A response by Nathan Grills, Millicent Hedditch, Xiao Jing Ong
7 MINUTE READ
Editor’s note: In 2021, one of our online readers asked if Luke’s Journal would be able to source an article giving some insight into the lag effects of the COVID-19 pandemic on different aspects of society. Two masters students, Millicent Hedditch and Xiao Jing along with their supervisor Professor Nathan Grills, made the following submission.
The COVID-19 pandemic has affected more than 500 million people globally, with 6.2 million lives taken1. As well as the direct health effects of the disease, there are a number of other ongoing impacts.
Social restrictions, such as lockdowns, have protected us from sickness, but have resulted in negative effects that will continue to be felt long after the pandemic has ended. They have had enormous impact on the social determinants of health, including the healthcare system, socioeconomic status, food security and access, as well as education2. This review explores COVID-19’s implications on the social determinants of health in low and middle-income countries.
The pandemic has stressed health systems worldwide. Hospital overcrowding, overworked doctors and nurses, workforce shortages and resource scarcity have been common. Many low and middle-income countries have been overburdened by COVID-19 due to the lack of expertise, infrastructure and human resources, as well as the finances needed to respond3.
A cross-sectional study in India reported high levels of emotional distress in healthcare professionals, including anxiety, depression, insomnia and even self-harm among frontline healthcare workers4,5. These psychological impacts on health workers were due to long working hours, heavy workload, insufficient Personal Protective Equipment (PPE), and the fear of transmitting the disease to family members6.
“The health systems of low-income countries are the most vulnerable.”
The health systems of low-income countries are the most vulnerable7. A survey conducted by the World Health Organisation (WHO) found services for non-communicable diseases (NCDs), such as hypertension and diabetes, were commonly disrupted8. Health staff working in NCD areas were largely reassigned to support COVID-19 services. COVID-19-related disruptions have also reduced screening, diagnoses, and treatment for cancer. Ghosal et al9 projected that the duration of lockdowns would be directly proportional to the worsening of glycaemic control in people with diabetes and would increase diabetes-related complications.
Other significant problems with COVID-19 in low-to-middle-income countries include unemployment, poverty, and food security10. Disease impact and public health measures (such as lockdowns and international border closures) collectively caused a global economic recession and a rise in poverty. The World Bank11 estimated that 88 million people would be pushed into “extreme poverty” in 2020 and an additional 150 million by the end of 2021, reversing two decades of progress in poverty reduction. The pandemic has resulted in widespread livelihood loss, worse in lower- and middle-income countries. Millions of businesses have shut their doors, and unemployment has skyrocketed12. Workers in the informal sector have little social protection and are at risk of being pushed into poverty.
The International Labour Organisation13 estimated that these measures would lead to the loss of employment for 195 million people. Another projection suggested that lockdown measures, combined with the limitation of personal freedom and food system disruption, could result in the gross national income (GNI) of low-to-middle income countries decreasing by an average of 7.9%12,14. The World Food Programme estimated this would lead to a doubling of the number of people suffering from food insecurity15.
“Without social and economic relief measures, many households fell into poverty and experienced food insecurity. This resulted in childhood malnutrition and associated child mortality.”
Using Africa as an example, public health policies designed to contain the pandemic resulted in declining economic activity and a reduced household income16. Without social and economic relief measures, many households fell into poverty and experienced food insecurity. This resulted in childhood malnutrition and associated child mortality. Consequently, there is a need to provide economic relief measures to protect vulnerable communities from falling into extreme poverty12.
Education level as a social determinant is strongly correlated with life expectancy, morbidity and health behaviours17. Yet education has been severely compromised in nearly every country. In order to slow transmission and protect health systems, most countries closed schools, resulting in an unprecedented interruption to education. While concerted efforts have been made to maintain learning during this pandemic, The United Nations Children’s Fund18 (UNICEF) estimates that more than 1 billion children were deprived of adequate education. In India, lengthy school closures exacerbated existing inequalities in education, widening the gap in literacy between the rich and poor. The learning poverty rate (the proportion of 10-year-olds unable to read a short and age-appropriate text) is expected to increase by 10% in low and middle-income countries due to COVID-19-related school closures19.
“In India, lengthy school closures exacerbated existing inequalities in education, widening the gap in literacy between the rich and poor.”
