How COVID-19 Reveals Structures of Vulnerability

As coronavirus infection spread across Europe and north America to much poorer parts of the world, calls for personal protection – hand washing, physical distancing, and masks – highlighted the structural challenges of implementation. Australians took to panic buying, physically fighting over toilet rolls in supermarkets, precipitating a national shortage. As Susan Levine noted dryly, elsewhere many people don’t have toilets. At the same time as the toilet paper rush, the South African Institute of Plumbers ran a 90-minute webinar for hundreds of plumbers and laborers on infrastructure and infectious disease control, with Lenore Manderson taking questions on the risks of what was now essential front-line work in maintaining taps, pipes and toilets. This was virtual applied anthropology.

These personal measures were complemented by public health directives, worldwide, for populations to stay home, or in the US, to “shelter in place.” In these noisy early days, little attention was paid to what this might mean for those who had nowhere to shelter, who were living in temporary, rudimentary or inadequate housing, or were already at risk at home. At any time, overcrowding, poor maintenance, intermittent power, lack of fuel and water, an insanitary environment, and lack of municipal services, compromise health, exacerbating mental health problems and nurturing the transmission of parasitic, viral and bacterial diseases. COVID-19 fed on this. It thrived on the structural vulnerabilities that worldwide shape access to, quality and security of housing.

Structural vulnerability, as defined by Quesada et al. (2011), derives from economic exploitation and discrimination; we use this term routinely to explain how the disparities of class, culture, gender, sex and race impact on individuals, families and communities. Here, however, we also acknowledge its use in relation to geography and engineering, and so the physical structures that provide shelter. To these structural vulnerabilities, the volatility of governments and the private sector make access to and the security of shelter precarious everywhere.

The multiple structures of social life, government and governance, economics and politics, space and place, shape people’s health and wellbeing, enabling or inhibiting the implementation of policy and people’s capacity to follow it. Transmissible diseases thrive in poorly ventilated, poorly built, crowded dwellings. Physical and social structures intersect and co-produce vulnerability, mimicking the entanglements of and often resulting in syndemics. Poor housing compromises health; poor health impacts employment; loss of employment depletes income; low income results in housing insecurity; and so on.

People who are impoverished, marginalized, threatened or stateless everywhere lack good-enough secure housing, even in relatively equitable and fair settings. In Australia and other high-income countries, the patterns of excess morbidity and mortality from COVID-19 diverted attention from housing and shelter in general, to the provision of institutional care. Aged and other residential care facilities have attracted most attention, highlighting systemic compromises in the ethics, work and practices of care. Institutional care is routinely, everywhere, constrained by the capacity of residents to pay, by poor funding support, understaffing, and overcrowding. Aged care workers are commonly undertrained, under-protected, underpaid and underemployed, working on a contract basis across multiple facilities, ineligible for paid sick and isolation leave. Meanwhile, residents often share bedrooms, meal rooms and bathrooms, and share equipment such as wheelchairs and commodes. People with dementia may wander and enter others’ rooms, may have lost basic hygiene skills, and may resist or be disoriented by others’ use of PPE (Wang et al. 2020). Personal care – feeding, showering, dressing, grooming, and changing continence pads – cannot be provided at a distance. Further, as paid carers have been infected, quality of care of residents has declined. One report of a coronavirus outbreak in a private aged care facility in Melbourne (Australia) (Davey 2020), for instance, described (and depicted) an elderly resident, with ants feeding on wound exudate from multiple pressure injuries.

Older people, particularly in institutionalized care, are over-represented in hospitalization rates and deaths from COVID-19 in the global north. There is far less information on infection among populations in other institutions, both in the global north and south – in prisons, refugee camps and immigrant detention centers, temporary housing shelters and refuges, rehabilitation centers, workers’ dormitories and boarding houses. The unreported impact of COVID-19 on residents who are crowded together by design points to their marginality. These are people whose lives Butler (2006) might consider “ungrievable” by those with wealth and power.

Homelessness and substandard residences are testimony to and the corollary of social inequality and structural vulnerability worldwide. In Australia, people who were homeless were readily identified as at risk of infection (and transmission) of COVID-19, leading to their temporary rehousing in hotels. In South Africa, people living under bridges and on the streets were likewise relocated, although in their case, to enclosed and policed encampments on sports grounds where the continued lack of capacity for physical distancing and increased handwashing was no easier. In Singapore, the second wave of COVID-19 took hold among low-wage migrant workers living in accommodation overcrowded to a degree that “there is no space to breathe” and people “just can’t move around in the room” (Dutta 2020: 6). Such conditions are common everywhere, despite innovations within communities and by the state (Fennell 2015; Mack 2017; Starecheski 2016). Further, for some, being in quarantine provided poor protection: in Australia, returning travelers were quarantined in hotels where low nurse-to-travelers ratio, lack of PPE, lack of swab kits, improper isolation measures, and poor hygiene and sanitation all contributed to outbreaks. Travelers in Melbourne reported used PPE on floors, bed linen unchanged after the departure of previous occupants, and bed bugs (Chain 2020). The blame for hotel outbreaks, however, was largely directed to contract workers on the front line, and their failure to adhere to isolation practices; the back down was to point to poor infection control training provided to them (Schneiders 2020).

