Clare Andrews is a GP in Tower Hamlets, East London and co-ordinator of Medact London. In this blog, Clare writes about her experience as a clinician during the coronavirus crisis and discusses how the social determinants of health, particularly socioeconomic inequality, have had a profound impact on her patients. 

From the first week of encountering COVID-19 in my work as a GP I have seen the way my patients have been able to deal with the virus and its consequences seriously affected by issues of economic injustice.  How problems stemming from loss of income, added to housing insecurity and precarious finances, all on top of difficulties in accessing public services have compounded alongside the virus to damage and destroy lives.

Early on in the crisis, before everyone was advised to stay home, I spoke to the mother of a child with a few days of fever and cough. I discussed with the mum how her household would have to stay at home for 14 days from the onset of the child’s symptoms. Her response to my advice was vague and apprehensive. I enquired further, “What does dad do?”

“An uber driver” she replied. “He has to go to work, we need the money.”

I tried to press the importance of everyone staying home and stopping the spread of the potentially deadly virus, explaining how it was so easy to pass on unknowingly especially when people sometimes didn’t show symptoms. But for her the possibility of losing their family income was something else significant to worry about.

Since the schools were closed and everyone was told to stay home, the conditions of the homes people live in have been brought to the fore. Many families where I work in east London have lived in significantly sub-standard, overcrowded accommodation for years. For most, being inside almost all day everyday has not been easy, but for those living on top of each other, it has been significantly harder.

This difficulty is exacerbated by fear of leaving the house, which for many is real, as low socio-economic status has been linked to worse outcomes with COVID-19. Along with this a number of my patients have relatives or friends who have had severe complications or died from the virus.

One mother told me that neither she, her husband nor their 3 children, all under 5, had left the 2 bedroom flat for weeks. This was, in part, because one child has severe asthma. His asthma, she felt, was made worse by the damp in their flat. Although an unforeseen benefit has been with the reduced traffic in the area, going outside might actually be better now, as usually the pollution triggers asthma attacks in many children in urban areas.

I think many in London now divide themselves and others into those who do and don’t have access to a garden. Even if it’s a shared one, or a roof space you can climb onto. In the high-rises of east London, there are not many gardens to be found. The effects of COVID19 seem to have deepened these divides. So for many it was devastating when the local large Victoria Park was closed. Where were they supposed to go then? With obesity and lack of exercise already being rife in the community, I worry about the rise in type 2 diabetes in the future, especially when the chicken shops are still open and access to genuinely affordable healthy food, or time for low income and time-poor parents to prepare it has been a problem for a long time. There is no doubt that requests for referrals to access foodbanks has increased across the area as well.

For many their accommodation is part of the private rental sector, and although there has been a mortgage holiday for some, rent still has to be paid. My telephone consultations which are so commonly about mental health now inevitably involve some form of financial concern and often about paying rent, and even worry about eviction.

Recently there have been plans to open up schools and nurseries again. This week I spoke to a teacher who lives with her husband and young child as well as her other teacher sister, bus driver brother and their mum in one flat. She asked me to write a letter saying her mum should be ‘shielding’ so they could protect her when the teachers in house have to return to work. We discussed that although her mum was older, of south-Asian heritage and had hypertension and diabetes, she didn’t fit the tight criteria. Besides, even if she did fit the criteria, we agreed it had been difficult enough already keeping her mum separate from her bus driver brother, so ‘shielding’ would be essentially impossible in their home. When the government strategy to control the pandemic is reliant on people being able to isolate themselves, not to mention use a smartphone app, how are people supposed to manage when they live in crowded housing, some with no access to the required technology or the education or language ability to use it?

The COVID-19 crisis has highlighted what I already knew about the inequalities in this country. What became clearer was how the social determinants of health from workers rights, housing, public services, community spaces and access to food, as well the macroeconomic policies surrounding these define the daily lives of my patients. It has emphasised that we, as those working in healthcare, who see these effects of these socioeconomic inequalities, must work harder to close the gap as the wellbeing of those we care for in order to achieve economic  and health justice.