Covid-19 in Seine-Saint-Denis (1/2): When the Pandemic Entrenches Health Inequalities

From the very beginning of the first lockdown, on March 17, 2020, a number of French media outlets reported on the social inequalities that were emerging in the face of the current health crisis [1] and the greater day-to-day difficulties faced by residents of working-class neighborhoods. In his speech on April 13, 2020, President Emmanuel Macron mentioned educational and housing inequalities, in connection with the need to limit the duration of lockdown measures. At the start of April 2020, following the publication of updated figures on deaths from Covid‑19 by the French public-health authority (Santé Publique France) and the national statistics office (INSEE), a flurry of articles reported “worrying” levels of excess mortality in the département of Seine-Saint-Denis, [2] particularly compared with other départements in the Paris region. And yet social and spatial inequalities with regard to health remained absent from the French president’s discourse. More broadly, these inequalities have not been well understood during the crisis, including in interviews and articles by social scientists on the issue of inequalities, which more often than not have been considered from economic, gender, and, to a lesser extent, ethnic and racial standpoints. When it comes to health, however, all these dimensions are in fact interconnected, with cumulative effects.

Socio-spatial health inequalities were at the heart of a survey on health policies, health professionals, and health practices in working-class areas that we conducted from 2012 to 2017 in a working-class town in Seine-Saint-Denis, which we will call Rouvil. [3] Rouvil is a town which, like many others in Seine-Saint-Denis, is marked by the situations of precarity that affect its population, as well as by a relative lack of family doctors, who choose to set up practices elsewhere. However, its situation in terms of health facilities and resources is less critical than in other towns in the département, owing to the presence of a hospital, the long-established existence of a local health policy, and a dense network of associations. We used our survey to analyze the increase in social inequalities relating to health caused by the pandemic. We also continued to work on the survey during lockdown by conducting documentary analysis (of the press and social media) and interviews, and by processing data from a collaborative database on the epidemic in France, compiled by département. [4]

The long-term nature of this research meant that we have been able to analyze the current crisis in terms of the relationship between social inequalities, health and public policies. The health system plays a key role with regard to these inequalities, and we will come back to this in a second article. [5] This first paper seeks to demonstrate how Covid‑19 has put the spotlight on the accumulation of social inequalities in working-class neighborhoods in terms of working, living and health conditions, but also that the health crisis and its political management have tended to exacerbate this accumulation of inequalities. These inequalities have in fact overexposed racialized urban working classes to the virus: [6] while the virus has affected Seine-Saint-Denis more than other areas, despite the lower average age of its population, it has also affected it differently than elsewhere, contributing to an overall deterioration of the health conditions of the département’s working-class populations.

A Covid conundrum: a young population overexposed to the virus

Within the two French regions most affected by the epidemic, Grand Est (eastern France) and Île-de-France (the Paris region), the situation of Seine-Saint-Denis—the second most affected département in terms of excess deaths—may be considered somewhat surprising (Figure 1), given that it is the youngest département in mainland France (with just 12% of people aged over 65, compared with 21.5% in the eastern département of Haut-Rhin, for example) and the risk of death from the virus is much higher in people aged over 65. And yet, from April 3 to April 13, 2020, Seine-Saint-Denis remained the département with the highest excess mortality rate among people under 65 (+70%), with Haut-Rhin in fifth place (+47%), behind other départements in the Paris region.

This apparent enigma can only be understood by relating it to the social condition of the inhabitants in question: the population of Seine-Saint-Denis mostly comprises urban working-class individuals, many of whom are racialized, and who accumulate multiple social inequalities that in turn contribute to poorer states of health than in the rest of the Paris region or elsewhere in France. This overall situation exposes them to the virus to a greater extent, and the epidemic further accentuates their “fragility” in terms of these criteria.

