When a flu pandemic swept through the United States in 1918, low-income people fared far worse than people on higher incomes. We have every reason to believe the current COVID-19 coronavirus outbreak will deliver the same inequality of suffering in Australia and around the world.

We know from research into social determinants of health that several key factors will lead to some families and communities having reduced resilience. So policymakers right now should be grappling with two big questions: How do you identify those most at risk? And what risk mitigation, communication and response interventions best meet their needs?

Strategies to reduce transmission can exacerbate social and economic inequalities. For example, working from home or avoiding public transport may be unrealistic for some vulnerable groups. Equitable responses will recognise the unique needs and cultural values of different members of the Australian community.

There are many relevant social determinants of health

Drawing on established research, we have identified 10 social determinants of health that can exacerbate existing disadvantage and the impact of pandemics.

1. Income, occupation, unemployment and job security. During a pandemic, low-income workers and those with low job security may have limited financial resources or economic safety net, which can influence their health-seeking behaviours. People and families experiencing poverty may have greater impacts if they need to miss work. Interruptions in income can impact food security and make treating existing health conditions even harder, with families having less means to pay for health services at a time when the system is under significant pressure.
2. Low literacy and education. People with low literacy or education levels need to understand public health communication and act on recommendations to reduce their exposure. We know they can disproportionality experience respiratory disease due to not being able to adequately receive public health messages.
3. Indigeneity. Inadequate housing, remoteness, lower socio-economic status and food insecurity can exacerbate health and social risks for some Aboriginal and Torres Strait Islander people. Previous pandemics such as the 2009 H1N1 influenza disproportionality impacted Aboriginal and Torres Strait Islander people, with higher rates of notifications, hospital and ICU admissions than the general population.
4. Pre-existing chronic conditions. People with chronic health conditions need to be able to access their regular medication and health and social services during a pandemic. Disruption to medications or supports can exacerbate illness and increase risk of exposure.
5. Mental illness and/or problematic drug and alcohol use. People with mental illness or problematic drug and alcohol use are more susceptible to infections due to low discernment for social responsibility (such as hygiene practices), poor access to timely healthcare and risk of relapse or worsening of mental health conditions due to stress and instability.
6. Location and living conditions. People living in crowded housing or with an inability to socially isolate or quarantine, such as people experiencing homelessness or in social housing, are more susceptible to exposure and may be unable to work remotely. People living in regional and remote areas face greater barriers to healthcare should they become infected.
7. Cultural and linguistical diversity. Lack of knowledge about risks, mistrust of health services, language and cultural barriers and lower healthcare-seeking behaviours can increase risk of illness in culturally and linguistically diverse families and communities. Some people may experience discrimination and stigma, such as toward Asian populations in the early stages of the COVID-19 outbreak.
8. Age. During public health emergencies, children can be at heightened risk of abuse, neglect, exploitation and violence. UNICEF reports that hundreds of millions of children will likely face increasing threats to their safety and wellbeing because of COVID-19 pandemic control measures. This may include mistreatment, gender-based violence, exploitation, social exclusion and separation from caregivers. School closures during the Ebola outbreak in West Africa from 2014 to 2016 contributed to spikes in child labour, neglect, sexual abuse and teenage pregnancies. The elderly, particularly those in aged care facilities, are at more risk during pandemics due to biological factors. They can also lose access to transport or other supports due to staff illness or social distancing.
9. Disability. People with a disability who require supports may experience adverse health effects if service availability is impacted due to increased demand, reallocation of health workers or staff illness. Social distancing can be difficult or impossible for those with high care needs or who live in residential facilities.
10. Gender. Women and girls can experience worse health and social outcomes during a pandemic. Women are more likely to be victims of domestic and family violence (DFV). Given abuse is often about power, an abuser may exploit an already stressful situation to gain more control. Evidence from COVID-19 in China and the Ebola outbreak points to a significant rise in DFV and teenage pregnancies. Women are often the primary caregivers in homes, communities and health facilities, increasing their likelihood of infection.

We all have an interest in caring for vulnerable groups

Previous successful public health responses – such as the eradication of measles, rubella and smallpox – had both general population strategies and specific interventions to reach vulnerable groups.

During the COVID-19 pandemic, as demand on health services increases and staff availability is reduced, the unavailability of health and social services are a major risk. This can drive poorer outcomes for vulnerable groups.

If services are not maintained, the ability for health systems to effectively manage COVID-19 may be further compromised. Vulnerable clients will still present at emergency departments and other acute health and crisis services, increasing demand and the risk of disease spread.

There are clear steps governments and organisations can take to minimise the impact

Evidence on what we can do to support vulnerable groups is limited, but some common themes emerge from historical public health emergency responses:

• Use data to target decisions. Undertake rapid analysis to identify who is at higher risk, understand their characteristics and anticipate potential demand hot spots. Data is needed to understand the impacts of social determinants. Identify indicators, existing information, data sources and reporting formats to document the status of essential health and social service delivery during the pandemic, and short- and long-term outcomes for vulnerable groups.
• Communicate and mobilise. To reach vulnerable groups, develop targeted, tailored communications that instruct, inform and motivate protective behaviours, build trust in the source and dispel myths. Community groups have valuable insights, networks and trusted relationships that can be used to communicate with and support vulnerable groups. They can translate scientific and government messaging that otherwise may be met with scepticism or mistrust. The community-led response to HIV and strong partnerships between government, health practitioners and researchers are the backbone of Australia’s successful strategy.
• Prioritise resources to vulnerable groups. Allocate social supports, access to health care and eventually access to a vaccine. Distribution requires data, but even without it, coordination between agencies can provide a better understanding of local needs. Survival during a pandemic is improved through cash transfers, sick leave, food security, medical supplies, accommodation and continuity of lifelines, such as energy utilities and essential transport.
• Leverage and improve existing structures. Australia’s Department of Health has already developed temporary policies to allow doctors, nurses and mental health professionals to deliver services remotely. Medical professionals and social service workers should consider opportunities for this in their services. Prior to H1N1 in 2009, pandemic plans were created with limited public consultation, so the unique needs and characteristics of many diverse groups were not adequately addressed. After the COVID-19 pandemic, it will be vital to better understand these needs as we prepare for future emergencies.

None of these will succeed on their own, but in aggregate they can be a lifeline for people on the margins. As the common COVID-19 refrain goes, we’re all in this together.

Get in touch to discuss how we can help your organisation support people experiencing vulnerability during the COVID-19 pandemic.

An expanded version of this paper, with full references, is available here.