The Intergenerational Mortality Trade-Off of Covid-19 Lockdown Policies in Low- and Middle-Income Countries

By Lin Ma, Assistant Professor of Economics, Singapore Management University, Gil Shapira, Economist, World Bank, Damien de Walque, Lead Economist in the Development Research Group, World Bank, Quy-Toan Do. Economist in the Development Research Group, World Bank, Jed Friedman, Lead Economist, Development Research Group, World Bank, and Andrei Levchenko, Professor of Economics, University of Michigan; CEPR Research Fellow. Originally published at VoxEU.

There has been ongoing debate over what type of lockdowns are warranted to counter Covid-19 and whether the benefits justify the accompanying economic contractions. This column uses a macro-susceptible-infected-recovered model to show that the impact of economic contractions on child mortality in poorer countries combined with their younger demographic composition, as well as the greater community-related transmission and lower healthcare capacity in these countries, mean that under certain circumstances, lockdowns could actually increase overall (COVID-19 plus non-COVID-19) mortality for the lowest-income countries.

At the start of the COVID-19 pandemic, governments across the world introduced unprecedented lockdown policies to contain disease transmission. Lockdown severity was remarkably similar across countries at different levels of development. On a scale of 0 to 100, the mean Oxford–Blavatnik lockdown stringency index in April 2020 was 79 in low-income countries, and 78 in high-income countries (Hale et al. 2021).

A debate soon erupted on what type of lockdowns were warranted and whether the benefits of such policies justified the accompanying dramatic economic contractions (Mobarak 2020). In a recent paper, we cast new light on this debate by focusing on an intergenerational mortality trade-off we argue is inherent in pandemic mitigation as the disease and the lockdown policies affect the mortality of younger and older people differently (Ma et al. 2021).

In the early days of the pandemic, evidence emerged that COVID-19 mortality risk increases substantially with age (Verity et al. 2020). On the other hand, previous research has shown that infant and child mortality in low- and middle-income countries is higher during economic contractions (Baird et al. 2007). Thus, in developing countries a lockdown would be expected to save the lives primarily of older adults, perhaps at the cost of higher child mortality due to severe reductions in aggregate economic activity (if shocks to household income were not compensated by other assistance).

To formalise and quantify this trade-off, our analysis relies on a macro-susceptible-infected-recovered disease transmission model that features agents whose behaviours vary by age group and a country-group-specific relationship between economic downturns and child mortality.

Low-income, middle-income, and high-income countries differ along several relevant dimensions:

  • First, economic contractions raise child mortality in poorer countries, but not in rich ones. We estimate that a percent decrease in per capita GDP can increase under-five mortality by up to 0.15 deaths per 1,000 children in low-income countries.
  • Second, the demographic composition of poorer countries features a larger ratio of young children to old people. Since survival rates of the former may be diminished by an economic downturn while the latter are most vulnerable to dying from COVID-19, a lockdown in lower-income countries could lead to more recession-induced deaths per COVID-19 fatality averted, other things equal.
  • Third, the preponderance of community-related transmission in low-income countries, as opposed to work or market-place transmission, might render government-mandated lockdowns comparatively less effective at reducing the spread of infections.
  • Finally, low healthcare capacity in poorer countries lowers the benefits from ‘flattening the curve’ with lockdowns as hospitals are quickly overwhelmed since the average number of hospital beds per capita in high-income countries is seven times higher than in low-income countries.

Our model is calibrated to data for 85 countries across all income levels. We then simulate economic and disease-related outcomes in two scenarios: one with no government intervention and one in which a uniform seven-week lockdown is implemented in all countries. The simulations suggest that, relative to the no-intervention scenario, the uniform lockdown could, under certain circumstances, lead to 1.76 children’s lives lost due to the economic contraction per COVID-19 fatality averted in low-income countries. That is, lockdowns could, under certain circumstances, actually increase the overall (COVID-19 plus non-COVID-19) mortality for the lowest-income countries.

The ratio stands at 0.59 and 0.06 in lower-middle-income and upper-middle-income countries, respectively. The specific lockdown used in the simulations was chosen to mimic policies adopted during the early months of the pandemic but is not designed to capture all the complexities of mobility and social gathering restrictions imposed by countries.

Rather, the simulations aim at highlighting the large heterogeneity in outcomes following a uniform policy. The fundamental mortality trade-off across the different ages would apply also to different types of lockdowns.

Our analysis relies on the epidemiological information that was available in March-April 2020 when the first lockdown decisions were taken. As such, it ignores the introduction of vaccines – unfortunately still not yet sufficiently available in low-income countries – as well as the emergence of newer likely more infectious variants (Davies et al. 2021), which confers a global public good quality to domestic mitigation policies.

