key: cord-1006110-gmne0anj authors: Fiske, Amelia; Galasso, Ilaria; Eichinger, Johanna; McLennan, Stuart; Radhuber, Isabella; Zimmermann, Bettina; Prainsack, Barbara title: The second pandemic: Examining structural inequality through reverberations of COVID-19 in Europe date: 2021-12-04 journal: Soc Sci Med DOI: 10.1016/j.socscimed.2021.114634 sha: 270ff3620d87ee31fb0c26ce968a11c2f0dce753 doc_id: 1006110 cord_uid: gmne0anj While everyone has been impacted directly or indirectly by the COVID-19 pandemic and the measures to contain it, not everyone has been impacted in the same way and certainly not to the same degree. Media coverage in early 2020 emphasized the “unprecedented” nature of the pandemic, and some even predicted that the virus could be a global “equalizer.” Ensuing debates over how the pandemic should be handled have often hinged on oppositions between protecting health and healthcare systems versus saving livelihoods and the economy, a dichotomy that we argue is false. Drawing on 482 interviews conducted in Germany, Italy, Ireland, Austria, German-speaking Switzerland and the UK over two points in a 6-month period as part of the ‘Solidarity in times of Pandemics Research Consortium’ (SolPan), we illustrate the ways that oppositions posed between saving lives or saving livelihoods fail to capture the entangled, long-standing nature of structural inequalities that have been revealed through the pandemic. Health- and wealth-related inequalities intersect to produce the “second pandemic,” a term used by a research participant to explain the other forms of devastation that run in parallel with virus. Our findings thus complicate such dichotomies through a qualitative understanding of the pandemic as a lived experience. The pandemic emerges as a critical juncture which, in exacerbating these existing structural inequalities, also poses an opportunity to work to better resolve them. While everyone has been impacted directly or indirectly by the COVID-19 pandemic and the measures to contain it, not everyone has been impacted in the same way and certainly not to the same degree. Media coverage in early 2020 emphasized the "unprecedented" nature of the pandemic, and some even predicted that the virus could be a global "equalizer." Ensuing debates over how the pandemic should be handled have often hinged on oppositions between protecting health and healthcare systems versus saving livelihoods and the economy, a dichotomy that we argue is false. Drawing on 482 interviews conducted in Germany, Italy, Ireland, Austria, German-speaking Switzerland and the UK over two points in a 6-month period as part of the 'Solidarity in times of Pandemics Research Consortium' (SolPan), we illustrate the ways that oppositions posed between saving lives or saving livelihoods fail to capture the entangled, long-standing nature of structural inequalities that have been revealed through the pandemic. Health-and wealth-related inequalities intersect to produce the "second pandemic," a term used by a research participant to explain the other forms of devastation that run in parallel with virus. Our findings thus complicate such dichotomies through a qualitative understanding of the pandemic as a lived experience. The pandemic emerges as a critical juncture which, in exacerbating these existing structural inequalities, also poses an opportunity to work to better resolve them. Early in 2020, media coverage emphasized the "unprecedented" nature of the COVID-19 pandemic: memes depicted humanity, caught in a single boat out at sea; others celebrated solidarity as people sang from balconies or clapped for healthcare workers. While there are many novel aspects to the COVID-19 pandemic, it has also exacerbated familiar fault lines of inequality and socio-economic disparities, and created new ones. This paper offers a unique perspective on the lived experience of the pandemic from a qualitative interview study drawing from data in six European countries as part of an emerging field of cross-national research on social inequalities in health (Health Inequalities, 2020). We explore how health-and wealth-related inequalities reverberate through the lives of our participants, and intersect to produce the "second pandemic," a term used by a participant to explain the entangled social and economic devastation that runs in parallel with the virus. Specifically, we draw on longitudinal data from qualitative interviews conducted as part of the 'Solidarity in times of a pandemic' Consortium (SolPan) with a total of 482 respondents in Germany, Italy, Ireland, Austria, German-speaking Switzerland and the UK. In contrast to public debates over how the pandemic should be handled which often position public health against public wealth, our data illustrates that oppositions between saving lives or saving livelihoods fail to capture the