Poverty, precarious work, and the COVID-19 pandemic: lessons from Bolivia

Bolivia is one of the poorest countries in Latin America with a gross domestic product of around US$3500 per capita, health spending of approximately $220 per capita, a labour market dominated by informal work, and a weak health system. However, in the response to COVID-19, Bolivia has fared better than other health systems in the region and provides insight with regard to the implementation of subnational non-pharmaceutical interventions and supporting workers without social protection. The Bolivian Government confirmed the first case of COVID-19 in the country on March 10, 2020, and responded quickly by cancelling events, closing schools and borders, and implementing a national lockdown on March 22, 2020. However, the Bolivian Government was under pressure to open the economy in an election season. In response, the Bolivian Government shifted responsibility for most non-pharmaceutical interventions to departmental and municipal governments on June 1, 2020. The Bolivian Government maintained a mask mandate, school and border closures, and a nightly curfew, while allowing departmental and municipal governments to set workplace, social gathering, population mobility, and public transit policies. Daily deaths from COVID-19 increased markedly from 20 on June 1, 2020, to 96 on Aug 1, 2020.1Institute for Health Metrics and EvaluationCOVID-19 projections. Daily deaths, Bolivia.https://covid19.healthdata.org/bolivia-(plurinational-state-of)?view=total-deaths&tab=trendDate: Nov 19, 2020Date accessed: November 29, 2020Google Scholar Subnationally, the first outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred in the wealthy, politically conservative department of Santa Cruz, followed by the poor, politically moderate department of Beni in May, 2020. These two departments maintained strict confinement policies in June, 2020, to manage outbreaks. Strict policies were also maintained in the wealthy, politically conservative department of Tarija, while the other six departments relaxed restrictions quickly in June, 2020, and subsequently a surge in cases was observed. In response to an increase in deaths in June and July, 2020, Chuquisaca and Cochabamba reinstated some restrictions and the other departments shifted to a policy of isolating municipalities with outbreaks. Daily deaths began to decline in August, 2020, decreasing to 35 per day by Sept 15, 2020.1Institute for Health Metrics and EvaluationCOVID-19 projections. Daily deaths, Bolivia.https://covid19.healthdata.org/bolivia-(plurinational-state-of)?view=total-deaths&tab=trendDate: Nov 19, 2020Date accessed: November 29, 2020Google Scholar The Bolivian Government announced a post-confinement phase on Sept 1, 2020, and subsequently all departments began to relax containment strategies. A national mask mandate, nightly curfew, school closure, event ban, and border closure were maintained while allowing most workplaces and transportation to open with restricted hours and distancing protocols. Departments differed with regard to opening hours of businesses, the level of intermunicipal transportation, the size of gatherings, and local enforcement. The relaxation of restrictions in some departments coincided with the nationwide surge in COVID-19 deaths in June and July, 2020. However, deaths declined in September and October, 2020, despite the post-confinement relaxation. Informality, inequity, and overlapping health disparities and pre-existing conditions of specific groups are systemic and persistent issues that amplified the impact of the pandemic and explain outcomes observed across the country. In the poorest departments, deaths in July, 2020, were more than seven times higher than that in July, 2019.2Órgano Electoral Plurinacional de Bolivia¿Cuántos decesos, nacimientos y matrimonios se registraron hasta agosto de 2020?.https://fuentedirecta.oep.org.bo/noticia/cuantos-decesos-nacimientos-y-matrimonios-se-registraron-hasta-agosto-de-2020/Date: Sept 6, 2020Date accessed: November 25, 2020Google Scholar In comparison, the peak of deaths in the wealthiest departments were only two times higher than that in the same period in 2019. More than 70% of working Bolivians do not have employment contracts or employer-based social security3Baker A Berens S Feierherd G González IM Informalidad laboral y sus consecuencias políticas en América Latina: Perspectivas #144.https://www.vanderbilt.edu/lapop/insights/IO944es.pdfDate: July 21, 2020Date accessed: November 29, 2020Google Scholar making strict containment especially difficult to achieve. National and departmental containment laws designated market, transportation, and agricultural labourers as essential workers,4Chávez JA Decreto Supremo 4179. Gaceto Oficial de Bolivia.http://www.gacetaoficialdebolivia.gob.bo/normas/buscar/4179Date: March 12, 2020Date accessed: November 29, 