Vulnerability and risk: reflections on the COVID-19 pandemic

Juárez-Ramírez, Clara; Théodore, Florence L.; Gómez-Dantés, Héctor

Clara Juárez-Ramírez

Instituto Nacional de Salud Pública de México, Centro de Investigación en Sistemas de Salud, Cuernavaca, Mexico.

http://orcid.org/0000-0002-1844-772X

Florence L. Théodore

Instituto Nacional de Salud Pública de México, Centro de Investigación en Nutrición y Salud, Cuernavaca, Mexico.

http://orcid.org/0000-0002-8111-0871

Héctor Gómez-Dantés

Instituto Nacional de Salud Pública de México, Centro de Investigación en Sistemas de Salud, Cuernavaca, Mexico.

http://orcid.org/0000-0002-2025-3641

Corresponding author: Florence L. Théodore Centro de Investigación en Nutrición y Salud, Instituto Nacional de Salud Pública de México. 7a privada de Fray Pedro de Gante, Sección XVI, Tlalpan 14000 - CDMX, Cuernavaca, Mexico ftheodore@insp.mx

Notable epidemiological factors	HIV/AIDS (1980’s)^(5-6)	Influenza (H1N1- 2009)⁽⁷⁾	COVID-19 (2020)
Route of transmission	Sexual, infected blood, breast milk.	Saliva droplets from sick people.	Saliva droplets, exhalation of particles from asymptomatic and sick people.
Lethality level	High (before the advent of antiretroviral treatments). Since the beginning of the pandemic and until 2019, 32.7 million deaths are estimated in the world according to UNAIDS.	Low/moderate in all age groups. Until 2018, 75,000 deaths were calculated.	High in people over 60 years of age and with comorbidities such as diabetes and hypertension. As of December 23, 2020, there were 76,382,044 cases and 1,702,128 deaths caused by the disease in the world (WHO)⁽⁴⁾.
Lethality level			Low in children
Main symptoms	From asymptomatic to severe immunodeficiency.	Fever, sore throat, nasal congestion, cough, muscle aches, headache, chills, fatigue.	Nasal secretions, fever, tiredness, smell and taste loss, difficulty breathing, among others.
Main symptoms	From asymptomatic to severe immunodeficiency.		Asymptomatic forms.
Treatment	High cost, very toxic initial therapy of limited efficacy (AZT); at the end of the 1990s, more effective drugs were combined that were widely distributed free of charge. It became a treatable chronic condition.	Tamiflu (oseltamivir) available since the first cases.	There is no specific treatment. Antivirals under evaluation Intensive care, management with mechanical respirators.
Prevention and behaviors promoted with the population	Vaccine: does not exist.	Vaccine: Rapid Development October 2009.	Multiple vaccines in development. Technological innovations.
	Use of condoms during sexual intercourse.	Sneeze etiquette.	Sick people isolation.
	Safe blood for transfusions and banning of blood trade.	Isolation of patients with symptoms of respiratory tract conditions.	Sneeze etiquette, hand washing, mask.
	Use of disposable syringes.	Use of protective barriers: gloves, face masks.	Voluntary confinement. Restriction of social life and use of public spaces.
	As of 2010, according to UNAIDS recommendations, “combined prevention” in HIV/AIDS of biomedical, behavioral, and structural interventions.	Avoid physical contact: greetings, hugs, kisses.	Physical distancing: greetings, hugs, kisses.
	-	-	Keep the house ventilated and clean.
	-	-	Disinfect commonly used utensils and surfaces.
Health measures	Banning of blood trade.	Unique health contingency.	School closings.
	Free diagnostic tests.	School closings.	Social distancing campaign.
	Creation of special centers to attend cases on an outpatient and inpatient basis.	Suspension of massive activities (religious events, movie theater, theater, sports events).	Suspension of “non-essential” activities
		Limited duration of measures	Quarantine
	-	-	Creation of traffic light model to identify areas of higher risk.
	-	-	Community approach, from the Primary Care.
Institutional interventions	Training, diagnosis, treatment of health personnel at all levels.	Adequacy of clinical facilities without worrying about hospital burden.	Hospital transformation.
	AIDS Clinics.		Private hospitalization and care services.
	Educational campaigns.	Accessible vaccine and treatment.	Acquisition of specialized equipment.
	Provision of condoms.	Accessible vaccine and treatment.	Test development: only confirmation, no test strategy, tracing of contacts and isolation of confirmed ones.
Participation of international organizations and society	WHO; UNAIDS; Civil society with NGOs (Act-Up; Aids) and organized groups to face the epidemic.	World Health Organization (WHO); Centers for Disease Control and Prevention (CDC), United States.	Criticisms to the World Health Organization (WHO).
			Heterogeneous national initiatives against the pandemic.
			Philanthropic influence from international foundations, such as the Bill and Melinda Gates Foundation.

