In the UK, Are We Rationing Who We Care About Amid COVID-19?

    Viruses are great levelers. So it is with COVID-19, which has no regard for social status or affluence. We are all at risk, although some groups, such as older people and particularly those with comorbidities, are thought to be more vulnerable to the impact of the virus.

    However, there are other groups we risk forgetting about—such as people sleeping on the streets, people who use drugs intravenously and people dependent on drugs—who are also likely to be more vulnerable to the effects. While these groups should not be lumped together, there is some overlap; in the UK, people who use drugs are seven times more likely to be homeless.

    Perhaps it’s unsurprising that these groups have so far been ignored in UK government communications. Despite rising numbers of homelessness and drug-related deaths, these issues haven’t been given the attention or investment they deserve. These groups have little voice and few advocates, so can be ignored without risking a public backlash or compromising political popularity.

    Ignoring these people, however, is shortsighted: If the government’s aim is to mitigate the impact of the virus, then all at-risk groups should be considered and appropriate planning and action taken to protect them.

    People who are homeless are unlikely to have regular access to hand washing facilities, soap or hand sanitizers, and they are in close proximity to each other—in hostels or in tents, for example. It will be that much harder for people who are homeless to carry out the social distancing measures that public health experts are advising, or to self-isolate if they have symptoms. Like older people, homeless people are also more likely to have comorbid physical problems, which place them at greater risk.

    We know then that homeless people are more likely to be vulnerable to infection and poorer outcomes, but what of their access to healthcare? For people who are sleeping on the streets or in hostels, this is a pretty poor picture. Personal Medical Services, which were set up in the UK over a decade ago by the Labour government with the aim of engaging such groups in health, have all but disappeared. This leaves homeless people with services that they are often reluctant to access, or which they avoid due to previous poor experiences.

    The lack of attention throws into sharp relief who we collectively think is deserving of care and who isn’t.

    Another group not well served by our healthcare system is people injecting drugs, such as heroin and cocaine. These drugs affect respiratory function, impacting the ability of the people who use them to recover from infection. Added to this is the higher rates of tobacco use among people using drugs, which also compromises respiratory functioning. Also, behaviors such as sharing a cigarette or picking up a used stub would seem likely to increase the risk.

    At the same time, the UK’s Home Office has identified the aging cohort of people using drugs as one of the reasons why record numbers are dying as they develop complex comorbidities. Some people in this group will already have compromised immune systems, due to poor diet and poor self-care, which will influence the outcome of infection with COVID-19.

    Intravenous drug use can be made safer with access to clean needles and syringes, and if those using this equipment don’t share it with others. The British state used to provide access to needle and syringe exchange services that offered sterile equipment, but those services have been hit hard by the cuts made to public health budgets.

    But it’s not just those injecting drugs who need support; there are some obvious infection risks that people face when taking drugs in other ways. These risks could be mitigated if public health messages targeted these groups and advised them on how to reduce the risks of transmitting COVID-19 while using drugs. Sadly, this easy and relatively cheap advice is unlikely to be given by government departments, as it could be viewed as condoning illegal drug use.

    So, as we are all encouraged by our government to pull together and consider the collective good, we appear to risk leaving some of our society behind. It’s in all our interests to ensure that people who are homeless or using drugs are protected and cared for during this coronavirus outbreak. The lack of attention and willingness by the government to mitigate the risks these groups face throws into sharp relief who we collectively think is deserving of care and who isn’t.

    This won’t be the first time that people from these groups feel ignored and marginalized. This latest oversight should make us all think about whether the government’s indifference is a reflection of a wider rationing of empathy towards some parts of our society.


    A slightly different version of this article was originally published by the British Medical Journal.  

    Photo of a person who is homeless in Norwich, England by Evelyn Simak, via Geograph/Creative Commons 2.0

    • Ian is a senior lecturer in Addiction and Mental Health at the University of York, England. He previously worked as a mental health nurse with people who had combined mental health and substance use problems.

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