key: cord-311745-jrc7hy2b authors: Sardar, Shaheen; Abdul-Khaliq, Iqra; Ingar, Aysha; Amaidia, Hanaa; Mansour, Noor title: ‘COVID-19 Lockdown: A protective measure or exacerbator of health inequalities? A comparison between the United Kingdom and India.’ A commentary on “The socio-economic implications of the coronavirus and COVID-19 pandemic: A review” date: 2020-09-29 journal: Int J Surg DOI: 10.1016/j.ijsu.2020.09.044 sha: doc_id: 311745 cord_uid: jrc7hy2b nan 'COVID-19 Lockdown: A protective measure or exacerbator of health inequalities? A comparison between the United Kingdom and India.' A commentary on "The socio-economic implications of the coronavirus and COVID-19 pandemic: A review" Dear Editor, We read with great interest the review by Nicola et al on the socio-economic impact of the COVID-19 pandemic (1) . In this letter, we focus on how worldwide lockdown measures have been an exacerbator of these socio-economic inequalities. The COVID-19 pandemic has been a source of considerable panic, concern, and feelings of uncertainty, with much ambiguity surrounding the virus remaining. The response to ensure public safety worldwide has been largely influenced by global and national politics most commonly leading to lockdowns on national levels with variable levels of success (success in this essay is defined as the overall biopsychosocial wellbeing of a people). Whilst early containment measures have shown to reduce the number of patients who contract the virus (2), it has also highlighted several hard truths surrounding socioeconomic and political inequalities on regional levels which have been exacerbated during the lockdown period. Johnson et al (3) describes that one of the six themes which make up influence global health is the socioeconomic and environmental determinants of health. This is influenced by patients social, political, economic, environmental and gender circumstances (3) . The comparison of two countries with varying national economic income can be used as a means of demonstrating this theme within the context of COVID-19 lockdown. Lockdown measures had somewhat different levels of success in the United Kingdom (UK) and India, which differ in their national economic income, with the latter considered a low-income and middle-income country (LMIC) (4) which may have been an influencing factor. As such, this essay aims to compare and critique the impact of lockdown measures within the UK and India and draw lessons on how this can impact individual everyday practise within the clinical environment. United Kingdom: The UK government implemented lockdown measures on March 23 rd , 2020, putting in place restrictions on social contact, changes to working conditions, and a significant reduction to public services. These measures were considered to be successful in reducing transmission of COVID-19; the Scientific Advisory Group for Emergencies (SAGE) reported that R at the beginning of the pandemic ranged from 2.7-3.0 depending on the region (i.e. on average one person with the disease would transmit it to approximately three others), as of the end of July, R has been reduced to 0.5-0.9 (5). However, despite this success in the reduction of transmission, lockdown measures are considered to be a means of exacerbating health inequalities. One of the notable consequences of lockdown measures on the public was on their mental health (MH) (6) . It has been noted that more demographic risk factors such as sex, age, and socioeconomic resources before the pandemic remain important determinants of individuals mental health during the pandemic (7). However, MH changes during this time has been thought to not be evenly distributed amongst the population. Additional factors that have also impacted susceptibility is acute financial difficulty (i.e. low income, unemployment), household environment (domestic abuse, living alone, or with young children) (8) and being a keyworker with exposure to potential infection. Protective factors have included those who live with higher levels of socioeconomic security; the reduction in commuting, alterations to education and work activities and more time with family may have decreased levels of stress and in fact promoted better mental wellbeing (6) . This demonstrates that lockdown may be viewed as potentially a measure that benefits those socioeconomically privileged and detrimental to those underprivileged. Gender and race inequalities have also been exacerbated during the pandemic. Worldwide, women earn less and thus save less, and are more likely to work within the informal sector. In addition, they have less access to social protection measures and form most single parent households (9) . Consequently, women's capacity to withstand economic shocks is less than their male counterparts. In the UK this has been demonstrated with a report showing that mothers were 1.5 times more likely than fathers to have lost or quit their jobs within the quarantine period (8), again demonstrating how lockdown measures can be considered somewhat unsuccessful due to its negative social implications and exacerbation of health inequalities. Race inequalities were highlighted with the first individuals dying from COVID-19 in the UK all being of Black and Minority Ethnic backgrounds (10). Since its first case of COVID-19 being reported on January 30 th , India had worked rapidly to declare one of the world's largest nationwide lockdowns, impacting 1.3 billion individuals, which was praised by the World Health Organisation as being 'tough and timely' (2 and 11). Despite these measures, however, it was reported that at one point, India was the third most infected country worldwide (11) . It is worth asking, what factors may have contributed towards the failure of what initially looked like promising measures? In a country with much inter-city travel, the shutdown of public transport forced millions into makeshift shelters, leading to their relying on food handouts and the use of public toilets resulting in social distancing become difficult to implement (2). Additionally, it was noted that lockdown measures resulted in the poorest and most marginalised members of society (who make up approximately 400 million informal workers), who have the least socioeconomic capacity to combat the pandemic without work and income, leading to deeper poverty and starvation (13) . Despite government promises to provide food and essential supplies to those in most need, these were often facilitated by informal supply chains that were easily disrupted during the quarantine period (4) . This would in turn threaten to negatively impact adherence to social distancing and lockdown rules. In addition, another threat to the response to lockdown has been the spread of misinformation amongst the public driven by panic, stigma, and blame. On a community level, increasing levels of violence against healthcare workers and stigmatisation of individuals suspected or confirmed of having COVID-19 may impact members of the public reporting symptoms and seeking help (11) . Societally, the pandemic has been used to exacerbate anti-Muslim sentiment, following accusations of a gathering from the group Tablighi Jamaat being to blame for the spread of many cases (11), again exacerbating a climate of stigmatisation and violence in a country where discrimination against religious minorities has been on the rise in recent years (14) . These reflect the significance of political, social, and economic factors as determinants of the overall success of lockdown measures, which may have contributed towards the high rates of infection. Both examples show that lockdown may be seen as a means of controlling an epidemic that has demonstrated a skewed success (in a biomedical, social and mental sense) towards the socioeconomically advantaged on an inter-country level (i.e. quarantine measures were less successful in reducing transmission rates in India, a LMIC) and an intra-country level (as demonstrated with the MH and gender disparities in the UK). It is worth noting that outbreaks are not only public health emergencies, but also socioeconomic and political emergencies as well (4) . Both countries can be considered guilty of falling into viewing the crisis with a singularly biomedical lens in the name of protecting the population at the expense of social and political factors putting the most disadvantaged individuals of society at risk. To protect the public from being developing COVID-19 (or any other communicable diseases), social, political, and psychological factors need to be addressed as these factors may hinder adherence to preventative and treatment advice. It may be possible that the governments in the UK and India may have been able to improve the success of lockdown measures if these factors were addressed alongside the implementation of social distancing rules. A lesson that clinicians can take from this on an individual level is to ensure that we see patients in a holistic manner, through the lens of the biopsychosocial model to ensure we are maximising improvements to their clinical outcome. Further to this point, the importance of the collaborative process and open communication between local healthcare professionals and politicians who both adeptly adhere to the biopsychosocial model in the realms of Public Health to ensure the overall wellbeing of the public should be emphasised. This may have been beneficial to LMIC's such as India who have been criticised by some media outlets for the implementation of a 'Western-style lockdown' (15) . In addition, the pandemic can be seen as deepening pre-existing inequalities, revealing vulnerabilities within social, political and economic systems, which consequently amplify the biomedical impact of the pandemic (6) . Whilst clinicians should focus on approaching individual patients in an holistic biopsychosocial manner, seeing that factors such as gender and race increased negative outcomes in the UK (increased rates of unemployment, mortality and deteriorating mental health) we should also strive to dismantle structures within the NHS and institutions that work to predispose and disadvantage certain groups to these outcomes. In conclusion, lockdown measures can be thought of as an effective biomedical measure to contain a pandemic in more affluent regions. However, more emphasis was required on the social, political, and economic factors of the public, which exacerbated the health inequalities that existed in both India and the UK. This reflects the requirement to broaden our definition of 'wellbeing' and 'health' to one that is more in line with the biopsychosocial model. Bibliography: The socio-economic implications of the coronavirus and COVID-19 pandemic: a review The 2019-nCoV pandemic in the global south: A Tsunami ahead. EClinicalMedicine Global health learning outcomes for medical students in the UK. The Lancet An appeal for practical social justice in the COVID-19 global response in low-income and middleincome countries. The Lancet Global Health Scientific Advisory Group for Emergencies. The R Number in the UK. The R Number in the UK Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry Data resource profile: Adult Psychiatric Morbidity Survey (APMS) How are mothers and fathers balancing work and family under lockdown?". Institute for Fiscal Studies The indirect impact of COVID-19 on women. The Lancet Infectious Diseases UK government urged to investigate coronavirus deaths of BAME doctors. The Guardian India under COVID-19 lockdown How India is dealing with COVID-19 pandemic. Sensors International COVID-19 and the world of work The Citizenship (Amendment) Bill, 2016: international law on religion-based discrimination and naturalisation law How India's lockdown restrictions have affected the poorest in the community This work is original and is not being considered for potential publication elsewhere, nor has it been published previously.All authors have contributed significantly and are in agreement with the content of the manuscript. There are no conflicts of interest in association with this paper.