Shah Ebrahim, London School of Hygiene and Tropical Medicine, UK
Leon Geffen, Samson Institute for Ageing Research, South Africa
Karla Giacomin, Fundação Oswaldo Cruz, Brazil
Aravinda Guntupali, University of Aberdeen, UK
Gabrielle Kelly, Samson Institute for Ageing Research, South Africa
Marin McKee, London School of Hygiene and Tropical Medicine, UK
Fabiana da Cunha Saddi, Universidade Federal de Goiás, Brazil
Lucas Sempe, University of East Anglia, UK
Peter Lloyd-Sherlock, University of East Anglia, UK

In March 2020, the BMJ published a comment on the potential effects that the COVID-19 pandemic might have on older adults in low and middle-income countries (LMICs) [1]. This predicted that older people in LMICs would account for a large share of COVID-19 mortality, since these countries contain around 70 per cent of the global population aged 60 or more and there is less access to effective health interventions than in high-income countries. It also predicted that older people in LMICs would be particularly affected by the indirect effects of the pandemic on their health, economic and social status.

One year later, it is instructive to evaluate these predictions. We review available data on both the direct and less direct effects of the pandemic on older people in LMICs. Given the diversity of national experience, we focus on three specific countries, selected because they have had the highest number of reported COVID-19 deaths in their respective regions: Brazil (Latin America), India (Asia) and South Africa (Africa). 

Mortality of older people in LMICs during the COVID-19 pandemic.

Figure 1 shows that Asia, Africa, and South America accounted for 38.2 per cent of total reported global COVID-19 deaths by 3 March 2021. If Mexico (which is not part of South America) is added to these regions, the global share increases to 45.6 per cent. These data are likely to under-state the share of global COVID-19 deaths in LMICs, due to problems in diagnosis, attributing cause of death, inconsistent definitions of COVID deaths, as well as incomplete mortality registration [2], an interpretation is supported by studies of overall excess mortality, which find a larger differential with reported COVID-19 deaths than in high-income countries [3]. It is therefore reasonable to assume that LMICs account for the majority of global COVID-19 deaths. This share is likely to grow as unequal access to vaccination means mortality becomes increasingly concentrated in these LMICs.

Figure 1: Global shares of reported COVID-19 mortality as of 9 March 2021.

Table 1 presents available national data on reported COVID-19 mortality for all ages and people aged 60 or more among LMICs reporting at least 20,000 COVID-19 deaths by 3 March 2021. Iran does not publish age-disaggregated data and three other countries are yet to do so in 2021. Moreover the robustness of this information has been questioned in some countries that do regularly publish age-specific data, such as Mexico [4]. Consequently, the reliability of these data is limited. Table 1 shows the share of reported COVID-19 deaths occurring among people aged 60 or more ranged from 40.1 per cent in Indonesia to 84.5 per cent in Chile. In six of the 11 countries for which data are available, people aged 60 or more accounted for over three-quarters of deaths.

Table 1. Reported COVID-19 mortality, all-ages and people aged 60 or more, selected LMICs. Most recent data available by 3 March 2021.

Source: COVerAGE-DB (all countries other than *); For Iran: Max Roser, Hannah Ritchie, Esteban Ortiz-Ospina and Joe Hasell (2020) – “Coronavirus Pandemic (COVID-19)”.

Table 2. Estimates of excess mortality for Brazil and South Africa.

Sources: https://www.samrc.ac.za/sites/default/files/files/2021-02-10/weekly6Feb2021.pdf; https://www.vitalstrategies.org/resources/excess-mortality-in-brazil-a-detailed-description-of-trends-in-mortality-during-the-covid-19-pandemic/

Table 2 presents estimates of excess mortality for Brazil and South Africa. There are no published national estimates of excess mortality during the COVID-19 pandemic for India. In Brazil, the number of all-age excess deaths was around double the number of reported COVID-19 deaths over the same period; in South Africa it was around treble. Separate data show gaps between excess and reported COVID-19 deaths are larger in South African provinces with lower rates of COVID-19 testing [5]. Together, these findings suggests that many COVID-19 deaths have gone unreported and that a large share of these deaths occurred at older ages.

Indirect effects of the COVID-19 pandemic on older people in LMICs.

Economic and social effects.

As for people of all ages, lockdowns and other restrictions on normal activities affect the social and economic status of older adults in many ways. The timing and rigour of lockdowns has varied across LMICs. In some, lockdowns have not distinguished between older adults and other people, while in others they have. In South Africa, a comprehensive lockdown for people of all ages was strictly enforced between late March and early May 2020. As the lockdown was relaxed, specific restrictions on people aged 60 or more were introduced, including a requirement to work from home whenever this was feasible. In India a strict national lockdown was implemented over a similar period, followed by more localised measures. In Brazil, lockdown measures were briefly adopted by local governments during April and May 2020 and re-established in January 2021 in response to a second pandemic wave. In parts of Brazil, this included specific restrictions on older people, such as only leaving home for urgent, unavoidable reasons. One supposed justification for age-specific lockdowns is that they do not affect people of “working age”. However, a high proportion of poor older people in LMICs remain economically active, and there is evidence that heavy-handed lockdowns can disrupt their livelihoods, as well as limit access to services and deepen social isolation [6]. 

