Pandemic preparedness has traditionally been assessed through technical capacity, yet COVID-19 revealed a persistent gap between preparedness on paper and outcomes in practice. This paper examines how structural inequalities, rather than scientific limitations, shaped transmission dynamics and mortality, arguing for a reframing of preparedness around equity and implementation. Drawing on epidemiological evidence, case studies, and policy analysis, we introduce the concept of “social niches” as key transmission engines: structurally defined environments (e.g., occupations, housing, mobility constraints) that concentrate exposure risk and connect otherwise separate contact networks. We show that disparities in COVID-19 outcomes were primarily driven by differential exposure rather than intrinsic biological susceptibility, with transmission amplified in high-contact, resource-constrained settings such as migrant worker housing, informal labour sectors, and care institutions. Early ‘one-size-fits-all’ pandemic response further magnified these effects, as delays in targeted interventions within high-risk groups led to widespread seeding across populations. We also highlight limitations in prevailing metrics, which prioritised laboratory and epidemiological indicators without sufficient integration of social context, leading to misaligned policy responses. We argue that preparedness frameworks must incorporate auditable equity metrics, disaggregated data, and operational strategies capable of reaching high-exposure populations. In conclusion, effective pandemic preparedness is defined not by assets alone, but by equitable reach and timely implementation. Embedding equity into preparedness planning is essential to prevent recurrent patterns of concentrated transmission and disproportionate impact in future pandemics.
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Best Prepared, Worst Outcomes: Ethnicity, Structural Inequality and Pandemic Preparedness
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Received: 10 Nov 2025 | Revised: 04 Jan 2026 | Accepted: 27 Jan 2026 | Published: 15 Apr 2026
Abstract
References
- 1.
Nuzzo, J.B.; Ledesma, J.R. Why Did the Best Prepared Country in the World Fare So Poorly during COVID? J. Econ. Perspect. 2023, 37, 3–22.
- 2.
Bilinski, A.; Emanuel, E.J. COVID-19 and Excess All-Cause Mortality in the US and 18 Comparison Countries. JAMA 2020, 324, 2100–2102.
- 3.
Ledesma, J.R.; Isaac, C.R.; Dowell, S.F.; et al. Evaluation of the Global Health Security Index as a Predictor of COVID-19 Excess Mortality Standardised for Under-Reporting and Age Structure. BMJ Glob. Health 2023, 8, e012203.
- 4.
Irizar, P.; Pan, D.; Kapadia, D.; et al. Ethnic Inequalities in COVID-19 Infection, Hospitalisation, Intensive Care Admission, and Death: A Global Systematic Review and Meta-Analysis of over 200 Million Study Participants. eClinicalMedicine 2023, 57, 101877.
- 5.
Thakur, N.; Lovinsky-Desir, S.; Bime, C.; et al. The Structural and Social Determinants of the Racial/Ethnic Disparities in the U.S. COVID-19 Pandemic. What’s Our Role? Am. J. Respir. Crit. Care Med. 2020, 202, 943–949.
- 6.
Pareek, M.; Bangash, M.N.; Pareek, N.; et al. Ethnicity and COVID-19: An Urgent Public Health Research Priority. Lancet 2020, 395, 1421–1422.
- 7.
Pan, D.; Sze, S.; Minhas, J.S.; et al. The Impact of Ethnicity on Clinical Outcomes in COVID-19: A Systematic Review. eClinicalMedicine 2020, 23, 100404.
- 8.
Sze, S.; Pan, D.; Nevill, C.R.; et al. Ethnicity and Clinical Outcomes in COVID-19: A Systematic Review and Meta-Analysis. eClinicalMedicine 2020, 29, 100630.
- 9.
Silva, S.; Goosby, E.; Reid, M.J.A. Assessing the Impact of One Million COVID-19 Deaths in America: Economic and Life Expectancy Losses. Sci. Rep. 2023, 13, 3065.
- 10.
Martin, C.A.; Pan, D.; Nazareth, J.; et al. Access to Personal Protective Equipment in Healthcare Workers during the COVID-19 Pandemic in the United Kingdom: Results from a Nationwide Cohort Study (UK-REACH). BMC Health Serv. Res. 2022, 22, 867.
- 11.
World Health Organization. From Emergency Response to Long-Term COVID-19 Disease Management: Sustaining Gains Made During the COVID-19 Pandemic; World Health Organization: Geneva, Switzerland, 2023.
- 12.
