COVID-19 in an inequitable world: The last, the lost, and the least

13 Feb 2023

As the toll of the COVID-19 pandemic continues to grow, knowledge of existing inequities is more evident than before. This essay approaches the topic from a global to national perspective by exploring the current and potential socioeconomic and health effects the pandemic has on three population groups, as labelled in the title and selected based on their historical inequities. Mark Kia Ik Tan was the winner of the RSTMH Student Essay 2020 competition for this essay on the theme of 'COVID-19 in an inequitable world'.


Within the Nicomachean Ethics, Aristotle proposed the concept of “Equity” characterised as a rectification of law where justice cannot be upheld (Shiner, 1987). Centuries later, equity has developed into several theories suggesting that inclinations to fair outcomes are biologically universal and integrated into daily decision-making, from individual sharing behaviour to government policy drafting (Li, Xu & Wang, 2018). Yet, despite our innate goals of achieving equity, society is plagued by inequities; unjust differences that can be avoided (Xu & Joyce, 2019).

As of writing, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected over 55 million people worldwide, additionally, killing more than 1.3 million (WHO, 2020). While governments are caught in a perpetual scramble to resolve the pandemic, the disproportionate impact of the disease within vulnerable marginalised populations have highlighted the longstanding conveniently-ignored inequities, which can only increase due to the pandemic (Krouse, 2020). However, to accurately tackle these issues, one must obtain comprehensive understandings of the inequities faced by such communities and the effects of the pandemic on them (Xu & Joyce, 2019). Therefore, this essay focuses on several population groups as categorised in the title, and the effects of the pandemic on them. 

The Last

With most HICs straining to cope under the weight of the COVID-19 burden, LMICs are overextended further due to their deep-rooted low resource setting (Shuchman, 2020). Despite making up an estimated 85% of the global population, LMICs account for 19% of global healthcare spending (Xu et al., 2019), making these countries last in healthcare spending. Medical necessities afforded by HICs are medical luxuries in the resource-taxed environment of LMICs. Thus, the category, the “Last”, is dedicated to the LMICs.

Like most inequities, those tormenting LMICs stem from historical roots by which prejudices from leftover colonial ideologies have helped preserve the current societal disparities (Hellmann, Williams-Jones & Garrafa, 2020). Developed from these prejudices, structural inequities driven by unfair policies, enforce the socioeconomic imbalances, effectively determining the living conditions of populations and creating health inequities (Orach, 2009). Structural inequities include unbalanced distribution of wealth (Ward & Viner, 2017), inadequate sanitation, and poor housing conditions (Bukhman et al., 2020). Under such circumstances, health inequities are inevitable and will be extremely prevalent during this pandemic (Shuchman, 2020).

Pandemic responses by LMICs can be characterised as under-resourced (Ullrich et al., 2020). LMICs have imposed numerous measures such as national lockdowns but unlike HICs, the unsustainable socioeconomic impacts on LMICs have often precipitated the premature termination of these measures regardless of contagion levels (Chowdhury et al., 2020), with most damage already inflicted upon the general population as shown by a Bangladeshi survey; within the early days of national lockdown, 72% of urban households and 54% of rural households lost their primary income source, increasing their food insecurities (Banks & Hulme, 2020). Additionally, rapid economic expansion in LMICs, notably in sub-Saharan Africa (SSA), is commonly associated with rapid urbanisation; a process that if accompanied by insufficient infrastructure which is rife in LMICs, provides a backdrop for far more adverse consequences than those experienced in HICs such as inadequate sanitation (Saghir & Santoro, 2018). As exemplified by the approximated 63% of SSA city-dwellers who are unable to access clean water (Chirisa et al., 2020), poor sanitation within the growing urban population may further compromise the effectiveness of LMICs pandemic responses (Shuchman, 2020).

