In the interest of strengthening national solidarity and by extension inspire compliance to preventative public health measures, a narrative of ‘we are in this together’ pervades popular and political discourse surrounding Covid-19. Such sentiments serve to convey the rhetoric that this pandemic is a ‘leveller’ of sorts, that Covid-19 does not differentiate by race, colour, creed, or border. A truism is masked: We did not enter this pandemic on a level playing field and, without adequate intervention, we will emerge from it with societal inequities far greater than when we started.
The question of ‘who do we protect?’ has, in large measure, focused on our older generations and those with pre-existing health conditions. However, previous influenza pandemics, for example the 2009 H1N1 pandemic and the 2003 SARS outbreak, have taught us that there is a third risk: social vulnerability. Research demonstrates that ‘socially vulnerable’ populations disparately experience the burden of pandemic influenza including; differential exposure to the virus; differential susceptibility to disease, if exposed; and differential access to timely and appropriate treatment, if infected. A synergistic interaction of these evidenced disparities results in unequal levels of influenza-related morbidity and mortality. Emerging data from the Covid-19 pandemic appear to be following the same worrying trend. For example, initial data analysis from the USA and the UK tentatively indicate that individuals enduring low income, high population density, and/or from black and minority ethnic (BAME) backgrounds are experiencing substantially elevated rates of Covid-19 infection and death.
Such findings do not surprise Social Epidemiologists. For decades, they have provided consistent evidence that socially vulnerable populations experience inequitable health outcomes. Covid-19 is no different. A cumulative clustering of harmful factors such as higher rates of pre-existing health conditions, high population density in their community, workplace conditions, and exposure to detrimental psycho-social and socio-political environments, will insidiously converge and severely disrupt their capacity to exert risk mitigating behaviours during and after the Covid-19 pandemic. Succinctly put, for socially vulnerable communities, the infection control prescription of ‘social distancing’ is easier said than done.
A critical analysis of the various mechanisms and environments required for an individual to avoid contracting COVID-19 clearly illuminates that protection from pandemics is a reprieve available to the privileged few and not the many.
The capacity to work from home is a privilege. Individuals with middle to high incomes are more likely to be in occupations which can be performed from home, consequently reducing their exposure to Covid-19. In contrast, many individuals with lower waged occupations are performing essential and in-person front-line services which can significantly increase their exposure to and consequent contraction of COVID-19.
The capacity to safely remain in your home is a privilege. People who live in congregated settings for example are not so lucky. Their capacity to safely socially distance is at the very least severely restricted if not impossible. In recent days and weeks, this assertion has borne out in the data with disproportionate rates of Covid-19 infection evident in the congregated living setting of nursing homes. Commensurate discourse and data is required to understand and respond to the equally nuanced risks Covid-19 poses for some of our more marginalised congregated settings such as direct provision, the Traveller community’s collective living spaces, prisons, homeless hostels, mental health residences and inpatient psychiatric wards. This is very important now, but also in a future wherein the emergency personnel and financial resources currently available in this early midst of the pandemic may, in the medium to long term, be rescinded.
It is not simply protection from infection which is a privilege. Protection from the economic precarities arising from the restrictive lockdown measures is also a privilege. Socially vulnerable cohorts are more likely to suffer loss of income during a pandemic. As businesses and industries, such as hospitality and construction, continue to be detrimentally impacted, many socially vulnerable cohorts will be at the coalface of the forthcoming recession. An exacerbated entrenchment of the current economic inequities now evident in our society will ensue.
Lastly, to have a home wherein physical and psychosocial safety can be secured is a privilege. For families wherein pre-existing incidence of violence, addiction and or mental health difficulties, was endured, the lock-down measures may escalate the acute severity of these experiences. Pre-Covid-19, potentially damaging behaviour by family members was, in some cases, conducted outside of the family home, thus providing a degree of safety and respite to the rest of the family. Now, in this era of lockdown measures, families may endure escalated rates of physical and psychological abuse within the home. For individuals recovering from addiction and/or an enduring mental health condition, the restrictions presents a disruption to their usual routine, limited access to established support systems and limited capacity to enact their tried and tested coping mechanisms. Maintaining their recovery will be a significant challenge. To date, many of these individuals and families may be suffering in silence, the true impact remaining largely invisible to many until such time when the supports of our already overwhelmed mental health and addiction services are called upon.
To return to the question of ‘who do we protect?’. The answer to this question needs to be broadened beyond the narrowed lens of older generations and those with pre-existing conditions. Social vulnerability must be visibly amplified and firmly integrated as the third risk factor in our Covid-19 priority response plans and actions.
Historical experience and current data from other jurisdictions provide a mandate to do so, directing us towards the demonstrably inequitable health, economic, and psychosocial burden that our socially vulnerable populations shoulder as a result of influenza pandemics. Failure to engage with the socio-economic, socio-cultural and socio-political dimensions of pandemics will not only result in the continuation of single or multiple population-specific transmission chains, rendering global transmission control efforts ineffectual but will also further entrench pre-existing inequities between the ‘haves’ and the ‘have nots’ in our society and condemn our most marginalised communities to a future in which they continue to be unseen and unheard.