In late December 2020, a 67-year-old resident of Ellingsrudhjemmet elderly care home in Oslo became the first person in Norway to receive the first dose of the COVID-19 vaccine. Many in Norway took this as a sign that the pandemic was coming to an end. But what determines who gets vaccinated first?
Svenn-Erik Mamelund, a researcher at the Work Research Institute (AFI) at Oslo Metropolitan University, has spent years advocating that socioeconomic factors are just as important as medical ones.
"It's not enough to prioritise people in care homes, the elderly, and the sick," Mamelund explains.
"We need to target people in lower socioeconomic categories — people of lower income and education, as well as recent immigrants and other socially vulnerable people in the eastern neighbourhoods of Oslo, the hotspot of the pandemic, to mention a few examples. We have seen pandemic planners use medical-only policies before, and they always end up with socioeconomic disparities in mortality rates. I fear we are going to see that again with COVID-19."
Pandemic expertise in high demand
Mamelund originally became interested in pandemics during a summer research job looking at 20th century death statistics in Norway. He was fascinated by the major increase in mortality caused by the 1918 flu pandemic and inequalities he identified in the data.
Mamelund went on to get a master's degree in human geography and a PhD in historical demography and has spent the past 25 years studying the effect of socioeconomics on pandemic outcomes.
In the past year, COVID-19 has resulted in high demand for Mamelund's expertise from pandemic planners and others seeking to understand the pandemic.
He has been interviewed extensively by Norwegian and international media. In 2019, he was appointed a World Health Organisation expert on the impact of non-pharmaceutical interventions on pandemic outcomes. He has also led the Norwegian Demographics Association since 2017.
Lessons from 1918
Mamelund sees many parallels between COVID-19 and the 1918 flu pandemic. Most of them are not encouraging.
Just as in 1918, the current pandemic is caused by a new and highly contagious virus. It has a higher mortality rate than the seasonal flu, and it seems to affect certain demographics more than others.
But it is the similarities between our current management of the pandemic and the 1918 flu response that has Mamelund worried.
"Back then, people thought they had conquered infectious diseases. They believed that horrendous pandemics with high crisis mortality were a thing of the past, and that they had the technology to keep them safe."
Modern day planners may have also been lulled into thinking that a terrible pandemic wouldn’t happen again. Recent pandemics have occurred far apart (before the 2009 H1N1 swine flu, the last major pandemic was in 1969) and been relatively mild. Emerging technologies make it seem like we can engineer our way out of any challenge. But when a pandemic hits, technology and apps cannot take the place of ventilators.
In fact, the most effective tools for limiting the spread of COVID-19 while we wait our turn for a vaccine are the old ones — wearing a mask and social distancing.
Historically, there were local measures and quarantines, but today’s lockdowns on a global scale have never been tried before. As frustrating as the lockdowns can be, Mamelund is a supporter. "If it hadn’t been for the public health measures and lockdowns, things would be much worse."
My hope is that public health planners will continue to consider socioeconomic inequalities in their planning, but it's a shame we had to go through this again.– Svenn-Erik Mamelund
The socioeconomic implications of lockdowns
Lockdowns are effective, but they have also caused economic hardship that has affected some demographic groups more than others. Planning committees worldwide, which tend to be made up exclusively of medical doctors and STEM researchers, have mostly overlooked this unintended side effect.
Without social scientists represented, interventions often do not account for differences in socioeconomic outcomes. Prioritising medical conditions is important but, as Mamelund puts it, "a recent immigrant living in East Oslo and a native Norwegian in Frogner might both have a heart condition, but the former is at much higher risk."
Focusing mainly on medical outcomes led to foreign-born people, especially those from Africa, East Asia, and the Middle East, being much harder hit than native-born Norwegians. Language issues, jobs that cannot be done from home, multigenerational living and housing density are all factors that increase vulnerability. Cultural familiarity and understanding how to navigate the healthcare system also play a part.
There exists a notion that pandemics are a 'great equaliser', but that simply is not true, Mamelund contends — they hurt people situated at the lower end of the socioeconomic spectrum much more than wealthy people who have the resources to isolate and receive first-rate care.
Health officials did not consider socioeconomics in their plans at the start of the COVID-19 outbreak. It took the pandemic group at the Norwegian Institute of Public Health (FHI) four months to put out their first report on socioeconomic factors.
FHI did not present advisories or advice for preventing infection in multiple languages until just before the end of the year. The current vaccine schedule from the Norwegian Institute of Public Health (fhi.no) still only prioritises people based on age and health conditions. And the initial versions of HelseNorge's Smittestopp app that was developed to assist in contact tracing were only available in Norwegian.
Despite being slow to address socioeconomic factors, Norway has had lower mortality rates and less economic hardship than many other countries. Demographic factors like relatively small cities, low population density, and high levels of interpersonal trust and trust toward the government have served Norway well.
The country's oil fund and safety net have supported people through the lockdowns with sick leave pay from day one and generous benefits for the furloughed and unemployed. By contrast, many western countries with high inequality (e.g. the United States and the United Kingdom) where people might show up to work sick out of fear of losing their jobs or homes have fared far worse.
Hesitations and risks
Paying close attention to less well-off members of society and targeting them for early vaccines would, in Mamelund's view, offer clear health benefits. At the same time, there is hesitation both from these communities and public health officials.
Around the world, socioeconomically vulnerable populations have historically been mistreated by the medical profession, so building trust in a new vaccine may prove difficult. Public health officials, for their part, worry that prioritising people based on socioeconomic factors will add to the false perception that these groups are to blame for the pandemic.
But Mamelund argues prioritising these communities is both possible and good public policy. The focus should be out on educating the majority population on the reasoning behind these priorities, rather than being afraid that prioritising immigrants would increase stigma and reduce testing among immigrants. "We already navigate stigmas when we prioritise based on comorbidities. If we don’t do anything specific to protect these people, I’m afraid they will face higher mortality rates and economic impact yet again."
What comes after the pandemic?
Now that the vaccine is being rolled out in Norway and around the world, Mamelund has some thoughts on what the future might look like. "I'd love to have a crystal ball to be able to tell you what will happen in the next few years. I don’t expect much to change in the long run, at least not in the big picture. After the 1918 pandemic, people wanted to get back to normal, hosting big dinners, shopping, et cetera."
"It will take some time before everyone is safe — don’t start planning a big wedding for this summer — but people will make up for lost time. Weddings and births will happen. My hope is that public health planners will continue to consider socioeconomic inequalities in their planning, but it’s a shame we had to go through this again."