[OPINION] Health inequity: The real health issue in our coronavirus response

Ronald Law
[OPINION] Health inequity: The real health issue in our coronavirus response
'COVID-19 doesn’t get more discriminating than this'

Sifting through the news, we’ve read or heard that the coronavirus is the great equalizer — that it doesn’t discriminate which person it will infect in terms of income level, employment status, level of education, gender, and ethnicity. 

This fact was recently given a human face with the death of Michelle Silvertino, a 33-year old Antipolo-based househelp and single mother of 4 from Bicol, who walked for kilometers and waited for a bus to the province just to be with her children. The bus never came because of quarantine restrictions, and her long wait led to her demise. 

Her lifeless body slumped on a footbridge along a major thoroughfare in Metro Manila was a sorry sight, rife with speculations that she could have died of hunger, heat exhaustion, or even humiliation. Her death certificate showed she was a suspected COVID-19 case and medical history revealed she had a long-standing lung infection, which could be the reason for her being rejected for work overseas. (READ: DSWD cash aid comes after Michelle Silvertino dies)

We know that COVID-19 has a propensity to affect more the vulnerable among the population in terms of age, pre-existing diseases, and other health conditions. This is the rationale for all the health policies and protocols to prioritize and protect them. This should have been the case for Michelle. She was vulnerable in every medical sense of the word. But her vulnerability goes deeper than this.

Hindi natin mauunawaan kung hindi natin napagdadaanan 

The medical vulnerability perspective is skewed, if not unfair. In countries the world over, especially in low-income countries like the Philippines, those already poor and marginalized before COVID-19 are bearing the brunt of the pandemic.

COVID-19 doesn’t get more discriminating than this.

It should not be surprising to see some evidence that the poor and marginalized have increased rates of infection and mortality from COVID-19 because of myriad social factors that further widen health disparities. Amid uneven access to health care and dismal health outcomes lies the issue of health inequity – arguably the real issue that must be dealt with in our coronavirus response.

As we have been hardened by sad realities, it is always tragic events that grab our selective attention. A social autopsy of the Michelle Silvertino case could help us dissect the following factors impacting health, as they determine the appalling vulnerability of the poor and marginalized in the midst of this pandemic:

Spaces/environmental factors

The poor have housing conditions characterized by cramped spaces, so overcrowding and poor ventilation are realities of everyday existence. Also, with limited outdoor space and a dense population to reckon with in their immediate environment, physical distancing is not an option. In the narrowest alleys and most decrepit places of urban blight, exposure to air pollution, noise, and even waste matter is common.

Violence, abuse, and criminality could also be rampant social ills in these quarters, which can further aggravate stressful quarantine conditions.

When they go around, the poor are reliant on public mass transport. In terms of traveling on their own, bicycles and motorcycles are the only viable but unsafe alternatives, considering unfriendly road conditions. Walking is a last-resort ordeal they are willing to undergo just to do essential activities like making a living.

Occupational conditions

Househelp, construction workers, itinerant vendors, mall employees, janitors and security guards all have work that can’t be done in the convenience of home. Most of them are not regular employees and are always on the brink of termination. They don’t have leave privileges; some don’t even have benefits. Some are lured to work in metropolitan areas and overseas to earn more, but choose to brave far worse labor conditions back home. They work themselves to death while taking home a meager income. (READ: ‘Walang-wala na’: Poor Filipinos fear death from hunger more than coronavirus)

Health-seeking behavior

Chief among the reasons for poor health-seeking behavior is not having enough financial means to pay for health care. The value of prevention over cure could unknowingly be wasted because of this. The poor would often seek health care with diseases that are already advanced in stage and fraught with complications and catastrophic health expenses. Low educational attainment and lack of access to information could also contribute. This can be compounded by the growing fear of having COVID-19 and the lack of means to survive it.

Access to health services and amenities

Since most are not formally employed and have low income, even with social health insurance, the poor can ill afford to be hospitalized. Out-of-pocket expenses to be treated and operated on could send a poor family to a more impoverished state. In geographically isolated areas, getting to a health facility that’s appropriate for a patient’s condition may mean moving mountains and walking on oceans. Telehealth and medicine is a good option but access to internet infrastructure and equipment may be limited. The cost of food and essential commodities, face masks, alcohol, and basic hygiene essentials, let alone maintenance medications to treat chronic diseases, can be prohibitive to the poor.

Other poverty-associated diseases like tuberculosis, hypertension, and diabetes can co-exist with and exacerbate COVID-19, making medical management more complicated and expensive.

Balanced and compassionate response to COVID-19

Regardless of the income level and health system capacities of pandemic-affected localities, under lockdown or not, the plight of the most vulnerable — the poor and marginalized — should be topmost priority. 

This can be done by making the response more balanced. It should offer both medical and socioeconomic solutions. Lives cannot be saved from the coronavirus if basic issues of daily living are neglected.

Medically, strategies don’t only need to be done just for the sake of doing them. They need to also consider inclusion, quality of care, and responsiveness. Being poor and marginalized doesn’t make people less of a patient. Instead, they should be triaged as the most important patient for the health sector’s prevention, testing, isolation, and treatment services. (READ: [ANALYSIS] Universal healthcare: Why we’re still not quite there yet)

In socioeconomic terms, they should be first on the list of beneficiaries for the government’s programs for labor and employment, social amelioration, and basic infrastructure and services (housing, transport, communications, education).

Lastly, as COVID-19 cases are steadily increasing and our health care system is slowly being stretched, a call for the dying art of compassion is necessary. Pursuing health inequity as an issue is one. Shifting our mindset from thinking beyond ourselves, our individual privileges, our personal COVID-19 risks to putting the good of the majority — the poor and marginalized – first and foremost is another.

Motivated by compassion, our coronavirus response can provide some sanity in these strange times and lend some fairness in this unfair world. – Rappler.com

Ronald Law is a physician, public health specialist in emergency and disaster management, and professor of public health. He was formerly an Australian leadership fellow and a US-ASEAN Fulbright scholar.