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Dying from inequality as much as from COVID-19: the reality for deprived communities

Nurses see the impact of poverty in the pandemic, and we must advocate for the disadvantaged

As nurses we see the impact of poverty in the pandemic, and we must advocate for the disadvantaged and vulnerable

On a Tuesday evening in January, I headed out on call to a home where I found a man dying of COVID-19.

His wife’s precarious health meant she was likely soon to follow him and the rest of his family was at high risk.

The impact of inequality

As a clinical nurse specialist in palliative care in south London, I had visited the man to assess and manage his symptoms and to support his family. He was in his early seventies and had cancer.

Later, I could

As nurses we see the impact of poverty in the pandemic, and we must advocate for the disadvantaged and vulnerable

Illustration showing people living in cramped conditions, which makes self-isolating near impossible
Living in cramped conditions makes self-isolating near impossible Picture: iStock

On a Tuesday evening in January, I headed out on call to a home where I found a man dying of COVID-19.

His wife’s precarious health meant she was likely soon to follow him and the rest of his family was at high risk.

The impact of inequality

As a clinical nurse specialist in palliative care in south London, I had visited the man to assess and manage his symptoms and to support his family. He was in his early seventies and had cancer.

Later, I could not get the man and his family out of my head. I had the powerful sense that he was dying from poverty and inequality, as much as from COVID-19.

The home was tiny: a small living room, galley kitchen, bathroom out back and two bedrooms upstairs.

The man and his wife lived and slept in the living room – he on a bed and she on the sofa opposite. Upstairs lived various other members of the family.

Avoiding infection is difficult in cramped housing

I was not surprised by the lack of space. I have worked in the community for a long time and seen many families living in cramped conditions.

What did shock me was the fact that now COVID-19 had come to the home, there seemed no way to hold it at bay.

‘Government advice on isolating stops short of what to do if the person with COVID-19 has their bedroom in the living room, because all of the other rooms are occupied’

The whole family had been swabbed for COVID-19 the day of my visit, but even if the results were negative, the chances of them avoiding becoming infected were tiny.

The government recommends that if a positive case is identified within a household, that person should isolate within the home, away from other members of the family.

However, the advice stops short of what to do if the person with COVID-19 has their bedroom in the living room, because all of the other rooms are occupied.

A household with various underlying health conditions

The man’s wife had multiple health problems. She was clinically extremely vulnerable to COVID-19 infection and was displaying symptoms during my visit.

The only space she had to lie down and rest was the living room. I strongly suspect her test results would have come back positive.

I wondered whether she would die from COVID-19 along with her husband, for lack of space to isolate from him and for lack of a proper place to rest.

One family member living upstairs was waiting to find out if she was pregnant. She was having a COVID-19 swab and a pregnancy test the next day.

If she found she was pregnant, and therefore clinically vulnerable, there was nothing she could do to make herself safer. There was no space in the home for her to isolate and protect herself and her child.

The same was true for the other members of the household, who were overweight and had underlying health conditions.

Misinformation on COVID-19 and lack of trust in the government and NHS

Despite these risks, the family was not nearly as alarmed as I was. They did not appear to appreciate the risks of infection. As they spoke, I recognised a deep mistrust of health messaging from the government and the NHS.

It seemed they had long stopped believing that the authorities cared about them or represented their best interests.

‘The family chose not to inform friends and neighbours that the man was dying of COVID-19. The stigma they felt seemed to be broadly related to conspiracy theories circulating on the internet and social media’

My patient’s wife had declined hospital admission earlier that day. She explained she did not trust the hospital to meet her needs and felt going there would only make her worse.

The family chose not to inform friends and neighbours that the man was dying of COVID-19. Instead, they told people he was dying of cancer.

The stigma the family felt that had led to this decision seemed to be broadly related to conspiracy theories circulating on the internet and social media.

These theories question whether COVID-19 is as dangerous as the government says it is, or whether it even exists at all.

The concealment of the man’s true illness further increased the risks of transmission, as those coming by to pay their last respects were unaware of the presence of COVID-19 in the home.

Families in deprived areas are more likely to live in inadequate housing, which increases risk associated with COVID-19
Families in deprived areas are more likely to live in inadequate housing, which increases risk associated with COVID-19 Picture: Alamy

Mortality rates in the most deprived areas more than double those in least deprived

I felt helpless in the face of the risks this family faced that meant they may suffer multiple deaths and complications.

In our wealthy nation, with a national system of heathcare, how had we allowed this to happen?

Such poor outcomes are not caused by COVID-19 alone. They are caused by inadequate housing, poor diet and physical heath, lack of health education, political disenfranchisement, the effects of stigma and vulnerability to misinformation.

This visit was a vivid representation of that.

We already know certain groups are more at risk of death from COVID-19. During the first wave, mortality rates in the most deprived areas were more than double those in the least deprived areas.

Tragically, the UK’s terrible death toll has been among the highest in the world, when considering deaths in relation to population density.

Time to reflect on our unequal society

When the country is able to move on from managing the crisis of the pandemic, there will be some tough thinking to do for the government and the NHS.

Public health services have been negatively affected by structural reform and spending cuts over the years.

We need to reflect on a society than has left so many behind and allowed people to die from inequality as much as from COVID-19.

We need to find a way to reach families like the one I visited.

As nurses we must advocate for the vulnerable and disadvantaged and visits such as these must not pass us by.

The communities hit hardest by COVID-19 must have their voices heard and the government must undertake future work to restore and strengthen public health services.

My only hope is that this family survives to benefit.


 Joanna O’Brien, a clinical nurse specialist in palliative care at St Christopher’s Hospice in London

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