Poverty, health, and covid-19
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n376 (Published 12 February 2021) Cite this as: BMJ 2021;372:n376Read our latest coverage of the coronavirus outbreak
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor
The excellent response from Dr Rhein highlights the importance of repleting Vitamin D deficiencies during viral pandemics. Vitamin D is not a drug but a very important essential nutrient which is antiviral. Blood levels can be measured and low Vitamin D levels have been found particularly in the old, poor and those with darker skins. There is no need to wait for results from lengthy drug-type Randomised Double Blind Control Trials before recommending 4000 ius of Vitamin D.
Recommending 400ius/day will not replete severe deficiencies.
Competing interests: No competing interests
Dear Editor
Thank you, Margaret Whitehead, for highlighting the plight of the recurring misery of the poor: in most past pandemics the less well off fared worse than the affluent. Apart from a fundamental redistribution of wealth, which seems remote, the only remedy I would suggest now: allow the humble vitamin D to work (1). We have widespread vitamin D deficiency in the UK, 40-60% are below optimal blood levels which affects resistance to any microbes, bacteria or viruses (2,3). We also know that vitamin D deficiency is more prevalent in lower social classes (4). Unlike wealth redistribution, recommending adequate vitamin D doses or even distributing them can be done instantly.
Why do CMO's hesitate?
(1) https://vitamindforall.org/letter.html
(2) https://www.clinicalnutritionjournal.com/article/S0261-5614(20)30639-7/fulltext
(3) https://www.mdpi.com/2072-6643/12/7/2097
(4) https://www.foodstandards.gov.scot/downloads/Report_Final.pdf
Competing interests: No competing interests
Dear Editor
COVID-19 and Discrimination
The number of COVID-19 cases is less in under developed countries than the developed nations.
COVID-19 does not discriminate in infecting people based on their economic status.
Countries with more hygienic behaviours are affected more by COVID-19 in the current COVID-19 Pandemic.
But during this Pandemic poor people are more affected because of less income due to economic recession.
So people with poverty are affected with many health issues along with the COVID-19 infection during this Pandemic.
COVID-19 is the cause for discrimination even after death, whether people are rich or poor during this Pandemic.
Competing interests: No competing interests
Dear Editor:
We are living in an unpleasant situation, a state of stupor and insensibility. One of the saddest pictures we see daily on streets of main Colombian cities is the presence of large numbers of indigent people; people collections of all sorts, children, schoolboys, workers in uniform, girls, students, men, women, circulating, with prostrated physical energies and mental activities; extremely reduced to serious suffering and great debility, excessively irritable; very furious with their political leaders; against their president and their respective regional governing representatives in Republic’s Congress, enraged with whole world. We see a lot of people lack freedom, education, opportunities, employment, and equity. Many of them are lining up in squares outside buildings where the main stations of official entities providing health services are located, with the purpose of requesting an appointment with a doctor for their care. Every day many children gather to ask for money at places located near to traffic lights.
Inside those cities there are neighborhoods where people live in the deepest poverty, sticky heat places plunged in forgetfulness and abandonment, without identity or roots of origin, where stilt and zinc slums are, and where mud and garbage every day grow and grow.
A similar and cruel panorama is also observed in rural, and suburban areas of those cities. The misery is the same, there are big poverty extensions, fields and villages with dirty and unpaved places, people living in small, dark, damp and badly ventilated places, rain and humidity do not change. There do not exist schools, nor aqueduct, nor decent neighborhoods or healthy places for recreation.
Nobody reacts and wants to solve those problems; for national government apparently those poor places do not exist, nor do their inhabitants; there has never been a coherent and truthful policy of any president, or of any minister, representative or official who really wants to take those places forward. The State abandoned people to their misery long ago. During pre-electoral campaigns those places are visited by several presidential candidates full of pretty words, superficialities, and promises, who commit only if they are elected to solve the problems. However, after being elected they do not return to those places and no progress is seen.