Racialized urban working classes more exposed and more affected

Social inequalities in the face of disease and death (Gelly and Pitti 2016) are particularly marked in Seine-Saint-Denis compared to national averages. The high prevalence of chronic diseases—significant comorbidities in Covid‑19 cases—means that the département’s working-class populations find themselves in a more fragile situation in the face of the virus. Among mainland départements (Figure 2), Seine-Saint-Denis ranks 1st for diabetes (behind only La Réunion and Guadeloupe, two overseas départements), 8th for respiratory diseases, and 14th for high blood pressure. The proportion of adults suffering from obesity is also very high, and in particular much higher than in the neighboring City of Paris. Several towns in Seine-Saint-Denis, taking their lead from Rouvil, which has run local experiments in “health sports” in recent years, are also trying to take action to combat these social inequalities in health.

These particularly poor health situations can be explained by an accumulation of social inequalities, as demonstrated in particular by the incidence of occupational cancers (Marchand 2016) in Seine-Saint-Denis. Unemployment in the département is high and service-sector jobs are numerous, indicating the prevalence of certain kinds of working conditions. The salaried working classes (white-collar and blue-collar workers) represent 55% of the active population (compared to 47.9% in France as a while), while 61.4% work in construction, retail, transportation, and services (compared to 53% nationally). It is also the département with the highest proportions of foreign (23%) and immigrant populations in France (Figure 3).

This social morphology may shed light on the prevalence of Covid‑19 in the département and the resulting excess deaths (Brun and Simon 2020), as racialized people are overrepresented in precarious service-sector jobs (taxi/transit drivers, delivery drivers, cashiers, cleaners, caregivers), and many of them are exposed to repeated contact with people throughout the day, each a potential vector of contamination. Some 52.7% of employees take public transportation to get to work, with Seine-Saint-Denis ranking second among France’s départements in this respect, behind the City of Paris (68.6%) and ahead of its southern neighbor, Val-de-Marne (48.9%). During lockdown, the impossibility of remote working for a large proportion of manual professions also meant that workers in Seine-Saint-Denis took public transportation more than in other areas—a factor which, along with pollution, plays a role in the spread of the virus. In this context, these workers were naturally among the first to suffer, along with caregivers.

These working conditions are combined with living conditions that are worse than elsewhere, in terms of access to good-quality food and housing. Seine-Saint-Denis is the poorest département in mainland France: 27.9% of its population were living below the poverty line in 2017, compared with 15.2% in the City of Paris. The population’s limited economic resources have an impact on diet, and consequently on health (diabetes, cardiovascular diseases, etc.). This issue has been the subject of prevention campaigns and experiments for a number of years in those towns in the département that have developed public-health policies, such as Rouvil. With respect to housing, in addition to workers’ hostels—high-density collective housing—which are more numerous in Seine-Saint-Denis than elsewhere, a significant proportion of the département’s inhabitants live in overcrowded housing. In 2016, more than a quarter of the area’s housing was overcrowded (26.5%), making it the second worst-affected département in France in this regard, after the City of Paris (32.3%). And housing has effects on health status: even before the epidemic, our survey in Rouvil showed the health effects of unsanitary housing, particularly on respiratory pathologies. Overcrowding and insalubrity have both played a role in intensifying the spread of the epidemic in Seine-Saint-Denis (Gilbert 2020), causing what journalists have called “family clusters,” using this epidemiological category to designate sources of contamination.

When the epidemic exacerbates existing suboptimal health conditions

In addition to the number of deaths (particularly among those under 65), the epidemic has also exacerbated cumulative social inequalities by causing a general deterioration in working and living conditions, which in turn has contributed to a deterioration in inhabitants’ health—in general, not just with respect to Covid‑19. After all, health does not just refer to the absence of disease: according to the definition adopted by the World Health Organization in 1946, health is a “state of complete physical, mental, and social well-being.” In Rouvil, a number of health professionals, social-services professionals, and civil servants responsible for local public action on health use this all-encompassing definition to guide their efforts to reduce social inequalities with regard to health (Mariette and Pitti 2016; Mariette 2017).