Similarly, LMIC healthcare systems suffer from economic inequities (Ullrich et al., 2020). Attributable to their limited budgets and in contrast to HICs, LMIC healthcare supply chains are less stable, leading to regular shortages of essential healthcare supplies (Bong et al., 2020), such as in India where for the projected million COVID-19 patients requiring ventilation, only 50,000 ventilators are estimated available for use (Kapoor et al., 2020). Furthermore, ICU capacity in LMICs is scarce; examples include Uganda and Nepal with 1.0 and 16.7 ICU beds per million inhabitants, respectively (Murthy, Leligdowicz & Adhikari, 2015). For perspective, Germany has 29.2 ICU beds per hundred-thousand inhabitants (Rhodes et al., 2012). Accompanying medical equipment shortages are usually staffing shortages, which generated by funding scarcity will be aggravated by loss of healthcare workers to COVID-19 (Ullrich et al., 2020). Together, the pandemic will devastate the thinly stretched healthcare services of LMICs as witnessed during the 2014 Ebola epidemic (Bong et al., 2020).

The Lost

At the end of 2019, the UNHCR estimated that 79.5 million people worldwide have been forcibly displaced (UNHCR, 2019). Cramped into temporary camps, refugees and displaced migrants lack basic sanitation and access to healthcare, providing the perfect environments for SARS-CoV-2 spread (Alawa et al., 2020). These individuals are usually neglected from countries’ preparedness plans, lost at sea, and lost to the institutional systems (Kluge et al., 2020). In this regard, the “Lost” are those forced from their homes for safety, only to become victims of COVID-19.

Refugees and displaced migrants frequently suffer from poor living conditions in their camps, lacking access to clean water or sanitation and hygiene products (Alawa et al., 2020). Connected to these conditions, infectious disease outbreaks are commonplace as observed from repeated cholera outbreaks in Kakuma Refugee Camp, Kenya (Mahamud et al., 2011). Thus, without the fundamental approach of handwashing to curb the pandemic spread, an uncontrollable outbreak is eventual. Overcrowding is also normal as represented by Moria Camp in Greece that has space for 3000 people but shelters 20,000 (Alawa et al., 2020), making self-isolation redundant (Raju & Ayeb-Karlsson, 2020). Identically, healthcare access, commonly provided by non-governmental organisations (NGOs) and volunteers, is restricted by legal frameworks and international goodwill (IFRC, 2020). For example, Cox’s Bazar houses 600,000 Rohingya refugees but is merely supported by 5 hospitals with a 340-bed capacity (Truelove et al., 2020). In comparison, the United Kingdom (UK) in 2017 had 2.5 beds per thousand inhabitants (Ewbank et al., 2020). Therefore, in these unfit conditions, SARS-CoV-2 will be permitted to thrive and with the pandemic exhausting governments and NGOs, negligence of refugees’ and displaced migrants’ needs are as imminent as the impending COVID-19 outbreak (Alemi et al., 2020). 

With the spread of misinformation, refugees and displaced migrants experience increasing stigmatisation (IFRC, 2020). This narrative of blaming it on “others” exploits social divisions to facilitate the propagation of xenophobia and stigma and justify their unfair treatment (Jones, 2020). Instances of discriminatory harassment and physical violence against refugees have been observed (IFRC, 2020). Additionally, credibility is lent to fallacious claims when political leaders incorporate them for political gain, epitomised by former deputy prime minister of Italy, Matteo Salvini who falsely associated COVID-19 spread to African asylum seekers (Devakumar et al., 2020). Misinformation has also pervaded the communities of refugees and displaced migrants, sowing distrust between them and healthcare workers with fears of being killed to reduce the pandemic spread leading many to refuse testing. Alongside the aforementioned social discrimination, such fears have encouraged the concealment of illness and discourage others from seeking treatment (Barua & Karia, 2020), thereby, delaying early treatment and detection (Alemi et al., 2020). Communication to quell the misinformation remains just as difficult due to language barriers (IFRC, 2020). Thus, as refugees and displaced migrants flee for safety, most still experience the same fears and endure unjustified and discriminatory mistreatment.

The Least

Aside from the aforementioned categories, the COVID-19 pandemic has given prominence to numerous social and health inequities of minorities. Being well documented, the disproportionate consequences of the pandemic can be ascribed to systematic social and racial discrimination (Kirby, 2020). Hence, the “Least” symbolises the national minorities; those who represent a small proportion of societies yet represent high disease burdens.

