in the Shadow
Why are poor people more likely to contract the coronavirus?
Almost all the towns and cities with a high number of corona patients are at the bottom of the Central Bureau of Statistics (CBS) socioeconomic rankings. Why are poor people more likely to get ill? Experts cite several reasons: overcrowded living conditions, lack of access to the media, inability to work from home, greater use of public transport, and reduced accessibility to medical treatment. They say that these factors are not unique to Israel.
A Shomrim analysis
May 22, 2020
When the coronavirus epidemic broke out in Israel, experts came to television studios and warned about the spread of the virus. They explained that the virus does not distinguish between people and that everyone has the same chance of being infected and contracting the disease. A little more than two months and 17,000 patients later, it has become apparent that this warning was only partially true. While the virus does not distinguish between people and everyone has an equal chance of being infected, a cross־check of data from the Ministry of Health and the CBS shows that the percentage of people in Israel who contracted corona was far higher among the poor than among the affluent.
The CBS data refers to socioeconomic "clusters," which divide Israel’s 255 towns and cities into ten groups: cluster 1 includes the poorest communities and cluster 10 the richest. The Ministry of Health data comes from the daily reports of the corona morbidity rates per district. This data shows the number of patients per 100,000 residents, even if a town’s population is below this number. An examination of the list of towns and cities with the highest percentage of corona cases shows that the vast majority belong to the lowest clusters; among the richest clusters, the rate of morbidity was negligible to zero.
What is the reason for this? How can the data be explained? Are these findings unique to Israel or similar in other countries? We asked an epidemiologist, a public health expert, and a social activist for answers to these questions.
Who cannot work from home?
Omer Lovton is a young social activist who is the secretary of the social justice department of the Histadrut (General Organization of Workers in Israel). Lovton has no professional medical background but claims to have gained a lot of experience in cross־checking data during the political campaigns in which he has participated. When the corona crisis erupted, the warning lights flashed in his mind. "Workers began to contact us to find out about their rights. I noticed that they were coming from the periphery of the country, from delivery people, cashiers, packers, etc. When I began to check the common denominator, I discovered that the morbidity rate in poor towns was significantly higher, even though the number of tests carried out in these towns and cities was much lower." This policy only changed in the middle of April with the start of widespread testing, and then it became apparent that the gap between rich and poor communities was even greater than previously thought. For example, Ministry of Health figures from May 15 show the following morbidity rates per 100,000 people: the Bedouin town Hura – 736; Deir al־Asad – 458; Bnei Brak – 319; Mitzpeh Ramon – 160; Bet Shemesh – 140. By comparison, morbidity rates on the same day show: Bat Yam – 44; Shoham – 38; Tel Aviv – 28; Zichron Yaakov – 9. The data also shows a number of exceptions, which will be discussed below.
Why is the incidence of coronavirus higher in poor communities? Lovton says there is a combination of factors: "It is a question of different kinds of accessibility. To a car, for example. Or to the media. To generalize, people at a higher socioeconomic level receive much of their information from various media outlets and act accordingly. It is also much easier for them to adhere to social distancing – their homes are more spacious and they don’t use public transport. It is relatively easy for them to work from home. For example, lawyers moved to working on Zoom very quickly. Delivery people, cashiers, and packers cannot work like this."
"My father, for example, is a self־employed window installer. As soon as the lockdown over Pesach was lifted, he returned to work and had to come in close contact with workers and clients. The well־off are less worried about their livelihood; they tell themselves reasoning that they will stay at home for an extra week – nothing will happen if they take a few more holiday days."
Professor Manfred Green is an epidemiologist with a rich resume in the field of public health who currently heads the international master’s program in Public Health at the University of Haifa. He concurs with the connection between morbidity rates and socioeconomic levels but notes that cultural and social habits are also significant: "We are talking about two main sectors of the population – the ultra־Orthodox and the Arabs. Among the ultra־Orthodox, large families live in small apartments, which encourages the spread of any disease. We saw this last year with the measles. The ultra־Orthodox are the most susceptible to the spread of epidemics. Similarly, among the Arab population, people live in crowded homes, many of them in large clans."
Professor Nadav Davidovitch heads the school of Public Health at Ben- Gurion University. He has a slightly different take on the socioeconomic issue. Davidovitch says that the virus first came to the country via Israelis on a high socioeconomic level who returned from aboard. It then spread rapidly to the densely populated areas of the country where, at least at the start of the outbreak, there were also problems of sharing information.
Davidovitch distinguishes between the ultra־Orthodox and Arab sectors. At the start of the outbreak, the ultra־Orthodox did not think that the coronavirus was "something so bad" and therefore were not careful about social distancing. Once they understood the seriousness of this situation, this sector suffered because of the high population density and also because many ultra־Orthodox visitors flew in from New York where the morbidity levels were extremely high.
"The Arab sector, on the other hand, did actively fight the spread of the coronavirus but were faced with the problem of accessibility to testing and medical treatment. We can now say that, on the whole, the coronavirus epidemic was a success story in the Arab sector: in most places the number of cases and fatalities was extremely low."
