By: Mariana Lazo, MD, PHD, SCM
Usama Bilal, PhD, MPH, MD
Manuel Franco

Lea la versión en español, publicada en el diario El País, aquí.

The nearly seven million people who live in the Madrid metropolitan area and 19 million and 21 million in the case of New York and Mexico City respectively place these cities as spotlights of work, training, entertainment, and great movement of people. During the last century, these cities have been a focus of attraction for migrants: Europeans and Latinos to New York, rural peasants to Mexico City, and Andalusian and Extremaduran workers to Madrid, who have been displaced by job opportunities and the search for a better life. However, the contemporary global city is also characterized by an enormous social and spatial segregation that determines the growing inequalities in health.

In Leganés, about 10 kilometers southwest of the center of Madrid, there are almost 200,000 working-class people who have settled there since the 1960s. Iztapalapa is one of the 16 delegations in the former Federal District of Mexico where 1 8 million people who move to other parts of the city every day to work in small peseros where overcrowding is the norm and not the exception. The Bronx is one of five boroughs, north of New York City, with 1.4 million people and a long history of segregation and racial discrimination.

Even thought at the beginning of the epidemic it was stated that the coronavirus "affects us all equally", the scientific evidence flatly denies this claim. The coronavirus does know of social classes and neighborhoods. The effects of the virus are unevenly distributed following a clear social gradient of the disease according to which the most disadvantaged populations are the most affected group. The social gradient of coronavirus transmission and its consequences is determined by factors such as the type of work, the type and use of housing, and the health status of the populations. These factors and the urban dynamics of global cities are the same in Madrid, Mexico City, and New York.

In the case of coronavirus, the inequalities and the social gradient are the result of large differences in exposure to risk factors for COVID-19 infection that cover different spheres of urban life. The population of the most disadvantaged neighborhoods often have jobs considered essential and necessary for the daily life of the entire population which entail greater contact with the public and do not allow teleworking. These populations generally reside in the periphery and have a long journey by public transport to get to their place of work. The characteristics of the housing of this population are very precarious and full of deficiencies, ranging from overcrowding to a lack of running water in extreme cases such as that of Iztapalapa.

Coupled with increased exposure to the coronavirus, even before an infection, the probability of suffering severe symptoms, hospitalization, and death is closely related to the presence of other diseases, such as cardiovascular co-morbidities, respiratory, diabetes and hypertension. We know that the prevalence of all these diseases is directly related to the social class and the neighborhood where one lives. Increased availability of junk food, higher unemployment rates, and higher rates of environmental pollution can lead to a shorter life expectancy in these more disadvantaged neighborhoods. The pandemic is accentuating these inequalities and bringing them to light for those who lived far away from them. Knowing and acting on urban inequalities during COVID-19 is unavoidable and urgent for social justice because these inequalities are preventable and because it is necessary to cover all of our populations in order to control of the pandemic. Given the situation of inequality in the face of exposure and vulnerability to the coronavirus in our cities, we must ask ourselves what to do. What would be the actions at the local, national, and international levels that allow the population of areas such as Leganés, Iztapalapa, and the Bronx prepare and protect itself against the coronavirus and its consequences?

Focusing on urban inequalities during the COVID-19 pandemic would allow organizing, in number and type, epidemiological surveillance services and health and social services, prioritizing the most vulnerable areas to improve control of the epidemic and de-escalation phases. Knowing which areas of our cities are most affected by COVID-19 will allow us to actively search for cases, for their early isolation. To decrease coronavirus exposure, we must first improve the working conditions of essential workers and urban displacement, as well as increase the possibility of teleworking. Second, we must improve the housing conditions of disadvantaged neighborhoods. To reduce vulnerability in the state of health to contagion, preventive, and community health reinforcement from primary care systems is essential. The measures necessary to tackle the social crisis of inequality and the pandemic, therefore, are the same: public health policies and social policies. An intersectoral and coordinated work that already has examples even within Spain in autonomous communities such as Asturias that are perhaps less affected compared to larger cities.

The coronavirus crisis has exposed the global structural, economic, and social determinants of health in a city, a country. The countries and the cities that are better equipped and prepared in public services like health and public transport, as well as better working and housing conditions, will come out better and before this crisis. The pandemic and its associated economic crisis require a clear focus on equity and international collaboration between researchers and public health technicians so that it does not become yet another factor that increases the already alarming inequalities in health.