Our paper highlights and quantifies a trade-off between human lives, namely children vs. adults. The results are consistent with work documenting falling living standards (Egger et al. 2021) and food insecurity (Drèze and Somanchi 2021) in developing countries in the past year as a partial consequence of lockdown policies.

It is important to stress that our analysis does not imply that lockdown policies should not be implemented in low-income countries. Rather, it highlights how the trade-offs differ for countries of different income levels. We find that lockdowns would still be needed, but those that would take the aforementioned trade-offs into account naturally tend to be shorter and milder in low-income countries.

Finally, to mitigate some of the worst potential outcomes, the negative impacts on child mortality and household poverty of lockdown policies necessary to protect older individuals could be attenuated or mitigated using targeted social assistance, such as cash transfers, towards poor households and families with young children and pregnant women.

References available at the original.

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About Lambert Strether

Readers, I have had a correspondent characterize my views as realistic cynical. Let me briefly explain them. I believe in universal programs that provide concrete material benefits, especially to the working class. Medicare for All is the prime example, but tuition-free college and a Post Office Bank also fall under this heading. So do a Jobs Guarantee and a Debt Jubilee. Clearly, neither liberal Democrats nor conservative Republicans can deliver on such programs, because the two are different flavors of neoliberalism (“Because markets”). I don’t much care about the “ism” that delivers the benefits, although whichever one does have to put common humanity first, as opposed to markets. Could be a second FDR saving capitalism, democratic socialism leashing and collaring it, or communism razing it. I don’t much care, as long as the benefits are delivered. To me, the key issue — and this is why Medicare for All is always first with me — is the tens of thousands of excess “deaths from despair,” as described by the Case-Deaton study, and other recent studies. That enormous body count makes Medicare for All, at the very least, a moral and strategic imperative. And that level of suffering and organic damage makes the concerns of identity politics — even the worthy fight to help the refugees Bush, Obama, and Clinton’s wars created — bright shiny objects by comparison. Hence my frustration with the news flow — currently in my view the swirling intersection of two, separate Shock Doctrine campaigns, one by the Administration, and the other by out-of-power liberals and their allies in the State and in the press — a news flow that constantly forces me to focus on matters that I regard as of secondary importance to the excess deaths. What kind of political economy is it that halts or even reverses the increases in life expectancy that civilized societies have achieved? I am also very hopeful that the continuing destruction of both party establishments will open the space for voices supporting programs similar to those I have listed; let’s call such voices “the left.” Volatility creates opportunity, especially if the Democrat establishment, which puts markets first and opposes all such programs, isn’t allowed to get back into the saddle. Eyes on the prize! I love the tactical level, and secretly love even the horse race, since I’ve been blogging about it daily for fourteen years, but everything I write has this perspective at the back of it.


  1. PlutoniumKun

    One item that doesn’t seem to be covered in this assessment is the impact on extended families of a Covid outbreak within an extended family. A Filipino man I know here told me his mother died from Covid, but the entire extended family are now in dire straits as they had to isolate in their home and several of the adults are very sick so there are no breadwinners left. They are essentially living on money sent by relatives from abroad. Its pretty disastrous for all the generations, from the youngest to the oldest.

  2. HotFlash

    World Bank and CEPR economists find that under certain circumstances, lockdowns could actually increase overall (COVID-19 plus non-COVID-19) mortality for the lowest-income countries.

    Well they would. Sigh. The potato blight of the 1840s hit much of Europe, but was only a famine in Ireland due to the (English) govt’s response, which was to permit the mostly English landlords to continue to export the produce of their Irish estates. Well, maybe a famine in Poland, too, and for similar reasons. That the World Bank would conclude that working the peasantry to death of either disease, exhaustion, or starvation is preferable to reducing profits of global corps one teensy bit is not a shocker. Peasants are cheap, but profits are priceless.

  3. Brian Beijer

    It’s interesting that the authors seem to ignore the most obvious factors impacting infection outcomes in poorer countries. The fact that Covid is an airborne virus and that many poorer families live together in larger numbers within smaller spaces which are often poorly ventilated. In some circumstances a person might have better odds of surviving Covid if the work environment is larger and/ or has better ventilation than the home environment. Plus, removing members of larger families from the home would provide greater possibily for more space for the remaining members. These factors are universal regardless of the GDP of any given country. It’s like they’re trying to use theoretical physics to open a can of Coke. This isn’t rocket science. Or, am I missing some other motivation the authors had in writing this article?

    1. EquitableEqual

      It’s the world bank. You can see the motivations in the last paragraph, where they somehow conclude that lockdowns were still the right thing to do despite their identifying increased child mortality as a result in the previous paragraphs.

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