key: cord-0794634-ft7o5t9r
authors: Patel, J. A.; Nielsen, F.B.H.; Badiani, A. A.; Assi, S.; Unadkat, V.; Patel, B.; Ravindrane, R.; Wardle, H.
title: Poverty, Inequality & COVID-19: The Forgotten Vulnerable
date: 2020-05-14
journal: Public Health
DOI: 10.1016/j.puhe.2020.05.006
sha: 3791391875affc6cc756aa169634f7437b1b79a2
doc_id: 794634
cord_uid: ft7o5t9r

nan

On various occasions, the phrase, "COVID-19 does not discriminate" has been repeated. This, however, is a dangerous myth, sidelining the increased vulnerability of those most socially and economically deprived. In response to the pandemic, UK policymakers imposed lockdown on its 66 million citizens, an act without parallel since WWII. Though enacted for the public's wellbeing, these policies have shown disregard towards those most economically disadvantaged. To date, policymakers have targeted people with multiple comorbidities after identifying them as the most vulnerable. However, this medical model of disease risks ignoring social factors, which can increase exposure to and mortality from COVID-19.

For people of low socioeconomic status (SES), a number of factors increase their exposure to COVID-19. First, economically disadvantaged people are more likely to live in overcrowded accommodation -7% of people from the poorest 20% of UK households live in overcrowded housing, a risk factor for lower respiratory tract infections (1,2). Poor housing conditions, limited access to personal outdoor space and overcrowding will reduce compliance with social distancing. Second, financially poorer people are often employed in occupations which do not provide opportunities to work from home (3). This includes but is not limited to supermarket and warehouse workers, those in certain forms of public transport and bus drivers, whose tragic deaths we have already witnessed.

Third, those of low SES groups are more likely to have unstable work conditions and incomes, conditions exacerbated by the responses to COVID-19 and its aftermath (4). Such financial uncertainty disproportionately harms the mental health of low SES groups and exacerbates stress (5) . Heightened stress is known to weaken the immune system, increasing susceptibility to a range of diseases and the likelihood of health-risk behaviours (5, 6) . Therefore, poverty may not only increase one's exposure to the virus, but also reduce the immune system's ability to combat it.

Fourth, people of low SES present to healthcare services at a more advanced stage of illness, resulting in poorer health outcomes (7). This will likely lead to poorer health outcomes from COVID-19 for economically disadvantaged people. Fifth, access to healthcare is also determined by a person's ability to use health services "with ease, and having confidence that you will be treated with respect" (8) . This can be hindered by language barriers, patients' attitudes towards healthcare providers and the behaviour and attitudes of healthcare professionals towards minority patients (8) . Healthcare does not exist in isolation, so discrimination in wider society influences healthcare professionals' practice and patient expectations, such as the anticipation of being dismissed, ridiculed or humiliated which may deter minority groups from accessing healthcare. These factors may also reduce access to healthcare for COVID-19 for patients of low SES.

Finally, there is emerging evidence that hypertension and diabetes are risk factors for death from COVID-19 (9) . This is notable because poverty is itself a risk factor for these conditions, with The Marmot Review showing that it increases the risk of cardiovascular disease, obesity, diabetes and hypertension (10) , suggesting people of low SES have an increased susceptibility to COVID-19 mortality.

In summary, a combination of factors leave the most economically disadvantaged particularly vulnerable to COVID-19. Possible causal mechanisms include an increased exposure to the virus, the stress and comorbidities associated with poverty and reduced access to healthcare. UK policymakers rapidly identified people with multiple comorbidities as particularly vulnerable. However, they must expand their definition of vulnerability to include social factors as risks for COVID-19. The pandemic has highlighted the stark inequalities within society, and it will likely exacerbate them. To address the vulnerabilities of the most economically disadvantaged within society, policymakers must introduce long-term legislation to improve social welfare.

Non-decent housing and overcrowding

Crowding: Risk factor or protective factor for lower respiratory disease in young children? BMC Public Health

Economic News Release -Employed persons working on main job at home, workplace, and time spent working at each location by class of worker, occupation, and earnings

Inner City Pressure: The voices of low income working families in inner London on the complex challenges they face

Associations between perceived stress, socioeconomic status, and health-risk behaviour in deprived neighbourhoods in Denmark: a crosssectional study

Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry

Socio-Economic Inequalities in Health Care in England. Fisc Stud

Access to health care for ethnic minority populations

Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis

Fair Society, Healthy Lives -The Marmot Review