The Institute for the Future of Knowledge at the University of Johannesburg has partnered with Picturing Health to make a short documentary depicting the impact of severe lockdown measures on those living in poverty in the developing world.

COVID on the Breadline from PICTURING HEALTH on Vimeo.

Regions and nations differ, but the advice issued by many international health organisations has been the same: COVID-19 is the overriding threat to public health at present, and merits social distancing and hygiene. This is good advice for physically interrupting the biological process by which the disease is transmitted. But public health advice must take into account more than the biology of disease transmission, as the history of public health has shown repeatedly. This lesson has not been learned: there is little advice on how different regions should tailor their approaches; the most influential and well-resourced modeling efforts do not consider differing costs, benefits and feasibility in different contexts; and “lockdown” has come to be seen as the only effective measure for slowing the spread of COVID-19, with any other measure seen as a brave and risky experiment.

COVID-19 on the breadline is a documentary film about lockdown in the developing world. More than that, it seeks to give a voice to those who stand to lose the most from lockdown. From their own mouths, we hear that they fear not just for their livelihoods but for their lives, in the face of malnutrition, and the disrupted medical services essential for the tenuous grip we have on other diseases. The costs of lockdown are not merely economic: not merely a line on a graph, a vanishing pension fund, or even a lost job. For those living on what they make each day, for the one in three Africans living below the poverty line, for the nearly 90% of African workers in the informal sector – the consequences of lockdown are extraordinary and horrible. This is not a matter of economy vs. health: it is a matter of two causes of death, COVID-19 and lockdown. The mortality-burden of lockdown in the developing world will be high, perhaps even higher than COVID-19 itself, in the eyes of some of the people we hear from in the documentary.

The film encourages a fuller cost-benefit analysis of lockdown. Not only are the costs higher for developing regions, but the benefits may be lower. The benefit of lockdown must be measured as the reduction of the risk the disease poses to population health. This depends on several factors, notably the susceptibility of the population and access to healthcare. The documentary goes on to explore these factors through discussion with a range of experts as well as individuals living in conditions of poverty. Other serious threats to life become evident. These explain the very low life expectancy within the region, with just 3% of sub-Saharan Africa making it past 65 and thus into the age-range where risk of serious, critical and fatal disease appears – in developed countries – to rise dramatically. By contrast, 20% of Europeans are over 65, and the median age is 42, compared to just 18 in Africa. If age is a good predictor of risk of serious disease in the African context, then susceptibility may be reduced accordingly. But even if the association between old age and serious COVID-19 does not carry over to Africa, the mere fact that African lives are so much shorter than those on any other continent demonstrates the presence of many other lethal risks. Against this background, COVID-19 may not be as much of a priority as it is in regions where the terrors of infectious disease have been nearly forgotten.

The documentary explores reasons for the focus on COVID-19, when we already accept such high levels of preventable mortality annually. The suggestion made by some interviewees is that COVID-19 places powerful people at risk, in developed countries. This is a sad comment on the way we differently value human lives. The number of deaths that COVID-19 may cause appears not to be the only factor explaining the global response: it also matters who the disease kills. Because this disease threatens powerful and wealthy people in the developed world, the whole world locks down; but, as a global community, we accept the deaths of poor people in developing regions on an annual basis, when we could prevent almost all these deaths at a fraction of a cost of the present lockdown.

Of the 40m annual deaths globally, 5m (12.5%) are children under 5 dying of malaria, pneumonia (the mechanism by which COVID-19 often kills) and birth complications. Because of the steep gradient at which risk increases with age, after the age of around 60, COVID-19 presents a generational challenge. Our interviewees point this out, emphasizing that lockdown measures shift mortality from older generations in developed countries to younger generations and especially children in developing countries. Malnutrition especially threatens children, and will be a consequence of lockdown in developed but not developing countries. Older people in both regions are at risk of COVID-19 but there are far fewer of them in the developing world, and in any case, they too are thretaned by malnutrition. And malnutrition increases the likelihood that COVID-19 will pose more of a threat to children in the developing than the developed world, meaning that lockdown could be paradoxical effect.

The documentary ends with positive suggestions, drawn from talking to local people in communities most likely to be affected by disease, malnutrition, and recession. In rural areas, isolation of older people is a feasibility. In townships and slums, vulnerable people may be taken to vacant hotels, in the absence of tourism. Travel between regions may be effective at slowing the disease, while economic activity could continue within regions. The costs of such measures may be considerably less, such that even if the benefits are somewhat less in terms of risk reduction, they may represent a better overall public health proposition in the region, given the threats of starvation and other disease. But the key message, above all, is that disempowered and voiceless people must be consulted, empowered, and given a voice. We hope that the film will, in a small way, give some prominence to the voice of the voiceless in the current cacophony of opinion around COVID-19.