Two tales of one city: Unequal vulnerability and resilience to COVID-19 by socioeconomic status in Wuhan, China

Highlights

• Higher SES is associated with a lower risk of infection of COVID-19.

• Higher SES reduces mental distress during the pandemic, particularly for individuals or family members confirmed or suspected with COVID-19.

• SES shapes the risk of infection and mental distress primarily through three channels: access to daily essential and protective supplies, employment status, and the community environment.

Abstract

Although disasters such as pandemics are events that are random in nature, individuals’ vulnerability to natural disasters is inequitable and is shaped by their socioeconomic status (SES). This study examines health inequality by SES amid the COVID-19 pandemic and its underlying mechanisms in Wuhan, China’s epicenter. Using survey data collected in the city during the lockdown period from February 20 to March 6, 2020, we identify two ways in which SES shapes health inequalities—vulnerability and resilience to COVID-19. First, higher SES is associated with a lower risk of infection for both survey respondents and their family members. Second, higher SES reduces mental distress during the pandemic, and this protective effect is particularly strong for individuals who contract the virus or who have family members infected with the disease. Mediation analysis further illustrates that SES shapes the risk of infection and mental distress primarily through three channels: access to daily essential and protective supplies, employment status, and the community environment. These findings lend support to the fundamental cause theory that links socioeconomic differentials to health inequality in a unique context. The outbreak of COVID-19 magnifies pre-existing socioeconomic inequalities.

Introduction

The outbreak of COVID-19 has caused tens of millions of infections and triggered a global public health crisis. As of February 5, 2021, the COVID-19 pandemic had resulted in more than 104.17 million infections and 2,265,354 deaths across 219 countries and territories around the world (WHO, 2020). Previous studies of natural disasters, such as earthquakes, tsunamis, and forest fires, have demonstrated devastating short- and long-term effects on physical and psychological health (Briere & Elliott, 2000; Corrarino, 2008; Leon, 2004; Mills, Edmondson, & Park, 2007). The COVID-19 pandemic is no exception. In addition to the severe damage that the virus can do to the human body, the fear of infection (combined with economic lockdown and social isolation) has impaired individuals’ psychological well-being and social relationships (Brooks et al., 2020; Dubey et al., 2020; Recchi et al., 2020). For example, even as the pandemic gradually abated in China, many cities have witnessed soaring rates of divorce and suicide (Prasso, 2020; Zhou & Goh, 2020).

Against this backdrop, the present study investigates health disparities evidenced by COVID-19 in Wuhan, China’s epicenter. Previous studies have shown a high correlation between SES and health outcomes (e.g., self-rated health and chronic disease), but empirical studies during disasters or epidemics (e.g., mortality and infection risk) are rare. Of particular concern is the fact that the decision to lock down the city of Wuhan was an unexpected event for all social classes, and no one was adequately prepared in terms of protective or living materials. In this context, all people were affected by the city's closedown, regardless of their SES. As a result, did the association between SES and health inequalities persist during the 72-days lockdown of the city? Specifically, our key research question is: are there socioeconomic disparities in health outcomes associated with the pandemic, as measured by infection risks and mental health distresses? One line of arguments posits that a natural disaster is a potential equalizer because of its universal impact on the population at the same period in time (Aguilar, Pante, & Tugado, 2016; Saguin, 2016). COVID-19 substantially restricts the economic activities of almost everyone regardless of SES (Jones & Jones, 2020). Also, the coronavirus is a threat to every individual because of the natural properties of viral contagion.

Another strand of research, however, contends that natural disasters exacerbate fundamental inequalities due to marked differences in material and non-material resources across socioeconomic groups (Bolin & Kurtz, 2018), that lower SES individuals are less able to buffer themselves against the effects of a disaster than their higher SES counterparts. For example, during and after Hurricane Katrina in the United States, low-income individuals, as opposed to high-income individuals, were less likely to be rescued, more likely to lose their homes, and less likely to regain employment and housing (Brodie, Weltzien, Altman, Blendon, & Benson, 2006; Elliott & Pais, 2006; Elliott, Hite, & Devine, 2009; Fussell, Sastry, & VanLandingham, 2010; Lachlan, Burke, Spence, & Griffin, 2009; Sastry & VanLandingham, 2009). Similar processes will likely unfold during the COVID-19 pandemic, resulting in a heavier burden placed on the shoulders of the disadvantaged (Ahmed, Ahmed, Pissarides, & Stiglitz, 2020; Bowleg, 2020; Lamarque, 2020). Emerging evidence points to an SES-gradient in economic and health outcomes related to COVID-19, such that those on the bottom rungs of the hierarchy ladder are hardest hit (Buchanan, Patel, Rosenthal, & Singhvi, 2020; Finch & Hernández Finch, 2020; Lederer & Kurtenbach, 2020; Pickett, 2020; Recchi et al., 2020).

