The WHO defines health as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This is amply illustrated by the ongoing COVID-19 pandemic which has had and continues to have significant adverse impacts on health, even for populations without infection or the disease.

Even if the situation seems to be slightly improving recently, India still faces a deadly second wave of the pandemic. In this short blog, we consider the impact of this second wave on different segments of society, through the lens of social determinants of health.

Among the homeless, the second wave of the pandemic has worsened conditions for the over 1.7 million homeless people that were already living without any shelter or formal housing, with serious consequences for their susceptibility and exposure to ill-health. For instance, lack of sanitation and malnutrition have rendered them more vulnerable to catching the infection, while restrictions have had an impact on mental and social well-being, giving rise to severe mental disorders, intellectual disability, and substance abuse. This poor mental health, in turn, affects physical health, leading to poorer overall health and quality of life, through a vicious cycle.

In migrant populations, memories of the uncertainty and panic triggered by the economic shock in the first wave have led to reverse migration from cities and resulted in increased spread of the virus in rural areas which are not prepared to deal with this shock, given the poor health infrastructure. For instance, 68% of health care providers do not have any formal education. The situation is exacerbated by the vaccine-hesitancy that is driven by the fact that the disease is new and there are many unknowns. This has led to a lot of confusion and anxiety which are expressed as lack of trust in the official vaccine information, a tendency to accept a range of conspiracy theories, and a fear of the possible side-effects. With an increase in harmful health and health-seeking behaviours as a result for migrant workers.  In addition to this, fear of the virus in some villages has meant that the returnees have not been “welcomed back”, to put it mildly, which in turn has consequences for both physical and mental health.

For the middle class, the end of the first wave brought with it a decrease in the perceived importance of preventive measures such as physical distancing, with social gatherings returning in full swing, a factor at least partly responsible for the sudden surge of active cases. One of the main overall effects of the pandemic in this population over the past year has been on mental health and psychosocial well-being, with – for many – long working hours, worries about the risk of infection, shortages of medical supplies, the financial burden of medical treatment all causing psychological stress. Unfortunately, many of these worries were proven right in the dreadful second wave. Students, a specific sub-category, were not able to pursue their education normally. More in general, for many people in the middle class, the paradigm shift compared to the “normal life from before” caused by the pandemic led to a feeling of uncertainty and hopelessness about the future, while social distancing also impacted interpersonal relationships, empathy toward others and even the carrying out of important rituals such as funerals.  Elderly people have also been hit hard, throughout the pandemic, due to prolonged isolation, among others.

Meanwhile, higher-income households faced their own battles for survival. While they had greater adaptive capacity to cope with the pandemic in general, when it came to accessing healthcare in the second wave, many also faced barriers. For instance, shortages in medical supplies could not simply be resolved by throwing money at the problem – for once, ability/willingness to pay any amount was no guarantee of success. The second wave of COVID in India was, in this sense, a sort of “great social equaliser”. Although only to some extent, the poor and vulnerable were still hit much harder.

Even in non-pandemic times, India is a country with wide socioeconomic disparities between the different segments of the population. The pandemic has exacerbated this, underlining how inequities in material conditions in work, education, income and housing, all impact on health status and health outcomes. While this pandemic (including the second wave) has disproportionately affected people at the bottom of the socioeconomic pyramid, it can nevertheless still yield positive fruits, if it is used as an opportunity to close the long-standing disparities in our society. It’s difficult to see a silver lining at this moment, though, in the midst of the second wave.