The COVID-AM blog is a partnership between the UMI 3157 iGLOBES and the Institut des Amériques, coordinated by François-Michel Le Tourneau, Deputy Director and Marion Magnan, researcher at the Institute. About the blog.

by Sébastien Hardy, researcher at the Institut de Recherche pour le Développement (IRD) and IRD representative in Bolivia since September 2017.

In Bolivia, the first SARS-Cov-2 case was detected on March 10, 2020.

On March 12, with the announcement of the Declaration of national state of emergency (DS n°4179), measures to handle the epidemic abruptly accelerated with school and university closings. On March 13, Bolivia banned all flights coming from Europe (DS n°4190) and on the 16th the authorities imposed the first measures to restrict contact, putting in place a curfew, reduced work hours, a ban on gatherings of more than 50 people in one spot, a ban on interdepartmental trips,  children and people over 65 were forbidden to go out in public places. No fewer than four executive orders were published between March 16 and 18 (DS n°4192, 4196, 4198 et 4197), making the information rather inaudible, the speed in changes in the measures being so rapid.

These measures were barely put in place that on March 21, the authorities decided on a complete lockdown of the country with a new presidential order (DS n°4199, then DS n°4200 on March 25): all borders were abruptly closed, commercial flights suspended, going out forbidden (except once a week and only one member of the same family, the day chosen by the government based on the ID card number, only on foot, to buy groceries). Initially put in place until April 4, these lockdown measureq were then extended several times until May 31. Overwhelmed by the spread of the epidemic - intensive care services overrun, slight capabilities of testing the population -, President Añez appointed a scientific council on April 24 to advise the government on the public health measures to be taken.

Since May 31, Bolivia has entered into a new phase in handling the epidemic, based on a lockdown considered dynamic. The measures are now the responsability of the towns (order 4245). The government manages the borders which are being kept closed, a curfew on the whole territory and a map of the three levels of risk (risk index: high, medium, moderate), set up for each town, according to data it collects once a week from the health department services. The level of risk is supposed to determine a general framework of possible actions for the towns. They must manage all the other measures within their jurisdiction, according to the risk map. For example, high risk means that the population can only go out once a week to get groceries (DS n°4229). In fact, starting on June 1, most towns such as La Paz have allowed the adult population to go out, with no restrictions during non-curfew hours (municipal law  n°414 of May 26, 2020) when the town is categorized as high risk by the national authorities. On June 1, the population found itself again in the difficult situation of interpreting what was allowed and what wasn't, which led to numerous contacts and a big increase in infections in June 2020.

CHANGING THE SCALE TO BETTER SEE WHAT IS GOING ON

Bolivia put in place strict measures of confinement early on. With a 2020 estimate of only 11.4 million people, the authorities hope to contain the spread of cases.

Yet, an analysis of the evolution of daily cases (Figure 1) shows that in March, when the total lockdown of the country was decided, the number of cases was very weak (5 cases on March 22). And it will remain that way (between 30 to 40 cases per day in April) until May 2 (241 cases), to then have an constant significant upward trend (1301 cases on July 2).

How then can we explain the reason the epidemic was not controlled? In what way did the handling of the health crisis fail?

On June 30, the Santa Cruz Department accrued 57% of cases against 9% for the La Paz Department (2nd urban area). Following are the departments of Beni with 12.4% of cases and Cochabamba with 11% of cases. In order to understand this situation, we need to look at certain elements under the microscope.

Bolivia is a country with a low population, but vast (1 098 581 km2), with many regional contrasts. Its economic capital, Santa Cruz de la Sierra, is the most populated urban area of the country and possesses the only Bolivian international airport located at low altitude. It quickly became a cluster of infections.

 Yet, the unequal distribution of cases cannot be solely explained by the distribution of the population. The Cochabamba urban area - the 3rd in the country - is less populated than La Paz'. And the Beni Department counts only about 420000 inhabitants, but it is the 2nd department the most hit.

Respecting the lockdown measure is another factor. They were respected at La Paz: the police forces and the military exerted a strict control. In comparison, controls were much more limited at Santa Cruz de la Sierra. In a huge department such as Beni, forested and with a low population, enforcing the lockdown was harder to do. 

In Beni and at Santa Cruz, the authorities had to encapsulate, that is to say put lines of security forces around certain cities to attempt to restrain the circulation of the virus and contain it within reduced territories.

Another factor has to do with the scale of informal work. In general, the population seems to have accepted the lockdown measures at first, conscious that the virus was contagious. Besides, the government had initiated several economic assistance measures for the poorest people that played a role during the first days of total lockdown in them being accepted. Furthermore, the government took over the payment of electrical and water bills of the more modest income populations. It also put in place specific social aids (Figure 2) such as the Bono Universal (79.50 USD[1]) and the beneficiairy increase of the Bono familia (79.50 USD), of the Renta dignidad (55.80 USD) and the Canasta familiar (63.64 USD) (DS n°4215 of April 14, 2020). 10 million Bolivians were able to benefit from these aids for a total amount of 703 million dollars between April and June 25, 2020.

Despite these aids, a large portion of the population that depended only on revenus from informal work quickly found itself without money and decided to start their activities back up. This behavior can explain the first rebound of cases in the month of May. Furthermore, in order to access the aids, the eligible Bolivians, few with bank accounts, went massively to financial institutions to receive cash, causing groups of people that came from the most vulnerable categories.

POLITICAL CURRENT AFFAIRS ARE STILL A PRIORITY IN BOLIVIA

The political context of this health crisis also plays a significant role on the performance of its management. The President of the plurinational country of Bolivia, Jeanine Añez, has taken on an interim presidency since November 2019, following suspicions of electoral fraud that led President Evo Morales to leave the country. Her mandate is to handle current affaires while a new general election is organized. But Mrs Añez declared herself a candidate for the Presidency, de facto provoking defiance from most of the political parti representatives who had accepted by default her interim role. The health crisis has postponed sine die the elections which gave her time to attempt to convince on her capacity to lead the country.

However, members of her government have been caught up by suspicions of misappropriation while handling the crisis, leaving black marks in the capacity of Mrs Añez to govern, corruption being one of the country's many problems to be resolved. Beyond the judicial aspect and the political consequences of this affair, Bolivia will have had three different ministers of health to handle the epidemic when the medical structures of the country are in an appalling state and that only two laboratories - one in Santa Cruz and one at La Paz - have the technical expertise to do PCR analyses, with a maximum capacity of 1400 tests per day. So not everything was put in place to handle this crisis well.

Mrs Añez' political opponents were not exemplary either. The leaders of the political party MAS[2] in this way encouraged social groups close to their ideas to organize the confinement of protests, such as in the Chaparé and in the urban area of Cochabamba. These gatherings where distancing measures were not respected have certainly fostered the spread of the virus.

A HEALTH CRISIS SITUATION STILL FAR FROM BEING CONTROLLED?

While it is difficult to predict the approximate date of the peak of the epidemic, the hospitals have been saturated for a long time and the number of deaths is increasing. Since June 1st however, Bolivia has started a reopening phase - its geometry abandonned to the town leaders -, with an electoral campaign that has started up again. On their end, the population seems resigned to count on themselves now to try to get out of this crisis that seems unending.