2020Google Scholar despite informal, open-air, street markets being identified as sites of contagion. Employment in these sectors continued amid a shortage of personal protective equipment (PPE) and testing. Departmental and municipal governments implemented mask and glove mandates, but these low-income workers were expected to source and purchase their own PPE and tests. COVID-19 cases were concentrated in these informal workplaces. In Cochabamba, market and transportation workers and their families account for 40–50% of confirmed COVID-19 cases despite low levels of testing among these groups.5Yujra ARC Serie “Reflexiones sobre la pandemia en Bolivia” IISEC-UCB N. 6 impactos del Covid-19 en la economía informal.http://www.iisec.ucb.edu.bo/publicacion/serie-reflexiones-sobre-la-pandemia-en-bolivia-iisec-ucb-n-6-impactos-del-covid-19-en-la-economia-informalDate accessed: January 14, 2020Google Scholar The national government expanded benefits for existing cash transfer programmes in late March, 2020, and extended income transfers to previously unprotected workers.6Blofield M Filgueira F COVID-19 and Latin America: social impact, policies and a fiscal case for an emergency social protection floor.https://www.cippec.org/wp-content/uploads/2020/04/Blofield-Filgueira-2020-1.pdfDate: April 5, 2020Date accessed: November 29, 2020Google Scholar Although such programmes represent a welcome anti-poverty policy, electronic distribution was impossible, benefits were collected in-person, and crowds formed at the distribution sites. The absence of strict social distancing protocols further increased health risk. Bolivia highlights the importance of labour market structures for understanding the spread of SARS-CoV-2 (panel). Non-salaried, unprotected workers and their families have been disproportionately affected by the COVID-19 pandemic. These groups are vulnerable for multiple reasons: their work requires close contact with the public and each other without PPE; their living spaces are overcrowded without access to clean water; and most workers do not have health and unemployment insurance.6Blofield M Filgueira F COVID-19 and Latin America: social impact, policies and a fiscal case for an emergency social protection floor.https://www.cippec.org/wp-content/uploads/2020/04/Blofield-Filgueira-2020-1.pdfDate: April 5, 2020Date accessed: November 29, 2020Google ScholarPanelLessons from BoliviaThe approaches used in Bolivia to deal with the COVID-19 pandemic are instructive for several reasons, and can be applied to many countries around the world, especially low-income countries.A high proportion of the Bolivian population are affected by unequal, precarious working conditions and poverty, which creates multiple, overlapping vulnerabilities and systemic issues that exacerbate the impact of the pandemic and complicate public policy responses. Similar to many other low-income and middle-income countries, these overlapping issues require a syndemic approach.In Bolivia, non-pharmaceutical interventions were combined with income supports targeted at workers at risk of impoverishment, but the safe delivery of such interventions was challenging. Although income support is a crucial part of pandemic relief, their delivery must be carefully orchestrated and organised in ways that do not further endanger health–eg, through electronic delivery of funds that do not require beneficiaries to be present in-person.Policy making at the subnational level has been a crucial aspect of the pandemic response in Bolivia and many other countries around the world. Ideally, local ministries of health should operate under the umbrella of effective national stewardship of public health policy to ensure a robust response to COVID-19. Where national responses are slow or inadequate, local governments must act quickly in the absence of federal support to implement or maintain non-pharmaceutical intervention where they have jurisdiction.Bolivia has a long history of delivering public services in cooperation with workers' unions and other civil society groups, yet the Bolivian Government has not engaged these groups to reach vulnerable populations during the COVID-19 pandemic. Governments should apply a multisectoral, interinstitutional approach that harnesses all available formal and informal networks and non-governmental actors to protect their citizens and combat the COVID-19 pandemic. The approaches used in Bolivia to deal with the COVID-19 pandemic are instructive for several reasons, and can be applied to many countries around the world, especially low-income countries. A high proportion of the Bolivian population are affected by unequal, precarious working conditions and poverty, which creates multiple, overlapping vulnerabilities and systemic issues that exacerbate the impact of the pandemic and complicate public policy responses. Similar to many other low-income and middle-income