certain locations if infections spike for some reason.

 

Monitoring of outbreaks

In order to know when tougher measures are necessary, we need extremely good monitoring of the epidemic. Ideally, we would have massive testing capacity like Iceland or South Korea, but Bolivia has the lowest testing capacity in South America at less than 1 in a thousand people (18), and we have to be realistic about what is actually feasible.

There are two alternative options that could provide us with valuable information in real time about how the pandemic is evolving:

  • A daily symptom tracker app on our phones, which could alert authorities to a local outbreak, and help individuals get the help they need. A simple such app exists in the UK, and much more elaborate apps are used in many places in Asia (19). It is trickier in Bolivia, as it requires high levels of trust in the government, and the population would need to perceive concrete benefits of using the app. For example, it could be linked to a generous donation of free phone minutes and Internet access, telemedicine consultations, free medicine delivery, and more. Such an app would be technically relatively easy to develop, but it would require serious thoughts on how to get a large share of the population to trust and use the app daily.
  • A less demanding option is to monitor weekly deaths from all causes at a sub-national (ideally municipal) level, so as to alert us if any region is beginning to spike, and would therefore need to implement stricter social distancing measures and receive more support from the central government. EuroMOMO would be a good model for this (20).

Both of these options would be much less expensive and damaging than shutting down the entire country for many months. A traffic light system could be designed to clearly communicate the current levels of restrictions in different parts of the country. Indeed, this should be part of the app mentioned above.

 

Sustainable transition towards a new Bolivia

Whatever systems we do implement, we have to make sure they can be sustained over time, because this is going to take at least a year to get through, and the world will look different on the other side. Families and firms will have to adapt to these new circumstances, and the government needs to support them through this transition. At the very least, the government has to make sure nobody starves to death (people should be able to request help through the app if they have urgent needs, and the government needs to develop the infrastructure needed to respond). The government also has to accelerate investments in absolutely crucial infrastructure, such as water, sanitation, electricity and Internet. In order to facilitate a more agile transition and response to the rapidly changing market conditions, now is a good time to eliminate the very strong rigidities in the Bolivian labor market, because many of the changes we will see are not going to be transitory. It would also be a good idea to make it much easier to close companies that have become unsustainable, so that people can spend their time and money on starting up new businesses, instead of spending months or years going through all the ridiculously difficult procedures to close a company.

Footnotes:

(1) Bolivia, as well as several other female-led countries, such as Taiwan, Hong Kong, New Zealand, Iceland, Norway, Finland and Germany, potentially could suppress and eliminate the virus, but that doesn’t help us much in this globalized world, if there are major male-led countries around us that fail to do that (e.g. United States, United Kingdom and Brazil).

(2) For example, 408 residents at a homeless shelter in New York was tested for the virus, and 36% of them was found to have the virus, but 87.7% of the people who had the virus, did not have any symptoms (https://jamanetwork.com/journals/jama/fullarticle/2765378?guestAccessKey=a5d28066-8f72-4633-a291-90b472754093&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=olf&utm_term=042720).

(3) Countries around the globe have been scrambling to buy mechanical ventilators, but it is not a treatment, it only provides life-support while the body’s own immune system battles the virus. A recent study of outcomes in 12 New York hospitals show that the vast majority of COVID-19 patients on ventilators die. Indeed, of those aged 65+, 97.2% of COVID-19 patients with an outcome by the end of the study, had died. For patients aged 18-65, 76.4% had died. See: Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775 ( https://jamanetwork.com/journals/jama/fullarticle/2765184)

(4) Some people are questioning whether we will even be able to achieve herd immunity, as some people who had previously been diagnosed and then cleared, have caught the virus a second time within a few months (https://www.reuters.com/article/us-health-coronavirus-who/who-says-looking-into-reports-of-some-covid-patients-testing-positive-again-idUSKCN21T0F1?il=0). See also this note about Corona virus immunity research at Columbia University: https://www.technologyreview.com/2020/04/27/1000569/how-long-are-people-immune-to-covid-19/?fbclid=IwAR3fkGPtqipyy_eieEBWaWOTeDnsdxkcb8BMpkYOXlaBW10OYaPs0CmUFVk.

(5) See this article for a discussion of what it takes to develop, test, produce and distribute a new vaccine: https://unherd.com/2020/04/when-we-get-the-covid-19-vaccine/?tl_inbound=1&tl_groups[0]=18743&tl_period_type=3

(6) The Chinese scientist who originally proposed the lock down of Wuhan, Dr. Li Lanjuan, has carried out ultra-deep sequencing of the RNA in different samples, and says that the SARS-CoV-2 virus mutates faster than previously thought, and that some strains are more infectious and more lethal than others ( https://www.scmp.com/news/china/science/article/3080771/coronavirus-mutations-affect-deadliness-strains-chinese-study).

