We are living in unprecedented times. The covid-19 pandemic is escalating rapidly with more than 173, 300 confirmed cases and over 7,000 deaths in 152 countries and regions (see Figure 1). The majority of cases and deaths are among people aged 60 years and older living in low- and middle-income countries (LMICs) where healthcare resources to treat people and control the epidemic are limited. 

Guidance largely ignores this issue in both high income countries (HICs) and LMICS, the latter of which contain 69% of the global population aged 60 years and over. Their health systems are also weaker, leaving them vulnerable to the worst impacts of covid-19. Limited guidance which is more relevant to HICs has been produced for older people but not for health and social care workers, care homes or day centres. No detailed age-specific data on global cases and mortality has been produced by the World Health Organisation (WHO) even though mortality rates jump sharply in older people, rising from 8% in those aged 70 to 79 years to 15% in those aged 80 and over (see Figure 2 which shows the effect of age on risk of dying from covid-19 from the Chinese outbreak).  

In the absence of clear comprehensive guidelines for prevention and control of covid-19 among older people, ad hoc policies are emerging. In Italy scarce hospital and intensive care services are being prioritised for younger, otherwise healthy patients over older patients, according to reports. In the UK, people aged 70 and over will be expected to self-isolate themselves for up to four months in the coming weeks.

In LMICs, older people provide an integral economic and social resource to societies, including bringing up grandchildren to support the labour mobility of their adult children and relatives. Beyond grief and bereavement the implications of covid-19 deaths among the older population will be profound, especially when family members working abroad are unable to return home at short notice. 

Increasing numbers of very old people are now being cared for in nursing homes in LMICs. These homes are often unregulated, provide care of very poor quality and may even act as incubators of infection (as do cruise ships, prisons, mines and HIC nursing homes). Outbreaks in LMIC institutions would have serious implications, further underpinning the need for international guidance similar to that issued recently by the International Federation of the Red Cross and Red Crescent Societies, UNICEF and the WHO regarding children and schools.

The ability of health systems to cope with a surge in demand is extremely limited, especially for patients needing intensive care. Health systems in LMICs face severe constraints on capacity at normal times and are unlikely to be able to keep up, especially if the precarious staffing levels—already depleted by migration, low salaries and poor working conditions—and limited gerontological expertise are reduced further by illness. The needs of older people are not being adequately addressed in developing covid-19 policy and practice. Current social distancing policies ignore the precarious existence of many older people and fail to account for the realities faced by those living alone and individuals who are dependent on others. The high levels of illiteracy in LMICs also present a challenge which has yet to be considered in any meaningful way. 

An age perspective needs to be explicitly included in the development of national and global planning for covid-19, and it is increasingly clear that a global expert group should be formed to provide support and guidance for older people, home carers, residential facilities and overburdened hospitals in LMICs. 

Shah Ebrahim is an honorary professor of public health at the London School of Hygeine & Tropical Medicine. He would like to thank Peter Lloyd- Sherlock, professor of social policy and international development, University of East Anglia; Leon Geffen, Samson Institute for Ageing Research, Cape Town, South Africa; and Martin McKee, professor of European public health, London School of Hygiene & Tropical Medicine, for contributing to this article.

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