But in other ways too structural vulnerability related to shelter undermines health and safety, highlighting the importance of anthropological expertise and voices. COVID-19 is only the most recent health crisis associated with proximity, and insecure and substandard housing is implicated in many infectious and non-communicable conditions, mental health problems and intimate partner violence. Everywhere, people are marginalized by the legacy of generations of institutionalized discrimination and structural violence; trapped by bureaucratic nightmares of civil status and residency; they are recent immigrants, indigenous populations, contract laborers, single-parent families, pensioners and others on fixed incomes, people of color, students, and people with disabilities. Homes may be derelict buildings, single rental rooms, dormitories, cars, granny flats, garages, shacks and mobile homes, often without the facilities that are preconditions for keeping clean, warm and safe, and preparing food (Larkins 2015; Margaretten 2015).

In early July 2020 in Melbourne, nine large social housing apartments, occupied predominantly by immigrants and secondarily by others with low incomes, were locked down without warning. The buildings were surrounded by police officers, prohibiting occupants and others entry and exit. Theses tower blocks of 20–30 storeys were built in the 1970s and 1980s, and plumbing and ventilation systems were dated; they had narrow poorly ventilated corridors and staircases; one lift served all levels; bedrooms were often shared by multiple occupants; laundries and other shared spaces were small. The occupants were largely characterized by their lack of English, low education and employment status, low household income, and limited health literacy. The blocks were spoken of as “vertical cruise ships” (alluding to the first wave of COVID-19 in the country), with “explosive potential” to spread infection (Slezak and Sadler 2020). The lockdown added to the vulnerabilities of people locked together with abusive partners; with chronic illnesses and without medication; with infants or others in hospital; with limited food (although food was supplied, not always immediately and sometimes with breathtaking inappropriateness); without explanations for confinement or support in languages other than English. People felt criminalized, and for some, lockdown brought back traumas of war, internment, imprisonment and flight.

Medical anthropology attends to context, and in the continued unfolding of this pandemic, our insights are critical. As suggested above, including in the other op eds in this issue, pandemics, like other kinds of disaster, expose the entwining of the personal, economics and politics. Structural vulnerability determines where and how people live, extending beyond physical structures to shape the everyday. Kline (2017, 2019), for instance, documents how law, policing, and fear compel people without papers in the US to balance working, purchasing food, or presenting for medical care against the risks of apprehension, family separation, and deportation. The conditions of labor and daily life produce ill-health, and social exclusion and discriminatory attitudes discourage access and undermine health care. As the present pandemic demonstrates, the inequalities of the basic conditions of the everyday – shelter and its affordances – and expansive disadvantage determine poor health outcomes. In linking the material and the physical, the social, the symbolic and the moral, we have the continued task of attending to and challenging the ways in which social organization produces inequality.

Acknowledgements

The authors acknowledge the preprint of this article deposited in the OSF Preprints repository: Team, Victoria, and Lenore Manderson. 2020. “How COVID-19 Reveals Structures of Vulnerability.” OSF Preprints. September 29. doi:10.1080/01459740.2020.1830281.

Additional information

Funding

Ideas for this op-ed emerged from research funded by the Australian Government Department of Health Medical Research Future Fund.

Notes on contributors

Victoria Team

Victoria Team is Editorial Assistant of Medical Anthropology and Senior Research Fellow in the School of Nursing and Midwifery, Monash University and Monash Partners Academic Health Science Centre, Melbourne. Her current research focuses on capacity building for pressure injury prevention. Contact her at: School of Nursing and Midwifery, Monash University, Level 5 Alfred Centre, 99 Commercial Road, Melbourne, VIC 3004, Australia. Email: [email protected]

Lenore Manderson

Lenore Manderson is the editor of Medical Anthropology, and Distinguished Professor of Public Health and Medical Anthropology in the School of Public Health, University of the Witwatersrand, Johannesburg. Her current research attends to social inequality and configurations of caregiving and receipt. Contact her at: School of Public Health, 27 St Andrews Road, Parktown, Gauteng 2193, South Africa. Email: [email protected].