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\begin{document}

\title{When Public Health Crises Collide: Social Disparities and COVID-19}



\author[1]{Richard Stein}%
\author[2]{Oana Ometa}%
\affil[1]{New York University Tandon School of Engineering}%
\affil[2]{Babes-Bolyai University}%


\vspace{-1em}



  
  \date{May 14, 2024}


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In \emph{To Have or to Be?} , psychoanalyst Erich Fromm writes about
pursuit after domination of nature, material abundance, and unlimited
happiness, which made modern society become more interested
in\emph{having} than in \emph{being} . Income, in his view, should not
be as accentuated as to create different experiences of life for
different groups {[}1{]}. Of the concepts that Fromm presents, the
domination of nature, which facilitates zoonotic spillover events by
increasing the overlap between the habitat of various species with that
of humans {[}2-5{]}, and the gap between the rich and the poor, which
recently has become the widest in years {[}6{]}, become particularly
relevant in context of the COVID-19 pandemic.

Even though susceptibility to COVID-19 does not know socioeconomic
boundaries, a critical and worrisome finding is emerging from
preliminary data and may re-shape infectious disease outbreak management
strategies for the future. An early analysis of COVID-19 data from
several jurisdictions in the United States found that counties with a
majority of African American residents had three-times higher infection
rates and six-times higher mortality rates than counties with a majority
of Caucasian residents {[}7{]}. Another analysis, of March 2020 COVID-19
hospitalization data from 14 states in the United States, found more
African American individuals among hospitalized patients whose race or
ethnicity was recorded {[}8{]}. These and other findings reveal a
disproportionately higher risk of serious or fatal COVID-19 in
minorities. What makes these observations remarkable is that
hypertension, diabetes, and obesity, which are risk factors for more
severe or fatal COVID-19 {[}9-13{]}, are exactly the chronic conditions
that have long been recognized as disproportionately affecting
racial/ethnic minorities and socioeconomically disfavored individuals
and groups {[}14{]}.

Obesity affects minorities and low-socioeconomic-status groups
disproportionately at all ages {[}15{]}, a finding that was reported in
several countries {[}16-19{]}. Some of the risk factors that account for
disparities in obesity include low socioeconomic status {[}20{]}, food
insecurity, restricted access to healthy diet and recreational
facilities {[}21-24{]}, residence in areas with fast food restaurants
{[}25{]}, a high neighborhood density of small grocery stores {[}26{]},
distance to a store {[}27{]}, exposure to obesogenic environments {[}28,
29{]}, shift work {[}30{]} and irregular sleep patterns {[}31-33{]}.

Obesity increases the risk for other chronic diseases {[}12{]},
including diabetes and hypertension {[}34{]}. African American adults in
the United States have among the highest rates of hypertension worldwide
{[}35{]}. Several factors were implicated in disparities in
hypertension, including socioeconomic status {[}36{]}, differences in
awareness {[}37{]}, residence in a food desert {[}38{]}, chronic stress
{[}39, 40{]}, fewer healthcare resources {[}41{]}, and income {[}42{]}.
Disparities for diabetes were described in minority populations in terms
of increased prevalence {[}43, 44{]}, worse management and control
{[}45, 46{]}, and higher rates of complications {[}45, 47{]}. Over the
past three decades the socioeconomic disparities for type 2 diabetes
have widened {[}48{]}.

Racial, ethnic and socioeconomic disparities also shape inequities in
the access to mental health care {[}49-52{]}. This is very relevant for
COVID-19, in context of the quarantine that was implemented in many
countries in various forms, including school closures, allowing
non-essential personnel to work from home, closure of mass transit
systems, cancellation of public events, and restrictions on the assembly
of groups of people {[}53-55{]}. Social isolation negatively impacts
mental health and, with \textgreater{} 70\% of the young people and
adults not receiving adequate mental health treatment from health care
personnel worldwide {[}56{]}, the implications in the wake of COVID-19
are extensive and far-reaching. The 2002-2003 SARS pandemic revealed
that a substantial proportion of the quarantined individuals may display
PTSD and depression symptoms, with longer duration of the quarantine
being associated with more severe PTSD {[}57{]}. During the same
pandemic, hospital employees from Beijing who were quarantined had
higher PTSD levels than those who were not, even three years later
{[}58{]}. Among individuals from South Korea isolated for two weeks
during the 2015 MERS outbreak, anxiety and anger were still present 4-6
months after the quarantine {[}59{]}.

The disproportionately higher suffering of socio-economically
disadvantaged individuals at a moment of crisis is, unfortunately,
nothing new. In the 14\textsuperscript{th} century, in the Black Death
pandemic, the poorest populations were also the most extensively
impacted ones in terms of mortality {[}60, 61{]}, and low-income
individuals had a considerably worse outcome after the 1918 flu pandemic
{[}62{]}. The disproportionate effect on socio-economically
disadvantaged individuals was also apparent in the wake of natural
disasters, such as Hurricane Katrina {[}63{]} or the Deepwater Horizon
oil spill {[}64{]}. One aspect that makes COVID-19 different is that
several segments of the population become more vulnerable not simply due
to socioeconomic disparities, but as a result of chronic medical
conditions that these disparities have at least partly fueled over
decades. The partial overlap between the risk factors for these two
groups of diseases is reminiscent of debates on whether the broad
classification of diseases into non-communicable and communicable ones
is a meaningful one, considering that the two groups often overlap and
interact markedly with one another {[}65-67{]}. Another aspect that sets
COVID-19 aside from other pandemics in recent history is the extent and
the duration of the quarantine and the resulting increase in
unemployment rates {[}68, 69{]}, which only promise to prolong and
exacerbate the extent of social inequities and the burden of chronic
diseases.

COVID-19 provides a steep and perplexing learning curve that underscores
the imperative need to envision infectious diseases not simply from a
biomedical perspective, but as part of a complex framework that
incorporates ethnic, socioeconomic, and political dimensions.
Racial/ethnic and socioeconomic disparities are conducive to the
development of chronic medical conditions that could increase the risk
of severe COVID-19, widening the disparities and accentuating the
chronic disease burden and, as a result, further marginalizing already
vulnerable individuals and groups. The implications of this positive
feedback loop for individuals, groups, and society, extend beyond
COVID-19 and beyond infectious diseases in general. The current pandemic
eloquently demonstrates, albeit at a high cost, that societies function
on the basis of a social contract, as described by Jean-Jacques Rousseau
and, undoubtedly, offers an important moment to reflect on the profound,
far-reaching, and multi-layered consequences of disparities in society.

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