School closures have other important consequences. Notably, school closures will exacerbate poverty. For example, a child who loses one-third of a school year reduces their income potential by approximately 3%20. For students living in poverty, schools are often a place for eating healthily. The temporary interruption in school feeding programs such as the Midday Meal (MDM) program in India has increased food insecurity, especially for students who are already undernourished. The United Nations15 reported that nearly 369 million children who normally rely on school meals for a reliable source of daily nutrition were forced to find food elsewhere. Children also stopped receiving routine health care from school-based health programs21. In addition, child abuse and neglect levels have likely increased during COVID-19 school closures22.
To tackle the issue of school closure, home-schooling and the use of remote teaching via online learning have been introduced. However, the COVID-19 crisis in India highlighted the digital learning divide faced by students23. Research conducted by Azim Premji Foundation, an Indian non-profit organisation, revealed that almost 60% of children could not access online learning opportunities for reasons such as lack of access to technology. The number of students unable to access online learning is far higher in low resource settings 24. To alleviate these inequalities, COVID-19-safe in-person teaching options should be explored and low-tech solutions implemented.
The other social determinant that has been dramatically affected by lockdowns and COVID-19 itself is fabric underpinning socialisation and community25. Indeed, various publications outline the division and stigma that restrictions and fear led to 26. This was also seen in religious communities who were restricted from meeting at the very time when such community was most needed. Some have suggested that religious communities may have been permanently disrupted, which may have longer term effects on community cohesion and, in turn, health27.
In summary, the spread of coronavirus has had immense human, social and economic costs that will affect health long after the pandemic ends. Many social determinants of health, including socioeconomic background, education, mental health and well-being, food security and healthcare access, have been considerably impacted. The COVID-19 pandemic has had an inequitable and disproportionate impact on the poor and those in low and middle-income countries. To avoid a health crisis that will play out over decades, public policy and the public health response to COVID-19 must be designed in such a way to limit the impact on these social determinants of health.
Professor Nathan Grills is a Public Health Physician at the University of Melbourne who has spent considerable time also working in global public health - particularly in India. During the covid-19 pandemic, he has been supervising students, Millicent Hedditch and Xiao Jing Ong, in looking at the social determinants and ongoing effect of the pandemic affecting public health. Millicent Hedditch is a 3rd year Bachelor of Biomedicine at the University of Melbourne. She is currently majoring in anatomy but has a keen interest in public health and biomedical research. Xiao Jing Ong is a Biomedicine Honours student at the University of Melbourne with a strong interest in public health. She was part of the Melbourne University Global Health Mentoring Program, which is an initiative that provides opportunities to students to discuss current public health issues and campaign for more awareness. Currently, she is involved in cancer research at the Peter MacCallum Cancer Institute.
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- Worldometers.info. COVID-19 Live Update, <https://www.worldometers.info/coronavirus/> (2022).
- Orgera, K., Garfield, R. & Rudowitz, R. Implications of COVID-19 for Social Determinants of Health, <https://www.kff.org/coronavirus-covid-19/issue-brief/tracking-social-determinants-of-health-during-the-covid-19-pandemic/> (2021).
- Hamid, H. et al. Current burden on healthcare systems in low- and middle-income countries: recommendations for emergency care of COVID-19. Drugs Ther Perspect, 1-3, doi:10.1007/s40267-020-00766-2 (2020).
- Raj, R. et al. Psychological impact of the COVID-19 pandemic on healthcare workers in India: An observational study. J Family Med Prim Care 9, 5921-5926, doi:10.4103/jfmpc.jfmpc_1217_20 (2020).
- Banerjee, D. et al. Impact of the COVID-19 pandemic on psychosocial health and well-being in South-Asian (World Psychiatric Association zone 16) countries: A systematic and advocacy review from the Indian Psychiatric Society. Indian J Psychiatry 62, S343-s353, doi:10.4103/psychiatry.IndianJPsychiatry_1002_20 (2020).
- Spoorthy, M. S., Pratapa, S. K. & Mahant, S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review. Asian J Psychiatr 51, 102119, doi:10.1016/j.ajp.2020.102119 (2020).
- Blanchet, K. et al. Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. BMJ Global Health 5, e003675, doi:10.1136/bmjgh-2020-003675 (2020).
- World Health Organisation (WHO). COVID-19 significantly impacts health services for noncommunicable diseases, <https://www.who.int/news/item/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases#:~:text=More%20than%20half%20(53%25),and%2031%25%20for%20cardiovascular%20emergencies.> (2020).