countries, these overlapping issues require a syndemic approach. In Bolivia, non-pharmaceutical interventions were combined with income supports targeted at workers at risk of impoverishment, but the safe delivery of such interventions was challenging. Although income support is a crucial part of pandemic relief, their delivery must be carefully orchestrated and organised in ways that do not further endanger health–eg, through electronic delivery of funds that do not require beneficiaries to be present in-person. Policy making at the subnational level has been a crucial aspect of the pandemic response in Bolivia and many other countries around the world. Ideally, local ministries of health should operate under the umbrella of effective national stewardship of public health policy to ensure a robust response to COVID-19. Where national responses are slow or inadequate, local governments must act quickly in the absence of federal support to implement or maintain non-pharmaceutical intervention where they have jurisdiction. Bolivia has a long history of delivering public services in cooperation with workers' unions and other civil society groups, yet the Bolivian Government has not engaged these groups to reach vulnerable populations during the COVID-19 pandemic. Governments should apply a multisectoral, interinstitutional approach that harnesses all available formal and informal networks and non-governmental actors to protect their citizens and combat the COVID-19 pandemic. Informal workers' organisations could be a crucial route for the government to respond to workers' short-term needs while addressing larger systemic issues.7Hummel C Disobedient markets: street vendors, enforcement, and state intervention in collective action.Comp Polit Stud. 2017; (published online Jan 16.)https://doi.org/10.1177/0010414016679177Crossref Scopus (47) Google Scholar Bolivia has previously used these groups for health policy enforcement, advocacy for workers' needs, and distribution of PPE. However, to date, Bolivia has missed an important opportunity to partner with workers' unions and civil society organisations to deliver health services, implement non-pharmaceutical interventions, and reach vulnerable populations. Bolivia, despite being a relatively small country with a population of around 11 million, mirrors the dynamics of COVID-19 in larger countries including Mexico, Brazil, Canada, and the USA: variation in subnational non-pharmaceutical intervention is key to understanding a country's response to the pandemic.8University of MiamiCOVID-19 observatory: observatory for the containment of COVID-19 in the Americas.http://observcovid.miami.edu/Date accessed: November 25, 2020Google Scholar, 9McCoy LG Smith J Anchuri K et al.Characterizing early Canadian federal, provincial, territorial and municipal nonpharmaceutical interventions in response to COVID-19: a descriptive analysis.CMAJ Open. 2020; 8: E545-E553Crossref PubMed Scopus (31) Google Scholar Understanding such variation might also provide essential insight with regard to the evolution of COVID-19 since subnational non-pharmaceutical intervention might be both a cause of, and a reaction to, deaths from COVID-19. Similar to Bolivia, many low-income and middle-income countries face the combined, structural challenges of poverty, inequity, and precarious work that require a syndemic approach.10Horton R Offline: COVID-19 is not a pandemic.Lancet. 2020; 396: 874Summary Full Text Full Text PDF PubMed Scopus (601) Google Scholar Governments struggle to provide employment-based crisis relief and enforce health policy when most people work informally. This has been a challenge throughout Latin America to which few countries have responded with effective income supports, non-pharmaceutical intervention implementation, or strategies for re-opening. Subnational policy making, combined with effective national testing and vaccination strategies, will be key to outbreak management, safe re-opening of the economy, and relief from pandemic-induced poverty. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on February 5, 2021 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on February 5, 2021 We declare no competing interests. Correction to Lancet Glob Health 2021; published online Jan 25. https://doi.org/10.1016/S2214-109X(21)00001-2Hummel C, Knaul FM, Touchton M, et al. Poverty, precarious work, and the COVID-19 pandemic: lessons from Bolivia. Lancet Glob Health 2021; published online Jan 25. https://doi.org/10.1016/S2214-109X(21)00001-2—In this Comment, the third sentence of the third paragraph should read “Strict policies were also maintained in the wealthy, politically conservative department of Tarija, while the other six departments relaxed restrictions quickly in June, 2020, and subsequently a surge in cases was observed”. Full-Text PDF Open Access

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