How socioeconomic data collection can strengthen the COVID-19 response
Authored by Dr Sophia Thomas
The COVID-19 pandemic is often touted as ‘the great equalizer’ – but nothing could be further from the truth. Pandemics tend to exacerbate existing health inequalities, mainly affecting disadvantaged socioeconomic groups. This calls for the inclusion of social measures (occupation, education and race/ethnicity) as data of clinical interest, to prepare a contextually relevant and timely COVID-19 response.
The impact of social determinants of health (SDOH) in the progression and health outcomes of infectious diseases has been evidenced in recent years. The World Health Organisation (WHO) lists poverty, social exclusion, poor housing, and deficient health systems among the main social causes of ill health. The newly emerged coronavirus infection (COVID-19) is no exception to this, as suggested by the growing body of evidence. For example, people experiencing homelessness run a higher risk of COVID-19 transmission owing to crowded living spaces and poor access to screening and testing facilities, especially in cities where there are large numbers of homeless people.
To understand the SDOH and related inequalities in the context of COVID-19, robust data collection of socioeconomic data, including race/ethnicity and gender, is imperative. A rapid review published in May 2020 makes a case for systematic recording of socioeconomic characteristics of patients with COVID-19, and treating them on par with clinical data. This would better inform public health prevention measures and interventions, which might greatly benefit vulnerable groups.
Socioeconomic position (SEP) data such as occupation, income and education can help in predicting the evolution of the disease in communities, and effectively prevent its transmission. The working conditions of people with disadvantaged SEP are prone to be stressful, which may adversely affect their immune system and make this group more susceptible to COVID-19.
In addition, migrants and informal workers are particularly vulnerable and exposed. In India, the national lockdown in March 2020 triggered an internal migration affecting over 40 million migrants. An acute loss of basic services such as food and shelter, coupled with unemployment and the anxiety of being infected, led migrant workers to return to their homes. This not only exposed the workers to health risks but may have also weakened the preventive measures for the wider population.
Living conditions associated with low income households are often characterised by overcrowding. This poses a significant risk of infection from potential pathogens (e.g. Tuberculosis, H. pylori). This calls into question the possibility of preventive measures such as social distancing in these neighbourhoods. This situation is worsened in refugee camps, for example for the Rohingya people sheltered in the world’s largest refugee camp located in Bangladesh. High population densities of up to 40000 per km2, poor health literacy, and lack of access to water, sanitation, and hygiene, considerably raises the risk of infection in these overstretched refugee communities. Failing to prevent the COVID-19 infection within the camps increases the likelihood of large-scale virus outbreak.
Lower levels of education is indirectly associated with higher prevalence of smoking and poor nutrition, which could supress the immune system, and subsequently increase the severity of COVID-19. Furthermore, limited health literacy can be detrimental to individuals who are poorly educated, resulting in a delay in seeking care. Building on the lessons learnt from major disease outbreaks (SARS, MERS, Ebola), the WHO has developed a guidance document for risk communication and community engagement (RCCE) readiness and responses to COVID-19. When implemented, RCCE can contribute to reducing social disruption, mitigate misinformation among at-risk populations, and convey complex scientific information in simple language to the local communities.
People belonging to racial and ethnic minorities face structural and systematic discrimination, which leads them to be socioeconomically disadvantaged, and less likely to be able to seek health care, putting them at risk of being severely affected by COVID-19. This trend was recently seen in the USA, where predominately black counties reported higher infection and mortality rates, when compared to their white counterparts. In Latin America, rural indigenous populations were left out from COVID-19 response strategies, as the governments have focussed their attention on urban populations speaking the dominant languages. These examples emphasise the importance of inclusive health care interventions to ensure equitable health services among minorities.
Despite gender being recorded as clinical data, it must be investigated with more granularity in the context of COVID-19. Gender intersects with occupation, education, and race/ethnicity. For example, in development and humanitarian settings, prioritising limited health services towards COVID-19 can adversely impact sexual and reproductive health (SRH) outcomes. This may increase the risk of sexually transmitted diseases, unsafe abortions, and maternal mortality. Women with multiple intersecting inequalities, such as adolescent refugee girls, disabled women of lower caste, or migrant workers from minority ethnicities, are more vulnerable. It is also worth noting the challenges faced by Lesbian, gay, bisexual, trans and intersex (LGBTI) people. They are at greater risk of being pushed into poverty during the pandemic due to loss of work, when compared to the general population.
The impact of COVID-19 is likely to follow a socially patterned population distribution. This tends to disproportionately affect the disadvantaged socioeconomic position (SEP) categories, especially persons with intersecting inequalities. This calls for an urgent need to record SEP information, and treat them on par with clinical data. Doing so will help in mapping the pattern of disease distribution in communities – reflecting the unique needs of vulnerable groups – to prepare contextually specific preventive measures and interventions. International and national agencies should recognise the impact of social determinants of health and their intersectional nature, while framing guidance documents to mitigate the pandemic.
Dr Sophia Thomas is a Research Fellow at the Public Health Foundation of India, Bangalore. Her research interests include: health inequality and social determinants of health, and heath policy and health care delivery. She can be reached at: firstname.lastname@example.org.