Income and Income Distribution

Income and income distribution are the most salient determinants within the Social Determinants of Health Framework [10], particularly as they intersect with the other determinants to exacerbate risk [6]. Lack of access to financial resources influences exposure, access to supportive care, an individual’s social safety net during pandemic, as well as health care seeking behavior [11-16].

Bouye et al. [55] identified public housing residents, lone-parent families, and low income populations as being at increased risk during a pandemic. With limited financial resources and unstable income, people are forced to live in inexpensive, crowded living accommodations, which increase risk of exposure during an outbreak [29, 33, 43, 56-58]. Substandard housing is often associated with inadequate sanitation which can increase exposure and the risk of contracting influenza [7, 59]. An additional source of exposure for people with limited financial resources is crowded public transportation [17].

In the context of the consultations conducted by the International Centre for Infectious Diseases
[9] several participants stated that poverty is contributing to pandemic risk for many sub-groups of the population. Lone-parent households and people with functional needs which limit their ability to work or sustain sufficient financial resources are particularly at risk in any situation which threatens their ability to meet basic daily needs for their families, such as shelter, food and clothing [17, 18, 25, 60]. Many people who live ‘paycheque to paycheque’ will have concern

about missing work to comply with quarantine protocols or provide care for children and other family members, as lost wages may threaten daily survival [7-8, 17, 28, 36, 55, 61]. Likewise many positions are not conducive to flexible work patterns (e.g. working from home, teleconferencing) due to the type of responsibilities and role in the organization [3].

Gaetz [18] suggests federal cuts in spending since 1995 have “… had a profound and disproportionate impact on low-income earning sub-populations, including single parent women, visible minorities and new Canadians” (p.22). The resultant increase in the number of people living in poverty has also forced more people to use food bank support in recent decades. Blickstead and Shapcott [14] suggest differences in socio-economic status and education levels provide the foundation for a “Preparedness Divide” which refers to the gap in preparedness between high and low SES groups, based on differences in the uptake of health promotion information and recommendations. Many jurisdictions recommend people keep enough supplies on hand to look after themselves and their families for 72 hours [62]. For individuals and households living in poverty, preparedness activities, such as stockpiling emergency supplies (eg. food, medication), may be a luxury [52-53, 55]. This is consistent with suggestions from Garoon and Duggan [8] that:

“in the event of a pandemic, access to cash, food, health care, and other necessary goods and services would be far more difficult for socially and economically disadvantaged groups – not only due to their lower financial resources, but also because of their more tenuous ties to both public and private institutions as well as familial and social networks.” (p.1137)

Vaccination, the most prevalent preventive health intervention for pandemic, can be influenced by income and income distribution; albeit differently depending on the funding structure and system for health service delivery in a given country. Coady et al. [63] and Vlahov et al. [64] examined vaccination uptake among high risk groups and found that being poor was associated with less adherence to vaccine recommendations, particularly among racial and ethnic minorities. This is consistent with the findings of Truman et al. [45] who found immigrants and refugees were at risk because of pre-existing chronic conditions, lack of vaccine coverage, limited access to medical care, and other social factors such as language and housing barriers.

Many individuals who live in countries where there is no universal coverage for vaccines will postpone vaccination due to lack of health insurance coverage [55,65-67]. For migrant workers, lack of documentation is a deterrent for seeking vaccination through publicly-funded vaccination programs [58]. In their study in the U.S., Steege et al. found that many people who lack health insurance will postpone seeking health care treatment until they absolutely have to [58]. Similar situations may arise in Canada for those who lack important health documentation like a valid health card, those that are visiting the country, and immigrants without documentation.