The World Health Organization and numerous national governments have made detailed recommendations on how people can best protect themselves from the new coronavirus.1 The prevailing recommendations have four main elements:
1. Learning: A fundamental requirement is to be able to receive reliable information on local disease incidence and protection measures. Compliance with this recommendation requires access to communication tools: radio, TV, phone, the internet.
2. Isolating: Social distancing (including lockdown as its extreme form) to lower the reproduction rate of the virus by reducing contacts per day. This requires both a personal behavioural response and suitable home-infrastructure. A dwelling with walls, a roof, and closures is desirable. In settings with large (often extended) families, intra-household transmission becomes more important; a sufficiently low density of people in the dwelling is advantageous. And there must be certain facilities: for example, you can’t isolate as effectively if you have to leave the dwelling or yard to go to the toilet.
3. Washing: Regular handwashing with soap and water is strongly emphasised for protection from the virus. This too requires suitable facilities within the residence.
4. Treatment: If key symptoms (fever, difficulty breathing) develop, seeking medical help is advised. This requires physical access to health-care facilities.
The belief that these non-pharmaceutical measures can help contain the spread of illness is consistent with the available evidence. However, virtually all of these recommendations require household environments that support the capacity to protect from the virus – what we call the ‘home environment for protection’.
The home environment for protection is the result of past wealth-constrained choices, and these are unlikely to change quickly. Dwelling attributes such as size, construction, and location (determining access to treatment) cannot be easily adjusted in response to the immediate virus threat; nor is health all that people care about when allocating their resources. All of the aspects of the home environment for protection are likely to be affected by wealth, meaning that poorer households have less capacity to follow WHO recommendations. This is to be expected between countries as well as within them.
Exacerbating matters are the likely behavioural responses to the WHO recommendations. Even if following all the recommendations is feasible given the dwelling and possessions, being poor in terms of income or wealth can be expected to reduce people’s capacity to survive in isolation for anything more than a short period (as discussed further in Ravallion 2020).
For informal-sector workers in countries with limited social protection, staying home is likely to entail a potentially devastating loss of income. There is evidence that people in poorer regions reduced their mobility for work and other activities less than those in wealthier regions (Bargain and Aminjonov 2020). Poverty diminishes an individual’s capacity to isolate and hence protect their family from the virus.
Thus, there is both a direct wealth effect on the capacity to socially isolate and an indirect effect via the attributes of the home environment that allow individuals to follow the recommendations for protection. Social protection policies responding to the pandemic focus primarily on the direct effect, by aiming to support consumption (especially of food) of the particularly needy while in isolation (Gentilini et al. 2020).
So what do we know about the indirect effect?
New evidence on the scope for self-protection in poor places
WHO and government recommendations for self-protection from the new coronavirus have been developed in relatively rich countries, where most people (though certainly not all) live in homes with the facilities – the attributes of a dwelling and its infrastructure – required for implementing them. However, the relevance of these recommendations is questionable in the context of many developing countries.
In a new paper (Brown et al. 2020), we systematically assess the adequacy of the home environments for protection in the developing world. We define the home environment for protection and propose an index of adequacy of the home environment for protection, using data from the Demographic and Health Surveys, with a total sample size of over one million households across the developing world. Our index allows for either partial or full compliance with a set of attributes of the home environment that we identify as being desirable to implement the WHO recommendations.
We focus on the strength of the wealth effect on the adequacy of the home environment for protection between and within countries. A positive wealth effect is to be expected: greater household wealth is very likely to support a home environment that is better able to protect someone from the virus. But how strong is this effect? In particular, how effectively can the wealth-poor protect themselves, and how does this differ between countries? Our approach allows us to assess to what extent the dwelling-related circumstances reinforce the direct wealth effect on a person’s capacity to protect themselves from the virus.
Our assessment shows that almost 90% of households in the developing world cannot comply fully with the six conditions we identify as necessary to follow the WHO recommendations. Table 1 summarizes our findings (with much more detail available in Brown et al. 2020).
