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Commentary—COVID-19 Challenges in Developing Countries

7/8/2020 Matthew E Levison, MD, Adjunct Professor of Medicine, Drexel University College of Medicine

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The novel coronavirus disease 2019 (COVID-19) pandemic first struck the world's wealthiest countries, likely as a result of their global interconnectedness, involving trade and tourism. It spread from China in early 2020 to the west coast of the US and from China to Europe and then the east coast of the US. These wealthy countries shaped the global public health responses aimed at reducing person-to-person viral transmission via respiratory excretions, which involve

  • Physical distancing
  • Use of face masks
  • Hand washing
  • Stay-at-home / work-at-home (where possible)
  • Isolation of infected individuals and quarantining their contacts
  • School closures
  • Economic lockdowns that involve non-essential business closures


These public health interventions have proven effective in wealthier countries in reducing viral transmission and preventing healthcare systems from being completely overwhelmed by a surge of COVID-19 cases.

However, such solutions would often be difficult to implement in developing countries. In developing countries, people often live in crowded, multigenerational households. They may not have ready access to food refrigeration in the home, requiring daily food shopping. They often lack ready access to running water for hand washing, lack adequate sanitation, have poor or no internet connection for home schooling or work at home, and little or no savings to back up a loss of income (1). Even basic supplies that are taken for granted in developed countries, like soap, are likely subject to shortages. In some wealthy large cities in developing countries, millions of poor people live in shanty towns, where local conditions make following preventive measures designed for developed countries challenging.  Examples include favelas in Rio de Janeiro and Sao Paulo in Brazil (2) or the townships of Cape Town and Johannesburg (3).

In addition, many of the healthcare and public health systems in developing countries are compromised by lack of equipment required to care for COVID-19 patients, such as personal protective equipment, bedside oxygen supply, pulse oximeters, ventilators, ICU beds, and insufficient infection control training of healthcare workers. For example, fewer than 2,000 working ventilators are available to serve hundreds of millions of people in public hospitals across 41 African countries (4). There are also chronic shortages of more basic supplies.  These challenges are exacerbated by the prevalence of tropical parasitic diseases, malaria, HIV/AIDS, tuberculosis, and cholera in these countries. Data from South Africa’s Western Cape province indicate that people living with HIV or tuberculosis have more than 2-fold increased risk of death from COVID-19 (5).

Similar conditions exist in poor and marginalized communities within developed countries. These communities too have significantly less capacity to absorb the shocks from the pandemic; examples of such communities include

  • Communities in the US with predominantly Latino populations where the prevalence of COVID-19 is 30 to 40%, such as the city of Chelsea in Massachusetts (6)
  • The Navajo reservations in New Mexico, where the COVID-19 incidence rate surpasses that of New York State (7)
  • The over 300,000 unskilled migrant workers in Singapore who live in packed dormitories that house up to 20 people per room and account for more than 90% of all the COVID-19 cases in Singapore (8)
  • Refugees, migrants and the homeless living in encampments on the outskirts or even the centers of cities like Los Angeles, Seattle, New York City, Oakland, Paris, and London

For all people living under these conditions, physical distancing is difficult to impossible.

In Africa, with 1.3 billion people (about 16% of the world's population), the COVID-19 pandemic was reported to have first arrived in Egypt on 14 February 2020, involving a Chinese national. The first confirmed case in sub-Saharan Africa was reported to have been in Nigeria on 27 February 2020, involving an Italian citizen. By 26 May 2020, more than half of all African countries were experiencing community transmission of COVID-19. The last African state to report a case of COVID-19 was Lesotho on 13 May 2020. Since the first COVID-19 case in Africa in mid-February, the pace of the outbreak has rapidly accelerated, taking 98 days to reach the first 100,000 cases and only 18 days to rise to 200,000 cases.

As of 20 June 2020, Africa reported 3.4% of the about 8.5 million total confirmed cases and 7.2% of the about 140,000 newly reported cases that day (9). However, only three African countries make up about 55% of Africa’s total confirmed cases: South Africa, Egypt, and Nigeria. These three have relatively well-developed health systems, suggesting there may be widespread under-reporting in many of the other African countries with less developed public health systems. South Africa, Egypt, and Nigeria are usually 1st, 2nd, and 3rd in terms of the 24-hour increase in cases. The case counts in these three countries have been steadily increasing, doubling about every 2 weeks. 

Taking South Africa as an example of difficulties to be overcome in developing countries, it is noted that about 80% of South Africa’s more than 58 million people, are of Black African ancestry and most black adults still live in apartheid-era townships (10). The townships are crowded. People live in small makeshift houses, built out of boards and corrugated metal sheets, less than one meter (3 feet) apart from each other, often with communal toilets and communal water taps, each used by 30 or 40 people a day (11). These factors make it very difficult for residents of the townships to comply with social distancing requirements. Furthermore, many township dwellers have essential jobs outside of the townships, particularly in the city's hospitals and food supply, and often need to travel long distances every day on public transportation to get to work (12, 13).

