COVID-19 inequalities are striking and uncompromising

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COVID-19 has caused the most unprecedented pandemic our world has ever seen, with over 7.8 million cases and 430,000 deaths. New York City (NYC) is at its epicenter with over 214,000 cases and 21,000 deaths (or approximately 5 percent of all global mortality burden). There are many reasons why we saw this disproportionate impact in the city —many of which make this city spectacular and unique. However, what was to come surprised even the most cynical. A rise of protests and associated violence not seen in the city for decades.

Infections have always had a predilection for areas of poverty and inadequate access. Indeed, Rudolph Virchow, a well-known German microbiologist, famously wrote: “…as disease is so often associated with poverty, physicians are the natural attorneys of the poor,” a mantra that drives many of us, social justice-driven infectious disease specialists.

Paul Farmer, the author of Infections and Inequalities wrote in an ensuing text that “…human rights violations are not accidents; they are not random in distribution or effect. Rights violations are, rather, symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm.”

The inequalities we have seen with COVID-19 have been striking and uncompromising. Indeed, in the United States, we’ve found both the incidence of infection and mortality to be disproportionately higher among people of color. In certain contexts, the disparities have been unforgivingly high among African Americans. Notwithstanding this obvious disproportionate impact seen in communities of color, the issue really stems from what is described as the social determinants of health

Vulnerable populations across the world (including NYC) are at the highest risk of adverse health consequences based on the woefully inadequate resources provided for people living in poverty. Vulnerable in this context can be understood as the greatest concentration of disease with the least access to adequate health care and associated social services. These conditions are endemic and are simply flared with infectious disease outbreaks.

COVID-19 seems to be the gold standard of this amplification of these health inequities. But nearly every infectious disease outbreak of global significance follows a similar narrative. The lack of access to basic sanitation, hygiene, vaccinations and nutrition as well as to the principles of isolation, the distrust of the very governments empowered to facilitate these isolations and the decades of preceding sociopolitical violence has led to perfect storms of infectious disease outbreaks and associative violence.

There are countless previous examples demonstrating the association between population stress and infectious disease —  e.g. leishmaniasis, cholera, typhus, trench fever, anthrax, tuberculosis (TB). Some cases are particularly compelling. HIV/AIDS and its rapid emergence in South Africa in 1999-2002 is one. While the origin is famously associated with a number of variable causal factors, the sociopolitical violence and associative population stress experienced during the latter stages of apartheid have been widely cited as significant contributing factors to the South African epidemic. 

Ebola has a similar tale. The outbreak of 2014-2015 was particularly telling with over 14,000 infections and nearly 4,000 deaths. The cumulative mortality for all previous outbreaks on record (starting in 1976) was less than 2,000. So, how did it emerge de novo in an area without any prior outbreaks on record? What was it exactly that led to the outbreak in West Africa? What leads to such variable case fatality rates in divergent areas? Sierra Leone has suffered from decades of war, foreign intervention, a highly precarious sociopolitical system, and anemic infrastructure.

It has the lowest recorded life expectancy in the world (at 45 years). Moreover, as the quality of health is inextricably connected with access to resources and highly correlated with the general quality of life, it is of no surprise that they are ranked the sixth lowest on the Multidimensional Poverty Index and 183 out of 187 nations analyzed on the Human Development Index (often colloquially referred to as the happiness index). 

As is often the case in impoverished settings, those systems that are most vulnerable, will be attacked —  whether it be the result of some perverted irony, or rather, the manifestation of that very poverty precipitating conditions that favor disease and warfare combined with the lack of foundational strength to withstand disaster (either natural or anthropogenic). The association between violence and epidemics is particularly striking. It is likely that fractured health systems worsened by episodic social disruption place inordinate stress on societies and disproportionately impact the most vulnerable in those respective societies. Given such woefully inadequate health care systems unequipped to manage the needs of its citizens coupled with latent microbes existent for decades awaiting perfectly opportunistic moments, we can speculate that stark inequalities may be one of the strongest precipitants of infectious disease outbreaks. 

As the circle of poverty and disease continue, population stress can not only be a precedent to outbreaks, but can also be the consequence of such. Months of government-facilitated isolation, quarantine and separation for COVID-19, disproportionate adverse health consequences, as well as further economic distress on populations predisposed to adversity likely precipitated a pressure cooker scenario that activated frustration from decades of systematic oppression and violence. Social norms and civic boundaries had dissolved, and it is plausible that populations felt more emboldened to express their sense of lived injustice. NYC (like cities across the world) were aggravated by the gross inequities seen in this world. It caused them to take to the streets and demand justice. It further caused thousands to break down the months of progress that social distancing had on the incidence of COVID-19 in NYC. This, in conjunction, with the anger and emotional exhaustion associated with the unjust killing of George Floyd likely led to a widespread compromise on the immune systems of thousands placing them at higher risk of infection and poor disease progression. Just in time for a “secondary wave,” as the cycle of social determinants continues.  

Tyler B. Evans, M.D. MS, MPH, is the Chief Medical Officer for the NYC Office of Emergency Management (NYCEM) and an associate professor at the University of Southern California (USC). He is an infectious disease/tropical medicine physician with extensive experience working with vulnerable populations throughout the world, including migrants (namely refugees, asylees and victims of human trafficking), the LGBTQ (with a special focus on transgender/nonbinary populations), the homeless, and Native Americans.

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