Iatrogenesis and harm in covid-19—when medical care ignores social forces

When we fail to recognise the systematically unequal social forces that drive the spread of disease, it can lead to harm, say Seth Holmes and colleagues

Covid-19 is at once a pandemic caused by an infectious and potentially deadly virus and also a syndemic at the nexus of important biological and social problems. We’ve seen a considerable amount of media coverage focused on how covid-19 exposes the stark inequalities within societies and across the world: we know that your odds of being infected by SARS-CoV-2 and having severe and deadly disease is shaped by social forces. Yet this awareness of the social dimensions of health is not just an important supplement to the core work of medicine. Rather, the covid-19 pandemic reminds us that ignoring social forces can lead us to commit misdiagnosis, mistreatment, and harm.  

For example, in the US, which has long led the industrialized world in social inequalities and related poor health outcomes, Black and Latinx people are significantly more likely than white people to die from covid-19, and working class people providing essential services are more likely to be exposed and infected. Governments have instructed people to “stay home,” while some continue conducting raids of immigrant communities, separating families, detaining people in overcrowded conditions that are ripe for viral spreading, and deporting people—all of which cause transnational spread of the virus. People who are homeless who thus cannot “shelter in place” face increased risks for infection. The same goes for those who are unable to “physically distance” because they are incarcerated or simply because they are tightly packed on mass transit to get to the low wage essential service jobs they depend on for income.

All of these inequities also increase a person’s risk for having already developed “pre-existing conditions” due to harmful living or working conditions, the effects of discrimination, and lack of preventive healthcare. And we know that having a pre-existing condition worsens a person’s odds of severe outcomes once infected with SARS-CoV-2. 

Not only can we do better for our patients; if we are to uphold the Hippocratic Oath, we must. 

When we misdiagnose the cause of the covid-19 pandemic as solely a virus, without acknowledging the critical role of an unequal social system, our misattribution can lead to iatrogenesis and harm. Considering the fact that social inequalities are the leading comorbid pathogen contributing to covid-19-related deaths, clinicians and health systems must reorient their work to consider and respond to the social structures and policies that drive those inequalities in the first place.

Health recommendations focused on individual behavior have limited success when they do not respond to systematically unequal social forces. Beyond the harm caused by these social forces, governments and health systems cause further damage by treating patients with covid unequally. We have witnessed the avoidable deaths of old and young people alike due to underfunded health systems built on private insurance companies or a person’s ability to pay out of pocket. The media have shown powerful people who’ve had quick access to testing while many have not been able to be tested unless they are severely sick (and have health insurance). This means that many people have not been able to quarantine and benefit from contact tracing—both of which are necessary to curb the pandemic. Such discrimination at the level of populations causes avoidable exposure, infection, and death. 

In addition, discriminatory mistreatment has been documented within health systems, intensifying distrust of healthcare institutions, with reports of Black patients in the UK refused treatment and people with disabilities fearing discrimination in triage decisions on who receives intensive care. As governments attempt to mobilize mass covid vaccination campaigns across the world, this distrust has become a major barrier to vaccine take-up: in one study in the US, only 18% of Black Americans stated they would definitely take the vaccine.

At the same time, inequalities in access to vaccines promise to worsen economic inequalities between nations and within nations. The director general of the World Health Organization warns that “the world is on the brink of a catastrophic moral failure” as millions of vaccines are administered in wealthy nations, and mere dozens in poorer nations.  

We are seeing early evidence that when communities provide health services for all and organize to protect one another across social differences, the pandemic is blunted for everyone. Grassroots movements, including groups of health professionals, aiming to address these inequities and forms of mistreatment have shown success in program and policy efforts that curb the pandemic. Unions of health workers have demanded protective gear for themselves and for patients. People living in homeless camps, along with advocates and policy makers, have organized to make shelter available, and in some cases have been able to change policy to increase the amount of affordable long term housing. Global health advocacy groups have argued that poor countries are likely to have widespread community transmission if protective equipment is hoarded by Europe and North America. And policy makers in the US, aware of the ways in which unequal access to new treatments can worsen health disparities, are working to make racial equity a stated goal in vaccine rollout

Covid-19 has not only infected individuals, it has also revealed the pathologies of our national and international programs and policies. Our collective wellbeing in the face of covid and future pandemics rests on recognizing and rectifying the systematically unequal social forces that drive the spread of disease.

Seth M Holmes is a physician and social anthropologist and associate professor at the University of California, Berkeley and University of California, San Francisco and Paoli Calmettes chair at IMeRA Mediterranean Institute for Advanced Study. He is also the author of Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States.

Competing interests: none declared.

Angela Jenks is associate professor of teaching and director of undergraduate studies in anthropology at the University of California Irvine. She is also editor in chief of Teaching and Learning Anthropology Journal. Twitter @angelacjenks

Competing interests: none declared.

Helena Hansen is chair of the research theme in translational social science and associate director of the Center for Social Medicine at the UCLA David Geffen School of Medicine. She is also author of Addicted to Christ: Remaking Men in Puerto Rican Pentecostal Drug Ministries.

Competing interests: none declared.

Scott D Stonington is assistant professor of anthropology, international studies, and internal medicine at the University of Michigan, Ann Arbor. He is also author of The Spirit Ambulance: Choreographing the End of Life in Thailand.

Competing interests: none declared.