entangled, long-standing nature of structural inequalities revealed through the pandemic. We complicate such dichotomies through a qualitative understanding of the pandemic as a lived experience, and conclude that the current moment presents an opportunity to address the structural inequalities which have emerged with greater force as a result of COVID-19. Structural inequality refers to the large-scale historical, social, political and economic factors that shape disparities in society, including property rights, health care outcomes and access, housing, education, and other resources (Farmer, 2004) . Examining how multiple, intersecting forms of privilege and disadvantage compound points to the ways that while everyone has been impacted by the COVID-19 pandemic and the measures to contain it, not everyone is impacted in the same way, nor to the same degree (Marmot et al., 2020) . Initial claims that COVID-19 would be a great equalizer have since been disproven, both in terms of health and wealth (Devakumar et al., 2020; Phillips, 2020) . In terms of health, certain groups have higher infection risk due to their work, social circumstances, or living conditions that do not allow them to maintain social distance. For example, many lower-paid, essential workers (eg., food, cleaning, delivery services) were required to keep working in person, resulting in greater risk of exposure for themselves, their families, and others at the work place or using public transport (Bambra et al., 2020 (Bambra et al., , 2021 . Socially disadvantaged and underserved groups are more likely to develop medical conditions that correlate with severe forms of COVID-19 infection (Marmot et al., 2020; Marmot, 2015) . For example, mortality rates in more deprived areas of the UK were two times those of less deprived areas between March and July (Johnson et al., 2021) . Infection risks in Germany followed regional patterns of inequality, with socio-economic differences among risk-groups for severe COVID-19 (Wachtler and Hoebel, 2020) . Contingently, the pandemic is also an unequalizer in terms of wealth (Schrecker and Bambra, 2015) . The measures enacted to contain the spread of the disease include restrictions on movement and on a variety of business and non-business activities that have serious socioeconomic repercussions. The "second pandemic" disproportionately affects those who were already in precarious social, economic or working conditions, and reduces services for those who were already poor (smaller businesses, unofficial forms of work, precarious contracts or economic conditions, poor housing, underserved areas). It has "exposed, fed off and increased existing inequalities of wealth, gender and race" by making the rich richer and the poor poorer (Oxfam, 2021) . Country-specific as well as global data are clear in this respect, raising significant concerns that the world has emerged even more unequal through the COVID-19 pandemic (Marmot et al., 2020; Oxfam, 2021; Human Rights Council, 2020) . Trends of increasing inequality are measurable throughout Europe. For instance, while northern Italy made headlines in March 2020 for being particularly devastated, a year later, secondary effects reached the entire country with a 105% increase of the "new poor" (people seeking aid for the first time) between March and May 2020 (Italiana, 2020) . At least one family member in 2.1 million Italian households is working irregularly; these households are expected to become actually poor due to the pandemic (Focus Censis Confcooperat, 2020) . In Ireland, the Economic and Social Research Institute calculated that 400,000 families would lose 20% of their disposable income without significant policy changes (Beirne et al., 2020) . The unemployment rate in Ireland rose from 5 to 20% during 2020, with a 20% consumption drop in the first lockdown period (McQuinn et al., 2020) . In Austria, those who were already at greater risk of poverty or exclusion were more affected by the socioeconomic consequences than the average, demonstrating increasingly visible divides between the poor and middle class, unemployed and employed, the old and the young (Austrian Federal Ministry, 2020). Those working part-time jobs to supplement unemployment payments or pensions were particularly affected (Austrian Federal Ministry, 2020) . Similarly, people working in lower income brackets in Germany lost the most income in relative terms, and were affected by losses almost twice as often as those with high incomes (Kohlrausch et al., 2020) . Structurally disadvantaged social groups have been most affected by the pandemic. In the UK, studies indicate that young workers were economically harder hit than middle-aged workers, as well as low earners more than higher earners, Black, Asian and ethnic minorities more than white British workers, and non-traditional