The fundamental cause theory addresses expectations as to how SES might affect the health outcomes of individuals affected by a disaster such as a pandemic (Link & Phelan, 1995; Lutfey & Freese, 2005). According to this theory, low SES individuals generally exhibit worse health status and higher mortality than their high SES counterparts at almost every stage of the life course (Lutfey & Freese, 2005). This is because SES shapes access to important resources that influence health, including income, knowledge, power, and beneficial social networks.. While it has been well documented that disparities in health outcomes and economic well-being (e.g., by gender, race, ethnicity, and geographic location) are found to be partially attributable to differences in SES across several countries in the current pandemic(Finch & Hernández Finch, 2020; Hu, 2020; Qian & Fan, 2020; Yaya, Yeboah, Charles, Otu, & Labonte, 2020), little empirical research has investigate the mechanism through which SES affects health disparities. The present study is to fill the void.

We proposed two stages in which SES affected health outcomes at the peak of the COVID-19 lockdown in Wuhan, China’s epicenter. In the first stage, we study differential vulnerability to COVID-19 by SES, as measured by infection risk. We speculate that high SES reduces the risk of infection because higher-status individuals are better able to secure resources to shield against viral infections. We specifically explore three underlying channels. First, SES affects access to daily essential and protective supplies, which helps individuals maintain normalcy and stay safe during the pandemic. Second, higher SES individuals tend to hold jobs with greater economic rewards, greater job security, and lower occupational hazards. During the pandemic, they are more likely to retain their jobs and be engaged in work remotely. These conditions reduce exposure to the infection. Finally, higher SES results in a more favorable living environment. Individuals with higher SES tend to live in communities with greater resources and networks, which ease access to supplies and information while minimizing contact with others and potential disease transmission. Taken together, these channels lower the risk of COVID-19 infection.

In the second stage, we examine differential resilience to COVID-19 by SES, as measured by mental health distress, which captures negative emotional effects such as depression, anxiety, or fear. We study the general role of SES in fostering resilience as well as how a protective effect of SES varies by infection status. We speculate a positive relationship between SES and resilience, which operates through three main channels. First, individuals of high SES tend to have greater access to daily essential and protective supplies. This brings a sense of normalcy and security and reduces fear and anxiety that can result from material shortages during the pandemic (Zhang et al., 2020). Second, higher status individuals tend to have greater employment stability and higher monetary rewards than their lower status counterparts, who are at a disproportionate risk for job loss and wage penalties (Hu, 2020; Qian & Fan, 2020). The more sufficient and stable the income, the lower the risk of depression and anxiety (Lei et al., 2020). High SES individuals are also more likely to hold jobs for which remote-work is feasible, which mitigates exposure to and concerns about infection. Finally, higher SES communities may provide more social support and cultivate collective efficacy (Cohen, Finch, Bower, & Sastry, 2006; Miao, Zeng, & Shi, 2021; Qian & Hanser, 2021; Wu, 2021). Such a social environment fosters mental health and resilience during a crisis. In sum, SES has a protective effect on mental health during the pandemic.

The protective effect of SES may be particularly strong among individuals who are infected or are exposed to heightened risks of infection. For those individuals, COVID-19 does take a toll on mental health. However, high-SES individuals are more likely to receive prompt, higher-quality treatment (Harris, 2020), which reduces their psychological distress. Also, these individuals have sufficient financial resources to cover medical and living expenses during hospitalization and quarantine, thereby mitigating financial insecurity. Moreover, high SES individuals tend to live in more spacious homes, thereby reducing the risk of within-family disease transmission and decreasing the mental health burdens of the infected. Therefore, we expect that there will be a larger protective effect of SES on mental health for those who are most vulnerable to mental distress. In other words, the mental distress posed by COVID-19 are greatest among individuals with low SES.