- Ghosal, S., Sinha, B., Majumder, M. & Misra, A. Estimation of effects of nationwide lockdown for containing coronavirus infection on worsening of glycosylated haemoglobin and increase in diabetes-related complications: A simulation model using multivariate regression analysis. Diabetes Metab Syndr 14, 319-323, doi:10.1016/j.dsx.2020.03.014 (2020).
- Gopalan, H. S. & Misra, A. COVID-19 pandemic and challenges for socio-economic issues, healthcare and National Health Programs in India. Diabetes Metab Syndr 14, 757-759, doi:10.1016/j.dsx.2020.05.041 (2020).
- The World Bank. COVID-19 to Add as Many as 150 Million Extreme Poor by 2021, <https://www.worldbank.org/en/news/press-release/2020/10/07/covid-19-to-add-as-many-as-150-million-extreme-poor-by-2021> (2020).
- Laborde, D., Martin, W. & Vos, R. Poverty and food insecurity could grow dramatically as COVID-19 spreads, <https://www.ifpri.org/blog/poverty-and-food-insecurity-could-grow-dramatically-covid-19-spreads> (2020).
- International Labour Organization. ILO Monitor: COVID-19 and the world of work, <https://www.ilo.org/wcmsp5/groups/public/—dgreports/—dcomm/documents/briefingnote/wcms_740877.pdf> (2020).
- Headey, D. et al. Impacts of COVID-19 on childhood malnutrition and nutrition-related mortality. Lancet 396, 519-521, doi:10.1016/s0140-6736(20)31647-0 (2020).
- United Nations World Food Programme. COVID-19 will double number of people facing food crises unless swift action is taken, <https://www.wfp.org/news/COVID-19-19-will-double-number-people-facing-food-crises-unless-swift-action-taken> (2020).
- Arndt, C. et al. Covid-19 lockdowns, income distribution, and food security: An analysis for South Africa. Global Food Security 26, 100410, doi:https://doi.org/10.1016/j.gfs.2020.100410 (2020).
- The Lancet Public Health. Education: a neglected social determinant of health. The Lancet Public Health 5, e361, doi:10.1016/S2468-2667(20)30144-4 (2020).
- UNICEF. COVID-19 and School Closures: One year of education disruption, <https://data.unicef.org/resources/one-year-of-covid-19-and-school-closures/> (2021).
- UNESCO. COVID-19: Two-thirds of poorer countries are cutting their education budgets at a time when they can least afford to, <https://en.unesco.org/news/COVID-19-two-thirds-poorer-countries-are-cutting-their-education-budgets-time-when-they-can> (2021).
- Hanushek, E. A. & Woessmann, L. The Economic Impacts of Learning Losses, <https://www.oecd.org/education/The-economic-impacts-of-coronavirus-COVID-19-learning-losses.pdf> (2020).
- Hoffman, J. A. & Miller, E. A. Addressing the Consequences of School Closure Due to COVID-19 on Children’s Physical and Mental Well-Being. World Med Health Policy, doi:10.1002/wmh3.365 (2020).
- Abrams, E. M. & Szefler, S. J. COVID-19 and the impact of social determinants of health. The Lancet Respiratory Medicine 8, 659-661, doi:10.1016/S2213-2600(20)30234-4 (2020).
- Grills, N., Gilbertson, A., Dey, J. & Deuchar, A. India’s COVID-19 divide in digital learning, <https://pursuit.unimelb.edu.au/articles/india-s-COVID-19-19-divide-in-digital-learning> (2021).
- Bheemeshwar, R. A., Jose, S. & Vaidehi, R. Of Access and Inclusivity Digital Divide in Online Education. Economic and Political Weekly 36, 23 – 26, doi:https://doi.org/10.48550/arXiv.2107.10723 (2021).
- The British Academy. The COVID Decade: understanding the long-term societal impacts of COVID-19. (2021). <https://www.thebritishacademy.ac.uk/publications/covid-decade-understanding-the-long-term-societal-impacts-of-covid-19/>.
- Mathias, K., Rawat, M., Philip, S. & Grills, N. “We’ve got through hard times before: acute mental distress and coping among disadvantaged groups during COVID-19 lockdown in North India – a qualitative study”. Int J Equity Health 19, 224, doi:10.1186/s12939-020-01345-7 (2020).
- Pillay, J. COVID-19 Shows the Need to Make Church More Flexible. Transformation 37, 266-275, doi:10.1177/0265378820963156 (2020).