By: Usama Bilal, MD, PhD, MPH
Assistant Professor
Dornsife School of Public Health

Coronavirus. Dengue. Zika. Ebola. Though non-communicable diseases dominate the mortality and morbidity landscape worldwide, including the Americas, it is epidemics of infectious diseases that dominate the attention of the media and the public given their capacity to overload health systems and cause crises of morbidity and mortality.

The current pandemic of SARS-CoV-2 and its pathological manifestation COVID-19 is a prime example of this overload. As of March 25 (the time of this writing), there have been 3,285 deaths in China, 2,077 in Iran, 7,577 in Italy and 3,647 in Spain, where fatalities are doubling every two days. These are very different countries, with very different demographics, baseline health status, and health system organizations, but all are strained to continue responding to the crisis. Whether this pandemic will strongly impact Latin American countries is yet to be seen. Still, some governments across the region have already imposed strong measures to prevent the spread of the virus. In contrast, others have decided not to adopt measures, or warn of the potential economic impacts of disproportionate measures.

The pandemic originated in Wuhan, China, a city with 19 million people in its metropolitan area. It then moved to other countries through the international travel network of business travelers and tourists. South Korea, hailed for its strong response in containing the epidemic, suffered a massive outbreak in Daegu, a city of around 2.5 million people. Italy and Spain have experienced the worst of the epidemic so far. Lombardy, Italy has recorded 4,474 deaths and 32,346 cases so far, overloading the health system. Around 6,000 of these cases occurred in Milan, a city of 3.1 million people. In Spain, most of the deaths to date have been recorded in Madrid, a city of 6.8 million people.

The size of these cities is directly comparable to Mexico City, Medellin, San Jose de Costa Rica, and Santiago de Chile. What would happen if this pandemic were to spread to these Latin American cities? With the Americas being one of the most urbanized regions in the world, the health of populations here is highly dependent on what happens in its cities. Reviewing a few key concepts could prove useful.

Flattening the Curve

Numerous versions of the figure above have been used by many public health officials in communications with the public. Let's review what influences the position of each part of this figure, and how we can "move" (intervene upon) each one, with a specific focus on cities.

First, absent any intervention, the infection will spread with a given intensity (see the red epidemic curve), which can vary from place to place. In the case of influenza, this depends, for example, on the size of a city, density and overcrowding, and humidity and temperature.

Second, a primary goal right now is to shift from the epidemic curve in red to the epidemic curve in blue. In other words, governments are aiming to prolong the spread of the epidemic to avoid an overload of health systems (horizontal dashed line). Evidence from the 1918 influenza pandemic in US cities suggests that the timing of public health interventions can help significantly in “flattening the curve”. On the one hand, public health interventions can attempt to prevent the spread of the infection through targeted approaches such as testing of suspicious cases, contact tracing, and isolation. On the other, public health interventions can also be implemented at the population level and include social distancing measures. The impetus behind social distancing is to reduce the possibility of people coming in contact with one another, thereby reducing potential contagion.

Third, the location of the horizontal dashed line, or healthcare system capacity, depends on the strength and robustness of the health system, its access to financial and human resources and necessary medical supplies, and how it is structured. If healthcare systems are already strained to begin with, their surge capacity may be minimal, and this line may not move at all. Decreasing investments in healthcare, ongoing privatizations, and downsizing in Lombardy and Madrid have not helped these cities to respond to this epidemic.

Fourth, we should not forget about the importance of the prevention of non-communicable diseases. The likelihood of a person experiencing a SARS-CoV-2 infection needing hospitalization or, worse, a critical care bed with a ventilator, seems to be highly dependent on the person’s baseline health status and chronic conditions. For example, while Spain and Italy rank 1st and 4th in life expectancy at birth for women among European countries in 2018, they rank 9th and 15th in healthy life expectancy at age 65 in the region.

Equity and COVID-19

Latin America is not just highly urbanized. It is also one of the most economically unequal regions in the world: 8 of the world’s 20 most unequal countries are in Latin America. Latin America also has wide health inequalities in its largest cities, with life expectancy disparities between the areas with the highest and lowest life expectancy being above 10 years in several cities. The role of economic and health inequalities has not been frequently discussed in the context of the pandemic. Still, these inequalities may prove vital to understanding the causes and consequences of the pandemic in Latin American countries and cities. 

First, if social distancing is useful and needed, the capacity of citizens to comply with it may be dependent on the levels of inequality. This may be especially true in Latin American cities, with high proportions of people forced to work in the informal economy, where safety nets are scarce and social protection systems may be insufficient to help people comply with "stay-at-home" recommendations or orders. Moreover, overcrowded and low-quality housing with little access to infrastructure is common in the informal settlements of Latin America, posing special challenges to comply with recommendations to avoid transmission.  While COVID-19 may have a relatively high fatality rate, it pales in comparison, certainly, with the fatality rate of lack of food or shelter. In other words, social policies are health policies.

Second, repeated messaging on how "everyone" is affected and how we are "all in this together" ignores an essential aspect of COVID-19 infection. Its fatality rate is highly dependent on the existence of chronic conditions, and these conditions are strongly socially patterned everywhere, including Latin America.

Third and last, it is still unclear whether Latin American countries and cities will take action (or will need to), but one thing is clear. There is a high likelihood of a global recession as one of the primary outcomes of this pandemic. The impact of this recession on the most vulnerable will most likely depend on what social and economic policies are enacted by governments.

In summary, it is too early to tell what the consequences of the COVID-19 epidemic in Latin American cities will be. Still, basic epidemiologic concepts and experience with other diseases reinforce the importance of addressing public health preparedness, health systems capacity, prevention of NCDs, and the critical role of social inequalities. While it may seem that everyone is equally exposed to this virus, its consequences will surely not be evenly distributed.