Notable social aspects	HIV / AIDS (1980’s)^(5.6)	Influenza (H1N1- 2009)⁽⁹⁾	COVID-19 (2020)
Risk groups	People with “risky” sexual practices Stigmatizing burden at the beginning of the pandemic. 4Hs: Hemophiliacs, homosexuals, heroin addicts and Haitians.	Universal susceptibility.	Universal susceptibility.
	People receiving contaminated blood (transfusion, syringes).	Adults older than 65, pregnant women, children, people with asthma.	Comorbidities: hypertension, diabetes, obesity, people with HIV/AIDS, people with asthma, smokers.
	Heterosexual women.	Comorbidity: Heart and cerebrovascular diseases, diabetes, HIV/AIDS, cancer, children with neurological conditions.	Greater biological vulnerability: older adults, pregnant women, people with chronic diseases.
Population risk perception	Link and stigma against gay, transgender, sex workers communities, injection drug users, etc.	Disbelief in the face of illness, theory of government conspiracy to generate social control and to obtain economic profit⁽⁷⁾.	Heterogeneity: denial of disease, risk factors, and transmission mechanisms; disbelief in protective measures (believed to be exaggerated). Others do understand and protect themselves.
Population risk perception	Safe sex with a condom.		Who are essential (poor and vulnerable), and nonessential (privileged)?
Related social vulnerability	People in a situation of social and economic inequity (women, sex workers, migrants).	People in a situation of social inequity who could not suspend their subsistence economic activities.	Health personnel.
			People in a situation of social inequity who could not suspend their subsistence economic activities.
		People without access to information.	People without access to health services.
		People without access to information.	No schooling.
		People without access to health services.	Afro-descendant, Latin⁽³⁾ population, native peoples.
		People without access to health services.	In nursing homes, prisons.
		People without schooling; non-Spanish speakers.	Food processor workers⁽³⁾.
		People without schooling; non-Spanish speakers.	Dependent elderly.
“Signs” of illness	Kaposi’s sarcoma, extreme thinness.	The Flu or common cold = influenza.	Invisible, asymptomatic disease, hospital isolation of the sick.
Social reaction	Fear, stigmatization and rejection of infected people and groups identified as “of risk”.	Fear.	Fear and stigma (Asian population).
		Acceptance of confinement measures.	Irrational rejection of health personnel perceived almost as “vectors”.
		On the international scene, discrimination against Mexicans for Mexico being the epicenter of the pandemic⁽⁹⁾.	Uncertainty about the return to “normality” (schools, work, and social life).
		-	Rejection of prolonged confinement (individual right).
		-	Non-adherence to prevention measures.
Popular explanation of disease: search for culprits	Punishment linked to religiosity towards groups identified as “of risk” (plagued, sinners).	Punishment linked to religiosity towards groups identified as “at risk”⁽¹⁰⁾.	“I don’t see it, it doesn’t exist, I don’t catch it” (COVID-19 youth parties).
		Guilt of those who over-exploit natural resources.	Rich travelers who “imported” the virus from other countries.
		-	Stigmatization of the Asian population (China due to the origin of the virus).
Risk communication	Innovative prevention campaigns targeting specific groups (e.g. adolescents, men who have sex with men).	Information by official means.	Daily informative conferences by the government health administration.
			Information platforms on pandemics (cases, deaths, tests, etc.).
			Another level of information comes from the press and social media with false news to generate confusion in public opinion: infodemic, fake news.
	Campaign acceptance.		Political use of the disease. Ideological position on the ineffectiveness of the planning and operation of preventive strategy and care.
			Accountability: questioning of the whole care and prevention process.
			Prevention campaigns aimed at the general population.