(7) Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. Published online April 22, 2020. doi:10.1001/jama.2020.6775 ( https://jamanetwork.com/journals/jama/fullarticle/2765184)

(8) See https://www.worldometers.info/coronavirus/.

(9) Researchers at Stanford conducted antibody tests on 3,300 volunteers (a non-random sample obtained through facebook ads) in Santa Clara, California, and found that  1.5% of the sample tested positive for the antibodies, suggesting that the real number of COVID-19 infection was 50-85 times higher than the official numbers by April 1st, 2020 ( https://www.medrxiv.org/content/10.1101/2020.04.14.20062463v1.full.pdf). However, it should be noted that this was not a random sample. Volunteers who responded to the ad, might be people who had experienced COVID-19 symptoms, and were eager to find out if they have already had the virus.

(10) Researchers conducted anti-body tests on inhabitants of Gangelt, a German municipality near the border with the Netherlands, which was hard hit by covid-19 after a February carnival celebration. They found that 14% of the population had already been infected by late March (https://www.technologyreview.com/2020/04/09/999015/blood-tests-show-15-of-people-are-now-immune-to-covid-19-in-one-town-in-germany/).

(11) On 6-8 April 2020, Denmark tested 3,898 blood donations from asymptomatic people and found that 1.9% had COVID-19 antibodies (https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-ninth-update-23-april-2020.pdf).

(12) Between the 6th and the 12th of April 2020, the Netherlands tested 4,194 blood donations and found that 3.4% had COVID-19 antibodies (https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-rapid-risk-assessment-coronavirus-disease-2019-ninth-update-23-april-2020.pdf).

(13) See Dr. John Campbell’s discussion of these results here: https://www.youtube.com/watch?v=ypsUIh41xUw

(14) Unfortunately this has already started happening in Bolivia. A 12-year-old girl in the municipality of Montero killed herself after being quarantined without food for several days with her mother and her 7 siblings (https://www.lostiempos.com/actualidad/pais/20200422/tragica-muerte-menor-enluta-familia-humilde-montero-piden-ayuda-entierro).

(15) While other countries help, or at least allow, their nationals to return home, Bolivia has closed its borders so tightly that many Bolivians have been stranded either at border crossings, or wherever they happened to be at the time of the lock down. Especially inhuman was the treatment of a group of Bolivians, including pregnant women and women with babies, who tried to get home from Chile late March (https://eldeber.com.bo/171695_bolivianos-en-la-frontera-con-chile-claman-por-volver-y-el-gobierno-les-responde-que-no). I was also horrified to read than an opposition mayor in Cochabamba was arrested in her home last week for playing loud music and drinking “chicha” (a fermented beverage made from corn) together with her closest family. Although she tested negative in the alcohol test made on the “scene of crime”, all eight people present were arrested, and the youngest child was sent to a center for homeless children ( https://erbol.com.bo/seguridad/alcaldesa-de-vinto-dice-que-s%C3%B3lo-%E2%80%9Cbrind%C3%B3%E2%80%9D-con-una-%E2%80%9Ctutuma-de-chicha%E2%80%9D).

(16) https://rpp.pe/mundo/actualidad/bolivia-covid-19-grupo-de-ciudadanos-bloquea-el-acceso-de-pacientes-con-coronavirus-a-hospitales

(17) https://www.nytimes.com/2020/04/23/world/americas/ecuador-deaths-coronavirus.html?smid=tw-share

(18) See https://ourworldindata.org/coronavirus.

(19) Here is the symptom app used in the UK: https://covid.joinzoe.com/. Google and Apple are also working to develop a contact tracing app that can alert you if you have been near a confirmed COVID-19 infected person (https://www.theverge.com/2020/4/10/21216715/apple-google-coronavirus-covid-19-contact-tracing-app-details-use), but that would have to be used in conjunction with extensive testing and it requires a very disciplined population for people to self-isolate for two weeks, just because their phone indicates they have passed by an infected person, so it does not seem ideal for Bolivia.

(20) EuroMOMO is a European mortality monitoring activity, aiming to detect and measure excess deaths related to seasonal influenza, pandemics and other public health threats ( https://www.euromomo.eu/graphs-and-maps/)

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* SDSN Bolivia.

The viewpoints expressed in the blog are the responsibility of the authors and do not necessarily reflect the position of their institutions. These posts are part of the project “Municipal Atlas of the SDGs in Bolivia” that is currently carried out by the Sustainable Development Solutions Network (SDSN) in Bolivia.