The Differential Outcomes of Coronavirus Disease 2019 in Low- and Middle-Income Countries vs High-Income Countries | Global Health | JAMA Psychiatry | JAMA Network
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COVID-19: Beyond Tomorrow
June 11, 2020

The Differential Outcomes of Coronavirus Disease 2019 in Low- and Middle-Income Countries vs High-Income Countries

Author Affiliations
  • 1Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
  • 2Instituto Superior de Formación de Postgrado, Asociación de Psiquiatras Argentinos, Buenos Aires, Argentina
  • 3Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
  • 4World Health Organization Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, Department of Psychiatry, University of Ibadan, Nigeria
JAMA Psychiatry. 2020;77(12):1207-1208. doi:10.1001/jamapsychiatry.2020.2174

A Perfect Storm

Coronavirus disease 2019 (COVID-19) has affected high-income countries (HICs) first and, to date, foremost: Asia to begin with, then Europe and North America. Industrialized countries have driven the 5.3 million confirmed cases of COVID-19 worldwide and 350 000 global deaths to date.1 Most low- and middle-income countries (LMICs) may seem to have been spared; for example, 80 000 confirmed cases and 2000 deaths in the whole of Africa may spur relative optimism.1 Many LMICs have implemented some version of the lockdowns adopted by HICs, and some have sought to mitigate the economic paralysis by distributing food, cash, tax benefits, and loans. Compared with HICs, lockdowns in many LMICs appear to have been implemented earlier and more forcefully, while the aid seems woefully insufficient.2 This has led to an impression of successful viral control followed by economic catastrophe. Most of the labor force in LMICs (53% in Latin America, 68% in Asia-Pacific, and 86% in Africa) is informal.3 People can go hungry within a day if they cannot work. Governments lack resources for palliation, and even if they create them by printing money or acquiring debt, they lack effective disbursement and control mechanisms. In settings where most adults with low incomes may not own bank or mobile banking accounts, people may be left out and funds diverted.

Optimism about viral control in LMICs is misplaced and deleterious. Several factors may explain the current picture: younger populations (eg, a median age in Africa of 19 years, vs 31 years globally) lead to lower severity and lethality4; less travel, warmer weather, greater humidity, and/or more direct sunlight may affect virus dissemination; and other pervasive infections may provide a different immunologic profile. This fleeting illusion of control coupled with economic catastrophe is leading governments to lift restrictions haphazardly or avoid them altogether, as is the case with Brazil. This leads to a perfect storm: in some LMICs, a first wave with few severe cases and deaths; heavy-handed measures causing financial pain and public discontent; and reasonable restrictions lifted or forgone. Brazil has emerged as the next global epicenter, highlighting the catastrophic consequences of policy paralysis. Containment measures elsewhere are breaking down because of their socioeconomic effects, paving the way for a second wave hitting impoverished and restless communities during cooler seasons. Further, after HICs outbid each other to stockpile resources, LMICs will have a lack of access to testing, personal protective equipment, ventilators, and/or forthcoming vaccines.5

Mental Health in LMICs

Coronavirus disease 2019 and its economic consequences will profoundly affect the mental health of the community, essential workers, people with preexisting mental disorders, and people with the infection.6 In LMICs, the focus needs to be on mitigating the mental health consequences of the unemployment, poverty, food insecurity, and social disruption caused by economic lockdowns. The treatment gap for mental disorders, which already leads to only 2 in 100 people in need in LMICs receiving minimally adequate care for severe depression,7 will increase. Attempts to bridge this gap have focused on shifting tasks from specialists to lay health workers, who will now be unable to deliver services. While services were transitioned to online platforms in HICs, this will not be feasible in LMICs. Hospitals, health care centers, and clinicians do not routinely use online tools; computers and smartphones are less available, with connectivity tariffs still a limiting factor. Real-time training, supervision, or intervention will rarely be possible, and referrals will be disrupted. Group supports will be discontinued, terminating the only opportunity many people have to maintain tangible human connections. Physical distancing will affect the informal networks that patients rely on where formal services are lacking, shutting down their only source of emotional and material assistance.