However, when it comes to “physical, mental, and social well-being,” the health crisis has further entrenched inequalities in terms of employment and living conditions. Informal interviews conducted in Rouvil suggest that a portion of the working-class population experienced a significant decrease in income due to job losses or a forced shift from full-time to part-time work during lockdown. Lockdown also increased marital and family tensions in a context of overcrowded housing and school closures, and heightened issues relating to access to food, such as the effects of school meals no longer being provided during lockdown, and more broadly of what is described by some senior civil servants and journalists as a “food crisis.” [7]

Still on the theme of “physical, mental, and social well-being,” the health crisis and the way it has been managed by politicians have also had the effect of increasing the stigmatization of Seine-Saint-Denis. The members of the urban working classes who live there, many of whom are racialized, have long suffered from an accumulation of stigmas that have, in effect, made them the new figures of the “classes dangereuses” (“dangerous classes”), to use the expression coined by Louis Chevalier to designate the perception of the working classes by public authorities in the first half of the 19th century, particularly after the cholera epidemic of 1832 (Chevalier 1958). These racialized residents have also long been treated unequally and discriminated against in terms of both health and public services, as highlighted in a report by two members of parliament (François Cornut-Gentille and Rodrigue Kokouendo) published in May 2018, which concluded that there is an accumulation and reproduction of inequalities in relation to schools, policing, and justice, which public action has played a role in perpetuating. These racialized urban working classes have also been othered—that is, considered as “other” by nature—and consequently stigmatized in a number of public and press discourses, as shown by the media’s coverage of the issue of “non-compliance” with lockdown restrictions “in the projects,” which was all too often reductively correlated to essentialized “cultural” habits—and all this despite the fact that these reports of non-compliance were invalidated by statements made by the prefect of Seine-Saint-Denis. The increase in targeted checks and controls in working-class neighborhoods (“220,000 checks in Seine-Saint-Denis” between the beginning of the first lockdown and April 23, 2020, “a little more than double the national average,” according to the French interior minister) has reinforced this unequal and discriminatory treatment, [8] while repeated incidents of police violence have exposed the racist nature of many of these checks. [9] Furthermore, stigmatization and discrimination have effects on health and, as shown by a recent survey (Khlat, Wallace and Guillot 2019) [10] on life expectancy, in particular for male descendants of immigrants from North Africa—a group that was one of the key targets of these police controls. [11]

Finally, on the question of pathologies, the epidemic and lockdown restrictions have compounded the problems posed by chronic disorders (diabetes, respiratory diseases, high blood pressure, obesity), which were already very frequent in Seine-Saint-Denis. The département’s lack of health-care facilities has led hospitals, probably more so than elsewhere, to reorganize themselves into “Covid units” and to temporarily suspend the monitoring of chronic diseases, as Yasmina Kettal, a nurse in the emergency room of one of the département’s hospitals, explained on April 20, 2020: “Above all, in early March, our hospital put its ‘extended emergency plan’ into action […]. We closed what we call “weekday hospital” and consultations, but by closing them we knew that this would inevitably pose problems for the follow-up of chronic pathologies, and that it would have an impact on the health of our patients.” [12]

Covid‑19 has thus affected Seine-Saint-Denis more than other départements in the Paris region, and more even than the eastern Haut-Rhin département (one of the worst-affected in France at the start of the pandemic), but the health crisis and the way it has been managed politically have also had a greater impact here than elsewhere on the deterioration of the “physical, mental, and social” health of its inhabitants and the increase in accumulated inequalities. To understand the amplified effects of the epidemic in Seine-Saint-Denis, it is therefore imperative to objectively identify funding inequalities—in this case, the under-resourcing of the département in terms of health facilities and budgets compared to the rest of the country (Amdaoud et al. 2020), in a context where the population’s access to basic rights and health care is more limited than elsewhere (see “Covid‑19 in Seine-Saint-Denis (2/2): How the Health System Increases Inequalities”, forthcoming).

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