Fighting COVID-19 has forced countries around the world to make trade-offs between lives and livelihoods. But in countries where many people already live at or close to subsistence, the alternatives are more excruciating yet. This column analyses cases in which the trade-off is actually between lives and lives; in other words, countries that can save their populations from the pandemic or from deprivation, but not both. The authors consider ways to alleviate these trade-offs, as well as their implications for policy – both national and international.