Seeking to enhance health equity and social justice, a recent commentary co-authored by University of Iowa College of Public Health researchers argues that the definition of people most at risk for COVID-19 illness and death should be expanded beyond biological factors to include social factors.

The most common definition for those most at risk for COVID-19 habitually focuses on biological factors such as age and pre-existing chronic health conditions, despite evidence of health disparities linked to social, economic, and political factors. Inequitable social conditions have been found to play a significant part in COVID-19 infections and outcomes, as they have with all other health outcomes, state the authors who include College of Public Health researchers Rima Afifi, Nicole Novak, and Paul Gilbert.

COVID-19 prevention strategies, such as hand washing, physical distancing, sheltering-in-place, and self-isolation when sick, are most accessible to privileged individuals—those with secure housing, financial resources, social support, access to medical care, and white-collar professions that easily transition to remote work. Access to these resources is limited or unavailable to groups that are disadvantaged based on gender, race, ethnicity, social position, education, class, physical and cognitive ability, sexual orientation, and citizen status.

“It is clear—even at this early stage of the pandemic—that inequitable social conditions lead to both more infections and worse outcomes,” the authors write in their commentary published in Preventive Medicine.

Recent data from large U.S. cities as well as more rural states show significant patterns of inequitable mortality from COVID-19 by race and ethnicity. Similar inequities among minority groups are found globally.

The authors point out that the risk of exposure to COVID-19 is higher in crowded settings such as jails, immigrant detention centers, refugee camps, homeless shelters, inner city housing complexes, indigenous people’s reservations, impoverished communities, naval ships, and crowded workplaces, among others. Those without housing or with inadequate, insecure, or crowded housing lack even the most basic resources to wash their hands or enact physical distancing.

The authors call for the collection of data on social factors as part of the analysis of COVID-19 morbidity and mortality, as well as including social factors in decision-making to identify risks and plan strategies for COVID-19 and all other health outcomes.

Additionally, when a coronavirus vaccine becomes available, the authors advocate “that vaccines become rapidly accessible to those most at risk as a result of both biological and social vulnerabilities.”

“In our prevention and mitigation responses, we must prioritize the most socially vulnerable to begin to reverse disparities and health inequities,” the commentary concludes.

Additional co-authors include Bernadette Pauly, University of Victoria School of Nursing; Sawsan Abdulrahim, American University of Beirut; Sabina Faiz Rashid, BRAC University; Fernando Ortega, Universidad San Francisco de Quito; and Rashida A. Ferrand, London School of Hygiene and Tropical Medicine.