Sabatello, M.; Jackson Scroggins, M.; Goto, G.; et al. Structural Racism in the COVID-19 Pandemic: Moving Forward. Am. J. Bioeth. 2021, 21, 56–74.
- 13.
Pan, D.; Sze, S.; Martin, C.A.; et al. Covid-19 and Ethnicity: We Must Seek to Understand the Drivers of Higher Transmission. BMJ 2021, 372, n2709.
- 14.
Lin, Q.; Paykin, S.; Halpern, D.; et al. Assessment of Structural Barriers and Racial Group Disparities of COVID-19 Mortality with Spatial Analysis. JAMA Netw. Open 2022, 5, e220984.
- 15.
Lee, H.; Andrasfay, T.; Riley, A.; et al. Do Social Determinants of Health Explain Racial/Ethnic Disparities in COVID-19 Infection? Soc. Sci. Med. 2022, 306, 115098.
- 16.
Koh, D. Migrant Workers and COVID-19. Occup. Environ. Med. 2020, 77, 634–636.
- 17.
Gorny, A.W.; Bagdasarian, N.; Koh, A.H.K.; et al. SARS-CoV-2 in Migrant Worker Dormitories: Geospatial Epidemiology Supporting Outbreak Management. Int. J. Infect. Dis. 2021, 103, 389–394.
- 18.
Tang, J.W.; Bird, P.W.; Holmes, C.W.; et al. The UK Leicester COVID-19 ‘Exceedance’ May–July 2020: An Analysis of Hospitalised Cases. J. Infect. 2021, 83, e5–e7.
- 19.
Ball, J. More than 1200 Textile Workers Illegally Underpaid. BBC News, 19 April 2020.
- 20.
Pittam, D. Coronavirus: ‘Big Problem’ at Leicester Factories, Say Workers. BBC News, 7 July 2020.
- 21.
Ngiam, J.N.; Chew, N.; Tham, S.M.; et al. Demographic Shift in COVID-19 Patients in Singapore from an Aged, At-Risk Population to Young Migrant Workers with Reduced Risk of Severe Disease. Int. J. Infect. Dis. 2021, 103, 329–335.
- 22.
Iacobucci, G. COVID-19: Lack of Capacity Led to Halting of Community Testing in March, Admits Deputy Chief Medical Officer. BMJ 2020, 369, m1845.
- 23.
Zhang, X.; Barr, B.; Green, M.; et al. Impact of Community Asymptomatic Rapid Antigen Testing on COVID-19 Related Hospital Admissions: Synthetic Control Study. BMJ 2022, 379, e071374.
- 24.
Giebel, C.; Hanna, K.; Cannon, J.; et al. Are We Allowed to Visit Now? Concerns and Issues Surrounding Vaccination and Infection Risks in UK Care Homes during COVID-19. Age Ageing 2022, 51, afab229.
- 25.
Feathers, L.; Hinde, T.; Bale, T.; et al. Outbreak of SARS-CoV-2 at a Hospice: Terminated after the Implementation of Enhanced Aerosol Infection Control Measures. Interface Focus 2022, 12, 20210066.
- 26.
Cheng, C.; Wu, H.-Y.; Kuo, S.-C.; et al. Excess Mortality and Containment Performance during the COVID-19 Pandemic: Evidence from 34 Countries. Am. J. Public Health 2025, 115, 1518–1528.
- 27.
Zhu, D.; Ozaki, A.; Virani, S.S. Disease-Specific Excess Mortality during the COVID-19 Pandemic: An Analysis of Weekly US Death Data for 2020. Am. J. Public Health 2021, 111, 1518–1522.
- 28.
Arnold, K.F.; Gilthorpe, M.S.; Alwan, N.A.; et al. Estimating the Effects of Lockdown Timing on COVID-19 Cases and Deaths in England: A Counterfactual Modelling Study. PLoS ONE 2022, 17, e0263432.
- 29.
Martin, C.A.; Jenkins, D.R.; Minhas, J.S.; et al. Socio-Demographic Heterogeneity in the Prevalence of COVID-19 during Lockdown Is Associated with Ethnicity and Household Size: Results from an Observational Cohort Study. eClinicalMedicine 2020, 25, 100466.
- 30.
Pan, D.; Martin, C.A.; Nazareth, J.; et al. Ethnic Disparities in COVID-19: Increased Risk of Infection or Severe Disease? Lancet 2021, 398, 389–390.
- 31.
Reynolds, J.; Kincaid, R. Gig Work and the Pandemic: Looking for Good Pay from Bad Jobs during the COVID-19 Crisis. Work Occup. 2023, 50, 60–96.