Author	Main contributions	How does it help to understand the current context?
R. Castel⁽²²⁾	There are two types of risk: social (illness, loss of job, death); and modern (a product of industrialization and globalization, such as global warming) ones.	Greater individualization of modern societies brings as a consequence more uncertainty about how to face risks.
	Stage of “safe society” through the establishment of the Social Security/Welfare State.	Greater emotional burden on the uncertain future.
	The phase of modernity in today’s societies is characterized by greater “individualization” and loss of the collective sense.	Paradox of the current epidemic: With COVID-19, people are asked to think from the collective (stay home to save the lives of others).
A. Giddens⁽²⁰⁾	Modernity is a culture of risk (p. 35).	Knowledge takes the form of permanent hypotheses about everyday events.
	Modernity is a culture of risk (p. 35).	People build their explanations about COVID-19 based on what they hear in the media.
	Risk and trust, two concepts united in times of uncertainty.	Paradox of the current epidemic: With COVID-19, fake news is mixed with scientific data, infodemic affects people’s trust in the information received to prevent risks.
		Ambivalent.
		Stopping routine and daily activities leads to distress.
		People need to feel confident to perform well.
U. Beck⁽¹⁶⁾	“Global threat situations that arise for all humanity” (e.g. nuclear accidents).	Not only were COVID-19 cases identified in less than three months in most countries, but also their inhabitants were quarantined, at the same time, in their homes.
U. Beck⁽¹⁶⁾	“They endanger life on this Earth, and all its forms of manifestation.”	Although the author referred mainly to the danger derived from nuclear activity and the consequences of climate change, COVID-19 has endangered social life, due to the prevention measures that were taken, necessary to reduce the risk of contagion: restricting social encounters, physical contact, etc., which are the essence of human life.
D. Le Breton⁽²³⁾	All societies have developed symbolic systems or a ‘management’ model to eliminate ‘danger’, as in the past: wars, famines, diseases such as the Black Death. To pray (religion), discriminate and blame the other, minimize the threat in relation to other priorities (economy).	Risk control and management has been the object of political struggle between a scientific approach that recommends confinement to ‘flatten the curve’ and to avoid hospitals saturation to be able to attend to the serious forms of COVID-19, and an approach defended by some Heads of State who minimized the danger of the virus and the risk of contagion that this pandemic represents, stating that it was a form of flu, and rejecting quarantine.
D. Le Breton⁽²³⁾	“Risk” is the key element of the modern societies symbolic system and has become the object of political, ethical, and social struggles to define the risky situations and the ways to prevent them.
Z. Bauman⁽¹⁵⁾	Intolerance and ambivalence, two concepts derived from modernity.	Ambivalence results in disarrangement, inner discomfort from not being able to interpret the signs and choose alternatives.
	Ambivalence: possibility of relating an event to more than one category.
	The disposable lives.
M. Douglas⁽¹⁹⁾	Risk is built through a process of perception, interpretation, understanding, and actions in the people’s immediate reality.	The population group to whom we want to communicate the health risk shall be defined so as to define strategies.
M. Douglas⁽¹⁹⁾	Through experience and the family values system, one learns how to take care of him/herself.	As time goes by and we get used to living with the virus and the measures, an idea of ‘subjective immunity’ is created that the measures to prevent contagion can be relaxed.

[1] Corresponding author: Florence L. Théodore Centro de Investigación en Nutrición y Salud, Instituto Nacional de Salud Pública de México. 7a privada de Fray Pedro de Gante, Sección XVI, Tlalpan 14000 - CDMX, Cuernavaca, Mexico ftheodore@insp.mx

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Vulnerability and risk: reflections on the COVID-19 pandemic

ABSTRACT