There is substantial variation in the proportion of households that meet each of the criteria. For example, almost all households across the developing world have some type of communication device, while only about 40% of households have a water source on their property and 40% do not have a formal healthcare facility within 5 kilometres.
Table 1 Potential compliance with recommendations for protection from COVID-19 in developing countries
Notes: The top panel shows the proportion of households with any health facility within 5 kilometres. The mean is a simple average of the six indicator values. ‘Has internet, phone, TV, or radio’ equals 1 if the household has an internet connection, a landline or mobile phone, a TV, or a radio, and zero otherwise. ‘Two members or less per room’ is equal to 1 if household size divided by the dwelling’s total number of rooms is 2 or less. ‘Has toilet and doesn’t share’ is equal to 1 if the household has any type of toilet and does not share it with other households. ‘Has any wall or roof’ is equal to 1 if the household reports having some type of wall and roof. ‘Water source in dwelling or yard’ is equal to 1 if the household has a water source in either the dwelling or its surrounding private area. ‘Has place to wash hands and soap’ is equal to 1 if the household has both a place to wash hands and soap in that place. Statistics are country population-weighted. The home environment for protection index is the proportion satisfying all six criteria, i.e. full compliance. Brown et al. (2020) provide results for partial compliance.
For most countries, we find that households can fulfil any two of the six conditions, which are typically the presence of a closed dwelling (with walls and a ceiling) and access to media. However, even for these (rather basic) conditions, there are some countries with weak levels of protection: for example, only 56% of the households in Liberia and 66% of those in Yemen have a dwelling with walls and ceiling.
There is a strong wealth effect that is evident both within and between countries. Overall, a majority of households (54%) can satisfy four out of the six conditions; however, this is driven predominately by households in the upper wealth quintiles and those outside of sub-Saharan Africa. When we focus on the poorest two quintiles of the wealth distribution, virtually no households in sub-Saharan Africa can satisfy all six conditions.
The majority of households in the developing world do not have a place at home to wash their hands, and only one in five do so in sub-Saharan Africa. Nor is it the case that Africa’s poor are likely to be less vulnerable to the disease; the risk factors we can identify suggest that in some respects the poor are more likely to face serious illness if they get the virus.
The developing world, and especially its poorest half, is ill-prepared to protect itself from this virus. The recommendations that have been implemented on a massive scale in the rich world must be considered near fiction for the world’s poor. Given the virus’s infection rate, the likely degree of exposure among a large segment of the population of the developing world also points to a serious concern for the entire population.
If poor families have a low health environment for protection, then complementary policies will be needed to help protect the poor from the virus. While challenges in supporting the food system as well as cash and food transfers have been emphasised in recent policy discussions, inadequate home environment for protection cannot be ignored.
The housing stock cannot be changed rapidly. But some things can be done now. The current infrastructure for information (particularly mobile-phone coverage) holds promise for getting out public health messages and information on how to access consumption support. Policies such as distributing or subsidising sturdy face masks, soap, and improved water access could be feasible in the near term and justified by both external benefits and equity impact. Home-grown innovative adaptations to the realities of life in the developing world will be crucial.
Bargain, Olivier, and Ulugbek Aminjonov (2020), “Poverty and COVID-19 in developing countries”, Bordeaux University.
Brown, Caitlin, Martin Ravallion and Dominique van de Walle (2020), “Can the world’s poor protect themselves from the new coronavirus?”, NBER Working Paper 27200.
Gentilini, Ugo, Mohamed Almenfi, Ian Orton and Pamela Dale (2020), “Social protection and jobs responses to COVID-19: A real-time review of country measures”, Version 8, World Bank, ILO and UNICEF, 8 May.
Ravallion, Martin (2020), “Pandemic policies in poor places”, Center for Global Development, Washington DC.
1 See, for example, https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public