In 2018 only around 20 per cent of people aged 60 or more in LMICs received regular monthly pensions [7]. Limited social protection will have increased the economic impacts of the pandemic. A survey of older people in India found 65 per cent reported that their economic situation had deteriorated substantially during the lockdown [6]. Unusually, both South Africa and Brazil have pension systems providing monthly cash benefits of at least US$124 (South Africa) and US$190 (Brazil) to the majority of older citizens. During the pandemic, both countries have offered pensioners additional emergency payments. However, there is evidence of older people being coerced to share pensions with other relatives, as family livelihoods come under growing strain [8].

A lower proportion of older people live alone in LMICs than is usually the case in high-income countries. This may limit social isolation during lockdown, but (in contexts of crowded, substandard housing and family stress) it may also increase exposure to abuse and infection.  A survey of 5,000 older people across India found 56 per cent claimed they suffered at least one form of abuse and most reported this had worsened since the start of lockdown [9]. In South Africa, older grandparents have maintained caregiving roles in multigenerational households, despite health risks [10].

Access to health services.

Scarce hospital resources in LMICs have limited the access of all age groups to effective treatment for acute COVID-19; specific discrimination against older people has not attracted particular attention even though guidelines and protocols in South Africa present older age as a legitimate criterion for withholding acute and intensive care admission [11]. In August 2020, India’s Supreme Court ruled that older people should not be discriminated against in decisions to admit to hospital but it has been reported that this ruling has been ignored [12].

Hospital data from LMICs show that older people accounted for substantially lower shares of COVID-19 admissions than of reported COVID-19 mortality. In Brazil people aged over 60 accounted for around half of COVID-19 hospital admissions and, in South Africa, less than a third [13-14]. A study in India found the median age of people admitted to a tertiary level hospital for COVID-19 was just 33.5 [15]. These findings strongly suggest that old age has often been a criterion for not being admitted to hospital.

There are almost no data for LMICs on older people’s access to either inpatient or outpatient health services for conditions not directly related to COVID-19. Studies from Brazil report reduced all-age hospitalisations for non-communicable disease and disruptions to home visits for older people [16, 17]. In South Africa, interventions to maintain older people’s access to medication and ease crowding in health centres included giving prescriptions to cover longer periods and home delivery of medications [18].

Long-term care facilities (LTCFs).

Since fewer older adults in LMICs live in LTCFs than in high-income countries, these settings are unlikely to have accounted for comparable shares of COVID-19 mortality. Mortality data for LTCFs are not easily disaggregated from other settings, as deaths of residents may occur in hospitals. Likewise, data on infections in LTCFs are of limited validity, due to low levels of testing. Nevertheless, studies of LTCFs in Brazil and India indicate higher infection prevalence than for community-dwelling older people [19, 20].

Before the pandemic, oversight and regulation of LTCFs in LMICs was often limited and, where it existed at all, delegated to local government. The pandemic has reduced capacity to monitor or support facilities over the past year. India and South Africa have seen little specific state support for LTCFs. In Brazil, a national stakeholder network lobbied for more government action, prompting an emergency allocation of US$25 million to LTCFs, although the use of these funds remains unclear [21].

Conclusion.

The available evidence to assess how the COVID-19 pandemic has affected older people in LMICs is limited, fragmentary and sometimes of dubious validity. The lack of age-disaggregated mortality data for many LMICs constitutes a major failure of surveillance and public accountability that has largely gone unchallenged by global health agencies. The available data indicate LMICs have accounted for the majority of global COVID-19 deaths and that older people have accounted for the majority of COVID-19 deaths in these countries.

The three country cases are not necessarily representative of their respective regions, but provide insights about different national experiences. The fragmentary evidence indicates older people are just as vulnerable to the wider economic and social effects of the pandemic as other age groups. Co-residence with other relatives means the social and economic harms resulting from the pandemic will have spread across increasingly distressed households. Although some older people in LMICs have continued access to pensions, most depend on paid work and family support. Evidence about how the pandemic has affected older people’s access to health services remains scant and indirect: this calls for urgent, focussed research.

Will these effects on older people continue through 2021? Beyond vaccine nationalism, capacity to deliver vaccines will depend on the state of health service infrastructure predating the pandemic. The inability of many LMICs to vaccinate the majority of their older people against influenza indicates the scale of this challenge [22].

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