Sri Lanka’s most recent outbreaks of Covid are spreading panic. The authorities have reacted with limited curfews and heavy handed isolation; rounding up suspected contacts and bundling them away into inhospitable quarantine camps. Activists have complained of a militarised approach to a public health problem. Similar stories were reported from China. Are the authorities are simply following a Chinese model?
There is also a lot of ire directed towards Brandix, where the first new cases were detected.
Lets try and put the issues in perspective.
People seem to have panicked because they believed the country to be free of the disease. It’s ‘sudden’ reappearance seems to have caused a shock. Were we really free of the disease? I think this was largely a case of wishful thinking. This is not a problem that will simply disappear, however hard we may wish otherwise.
Dr Ranan Eliya of the Institute of Health Policy said as much in March this year and in April warned of community spread.
He also touched the core of the current issue when he said “A competent public health response cannot blame people for its failure – it only indicates the policy itself was badly designed. Blaming the public is an admission of failure.”
What we see now is victims of the disease being blamed for spreading it and being treated as enemies, to be rounded up and imprisoned to keep the public safe.
This approach (even ignoring all the other associated problems) can only work if the disease was eradicated in the first place. Prof. S.B. Agampodi, Professor of Community Medicine, at the Rajarata University also raised the problem of community spread in an interview this week.
“All indicators are that community transmission has been around in the country for some time and it would be very difficult to pinpoint whether the infection started in the Minuwnagoda factory of Brandix Apparel Limited or outside,”
“he explains that when looking at the numbers, there simply cannot be 1,000 positives within the factory in two weeks”.
A response based on short-term knee jerk reactions is not good enough. It’s good politics to ‘show’ quick results but not good policy. This adhocracy is unfortunately only too familiar to observers of economic policy.
The worry is that the government imposes another wide-ranging curfew.
I have wondered before whether lockdowns are an appropriate containment measure for the pandemic in poorer countries. A recent paper (that has not been peer reviewed) also posits that they are not.
One of the aims of a lockdown is to buy time - to allow the capacity of the health care system to be expanded. The problem in poor countries is that the healthcare systems may already be overstretched which means that there is little likelihood of being able to reduce the caseload to a level that is within the capacity of the healthcare system. (ie an already overloaded system cannot cope even with a reduced caseload).
"The healthcare systems in poor countries have few hospital beds and ventilators per capita, and are predicted to be unable to absorb a rapid influx of COVID-19 patients. This means, however, that flattening the curve of the disease to fall within the capacity of the healthcare system may not be feasible, no matter the extent of the lockdown or mitigation efforts employed."
Sri Lanka seems to face this issue, there are only around 500 ICU beds. A recent gift of 200 ventilators from the US has expanded this but capacity seems low. Not much attention seems to have gone into its expansion either.
A lockdown does slow the spread of the disease but the consequence is that the resultant reduction in economic activity results in income losses. Richer countries try to compensate for this with increased welfare payments. Poorer countries with weak social protection schemes are unable to do this, so a greater part of the population suffers.
"Many more workers in poor countries are self-employed or in the informal sector and depend on daily wages to feed their families. In the absence of strong social protection and insurance, the cost imposed by social (and economic) distancing may be large in terms of immediate deprivation and hunger. As a result compliance rates with lock-down orders or social distancing guidelines may be lower in countries with weaker enforcement capacity."
The Labour Force Survey for 2019 (p37) estimates that around 57% of Sri Lanka’s workforce is informal. How did these people survive the curfew? There is no published data but I believe some development agencies did a few surveys and it would be good to have some data to go on.
The few informal conversations that I had with people, I was told that they survived by borrowing money together with what limited handouts they received. The question is, if they are to be subjected to another curfew, will it push them into deeper debt? Could this lead them into a poverty trap? A long term cycle of poverty? The longer the lockdown, the greater the likelihood of debt accumulating. Considering that we already endured eleven weeks of curfew there is a real danger of this. Could another extended curfew condemn a large section of the population to permanent poverty? Policymakers must not ignore this question and in the event a curfew is contemplated adequate relief needs to be provided.