- 32.
Ravenelle, A.J.; Kowalski, K.C.; Janko, E. The Side Hustle Safety Net: Precarious Workers and Gig Work during COVID-19. Sociol. Perspect. 2021, 64, 898–919.
- 33.
Henderson, R. How COVID-19 Has Transformed the Gig Economy. Financial Times, 10 December 2020.
- 34.
Abu-Raddad, L.J.; Chemaitelly, H.; Ayoub, H.H.; et al. Relative Infectiousness of SARS-CoV-2 Vaccine Breakthrough Infections, Reinfections, and Primary Infections. Nat. Commun. 2022, 13, 532.
- 35.
Singanayagam, A.; Patel, M.; Charlett, A.; et al. Duration of Infectiousness and Correlation with RT-PCR Cycle Threshold Values in Cases of COVID-19, England, January to May 2020. Euro Surveill. 2020, 25, 2001483.
- 36.
Pan, D.; Sze, S.; Abraham, S.; et al. Rapid Tests for Quantification of Infectiousness Are Urgently Required in Patients with COVID-19. Lancet Microbe 2021, 2, e286–e287.
- 37.
Dehesh, P.; Baradaran, H.R.; Eshrati, B.; et al. The Relationship between Population-Level SARS-CoV-2 Cycle Threshold Values and Trend of COVID-19 Infection: Longitudinal Study. JMIR Public Health Surveill. 2022, 8, e36424.
- 38.
Karlinsky, A.; Kobak, D. Tracking Excess Mortality across Countries during the COVID-19 Pandemic with the World Mortality Dataset. eLife 2021, 10, e69336.
- 39.
Tang, J.W.; Pan, D.; Loh, T.P. East Meets West: Overcoming Barriers to Compliance with Mitigation Behaviours during the COVID-19 Pandemic. Dis. Biol. Genet. Socioecol. 2025, 1, 5.
- 40.
Majeed, A.; Seo, Y.; Heo, K.; et al. Can the UK Emulate the South Korean Approach to COVID-19? BMJ 2020, 369, m2084.
- 41.
Beaumont, P.; Connolly, K. COVID-19 Track and Trace: What Can UK Learn from Countries That Got It Right? The Guardian, 21 May 2020.
- 42.
Tang, J.W.; Bahnfleth, W.P.; Bluyssen, P.M.; et al. Dismantling Myths on the Airborne Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). J. Hosp. Infect. 2021, 110, 89–96.
- 43.
Morawska, L.; Cao, J. Airborne Transmission of SARS-CoV-2: The World Should Face the Reality. Environ. Int. 2020, 139, 105730.
- 44.
Lewis, D. Why the WHO Took Two Years to Say COVID Is Airborne. Nature 2022, 604, 26–31.
- 45.
Cheng, V.C.-C.; Wong, S.-C.; Chuang, V.W.-M.; et al. The Role of Community-Wide Wearing of Face Mask for Control of Coronavirus Disease 2019 (COVID-19) Epidemic Due to SARS-CoV-2. J. Infect. 2020, 81, 107–114.
- 46.
Wong, S.Y.S.; Kwok, K.O.; Chan, F.K.L. What Can Countries Learn from Hong Kong’s Response to the COVID-19 Pandemic? Can. Med. Assoc. J. 2020, 192, E511–E515.
- 47.
Gurbaxani, B.M.; Hill, A.N.; Patel, P. Unpacking Cochrane’s Update on Masks and COVID-19. Am. J. Public Health 2023, 113, 1074–1078.
- 48.
Jefferson, T.; Dooley, L.; Ferroni, E.; et al. Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses. Cochrane Database Syst. Rev. 2023, 1, CD006207.
- 49.
Tang, J.W.; Caniza, M.A.; Dinn, M.; et al. An Exploration of the Political, Social, Economic and Cultural Factors Affecting How Different Global Regions Initially Reacted to the COVID-19 Pandemic. Interface Focus 2022, 12, 20210079.
- 50.
Irizar, P.; Pan, D.; Taylor, H.; et al. Disproportionate Infection, Hospitalisation and Death from COVID-19 in Ethnic Minority Groups and Indigenous Peoples: An Application of the Priority Public Health Conditions Analytical Framework. eClinicalMedicine 2024, 68, 102360.
- 51.
UNAIDS. Breaking the Inequality-Pandemic Cycle: Building True Health Security in a Global Age; UNAIDS: Geneva, Switzerland, 2023.
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