Covid-19: The scientific approach blind to the social context

The health crisis linked to the Covid-19 pandemic has brutally revealed the reality of social inequalities in health.

À like the national health strategy or national public health plan, the major guidelines for French public health aim to reduce these inequalities as much as possible. In addition, access to health, and not only to care, is an issue of social cohesion widely shared in our country. We note, however, that in the scientific community, this concern remains very marginal.

First and foremost biomedical lighting

Since the start of the pandemic, the opinions of the various committees, agencies and councils have in fact not addressed this issue. Lighting of the scientific council, in March 2020, was essentially biomedical in nature, despite a reference to equity and the socially differentiated effects of containment. And this, even though the social issues were underlined at that time in the international literature, showing that the inequalities were probably major.

For example, in the United States, the incidence was three times higher in counties with predominantly black population than in those where it is white and death rates were six times more frequent. And consistent data was published by the UN at the same time.

In France, the social distribution of the Covid-19 epidemic was known late. The first data come from the Île-de-France Regional Health Observatory. They revealed that Seine-Saint-Denis, the poorest department in metropolitan France, was particularly affected by the epidemic: in Île-de-France, it is in this department that mortality, compared to that of the year previous, increased the most (+ 118% between the 1er March and April 10).

These data attested to the extent of territorial inequalities in terms of urbanization, housing conditions, demographic and social characteristics of households, state of health of populations and also occupational exposure. They also underlined the need for analyzes on the context of life, carried out at finer geographical scales.

The report of the Research, Studies, Evaluation and Statistics Directorate, published in July, made a very complete review of the available information and the hypotheses suggesting that the Covid-19 crisis would be accompanied by major inequalities. And this, while pointing out the lack of data on the subject in France. Finally, the work of various research teams, and in particular theEpiCov survey, confirmed in October the strength of the socio-economic conditions that could be anticipated.

Major role of the social context in the occurrence of diseases

Research carried out for several decades on social inequalities in health in all its aspects we have learned this: the social and territorial conditions of life play a major role in the occurrence of diseases. They therefore necessarily have an impact on the incidence of Covid-19, on its severity, on the risk of death, but also on the effectiveness of prevention measures, and in particular physical distance. And ignoring them prevents the development of equitable and effective public health policies.

Can we imagine developing public policies against the AIDS virus (or HIV infection), without including sexual behavior in the discussions? Obviously, the answer is no. Yet this is precisely what is being done with the current health crisis. It focuses on inpatient and intensive care, vaccines and the development of treatments. The social inequalities in which it is part have not been taken into account in the scientific opinions submitted to the political authorities. Raising these questions in the scientific and medical world still leaves a scent of activism or "social medicine" likely to tarnish the rigor of science.

Mathematical models have been widely used to predict the course of the pandemic. However, specialists emphasize the sensitivity of these models to the parameters initially included. Ignoring living conditions is therefore in the best case to impoverish them, and in all cases to move away from reality.

Taking into account the social context: a scientific approach

How to understand the social and territorial distribution of an epidemic without including in the models which simulate it, whether they are simple or complex, the density of housing? Doesn't the latter have an influence on the incidence of the disease, on the possibilities of prevention or on the difficulties in respecting the barrier gestures?

Likewise, with regard to the dynamics of the epidemic's spread, how can we not take into account the different populations who will be able to work remotely or, on the contrary, to take transport for work exposing them to be contaminated? The epidemic and especially its severity will evolve according to the distribution of risk factors (obesity, diabetes, etc.), and this will depends on social backgrounds.

Finally, how to assess and predict the non-infectious consequences of the health crisis, without integrating “social parameters” into the models? For example, social isolation caused by confinement is a major factor in suffering, mental health problems and ultimately mortality. Psychic suffering, domestic violence, sedentary lifestyle, exposure to screens, sleep disorders or food insecurity do not strike at random.

Making a decision in terms of health policy requires considering the multiplicity of consequences of the epidemic, the distribution of which depends on living conditions. It also means thinking about the long term, as the example of children shows. Closing schools has immediate consequences on their socialization and mental health. But it also has a longer-term impact on educational inequalities and on the health of schoolchildren.

From the interior environment to the exposome

Some suggest that the participation of researchers in the human and social sciences in the various committees responsible for informing political decisions would make it possible to remedy the lack of social reflection in public health expertise. It would undoubtedly be progress. But that would probably not be enough.

In fact, there cannot be a biological and medical approach on the one hand, and a “social supplement” on the other. The health approach, epidemiological and biological models themselves must integrate the strength of social factors in the behavior of an epidemic.

The social context is an integral component of the exposome, that is to say the set of elements to which a person is exposed throughout his life. The improvement of knowledge is at stake, which cannot ignore the omnipresence of social factors when one is in a human population, that is to say in "real life", whether before, during or after contamination, from primary prevention to mortality. And it is the responsibility of scientists not to obscure this complexity.

To ignore it is to construct an experience in an artificial environment which cannot be generalized to the population. Social justice and cohesion are at stake. It is also a scientific issue.

Let us remember: in its "Lessons on the phenomena of life common to animals and plants", the French physiologist Claude Bernard insisted on the necessity of taking into consideration for any animal of the interior environment "formed by the circulating organic liquid which surrounds and where bathes all the anatomical elements of the tissues", by specifying beforehand its importance in the existence of being, in relation to the external environment.

It is the social role of scientists to face complexity and to make it explicit. "The social" is incorporated, "Penetrates under the skin" and modifies biological mechanisms. It is now a question of situating the interior environment in its social and territorial reality.

Thierry lang, Epidemiologist, professor emeritus of the University of Toulouse, “Equity” team of UMR Inserm 1027., Inserm et Marie-Josephe Saurel-Cubizolles, INSERM epidemiologist, Inserm

This article is republished from The Conversation under Creative Commons license. Read theoriginal article.

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