Davidovitch adds that there is a clear connection between socioeconomic level and morbidity and mortality rates. "There seems to be a rule, the world over unfortunately, that poorer sectors of the population tend to be less healthy and have reduced accessibility to health services. In Israel this is the case because of the privatization of the health system and market failures among other reasons . For example, competition that is meant to benefit the patients by improving accessibility takes place mainly in the center of the country and less in peripheral areas."
Both of these public health experts agree that the coronavirus is just one more link in the chain of epidemics and viral diseases that cause more harm among poor people. For those who have already forgotten, less than one year ago, we were faced with a measles outbreak. Professor Green reminds us "there is a vaccination for this disease, but among the ultra־Orthodox sector there was a problem because their vaccination levels were not high enough. Measles was seen mainly in this sector."
The Ministry of Health data from July 2019 about the measles outbreak are very clear. Of the 4292 cases of measles, 1444 were recorded in Jerusalem, 422 in Bet Shemesh, 279 in Tsfat, 240 in Beitar Illit, and 212 in Bnei Brak [all are cities with large ultra־Orthodox populations]. In contrast, only 4 cases were reported in Givatayim for the same period, 1 case in Savyon, and 1 in Omer. 121 cases were recorded in Tel Aviv־Yafo.
Professor Davidovitch told us: "It is true that the ultra־Orthodox population was a central player in the most recent measles outbreak, however, as far as vaccination is concerned, there is an interesting phenomenon: lower socioeconomic populations actually have higher vaccination levels. In this context, the ultra־Orthodox are an exception, while the Arab population has above־average vaccination rates.
Between Bnei Brak and New York
"If it is of any comfort, the poor in Israel are not alone in their higher morbidity rates," recounts Lovton. " In New York, the incidence of corona among the African American population is almost 8 times higher than among white people. And there is more: among African Americans in New York, the mortality rate from corona is around 100 per 100,000 people; among the Hispanic population, the rate stands at 75 per 100,000; and among whites, only 42. In other words, the death rate among Hispanic people is 50% higher and among African Americans 100% higher than among white people."
Professor Green said: "When we talk about socioeconomic level, we are referring mainly to cramped living quarters and inferior living conditions. This is not a question of biology. Unfortunately, the minorities are often poorer and live in conditions that are a recipe for the spread of epidemics. This is the main explanation and everything else is just an extra factor. Nevertheless, it should be noted that the African American population in the United States also has other risk factors – obesity, diabetes, and hypertension. This is probably connected to lifestyle and also an outcome of poverty because of diets based on cheap, high־calorie products that have less nutritional value. These risk factors usually greatly increase the risk of becoming severely ill if and when people contract corona, and this explains the high mortality rates."
Professor Davidovitch: "In New York too, the disease began among people with a high socioeconomic status and quickly spread to poorer sectors of the population. The official reaction to the spread in New York was very slow in coming, and poor people in the city have very limited access to healthcare."
The fact that the poor contract coronavirus at higher rates does not necessarily mean that the rates among richer people are lower. The experts we interviewed for this report note that there were also outbreaks in communities with a higher socioeconomic level, and they offer various explanations for this. Lovton recalls the case of Even Yehuda, a town in the cluster 8 according to CBS, where there was a large outbreak at the beginning of the crisis. "The residents there did not stop going to synagogue, the health regulations were late in coming, and people did not exactly comply with them. This also happened in other relatively affluent communities, especially in the first week or two when people had not yet understood what we were dealing with."
In Italy, which was one of the most hard־hit countries in the world, the epicenter of the outbreak was in Lombardy, the richest region of the country. Professor Davidovitch explains: "A number of factors came together in Lombardy. First of all, people from morbidity hotspots such as China had visited Lombardy. In addition, the area has a very high percentage of older residents, and the authorities reacted very slowly and very late. Above all, the health system in northern Italy has been privatized, unlike other regions, such as Tuscany, which have strong public health systems."
"We have to be suspicious of people who say they know what the future holds," says Professor Davidovitch. "We have finished with the first wave, but we have clearly not reached the stage of herd immunity. At this point, we cannot even know with certainty what percentage of the population contracted the virus or whether some people have a certain degree of immunity to the current coronavirus (Covid–19) because of the other coronaviruses that affect the population every winter. Of course, the million־dollar question is whether the virus will return in the winter. It is clear that we should now be preparing for this possibility, but I am not only referring to hospitals. We should also be reinforcing healthcare services in the community and public health services that have been significantly weakened in recent years, as was seen in the State Comptroller’s report which was published during the corona outbreak. We also need to reinforce the additional aspects that affect our health including mental health care and social services."
Professor Green, on the other hand, insists on remaining in the medical field: "We are still at the beginning. Obviously, we all hope that this will not be the case, but the ease with which the virus spreads from one person to the next means that we will probably get through the summer relatively easily, but when fall arrives, we will probably begin to see another spike in the number of cases. We may possibly see a larger wave next winter than what we have experience so far. I believe that a vaccination will only be available in another year or maybe even later."
Do we have to end on such a pessimistic note?
"I’ll end with something optimistic: I expect that palliative care will be better in the next round. More severely ill patients will survive."
The report was published together with HaMakom Independent Magazine.