People with severe illness face double jeopardy. They are usually without employment or government support, and now their caregivers will be without income. With inpatient care disrupted, those who are unable to afford medications, without specialist or community-based care, and in households with relatives without employment risk becoming homeless or in chains (eg, in sheds or putative healing centers). A large proportion are in the care of traditional healers who may disavow the medical origin of COVID-19, and people in their care may therefore remain undiagnosed and continue to disseminate infection.8

Finally, the situation in precarious settlements where physical distancing is impossible will become exceedingly stressful and trigger onset or relapse of common and severe mental disorders. Anxiety, depression, and harmful behaviors toward oneself and others (including domestic abuse) may increase because of the stress of isolation, sudden unemployment, and increased poverty. People with severe disorders will see their formal care and informal networks disrupted by physical distancing. In this context, the key mental health intervention is doubling down on the training of community members to provide psychosocial supports and human connection, which should now be combined with the ability to clinically screen for COVID-19 symptoms, trace contacts, and provide instructions to prevent dissemination.

We know that there is no health without mental health. We now highlight that there is no mental health without survival, and the lives of large swaths of the population in LMICs are at stake. Mental health mitigation strategies are fundamental, but general health and economic measures to keep people alive and out of poverty, particularly those with heightened vulnerability because of severe mental illness, may be the most urgent.

Locally Grounded, Evidence-Based Public Policy Supported by Global Solidarity

Coronavirus disease 2019 grew to pandemic proportions because of the lack of preparedness in global health systems. The responsibility to mitigate suffering needs to be shared by all countries. As HICs rush to build testing capacity, develop treatments and vaccines, and deploy massive economic aid for their populations, it is imperative that they share resources with LMICs. High-income countries need to provide financing mechanisms so that LMICs can develop locally grounded, evidence-based policies. The early problems of the Ebolavirus disease response illustrate the foreseeable frictions and unintended consequences of hasty policy transplants. Sound local policy requires both public health and economic measures: building a community-based workforce to diagnose cases and trace contacts but also provide human connection and psychosocial support; implementing physical distancing when feasible and alternative measures when not; distributing personal protective equipment, treatments, and eventually vaccines; and mitigating the economic effects of the pandemic while reinforcing care and livelihood for those who are most vulnerable. The window of opportunity for testing and contact tracing is closing rapidly as the virus takes root in communities where rational containment measures were absent or break down. For LMICs to develop long-term policies to manage infection rates, restriction levels, and economic activity, they will need substantial resources from HICs and multilateral organizations. These include suspending the burden of debt services, mobilizing global solidarity to keep populations out of misery, and sharing the vital medical public goods required to mitigate the health effects of COVID-19. As Ebola outbreaks have also shown, this could be an opportunity to build back better and strategically strengthen health systems.9 The rationale for HICs to support these measures may be altruistic but is mainly pragmatic. It is altruistic in that, at a critical juncture where we are all forcefully connected by the pandemic, the global community needs to acknowledge that life-saving resources should be allocated in proportion to need. It is pragmatic because the alternative situation, in which industrialized nations gradually recover while the developing world lacks resources and becomes a reservoir in which the virus festers, is untenable.

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Article Information

Corresponding Author: Daniel Vigo, MD, Lic Psych, DrPH, Department of Psychiatry, University of British Columbia, 2255 Wesbrook Mall, Vancouver, BC V6T2B8, Canada (

Published Online: June 11, 2020. doi:10.1001/jamapsychiatry.2020.2174

Conflict of Interest Disclosures: Dr Thornicroft is supported by the National Institute for Health Research Applied Research Collaboration South London at King’s College London National Health Service Foundation Trust, the National Institute for Health Research Asset Global Health Unit award, the National Institute of Mental Health of the National Institutes of Health (grant R01MH100470), and the UK Medical Research Council in relation to the Emilia (grant MR/S001255/1) and Indigo Partnership (grant MR/R023697/1) awards.

Disclaimer: The views expressed are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research, or the Department of Health and Social Care.

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    1 Comment for this article
    A very patronising view
    Raghunadharao Digumarti, MBBS MD DM FRCO | KIMS ICON Hospital, Visakhapatnam
    A very typical response from a so called high income group country: only 'we' have the means and tools to take care of the mental health of the 'poorer' nations! It is incorrect to surmise that 'poor' people lack coping skills to handle personal and societal disasters. On the other hand, too much emphasis is given to the so called 'tools' and access to 'online' systems to assess distress. There is overemphasis on intervention by a psychiatrist in the so called high income groups. No proof exists that help one surmise that people with better 'psychiatrist with laptops' to people ratio to prove such communities are mentally healthier or more resilient. It is simply a article exploiting a socio-economic divide.