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Must Demographics be Destiny?

Updated: Apr 7, 2020

Race has been a central narrative around coronavirus. However, the ignorant xenophobia tied to COVID-19 is not only dehumanizing - it’s distracting - as it draws the conversation away from evidence-based prevention strategies. Without social distancing measures, the coronavirus is an equal opportunity pathogen. However, as communities world-wide take action to protect themselves, a different demographic divide will predict health outcomes- socioeconomic status.

Both at the national and global levels, socio-economic status (SES) shapes spread, mortality, and the community’s resilience to bounce back.

Domestically, long term spread will fall on those with low SES.

Data shows that low income neighborhoods in New York are recently hit the hardest. Preventing further spread in these neighborhoods will be difficult. Low-income families are more likely to live with extended family or multiple generations, adding a precarious challenge to quarantine. Additionally, proper quarantine is economically challenging, as it requires a separate bedroom and ideally bathroom for the sick person, a stockpile of food, and time off work.

During social distancing, low-income workers are more likely to contract coronavirus. An Axios poll conducted the last week of March found that 39-48% of upper-middle and upper SES respondents were able to continue their work remotely. Americans with lower incomes were more likely to have either lost their jobs or to be continuing their work outside of the home. This increases their risk of contracting the disease or worsens their quality of life through loss of income.

Social determinants of health, such as housing, healthy food access, education, safety, income, and social support account for 80% of the modifiable factors that impact health outcomes. Because of these factors, people with low-income are more likely to suffer from chronic diseases like diabetes or heart disease, pre-existing conditions that are risk factors for Coronavirus mortality. Following age and pre-existing conditions, low SES is becoming the third major risk factor for Coronavirus death.

A patchwork response among insurance companies and states creates an incongruous and confusing message for a panicked public. Unless clear strategies are put in place to improve equitable healthcare access, the uninsured and underinsured will be reluctant to seek care until the last second. This will compound their burden of mortality due to coronavirus and other diseases during this period.

The racial economic disparity in America means this will lead to worse outcomes for communities of color. In Chicago, 70% of those who died from COVID-19 were black, although they are only 29% of Chicago’s population. Information about the demographic breakdown of patients and mortality isn’t available at the national level, but racial inequality across rates of uninsured, chronic diseases, and wealth show that this trend will continue.

The burden of disease globally will shift towards developing countries.

After some time, industrialized countries will scale diagnostics, build hospital capacity, and manufacture PPE. However, countries without the physical and social infrastructure to support its citizens will be hit the hardest.

Mitigation measures like social distancing are predicated on assumptions of privilege. They assume that people have food, space, and some financial security. The sheer density of tightly packed slums and urban centers makes social distancing difficult to regulate and ignores pressing hygiene and nutrition-related needs.

“If I do not go out for a week, my children and my wife will die,” says a laborer in Mumbai in an article in Foreign Policy by Rana Ayyub. The informal sector makes up between 30-90% of the workforce in African countries and many other developing countries. Many workers continue to operate out of need, living primarily hand-to-mouth. This sector is unregulated and involves primarily cash-based transactions, which require person-to-person interactions.

Working increases their chance of contracting and spreading the virus, but the alternative may be worse.

Coronavirus does not exist in a vacuum- it is one more hurdle for health systems already spread thin.

Problems like tuberculosis, malaria, undernutrition, and sickle cell disease often strain the existing health care capacity in many low income countries. Hospitals are rarely equipped with any surplus of PPE or beds, let alone ventilators. Many pharmaceuticals and supplies are imported and supply chains will likely be disrupted in the coming months.

There are other complex hurdles. Diversity of language requires that public health communication is accurately translated from the national language into several local languages. Use of WhatsApp as a primary news source lends itself to the dissemination of hyperbolic, panic-inducing, and false information. Inadequate infrastructure and capacity, including hospital space, quarantine rooms, and access to trained medical personnel will add to the need for creative solutions.

Revising Destiny

At this rate, vulnerable populations will bear the brunt of mortality, disease, and economic loss. However, it is possible to avoid a worst-case scenario where coronavirus targets low SES groups and exacerbates inequality.

First, social safety nets must be fortified, particularly for those with low SES. This will look different in each country based on their capabilities and the expected resiliency of various communities. This is not the time to reinvent the wheel, but to have productive policy conversations about housing, wages, workers’ rights, and insurance.

Next, cohesive and effective communications strategies must be employed to increase compliance and assuage panic. This is critical when directing public health measures, such as whether or not to wear masks. Messages must be created for at-risk groups using language they understand, giving clear and feasible directives. For example, in areas with no running water, hand washing messaging should include strategies to safely obtain water (ie: bring your own water receptacle to the well).

Lastly, words matter. We must be vigilant in preventing and calling out xenophobic and discriminatory language as low-income population segments and countries begin to bear the burden of disease. Also, it may feel cathartic to declare war on an invisible virus, but messages of solidarity across the population would reduce xenophobia, reduce anxiety, and drive compliance to public health guidelines.

The virus is dangerous, but if left unchecked, the long-term economic and social losses to communities will be more devastating. Communities with better health outcomes will rebound faster economically and socially. If we fail to consider the needs of the most vulnerable, COVID-19 will create a crippling lasting legacy across the global community. Social solidarity is the most efficient way to build global resilience in the face of a pandemic and fuel hope that a better tomorrow is coming.

- Molloy Sheehan,

Public Health Contributor

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