As the pandemic sweeps across countries, minority groups are afflicted by higher disease burdens, measurable by death and infection rates (Kirby, 2020). In April, despite comprising less than a third of Chicago’s population, the black minority group constituted 45.6% of the city’s SARS-CoV-2 infections and 56% of the city’s confirmed COVID-19 fatalities (Kim & Bostwick, 2020). Likewise, in the UK, of the 106 healthcare worker fatalities in the first peak of COVID-19 cases, 63% were from ethnic minorities and the black African ethnic population death rate was 3.5 times higher than the white British population (Kirby, 2020). This disproportion is the manifestation of the inequities that minorities are constrained by such as educational gap and occupation (CDC, 2020). Affecting employment prospects, educational gaps across the United States, produced by differential resource allocation that favours schools with lower minority percentage, are reflected in high school completion rate disparities. Having a 62% high school completion rate (The AECF, 2006), the American Hispanic minority accounts for 55% of painters, construction, and maintenance workers (BLS, 2018), work that cannot be conducted at home, exposing them to a greater risk of infection (CDC, 2020). Furthermore, out of fear of being deported, undocumented migrants may also justifiably stray away from obtaining treatment, depriving them of much-needed healthcare (Page et al., 2020).  As such, cycles of inequities imposed on minority groups have accelerated the immediate effects of the pandemic, cumulating into the disproportionate disease burden.

More importantly, the underlying pandemic effects are intensifying the inequities (Shadmi et al., 2020). Many job sectors affected by the pandemic constitute high proportions of immigrant employment. In the European Union, immigrants on average form 25% of the hospitality industry, and in Canada, they represent 30% of the security and cleaning service industry. Illustrated by growing unemployment, notably in Sweden where 58% of unemployed are immigrants, these minority communities are losing their sources of income (OECD, 2020). Similarly, coupled with historically lower wages, ethnic minorities lack substantial cash reserve to weather the pandemic (Hugo, Rainie & Budiman, 2020), resulting in increasing financial instability-related problems (Gould & Wilson, 2020); increasing food insecurities has affected all ethnic minorities in the UK (Loopstra, 2020), decreasing access to healthcare due to loss of insurance in the United States (Poteat et al., 2020), unequal education opportunities for dependents (OECD, 2020), escalation of domestic violence, and psychological illness (Sapkota, 2020; Moreira & Pinto da Costa, 2020). Motivated by media sensationalisation, acts of discrimination and social discordance are also exhibited globally, jeopardising community cooperation and mutual understanding, which are essential to the success of pandemic measures (Karalis Noel, 2020). Alienating the minority groups further, the COVID-19 pandemic not only undermines previous progress at achieving health equities for them but also reinstates the past cycles of inequities that they have sought to escape from at a greater severity.


While the pandemic continues to place the world in peril, a clear urgency should be shown to address the inequities vulnerable communities face (IFRC, 2020; OECD, 2020; CDC, 2020). Fortunately, some countries have recognised and taken measures to ensure vulnerable communities are not disregarded (Shadmi et al., 2020; Subbaraman, 2020). In Brazil, social assistance programs have helped Afrodescendants and indigenous populations offset a greater poverty increase (Lustig et al., 2020). In many countries, healthcare material is translated to improve communication with non-native language speaking communities (Shadmi et al., 2020). In a combined effort, Doctors without Borders has prioritised clean water facilities to refugee camps and the European Union has pledged €350 million to aid refugees (Subbaraman, 2020). Although these efforts are commendable, they are still conducted in the pandemic context, meaning a return to the status quo may occur when the pandemic subsides. Therefore, more long-term actions such as improving social integration through cultural understanding and empowerment of vulnerable groups in political systems are needed to counter the established inequities.

When Aristotle envisioned equity, he differentiated justice into two types, one with equity and another without, and emphasised that the former is the better of both because only with equity, can the virtues of justice be preserved in accordance with an individual’s circumstance. Simply put, systems generalise to function, leading them to fail to consider one’s situation (Rees, 2008). In this regard, many institutions and systems have historically overlooked the situations of vulnerable communities, resulting in their inequities and the inevitable outcomes observed during this pandemic. It is imperative to do these communities justice by channeling the momentum generated today, to create equity in this inequitable world.