contracts and the self-employed more than salaried employees (Brewer, 2020; Adams-Prassl et al., 2020; Gardiner and Slaughter, 2020) . In Switzerland, women, LGBT+, those with low income, basic formal education level, addiction problems or migration background were found to be at a higher risk to be negatively affected by the COVID-19 pandemic (Hurst, 2020; Luder, 2020) . A comparative study of Germany, Austria, and Switzerland found school closures to cause long-lasting negative effects, leaving already disadvantaged children behind (Huber et al., 2020) . Numerous out-of-home support services provided by the state or civil society ended during lockdowns, with consequences for the neediest youth (Stiftung, 2020) . Additionally, the mental health of children from socially disadvantaged or migration backgrounds in Germany was found to be disproportionately more affected than that of their peers (Ravens-Sieberer et al., 2021) . Various federal aid programs to mediate the socioeconomic effects of the pandemic have been initiated across Europe, ranging in the billions of euros per country (Table 1 ). In Germany, Switzerland, and Austria this has ranged from economic stimulus aid and support for businesses, to employment aid, support for charities and research related to COVID-19. The Irish government implemented an income support scheme to help workers and businesses who had been affected, and the Italian government implemented a variety of measures to mitigate the economic consequences of the crisis including a layoff freeze, payroll subsidies, and an 'emergency salary.' In many countries, support programs were prolonged throughout spring 2021 to offset the continued effects of the pandemic. Mental health programs were also initiated, with organizations providing remote support for those in need. Frequent distinctions drawn in the media, policy reports, and public debate between the health effects of the pandemic and the wealth effects were reflected in our interviews. Yet, in analyzing the relationships between these concerns as retold by participants, we find that this supposed dichotomy between life and economy quickly breaks down in the tensions and connections that are woven within participants' own accounts of how inequality is reproduced. We show how the pandemic emerges as a critical juncture which, in exacerbating existing structural inequalities across realms of health and wealth, also poses an opportunity to work to better resolve them. This study is part of the qualitative, longitudinal, and multinational SolPan study and has been made possible by the joint work of the members of the SolPan research commons. The consortium, comprised of social science researchers working in nine European countries, was formed in March 2020 to explore peoples' experiences during the pandemic. Participants were recruited through online advertisement on university websites, social media networks, and through snowball sampling. All above 18 in the respective countries were eligible to participate. Participants were recruited with attention to age, gender, income, household structure, geographic area, education, and employment. Participants were interviewed twice. The first (referred to as "T1") covered the "lockdowns" in spring (6 April-6 May 2020), and the second in the fall ("T2"; 2-28 October; until 31 October in Italy, and until 3 November in Ireland). The interviews followed an interview guide developed by the SolPan consortium. Interviews ranged from 30 to 80 min, and were conducted in the official language of the country, with the exception of one English interview in Germany. Consent was obtained orally. Interviews were recorded on a digital recorder or using a GDPRcompliant video chat recorder. Only audio material was stored. The interviews were transcribed and pseudonymized. The study was approved by the following ethics committees: Technical University of Munich (208/20 S; also covered Switzerland), University College Dublin (HS-E− 20-70-Galasso), the University of Vienna (00544; also covered (continued on next page) UK and Italy). T1 data consisted of: 46 interviews in Germany, 80 in Austria, 35 in the UK, 33 in Italy, 32 in Ireland, and 31 in Switzerland. Of these, 43 participants in Germany, 72 in Austria, 30 in the UK, 29 in Italy, 25 in Ireland, and 26 in Switzerland were interviewed again in T2. 