Infectious diseases – pandemic as a syndemic

When the Covid 19 pandemic took its course, there was talk of the fact that the virus was the big equilibrium and did not distinguish between poor and rich. It became clear relatively quickly that this was by no means. At least in the United States and Great Britain, where studies were proven early on that there was a more violent infection among poor, certain ethnic minorities and in areas with poorer health care. This also met areas in which opponents of masking or vaccinations were politically dominated. We were talking about a “syndemic”, the collapse of diseases with political and socio -economic upheavals.

In Germany, on the other hand, there were no systematic studies – due to strict deficiency due to strict data protection regulations and political fears that the results could stir up racist or other prejudices. A good three years after the end of the pandemic, a project financed by the German Research Foundation with the cryptic abbreviation Inhecov is now entering this gap. The results after almost four years of work were not published in a specialist magazine after an independent review, but in the “Epidemiological Bulletin” of the leading Robert Koch Institute (RKI).

In the study entitled “Socio-Economic inequality in Covid 19 Pandemic”, ten researchers from various disciplines evaluated the reports of laboratory-confirmed Corona cases from 2020 to 2023. Since this contained no information on social stratification, the numbers were broken down at the level of the 401 counties and independent cities and linked them to the “German Index of Socioeconomic Deprivation” – this measures the extent of socio -economic disadvantage of the population according to the criteria of education, profession and income. According to the index, there is a higher deprivation in sub-regions of the new federal states, but also in Saarland, in North Rhine-Westphalia and Lower Saxony.

The mortality rate in circles with high disadvantage was 1.5 times as high.

Central result of the inhecov study: “Regions with more people with a low socio-economic position were associated with more frequent SARS-COV-2 infections and increased number of death.” Although there were probably higher infection figures in better-off regions at the beginning of the first pandemy (March and April 2020). In the course of the pandemic, however, the infection initially shifted into southern Germany And from the second wave (from December 2020) across Germany in regions with socio -economically disadvantaged population. Even then, mortality in circles with high deprivation was 1.5 times as high as in circles with a better-off population, with differences in population density, age and settlement structure. It stayed that way in the third and fourth wave.

Another finding: counties with many employees in industry showed higher incidence from the second wave than circles with many employees in service areas. This is attributed by the authors to the lower possibility of the home office.

For the world of work, the finding is deepened by paying RKI monitoring, which is based on the socio-economical panel, a long-term survey among Germans. Accordingly, people with low formal education 2021/22 had a 40 percent increased risk of corona infection compared to participants with high education. In the first two pandemicals, people in health professions had about twice the risk of infection as other employees. That changed later, but then in particular female employees in other personal service professions such as cleaning and logistics had an increased risk of hospital stay or die. The authors attribute the changing infection protection measures and the availability of respiratory protection masks and vaccinations in the course of the pandemic, which apparently not all benefited from the same way.

So far, the biological age and certain previous illnesses in Germany have been regarded as factors of infection dynamics, disease burden and mortality. As the study now shows, social heterogeneity is also part of it. People with low incomes in particular are generally affected by uneven health opportunities and health problems, says Inhecov employee Dagmar Starke. “A problem that became even more clearly visible due to the SARS-COV-2 pandemic,” said the graduate teacher and head of the Academy for Public Healthcare in Düsseldorf. To change this, health inequalities would have to be reduced, and all people should be able to actively participate in society – be it in terms of education, work, living or political participation.

As a specific conclusion, the study requires a socially just pandemic planning. A legally stipulated obligation to take into account health inequalities in the population is central to the commitment of appropriate measures. Suitable data that enable monitoring of social inequality are also required, but also more home office and better occupational safety. Finally, there should be mobile prevention offers, accompanied by multilingual advice and intercultural consultants who are well accepted by marginalized population groups.

Better pandeme control will only work if you know exactly how social inequality and incidence are related. The authors give that “so far there is significantly less knowledge about the concrete mechanisms of action.” And you can also only make guesswork: for example, that people with low formal education and low incomes have less often met the recommendations or specifications for contact reduction. Or that the lower vaccination rates have come about through structural barriers, inadequate addressee -specific communication as well as falling trust in politics and institutions.

Despite open questions, the study has an important message: social inequality increases the risks of infection, of course not only in pandemic. And when the next pandemic comes, the syndemic must also be combated.