The root causes of people's health problems are in those above mentioned adverse living conditions in miserable places. Respiratory diseases constitute an enormous burden on those poor communities. The atmosphere of infectious diseases is mainly influenced by manners, habits, customs, and vices, which are generated as a product of a bad distribution of economic resources in a community. They have a great impact upon the occurrence of those diseases. Paraphrasing our Nobel Prize in Literature, Gabriel Garcia Marquez, now, in the time of CoViD, we are in the same situation as living in the time of cholera, or in the time of smallpox, varicella, rubiola, leprosy, typhus or scarlet fever. The only and true paramount principle for solving people's health problems is by aggressively tackling their poverty.
Competing interests: No competing interests
Dear Editor
Whitehead and colleagues are right to highlight the impact of growing inequalities on health during the present pandemic.(1) We fully agree that without intensive immediate, and long-term action the health of disadvantaged individuals, families and communities will be disproportionately affected during the coming years: inequalities will increase.
Many doctors and nurses witness first-hand the detrimental effects of poverty on patients and their families’ health.(2) They will be well aware that social deprivation is a major determinant of poor health status. They will also be aware that for many public health problems including mental health, accident prevention, obesity, and lack of physical activity there are socioeconomic patterns and that the problems have common roots.
There is nothing new or unique about the existence of poverty and inequalities in health.(3) For example, Dickens and Zola eminent writers of the nineteenth century clearly described social and economic factors and the physical environment, that had major influences on families.(4-6) They brought attention to what they regarded as some of the key social issues of his time. Since then there has been a plethora of research on inequalities in health and the evidence for action is compelling.(3, 7-17) The growing health inequalities can, and should be stopped and reversed.
In order to ‘build back fairer’(17) there will need to be actions directed to all dimensions of health inequalities in all sectors of the population. We do, however, welcome the emphasis in the article by Whitehead and colleagues on children and the associated health inequalities and the specific strategies proposed to improve the situation.(1) In particular we endorse the call for reinvestment in Sure Start children’s centres and child mental health services. Addressing the health inequalities in BAME communities for all ages will also be a priority.
The institute of Health Promotion and Education believes that there is need for action at two levels to redress inequalities. We need a raft of social and economic policies and strong national leadership including a new independent national organisation to coordinate, monitor and drive forward actions across sectors.(18) At a local level directors of public health and their multi-disciplinary teams need to be adequately funded so that they can facilitate change by empowering communities and creating health promoting environments.(19-22)
In the past there has been too much focus on individuals rather than creating supportive and health enhancing environments. We need a shift in our thinking away from merely treating ill health and towards promoting positive health. This would include establishing health promoting hospitals, schools and workplaces.(23-24) For example, hospitals should be sites where the health of all staff is maintained and promoted. These broad-based approaches have the potential to reduce inequalities.
As we move out of the current pandemic a new positive health vision is required.(25) The evidence-based strategy should combine diverse but complementary approaches including fiscal measures, legislation, education and organizational change.(26) Crucially long-term investment is needed to protect and promote health and to ensure that all individuals, families and environments are resilient enough for future public health threats and health inequalities are reduced.
References
1) Whitehead M, Taylor-Robinson D, Barr B. Poverty, health, and covid-19. BMJ 2021;372:n376
https://www.bmj.com/content/372/bmj.n376
2) British Medical Association. Health at a price: reducing the impact of poverty, 2017.
https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p....
3) Benzeval M, Judge K, Whitehead M. (eds) Tackling inequalities in health: an agenda for action. London, SAGE Publications, 1995.
4) Dickens C. Oliver Twist. Ware, Wordsworth Editions Limited, 1992.
5) Dickens C. A tale of two cities. Oxford, Oxford University Press, 2008.
6) Zola E. Germinal. Oxford, Oxford University Press, 1993.
7) Black, D. Inequalities in Health: Report of a Research Working Group. London, DHSS, 1980.
8) Whitehead, M. The Health Divide: Inequalities in Health in the 1980's. London, Health Education Council, 1987.
9) Wilkinson R. Unhealthy Societies. The Afflictions of Inequality. London, Routledge, 1996.
10) Department of Health. Independent Inquiry into Inequalities of Health: Report (chairman, Sir Donald Acheson). London, The Stationery Office, 1998.
11) Wanless D. Securing Good Health for the Whole Population. Final report. London, HM Treasury, 2004.