482 interviews were analyzed for this paper. The interviews were coded using an inductively-generated coding scheme following a Grounded Theory approach. Coding was checked by a second researcher for consistency. Relevant text passages relating to structural inequality across forms of economic, domestic, generational, educational, and technological inequalities were extracted and analyzed inductively via the Atlas.ti query function. Data analysis was initially conducted by authors working on the 6 country teams; authors wrote memos summarizing the main findings. Thus, while not engaging in a traditional comparison between national contexts where indicators are predetermined, we were sensitive to differences where they became apparent. At the same time, we sought to explore similarities in people's experiences across countries. The impacts of health and wealth on people's ability to cope with the situation, and the entanglements of the two domains, clearly emerged as the most dominant themes. Results were then analyzed again for sub-themes within these two categories. Although we discussed participant responses in relation to the five sub-themes that emerged, coding was conducted with attention to overlapping inequalities, and our organization of the data in the sub-themes does not aim to draw strict conceptual divisions between different concerns. Abbreviated interview codes are included to indicate the country of residence of the participant and the time period of the interview. All quotes have been translated into English; original language quotations are provided in Table 2 . Our research participants expressed their views on the impact of social inequalities across different groups, and reported practical experiences (their own or that of family members, and friends). Although not an explicit question in the interview guide, the interdependency of health and wealth emerged in most interviews: 1) Participants expressed concerns about the pandemic compromising the delivery of healthcare Italy has a regionally-based national health service, called Servizio Sanitario Nazionale (SSN). The SSN provides free of charge universal coverage. Examples of exemplary quotes used in text, with English translation and original language (English language responses from Ireland and UK not included). "this year I also had to struggle a bit with my psyche at home. You slip into a depressive phase quite quickly. And I would have liked to see that included: helping people who were already prone to mental illness before the Corona crisis … That they have a safety net, that they are not left alone." (DE-T1-H07) "Und dieses Jahr hatte ich auch zuhause ein bisschen mit der Psyche zu kämpfen. Da rutscht man recht schnell in so eine depressive Phase. Und dagegen hätte ich mir eigentlich gewünscht, dass das mit einbezogen wird. Dass man Leuten halt hilft, die schon vor der Corona-Krise anfällig waren für psychische Krankheiten …. Dass man da ein Auffangnetz hat, dass die da nicht alleine gelassen werden." (DE-T1-H07) "I see this also in terms of the psychological impact. I see big question marks there, also as far as mental health is concerned, as well as the ability to survive economically" (DE-T1-Z10) "Dort sehe ich, auch was die psychische Gesundheit betrifft, wie auch die wirtschaftliche Überlebensfähigkeit groβe Fragezeichen" (DE-T1-Z10) "If we learn that any of us is positive, what are we going to do? Nothing … what should we do? Close? Closing a restaurant because of the virus would mean staying 3-4 months without working, because nobody would go into a restaurant where someone was positive." (IT-T2-L04) "Se qualcuno di noi dovesse risultare positivo cosa facciamo"? Niente, di base. Non sapremmo cosa fare, perché cosa dovremmo fare? Chiudere? Chiudere comunque un locale per causa virus vorrebbe dire almeno non lavorare per 3/4 mesi, perché nessuno entrerebbe in un locale dove c'è stato un positivo. È molto difficile questa situazione." (IT-T2-L04) "luxury quarantine" situation in which they had plenty of space at home, a garden, and a job that could be done remotely (DE-T1-H03). "Wenn ich ehrlich bin: Diese drei Wochen waren eigentlich absolute Luxus-Quarantäne. Ich meine, da waren meine Frau und ich alleine hier. Wir haben ein relativ groβes Haus, wir haben einen groβen Garten. Also, ich habe drauβen im Garten gearbeitet, Rasen gemäht, konnte mich hier im Haus ja komplett frei bewegen. Habe mich drauβen in die Sonne gesetzt, im Garten gearbeitet. Wir mussten keine kleinen Kinder betreuen. Wenn man in einer kleinen Wohnung ist mit zwei oder drei Kindern, die man betreuen muss, das ist eine Herausforderung, das ist klar." (DE-T1-H03) "I expect that the situation will get much worse and I try to prepare my own situation in such a way that I can navigate this new scenario and that I can also support and protect myself and those who are important to me. We are preparing ourselves for a situation in which in the next 5 years people will live in poverty and hardship, such as our physiotherapist from [poorer European country] who we are trying to care for. We are planning, casually, in the case of emergency, to give our flat and our office in [name of town] to someone to live in. (AT-T2-E01) "Und ich rechne damit, dass die Situation schlechter wird und richte mein Leben so ein, dass ich mich in diesem Szenario