Covid-19 has disrupted modern society. Globally, the refrain of “we’re all in this together” resounds. However, covid-19 does not impact everyone equally, prompting calls to account for the needs, vulnerabilities, and violations experienced by women, migrants, people with disabilities, and older people. The lack of gender analysis, including sex-disaggregated data, has been especially criticized. [1,2]

Having gained traction in global health, intersectionality moves beyond such siloed approaches and offers a platform to radically rethink covid-19 for the following reasons. [3] Firstly, intersectionality refuses a pre-determined hierarchy of vulnerable groups. Secondly, it rejects a universal conception of their experiences. Third, intersectionality shows that risks and impacts are shaped by a web of intersecting factors, including age, sex, gender, health status, geographic location, disability, migration status, race/ethnicity, and socioeconomic status (SES). Finally, intersectionality examines how factors experienced at individual and group levels are shaped by processes and structures of power (e.g., capitalism, globalization, patriarchy, racism, nationalism, and xenophobia) to create an interplay of advantages and vulnerabilities. [4]

Take for example early data indicating that males, older people and those with underlying conditions are at greater risk of severe illness and death. [5,6] Accounting for sex, age, and health co-morbidities is important, but it does not capture the disparities in distribution of these risk factors. For instance, risks of cardiovascular disease and diabetes are heightened for ethnic minorities in high-income countries, as well as for Indigenous populations living in remote and impoverished locations. [7,8] Where data on race and ethnicity is available, alarming rates of covid-19 infection and death are being reported among Black and Asian minority ethnic population in the UK and African-Americans in underserved communities. [9] Specific risks, including lack of basic amenities like housing, healthcare, and culturally and linguistically accessible information on covid-19, also place other groups, like low-income migrants and refugees, at greater danger of infection and death. [10]

Regarding prevention strategies, homeless people, those living in slums, low-income migrants, and refugees residing in camps and detention centres face particular challenges. These environments lack space, food, water, and sanitation facilities necessary to maintain hygiene or practice physical distancing. Meanwhile, the care burden of the pandemic, while gendered, is not evenly distributed. Single mothers, those with precarious employment without social security, and women in frontline caring, domestic and health work, are worse off. Staying at home also increases the risk of gender-based violence for women and also LGBTI populations; among these poorer women, people from ethnic minorities, and disabled women are likely to have less access to resources or support to exit abusive relationships. These examples underscore the need to not only collect data on a wide range of factors, but also explore how they interact to shape covid-19 risks and responses.

Intersectionality furthermore reveals how interacting processes and structures of power shape the context for covid-19. Capitalism and neoliberal economic globalization sharpen competition over covid-19 supplies. Fights against the pandemic reveal racism, xenophobia, and scapegoating of some groups (e.g., religious minorities in India, migrant workers pathologized as vectors, Trump deeming covid-19 a “Chinese” virus). [11] Nationalistic impulses compound these trends, resulting, for example, in the US and Germany blocking shipments of needed medical equipment and supplies to other countries. 

Bringing intersecting disadvantages to the fore can ensure a more equitable and effective response to covid-19. This requires inclusive research and coalition building across single-axis campaigns, as well as asking tough questions about power: Who determines priorities, who benefits and who is left behind in global and nation-state pandemic responses? Answers can reveal where power lies and how people can challenge it.

Olena Hankivsky is Director of the Centre for Health Equity and Research Chair in Gender and Equity at the Melbourne School of Population and Global Health, University of Melbourne. She is formally founder and Director of the Institute for Intersectionality Research and Policy, Simon Fraser University, Canada.

Anuj Kapilashrami is Senior Lecturer in Gender and Global Health Policy at the Centre for Global Public Health, Institute for Population Health Sciences in Queen Mary University. She’s also Visiting Senior Research Fellow of the United Nations University-International Institute for Global Health (IIGH), Malaysia. Twitter: @AKapilashrami

Competing interests: None declared

References:

1] Wenham C, Smith J, Morgan R. COVID-19: the gendered impacts of the outbreak. Lancet 2020;395 (10227): 846–48.

2] Purdie A, Hawkes S, Buse K, et al. Sex, gender and COVID-19: disaggregated data and health disparities. BMJ Global Health Blog 2020, March 24, 2020. https://blogs.bmj.com/bmjgh/2020/03/24/sex-gender-and-covid-19-disaggregated-data-and-health-disparities/ (accessed March 4, 2020).

3] Kapilashrami A, Hankivsky O. Intersectionality and why it matters to global health. Lancet 2018;391(10140):2589–91.

4] For further guidance see Hankivsky O (ed.). An Intersectionality-Based Policy Analysis Framework. Vancouver, BC: Institute for Intersectionality Research and Policy; 2012.

5] The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020. CCDC Weekly 2020;2(x):1-10. http://www.ourphn.org.au/wp-content/uploads/20200225-Article-COVID-19.pdf (accessed March 12, 2020).

6] Wang W, Tang J, Wei F. Updated understanding of the outbreak of 2019 novel coronavirus (2019‐nCoV) in Wuhan, China. J Med Virol 2020;92(4);441–47.

7] Di Cesare M, Khang YH, Asaria P, Blakely T, Cowan MJ, Farzadfar F, Guerrero R, Ikeda N, Kyobutungi C, Msyamboza KP, Oum S. Inequalities in non-communicable diseases and effective responses. Lancet 2013;381(9866):585–97.

8] Yeates K, Lohfeld L, Sleeth J, Morales F, Rajkotia Y, Ogedegbe O. A global perspective on cardiovascular disease in vulnerable populations. Can J Cardiol 2015;31(9):1081–93.

9] Williams. V. U.S. government is urged to release race, ethnicity data on covid-19 cases. Washington Post. Politics April 6, 2020.; Razaq, A. et al. Are UK BAME populations at increased vulnerability from COVID-19? CEBM. 05 May 2020. https://www.cebm.net/covid-19/bame-covid-19-deaths-what-do-we-know-rapid-data-evidence-review/

10] Kluge HH, Jakab Z, Bartovic J, D’Anna V, Severoni S. Refugee and migrant health in the COVID-19 response. Lancet 2020; Mar 31. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30791-1/fulltext (accessed March 10, 2020).

11] Kapilashrami, A, and Kamaldeep B. “Mental Health & COVID-19: is the virus racist?.” The British Journal of Psychiatry (2020): 1-6. Accepted 30 April 2020.