12) Marmot M, chair. Fair society, healthy lives (the Marmot review). UCL Institute of Equity, 2010.
http://www.instituteofhealthequity.org/resources-reports/fair-society-he...
13) The Kings Fund. Inequalities in Life Expectancy. London: The Kings Fund, 2015.
https://www.kingsfund.org.uk/publications/inequalities-life-expectancy
14) British Medical Association. Health in all policies: health, austerity and welfare reform. London: British Medical Association, 2016.
http://bmaopac.hosted.exlibrisgroup.com/exlibris/aleph/a23_1/apache_medi...
15) Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Feb 2020.
https://www.health.org.uk/publications/reports/the-marmot-review-10-year...
16) Royal College of Paediatrics and Child Health. State of child health 2020. March 2020.
https://stateofchildhealth.rcpch.ac.uk/
17) Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. December 2020. London: Institute of Health Equity.
https://www.health.org.uk/publications/build-back-fairer-the-covid-19-ma...
18) Watson M C and Tilford S. Health promotion is at a crossroads with the demise of Public Health England. BMJ 2020;370:m3750.
https://www.bmj.com/content/370/bmj.m3750
19) Watson, M., and Tilford S. Directors of Public Health Are Pivotal in Tackling Health Inequalities. BMJ 2016;354:i5013
https://www.bmj.com/content/354/bmj.i5013.long
20) Watson M C and Lloyd J. Need for increased investment in public health BMJ 2016;352:i761.
https://www.bmj.com/content/352/bmj.i761
21) BMA. Funding for ill-health prevention and public health in the UK. May 2017.
http://bit.ly/2quLN3K
22) Watson M C and Thompson S. Government must get serious about prevention. BMJ 2018;360:k1279.
https://www.bmj.com/content/360/bmj.k1279
23) Watson, M. Going for gold: the health promoting general practice. Quality in Primary Care. 2008; 16:177-185. https://pdfs.semanticscholar.org/c1b6/3555f6b033effdc0062235adb7bab3de43...
24) Thompson S R, Watson M C, and Tilford S. The Ottawa Charter 30 years on: still an important standard for health promotion. International Journal of Health Promotion and Education. 2018,56(2), 73-84. https://www.tandfonline.com/doi/abs/10.1080/14635240.2017.1415765
25) Watson M C and Owen P. Public health priorities for 2020. Inequalities in 2020: time for a health strategy that unites the country. BMJ 2020;368:m544
https://www.bmj.com/content/368/bmj.m544
26) World Health Organization. Ottawa Charter for Health Promotion. Copenhagen: World Health Organization, 1986.
https://www.who.int/healthpromotion/conferences/previous/ottawa/en/
Competing interests: No competing interests
Re: Poverty, health, and covid-19
Dear Editor
Covid19 is just a new infection. No more.
Look back. When England became industrialised - too rapidly I would say - the villagers crowded in to centres of industry. At the same time poor Irishmen crossed St George's Channel, in their thousands.
Result. ? The poor people, Brits, Irish, squeezed in to shabby tenements, eating poorly, drinking plenty of beer.
Tuberculosis flourished.
Came WW2.
At its end, once again, industry flourished. And more workers were needed . They came from the West Indies,, Ireland, India,
Same story. Labourers squeezed in to tiny houses. Often, a dozen would sleep at night and go to the factories for day shifts. And their warm beds would be occupied by their friends, brothers, uncles, friends, from their villages across the Seas.
Around 1960 I saw such “houses in multiple occupation” .
Tuberculosis flourished again..
We can talk about levelling - till kingdom come.
In the 19th century, there were at least sone rich factory owners, some FRIENDS ( in the religious sense) who provided decent accommodation to their labourers.
Now? There are none.
Public Health? It is now talk, talk , talk.
What we need is - public health doctors who can not only organise and run services for children and the poor mothers.
What we need is a Central Government willing to fund locally run public health with funds used only for these services. The Centre can monitor what is going on, and it can criticise openly where there are faikures.
The local councillors can publicly discuss the functioning of the “public health departments”.
I am sure there are flaws in what I write.,
I welcome improvements.
Competing interests: Memories of public health problems and solutions