aber gut bewegen kann und mich und mein Umfeld und die, die mir wichtig sind, "mittragen kann, beschützen kann, wie auch immer. Also wir bereiten uns auch vor, dass möglicherweise die nächsten fünf Jahre Leute in eine Armut, oder in eine Not kippen, die wir kennen. "basta un mese di fermo e già queste persone sono nella miseria" (IT-T1-M09) … with others describing the restaurant, bar, and shop owners as being "brought to their knees" by the closures, bankrupted before being allowed to open again (IT-T1-L09). "Alcuni non riapriranno più, purtroppo. Sono già falliti ancora prima di ricominciare, perché avranno elle spese … perché le tasse le devi pagare, gli affetti li devi pagare, la merce se la vuoi la devi comprare e devi comprarla coi soldi. Cioè, questa gente qua è in gin cchio. In ginocchio. Ma tu non puoi far riaprire un ristorante a mezzo servizio. Lo fai fallire." (IT-T1-L09) (continued on next page) that socioeconomically disadvantaged people are less able to compensate for, and longed for more governmental support while noting that existing initiatives fail those who most need them. 2) They expressed concern about some occupations being more at risk of infection, or precarious conditions compromising the ability to comply with safety measures, and 3) shared their fear, anger or sorrow for their own or others' economic struggles. 4) They observed that already vulnerable social groups, such as ethnic minorities and migrants, were exposed to further segregation and discrimination. 5) They worried about the widening of the socioeconomic gap, and criticized privatization and austerity as upstream causes of the crisis. (1) Inadequate assistance The pandemic compounded already challenging situations, and participants across all countries expressed a need for more public support, including increased healthcare and wellness services, and government economic relief programs. Participants were concerned about family and friends who needed health services, and in particular, those they considered to be more vulnerable than themselves. For many, scheduled operations and therapy appointments were cancelled, or others had difficulty getting necessary medications. In one case, IVF appointments were postponed, and another respondent's brother-in-law had critical appointments for his brain tumor treatment cancelled. The brother-in-law subsequently had a stroke over the summer, and his partner was unable to accompany him to the hospital due to COVID restrictions. While participants across all economic and social strata expressed the feeling of being "left alone" by the state, employers, or other entities that they expected support from, those at the bottom of the socioeconomic pyramid typically had fewer ways to empower themselves. The feeling of "collective isolation" that one Austrian respondent mentioned was more bearable for some than for others. Those with differing abilities, such as one participant from the UK who was visually impaired, noted that social distancing guidelines made it difficult to do simple things like grocery shopping because they required assistance getting around the store. Those with chronic medical conditions expressed heightened anxiety around exposure and the need for additional precautions. The pandemic exposed a series of inadequacies and deficiencies in the healthcare system. In some countries this was felt much more immediately and earlier than others. In Italy many participants said that the healthcare system was doing well despite years of inadequate funding, and in Ireland participants underscored inadequacy and unpreparedness for a crisis of this nature. "E' molto dicotomica la situazione" (IT-T2-L04) "two realities that are apparently in conflict with one another" (IT-T2-L01). "e mi sembra che appunto ci sia veramente un conflitto con le due realtà." (IT-T2-L01) "we cannot afford a surplus of patients in intensive care either" (IT-T2-L04). "Cioè, però in generale dico che bisogna comunque attuare … non possiamo permetterci di avere un esubero di pazienti in rianimazione" (IT-T2-L04) "I don't know, for example, people with a migration background … do they have information? … my friend, who runs a clinic together with her husband, said that these people did not know what was going on at the beginning, because they simply lacked the translation." (AT-T1-R05) "Ich weiβ zum Beispiel nicht, mit dem Migrationshintergrund, wie geht es denen, haben die Informationen. Haben die, ich weiβ nur bei uns, hat meine Freundin, die mit ihrem Mann eine Ordination führt, hat gesagt, haben am Beginn nicht gewusst, was los ist, weil sie einfach die, weil ihnen die Übersetzung gefehlt hat." "I think it will be fatal for the children. I think it will also be very difficult for the mothers. And for women to recover, to gain a foothold, and I believe that the gender gap will widen. I believe