Poverty, inequality and COVID-19: the forgotten vulnerable

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 World War II. Although enacted for the public's well-being, 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 coronavirus disease 2019 (COVID-19).

For people of low socio-economic 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 that 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 in 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 those in low SES groups and exacerbates their 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 health care is also determined by a person's ability to use health services ʻwith ease, and having confidence that you will be treated with respectʼ.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 Health care does not exist in isolation, so discrimination in wider society influences healthcare professionals' practice and patients' expectations, such as the anticipation of being dismissed, ridiculed or humiliated, which may deter minority groups from accessing health care. These factors may also reduce access to health care 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 leaves 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 health care. 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.

Competing interests

None declared.