Apr 04, 2020 Volume 39 5Number 10230 p1089-1166, e62-e63
Redefining vulnerability in the era of COVID-19
What does it mean to be vulnerable? Vulnerable groups of people are those that are disproportionally exposed to risk, but who is included in these groups can change dynamically. A person not considered vulnerable at the outset of a pandemic can become vulnerable depending on the policy response. The risks of sudden loss of income or access to social support have consequences that are difficult to estimate and constitute a challenge in identifying all those who might become vulnerable. Certainly, amid the COVID-19 pandemic, vulnerable groups are not only elderly people, those with ill health and comorbidities, or homeless or underhoused people, but also people from a gradient of socioeconomic groups that might struggle to cope financially, mentally, or physically with the crisis.
The strategies most recommended to control the spread of COVID-19—social distancing and frequent handwashing—are not easy for the millions of people who live in highly dense communities with precarious or insecure housing, and poor sanitation and access to clean water. Often people living in these settings also have malnutrition, non-communicable diseases, and infectious diseases such as HIV/AIDS and tuberculosis. In South Africa, 15 million people live in townships where the incidence of HIV is around 25%. These immunocompromised populations are at greater risk to Covid-19. Another concern in African countries is that the response to COVID-19 will come at the expense of treating other diseases. For example, in the Democratic Republic of the Congo, the response to Ebola resulted in the resurgence of measles.
The effect of the policy response on children in the fight against COVID-19 is also a concern. On March 23, UNICEF reported that in Latin America and the Caribbean over 154 million children are temporarily out of school because of COVID-19. The impact of this policy is more far-reaching than just the loss of education—in this region, school food programmes benefit 85 million children, and the UN Food and Agriculture Organization assessed that these programmes constitute one of the most reliable daily sources of food for around 10 million children.
Questioning whether appropriate evidence exists to support the reduction of transmission through school closures, Richard Armitage and Laura Nellums considered the long-term risks of deepening social, economic, and health inequities for children in a letter published in The Lancet Global Health. A 2015 UN report analysing the socioeconomic effects of Ebola in Africa also highlighted the increased risks of pregnancy in young girls, school dropout, and child abuse.
The most vulnerable children are part of families in which parents have informal jobs and are not able to work from home. This predicament is particularly concerning in countries like India, where over 80% of its workforce is employed in the informal sector and a third of people work as casual labourers. In socioeconomically fragile settings, a lockdown policy can exacerbate health inequalities and the consequences need careful consideration to avoid reinforcing the vicious cycle between poverty and ill health. Human Rights Watch has reported that the lockdown in India has disproportionately affected marginalised communities because of the loss of livelihood and lack of food, shelter, health, and other basic necessities. Under this unprecedented challenge, governments must be mindful that strategies to address the pandemic should not further marginalise or stigmatise affected communities.
Vulnerable groups and health inequalities are also evident in developed countries. The USA is a stark reminder of the divide that exists in countries without a universal health-care system. For people who do not have private medical insurance, this pandemic might see them face the choice of devastating financial hardship or poor health outcomes, or both. During the 2009 H1N1 influenza pandemic in the USA, individuals with poorer health outcomes were those in the lowest socioeconomic groups. This same group of vulnerable people have now been caught in the middle of a major health emergency as a result of long-standing differences in affluence.
While responding to COVID-19, policy makers should consider the risk of deepening health inequalities. If vulnerable groups are not properly identified, the consequences of this pandemic will be even more devastating. Although WHO guidance should be followed, a one-size-fits-all model will not be appropriate. Each country must continually assess which members of society are vulnerable to fairly support those at the highest risk.