that the consequences for children who simply do not have the educational support at home, and especially through the school system, will worsen." (AT-T2-E04) Und ich glaube manchmal gar nicht so, dass die eigentlich wissen, was sie der Otto-Normal-Bevölkerung mit ihren Maβnahmen immer so unbedingt an tun." (DE-T1-S06) "the rich will be richer and the poor will be poorer" (IT-T1-M04). "i ricchi saranno sempre più ricchi e i poveri saranno sempre più poveri." (IT-T1-M04) "with these further restrictions, the social gap between the well-off and the worse-off will become wider, to the detriment of the society as a whole" (IT-T2-M02). "ora come ora con queste ulteriori restrizioni che abbiamo in atto il divario sociale tra chi stava bene e chi stava meno bene, il divario andrà ad aumentare sempre di più, a discapito di tutta la società" (IT-T2-M02) "we needed this crisis to uncover social inequalities" (CH-T1-H01). "was mir am meisten aufgefallen wäre, dass es eben die Krise braucht, damit soziale Themen stärker angesprochen werden. Und so der Gegensatz, der recht prägnant gewesen ist zwischen Wirtschaft und Gesundheit. Und halt die prekären Situationen, die verstärkt werden. Die halt dadurch mehr in die Ö ffentlichkeit geraten." (CH-T1-H01) "the longer it lasts, the stronger the effects will be" (DE-T1-Z01) "Je länger es dauert, umso stärker werden die Effekte sein." (DE-T1-Z01) The healthcare systems are not fit enough if a crisis hit … even with normal times in Ireland the hospitals are already up to capacity and people are lying outside on the aisle. Something is wrong there and I think the virus crisis has shown this, has brought this up to the surface even more and made it more visible. (IE-T1-V04) In contrast, participants in Austria and Switzerland expressed high levels of confidence in the continued functioning of healthcare services. On the whole, the need for more social support as part of the public health response to the pandemic emerged clearly, such as for those who had lost jobs, had limited familial support, were single parents, or had children with special needs. In particular, the pandemic exposed shortcomings in mental health care, both for those who struggled with existing mental health concerns, and for those who were carrying a bigger burden due to economic pressures or increased stress. As one participant in Germany noted, … this year I also had to struggle a bit with my psyche at home. You slip into a depressive phase quite quickly. And I would have liked to see that included: helping people who were already prone to mental illness before the Corona crisis … That they have a safety net, that they are not left alone. (DE-T1-H07) One person in the UK who suffered from bipolar disorder noted that the lack of mental health services during the pandemic had been particularly difficult. They related a series of challenging situations and diagnoses, all made more difficult by the pandemic. While being interviewed, they described looking out of their window at someone they knew on the street who had been treated at the same psychosis clinic and was very ill. They expressed their concern over what the next six months would bring in this regard, noting that unmet mental health concerns went far beyond any half-hearted public health emphasis on "wellness" during the pandemic. These problems, according to the participant, were not new, but were in part due to years of underfunding of mental health services, what they called the "Cinderella service of the health system," (UK-T2-P02). The entanglement between health-and wealth-related inequalities was also evident in connections between the measures to control the pandemic and the precarity of those already struggling with health issues. A participant in Germany underscored the dual role of economic and personal wellbeing, noting, "I see this also in terms of the psychological impact. I see big question marks there, also as far as mental health is concerned, as well as the ability to survive economically," (DE-T1-Z10). Another participant described her brother's concern for his own health. As someone who had long dealt with mental health issues, the thought of being without work was a scary proposition. For some who were suffering from increased anxiety from spending more time at home, being a key worker had brought a sense of relief and normalcy. In describing the mental health struggles associated with lack of work, one participant noted that it was important that COVID not eclipse all other concerns, health or otherwise: Yes, the coronavirus is bad, but you're also ignoring the other illnesses that are going on in the world at the moment too … So, it's a constant worry for all different things that are not just caused by the coronavirus. They're not caused by it, but now where it's there, it's causing problems to them. (UK-T1-M05) The