The initial COVID-19 cases in South Africa involved people who were wealthy enough to have recently traveled abroad. The first known COVID-19 patient in South Africa was a man who tested positive upon his return from Italy on 5 March 2020. By 11 March, 6 new cases were reported, with 1 case from the same travel group from Italy and 5 others who had traveled to other European countries. On 15 March, the first local transmissions were reported. The number of cases rose to 150 on March 19 and then skyrocketed to 554 in merely five days. Within a month of the 1st case, there were 1500 cases; the number then doubled about every 10 to 14 days, reaching a total count of about over 92,000 on 21 June 2020. 

 From the official surveillance reports, it is difficult to tell how hard the townships have been hit by COVID-19. The national South African institute for Communicable Diseases website breaks down case counts only by age, sex, and province (14). As of 22 June 2020, the Western Cape province (the location of Cape Town, the country’s 2nd most populated city) is the epicenter of the South African COVID-19 outbreak, with about 53% of the national cumulative cases, followed by Gauteng (the location of Johannesburg, the country's most populated city, and Pretoria, its administrative capital) at 21%. 

The Western Cape provincial government website breaks down case counts by districts and by the eight health subdistricts within the city of Cape Town, namely Eastern, Western, Northern, Southern, Khayelitsha, Klipfontein, Tygerberg, and Mitchells Plain (15);  the province’s hot spot is the city of Cape Town, with now 78% of the province’s cases. One third of Cape Town’s population of 3.7 million lives in townships (16) ), which news reports say are the COVID-19 hot spots within the city (Khayelitsha, Klipfontein, Du Noon in Western, Hout Bay in Southern, and Mitchells Plain), as are the “working class” areas of Tygerberg (17, 18).

South African officials acted quickly to contain COVID-19’s spread. At the end of March, the country entered into one of the strictest lockdown regimens in the world. People, many from the townships, were allowed to leave their homes during this period only to work in “essential services,” access health care, collect social grants, attend small funerals (no more than 50 people), and shop for essential goods. Easing restrictions started 1 May 2020, at a time when South Africa was reporting fewer than 500 new cases daily; but, by the beginning of June, about 1000 to 2000+ new cases were being reported daily. Nevertheless, because of a deteriorating economy, the government opted to further ease the lockdown despite the rapidly rising case counts.

Almost 1 billion people, or 32 percent of the world’s urban population, live in “informal settlements” under crowded and unhygienic conditions (eg, the South African townships), the majority of them in the developing world (19). Interventions to prevent the spread of COVID-19, like physical distancing, that have worked well in resource-rich settings are impractical in these circumstances either in South Africa (1), /), in other resource-limited countries, or even in certain parts of some wealthy cities in developed countries. Rapidly correcting the crowded conditions in these areas will be difficult, but Singapore is immediately reducing the population density of the current accommodations for their migrant workforce and rethinking their future housing (20). The South African government is said to be planning to “de-densify” the overcrowded “informal settlements” (21). When possible, changing the living conditions in “informal settlements” such as the townships, favelas, and homeless encampments needs to be carried out in partnership with community organizations in those areas so that any measures taken are more likely to be effective. 

In addition, stay-at-home policies during the COVID-19 pandemic have imperiled the lives of many people dependent on each day’s income to feed their family. Because the negative economic effects of the lockdowns have major effects on socioeconomically disadvantaged communities, important components of pandemic response planning include food rations and monetary support (11).



