The Rich Get Richer and the Poor Get Poorer: The Inequality of COVID-19

The coronavirus disease-2019 (COVID-19) pandemic has had a reciprocal relationship with socioeconomic status (SES). The poor, elderly, and chronically ill are more likely to contract the infection and in turn the pandemic has widened SES gaps on a global scale. The Asia Pacific Academic Consortium for Public Health and this journal recognize the importance of the social determinants of health. We are committed to narrowing the differences in access to health and health outcomes between social and ethnic groups, within and between the countries of the Asia-Pacific region. Without moving toward equity in economic development and in public health, it will be impossible to achieve the health components of the Sustainable Development Goals. Five years after the adoption of the Sustainable Development Goals in a review by the former prime minister of New Zealand, Helen Clark, she restated the importance of equity for the present and future well-being of all children. ¹ In his keynote address to the 2020 Asia Pacific Academic Consortium for Public Health Conference, Sir Michael Marmot restated the importance of equity for health and noted that the prevalence of COVID-19 was related to social class and in turn social class differences were being widened by the infection. ²

The COVID-19 pandemic has once more shown the importance of equity in public health, as it shows no respect for wealth or health expenditure of a country. As this issue of the journal goes to press, the country with the most cases (28 million) and most deaths (0.5 million) is the United States, the wealthiest country with a per capita expenditure on health of almost double the next wealthiest. It is also a country with marked inequity in wealth and access to health services. Within each population group, COVID-19 is more likely to infect, and to have more severe consequences, in those who are socially disadvantaged. Within the United States, there has been large variations in COVID-19 incidence and mortality between the upper and lowest socioeconomic groups. For example, the death rate from COVID-19 in African Americans is double the rate in Asian Americans (80 and 45 deaths per 100 000), and in Arizona, the gap between American Natives and Asians is 5-fold. ³ Countries with less of a gap between the highest and lowest socioeconomic groups (e.g., Vietnam) have lower overall COVID-19 mortalities. ⁴ In the United States, one third of COVID-19 cases occurred in African Americans, who are 13% of the US population. Disadvantaged communities are less able to adopt preventive measures, for example, high-density living, social distancing, and mask wearing, than higher SES communities. Native Americans are more likely to live in overcrowded conditions, more likely to contract COVID-19, and more likely to die from it. ⁵ The COVID-19 epidemic has widened the gap in life expectancy at birth between the ethnic groups in the United States. In Whites (non-Hispanic), life expectancy fell from 78.8 years in 2019 to 78.0 years in the first half of 2020. The decline in life expectancy was greater for Black Americans from 74.7 to 72 years. The decline in Black life expectancy undid 2 decades of improvement. ⁶ This large gap may also reflect the decline in health services available to the poor in the United States under the previous administration and this may change under the new president.

In Singapore, there are many manual workers, almost 200 000 with a median age of 33 years, who live in crowded dormitories. Almost all were given polymerase chain reaction tests and many had positive serology. About 12% of the residents developed clinical COVID-19 and another 44% had subclinical cases. ⁷ This is an example of how the overcrowded conditions of lower SES groups results in rapid spread of the deadly virus.

There are many ways in which the pandemic has increased SES disadvantage. The World Health Organization and United Nations Children’s Emergency Fund have highlighted the problems in the delivery of routine vaccinations and nutrition to millions of children around the world due to shutdowns to prevent the spread of COVID-19. ⁸ It is now estimated that at least 80 million children are at increased risk of an infectious disease. To stop the spread of the disease and because of the lack of teachers, most schools were closed at the peak of the epidemic. At the peak of school closures in April 2020, the World Bank estimated that 1.6 billion children were out of school worldwide. Until the epidemic subsides, probably not until almost universal vaccination is achieved, large numbers of children will be denied education. Many education systems have moved to online learning, which exacerbates SES differences as only the upper classes can afford internet access. The extended school closures are made worse by the economic downturns resulting from the epidemic, which put school fees, computers, and textbooks out of reach. Girls are more at risk of leaving school early, perhaps even to early marriage, as a result of the education crisis. ⁹ Education of children, especially girls, is related to health literacy and good nutrition. The education level of mothers is one of the most important factors in infant health and nutrition, which then sets a healthy trajectory for life.^10,11

The pandemic is now in its second year and more consideration needs to be given to its long-term effects. After the immediate effect of deaths of many of the productive members of society, it is now evident that many people will have long-term complications. While children have lower rates of infection, we must not forget the emotional burden and mental health impact of losing a parent or other significant member of their social networks. They have suffered from poor diets, social isolation, addiction to screens, and lack of schooling and health care, and this is particularly so among the more vulnerable groups of society. ¹² It is not yet known if infection at an early age will have long-term effects on development and health. ¹³ After the severe acute respiratory syndrome (SARS) epidemic of two decades ago, 40% of recovered SARS patients developed chronic fatigue syndrome four years later. Pulmonary fibrosis may occur as the consequence of lung damage following SARS-Cov-2 infection. ¹⁴ The nervous system effects include anosmia, thromboembolic events such as pulmonary embolism, heart attack, and stroke, and cognitive impairment. Longer term mental health consequences include anxiety, depression, posttraumatic stress disorder, and sleep disturbance.^15,16

The long-term economic effects of the pandemic are not evenly distributed across society, but are falling disproportionally on those who are already poor and disadvantaged. ¹⁷ In the early stages of the pandemic, most of the world suffered economic hardship. Now, the Oxford Committee for Famine Relief has estimated that it took just 9 months for the top 1000 billionaires in the world to regain their fortunes and since then their wealth has continued to increase. ¹⁸ In contrast, it is estimated that it will be at least a decade for the poorer groups of society to regain the limited amounts of wealth they had.

With vaccines now being distributed throughout the world, another example of inequality has come to the fore. The richer countries have given themselves priority over the limited supplies of vaccine. ¹⁹ The Director General of World Health Organization has outlined the problems with equitable distribution of vaccines when he stated:

I need to be blunt: the world is on the brink of a catastrophic moral failure—and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries. Even as they speak the language of equitable access, some countries and companies continue to prioritize bilateral deals, going around COVAX, driving up prices, and attempting to jump to the front of the queue. This is wrong. Vaccine equity is not just a moral imperative, it is a strategic and economic imperative.

The journal has received hundreds of papers describing experiences with the COVID-19 epidemic in our region. Because of space limitations, we are only able to publish a few papers and most are being accepted as Short Communications of 1000 words. As always, we expect papers to follow established epidemiological designs that will make a difference to public health and to be written in international journal standard English. Public health has always sought to study and address inequity, and if we are to control COVID-19, we must reduce inequity in our region.