connections between employment, social interaction, and wellbeing were drawn across the countries and many participants stressed the plethora of threats to health beyond the COVID virus alone. Across the countries, participants pointed to the need for more financial support from the government. Among the participants, some were included in government support programs, while others did not receive sufficient aid. Participants facing income loss in Italy longed for support; making rent payments was a major problem for some. Most participants in Italy complained about "delays" and "unfulfilled promises" with respect to governmental support. Seen as particularly egregious was total absence of support for irregular workers, who did not qualify for support (while independent workers did). Participants highlighted the ways that social inequality increased without sufficient government intervention, a fact that would itself lead to significant health effects that were not directly related to the COVID-19 virus. As one participant in Austria commented, "I think to myself, this is actually madness that one accepts that hundreds of thousands of people are driven into poverty and poverty risk [when] everything also has health effects, and not only COVID," (AT-T1-S09). Some participants described how the government support they had received had kept them afloat financially. One individual in Ireland who had lost their job and had been receiving €350 weekly government support, described their relief of having financial security while some in other countries who had lost jobs were at risk of starving. A participant in Austria similarly reflected on their otherwise uncomplicated receipt of government funding following cutbacks at their job. Yet for other participants, there was a sense that government officials were not 'in touch' with the difficult realities that many people were living, for example the full effects of lockdown measures for those living in cramped conditions. As a participant in Germany noted, It makes you wonder whether the decision-makers still notice anything. Those who make the decision don't usually live in Plattenbau flats. And sometimes I don't think that they actually know what they are doing to the normal population with their measures. (DE-T1-S06) A similar critique was levied by a participant in Switzerland who criticized the authorities for not doing more for those in precarious situations and for treating some economic sectors unfairly (CH-T1-Z04). In general, however, most participants in Switzerland expressed confidence in state support for those suffering economically from the pandemic. (2) Unequal risk of being exposed to COVID-19 Participants were keenly aware of the relationship between occupation and risk of exposure, drawing a clear link between economic survival and personal health concerns, and an ability to comply with public health guidelines. This included observations from participants across several countries about the increased risk faced by healthcare workers, but extended to other key workers. As one participant in Ireland noted, this included many other occupations that were not adequately protected: "people that collect the rubbish … the post people, the people that bring the parcels … the bus drivers," (IE-T1-K03). Precautions, like social distancing, were only possible for those who had jobs which afforded distance work or who lived in domestic settings which enabled isolation when necessary. In particular, participants noted how histories of extractive industries and blue-collar labor intersected with the health risks posed by COVID-19. When describing the influx of people to the hospitals and their personal concerns that they would not receive adequate care if they were to need assistance, one participant in the UK noted that respiratory vulnerabilities due to working in industry were linked with the risk of suffering from COVID-19. If you're an older person in that particular area, because of the mining heritage and the steelworks and aluminum works, and all those things, there's a terrific number of poor chests … There are a lot of people who have underlying, very bad chest conditions. (UK-T1-S01) Individuals interpreted infection and mortality rates in relation to their understandings of demographic differences and local histories. Participants in Ireland noted that the highest rates of infection were in the more deprived areas of the country, and in particular in Dublin. Participants suggested the role of socioeconomic differences in noncompliance to the recommended public health measures, proposing that those with working-class backgrounds did not, or were not able to, follow the rules. One individual who worked with the homeless community noted that many individuals may not comply with anti-COVID measures because they face far more pressing