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

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).

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.