  1. Gibson L, Rush D: Novel coronavirus in Cape Town informal settlements: Feasibility of using informal dwelling outlines to identify high risk areas for COVID-19 transmission from a social distancing perspective. JMIR Public Health Surveill 6(2):e18844, 2020. doi: 10.2196/18844
  2. Briso CB, Phillips T: Rio’s favelas count the cost as deadly spread of Covid-19 hits city’s poor. The Guardian Apr 25, 2020. Accessed July 1, 2020. https://www.theguardian.com/world/2020/apr/25/rio-favelas-coronavirus-brazil
  3. Harvie A: Covid-19 pandemic: In a nation of extreme inequality, South Africa’s poorest are most at risk. Atlantic Council’s Africa source blog. March 24, 2020. Accessed July 1, 2020. https://www.atlanticcouncil.org/blogs/africasource/covid-19-pandemic-in-a-nation-of-extreme-inequality-south-africas-poorest-are-most-at-risk/
  4. Maclean R, Marks S: 10 African countries have no ventilators: That is only part of the problem. New York Times Apr 18, 2020. Updated May 17, 2020. Accessed July 1, 2020. https://www.nytimes.com/2020/04/18/world/africa/africa-coronavirus-ventilators.html
  5. Jerving S: South Africa data shows higher Covid-19 death rates for people with HIV, TB. Devex June 10, 2020. Accessed July 1, 2020. https://www.devex.com/news/south-africa-data-shows-higher-covid-19-death-rates-for-people-with-hiv-tb-97447
  6. Saltzman J: Nearly a third of 200 blood samples taken in Chelsea Show exposure to coronavirus. Boston Globe Apr 17, 2020. Accessed July 6, 2020. https://www.bostonglobe.com/2020/04/17/business/nearly-third-200-blood-samples-taken-chelsea-show-exposure-coronavirus/
  7. Silverman H, Toropin K, Sidner S, Perrot L: Navajo Nation surpasses New York state for the highest Covid-19 infection rate in the US. CNN.com May 18, 2020. Accessed July 6, 2020. https://www.cnn.com/2020/05/18/us/navajo-nation-infection-rate-trnd/index.html
  8. Ministry of Health Singapore: Updates on Covid-19 (coronavirus disease 2019) local situation. June 23, 2020. Accessed July 6, 2020. https://www.moh.gov.sg/docs/librariesprovider5/local-situation-report/situation-report---23-june-2020.pdf
  9. World Health Organization: Coronavirus disease (COVID-19)---situation report 150. June 18, 2020. Accessed July 6, 2020. https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200618-covid-19-sitrep-150.pdf
  10. World Elections: Race, Ethnicity, and Language in South Africa. Guide to the 2014 South African Election. Accessed July 6, 2020. https://welections.wordpress.com/guide-to-the-2014-south-african-election/race-ethnicity-and-language-in-south-africa/
  11. Maringira G: Covid-19: Social distancing and lockdown in Black townships in South Africa. Social Science Research Council’s Kujenga Amani blog May 7, 2020. Accessed July 6, 2020. https://kujenga-amani.ssrc.org/2020/05/07/covid-19-social-distancing-and-lockdown-in-black-townships-in-south-africa/
  12. Trenchard T: Photos: Lockdown in the world’s most unequal country. NPR Goats and Soda. Apr 21, 2020. Accessed July 6, 2020. https://www.npr.org/sections/goatsandsoda/2020/04/21/837437715/photos-lockdown-in-the-worlds-most-unequal-country
  13. Findley L and Ogbu L: South Africa: From Township to Town. Places Journal November 2011. Accessed July 6, 2020. https://placesjournal.org/article/south-africa-from-township-to-town/?cn-reloaded=1
  14. National Institute for Communicable Diseases: Covid-19 surveillance reports. National Public Health Institute of South Africa. June 22, 2020. Accessed July 6, 2020. https://www.nicd.ac.za/diseases-a-z-index/covid-19/surveillance-reports/
  15. Winde A: Update on the coronavirus by Premier Alan Winde-22 June. Western Cape Government. Accessed July 6, 2020. https://coronavirus.westerncape.gov.za/news/update-coronavirus-premier-alan-winde-22-june
  16. Milne N: The tale of two slums in South Africa as residents seek to upgrade their lives. Reuters Dec 14, 2016. Accessed July 6, 2020. https://www.reuters.com/article/us-safrica-slums-upgrading/the-tale-of-two-slums-in-south-africa-as-residents-seek-to-upgrade-lives-idUSKBN1431PO
  17. Wroughton L and Bearak M: Why Cape Town has 10 percent of Africa’s confirmed coronavirus cases. The Washington Post May 19, 2020. Accessed July 6, 2020. https://www.washingtonpost.com/world/africa/south-africa-coronavirus-cape-town-superspreader/2020/05/18/4d332248-9566-11ea-87a3-22d324235636_story.html
  18. News24: This is where Cape Town’s Covid-19 “hot spots” are. Big News Network. May 22, 2020. Accessed July 6, 2020. https://www.bignewsnetwork.com/news/265169996/pics--this-is-where-cape-towns-covid-19-hotspots-are
  19. United Nations Human Settlements Programme: The Challenge of Slums: Global Resort on Human Settlements 2003. London and Sterling, VA, Earthscan Publications, 2003. https://www.un.org/ruleoflaw/files/Challenge%20of%20Slums.pdf
  20. GCR Staff: Singapore to overhaul worker dormitories to prevent future virus outbreaks. Global Construction Review June 3, 2020. https://www.globalconstructionreview.com/news/singapore-overhaul-worker-dormitories-prevent-futu/
  21. Staff Writer: Coronavirus: SA “planning” to relocate crowded townships. Tech Financials Apr 5, 2020. https://techfinancials.co.za/2020/04/05/coronavirus-sa-planning-to-relocate-crowded-townships/

COVID-19 Resources Home Page

Matthew Levison, MD

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The activity of drug-metabolizing enzymes often varies widely among healthy people, making metabolism highly variable. Which of the following factors is a major contributor to this variation?