With relief, the government faces two problems – the first that there is no proper mechanism to deliver relief. Samurdhi, highly politicised and poorly targeted, is thought is thought to reach only half the intended beneficiaries. There is a need to build a proper social registry, something the Yahapalanya regime started with World Bank assistance but which is probably yet incomplete. It may not include the whole of the informal sector either. Completing this should be a priority.
The other, perennial problem is the lack of funds – large budget deficits and already elavated debt, both problems made much worse by tax giveaways last year. The solution would be to look to aid, concessionary finance (where available) or resort to money printing, in that order.
In weighing costs and benefits I have been trying to think of this in terms of mortality rates and the costs of livelihood disruption, which is similar to the approach by Barnett-Howell and Mobarak-(but they use a proper model for this, of which more later).
If we look at the mortality rates, the highest in a country not in a war zone seems to be Mexico (10.2%) followed by Italy (9.1%), Ecudor (8.1%). Taking the worst case, assuming the entirety of the population is infected then 10% will die. A prolonged lockdown may save the 10% but it will disrupt the lives of the 100%. Of those disrupted, the 43% in the formal sector will suffer less.
Assuming people in the formal sector keep their jobs (not all will) they will probably be paid some part of their salary (as far as I know only the bank staff and government servants received full pay, others were paid reduced amounts) so they are better placed to survive.
The 57% in the informal sector will suffer more, many may have no income. So to save 10% at least 57% must suffer. If it is a temporary suffering and does not result in permanent increases in poverty perhaps this can be justified. There needs to be a proper assessment of these trade-offs.
It may be an idea to turn to the methodology used by the authors of the paper I mentioned previously. Perhaps either they or someone else could run the models that they used with local data?
To determine the relative value of suppression strategies in rich versus poor countries, we embed estimates of the country-specific costs of mortality developed by Viscusi and Masterman (2017) into the influential epidemiological model developed by the the Imperial College London COVID19 Response Team that predicts mortality from the spread of the virus (Ferguson et al., 2020; Walker et al., 2020)
One reason for the higher mortality rates in rich countries is the higher proportion of elderly (an average of 17.4%) than in poor countries (average 3%). The elderly are more vulnerable so deaths in countries with an ageing population are likely to be much higher than in a country with a younger population, other things being equal.
Thus in poorer countries with younger populations deaths are likely to be less, other factors being equal. Lockdowns therefore will save proportionately less lives in poorer countries.
Sri Lanka stands in-between, it has an ageing society although not as elderly as some of the richer countries.The population over 60 was 12.4% in 2016, which is closer to the older countries than to the younger ones. (For comparison, the elderly account for 22.8% of the population of Italy, 18.3% in the UK and 16% in the US).
The ageing argument therefore not as important a factor in Sri Lanka but for reasons of climate, lifestyle or greater immunity - the BCG vaccine being a possible (but not proven) cause, the death rate does not seem to be very high. Again we don’t have good data, the official statistics being impaired by limited testing but we don't appear to be experiencing a very visible massive increase in deaths.
How should we think about policy for Sri Lanka?
For a start policymakers should have been be gathering data on the costs of the curfew, how livelihoods were affected to assess the costs associated with the exercise. They should also be looking to simple, measures that reduce risks without unduly disrupting livelihoods, the paper suggests some measures:
1. Masks and home-made face coverings are comparatively cheap. A universal mask wearing requirement when workers leave their homes is likely feasible for almost all countries to implement.
2. Targeted social isolation of the elderly and other at-risk groups, while permitting productive individuals with lower risk profiles to continue working. Given the prevalence of multi-generational households, this would likely require us to rely on families to make decisions to protect vulnerable members within each household.
3. Improving access to clean water, hand-washing and sanitation, and other policies to decrease the viral load.
4. Widespread social infl uence and information campaigns to encourage behaviors that slow the spread of disease, but do not undermine economic livelihoods. This could include restrictions on the size of religious and social congregations, or programs to encourage community and religious leaders to endorse safer behaviors and communicate them clearly.