problems: … a lot of people don't want to be tested and particularly in the homeless community. […] A lot of homeless people are drug users, alcoholics, they have got other things that are much more important to them, partly their brain is bombed by the drugs and the drink, and partly COVID is way down their health priorities. They are worried about where they are going to get their next fix and where they are going to sleep for tonight and who has stolen their mobile phone … they just don't want to know [their COVID-19 status]. (IE-T2-G02) While participants in all countries were critical of people who did not follow guidelines to limit gatherings, maintain distancing, or stay home when sick, they also consistently acknowledged the role of socioeconomic constraints in relation to compliance. One family doctor in Italy observed that people who were struggling economically (such as those living in "poor settings" or immigrant communities) and had tested positive for COVID-19 would refuse to isolate because they could not afford to. A similar concern was expressed by a participant working in a restaurant in Italy who already was in a precarious economic situation: If we learn that any of us is positive, what are we going to do? Nothing … what should we do? Close? Closing a restaurant because of the virus would mean staying 3-4 months without working, because nobody would go into a restaurant where someone was positive. (IT-T2-L04) Participant responses illustrated the range of socio-economic and affective factors affecting individual's abilities and willingness to abide by public health guidelines. This also included mundane examples of how individual circumstances beyond questions of socioeconomic factors mitigate ability to comply: e.g., one individual in the UK admitted to having not complied with some rules in order to see her family members following a difficult divorce. In Austria and Switzerland, several participants reported breaking rules to see other people to "keep sane", or because their children were feeling lonely. (3) Economic struggles Restrictions on movement and the closure of businesses and restaurants had more negative impacts on those who could not work from home and on those who would suffer immediate income losses. Across all countries, participants had lost jobs, were furloughed, or had picked up several odd-jobs to make ends meet in the meantime. Participants could name multiple personal connections who had been greatly affected economically by the lockdowns, listing hairdressers, sports therapists, painters, carpenters, mechanics, taxi drivers, musicians, family members, friends, and neighbors. Several participants in Italy reported severe financial challenges related to the pandemic. As one individual said, "These people, if they stop working for one month, are in misery" (IT-T1-M09), with others describing the restaurant, bar, and shop owners as being "brought to their knees" by the closures, bankrupted before being allowed to open again (IT-T1-L09). Several participants in Switzerland and Austria who were in precarious job situations described how it was more difficult than usual to find a job, or fear of losing their job. Those who were self-employed faced particular challenges. By the second round of interviews in October 2020, individuals who had been laid off or furloughed during the earlier months of the pandemic were often still unemployed or were off furlough. Workplaces reopened, but not all workers were brought back. Some participants said they did not know how they would be able to pay bills; others had taken on new jobs such as online teaching or babysitting, and questioned if they would be able to start a family or move forward with other plans: "It's putting your life on hold" (UK-T2-F03). A participant in Switzerland, who described a precarious economic situation in April 2020 prior to the rollout of more significant forms of state support, expressed concerns about falling through the grid (CH-T1-Z20). The longer the pandemic wore on, those with the fewest resources to withstand the losses struggled more. Worries about economic downfall were common, however some participants explicitly discussed how achieving a balance between competing concerns of health and wealth was a dilemma, noting that lockdowns were necessary to protect the health care system and most vulnerable individuals. One respondent in Austria illustrated how economic preocupations prompted them to think about how to protect others' wellbeing: I expect that the situation will get much worse and I try to prepare my own situation in such a way that I can navigate this new scenario and that I can also support and protect myself and those who are important to me. We are preparing ourselves for a situation in which in the next 5 years people will live in poverty and hardship, such as our physiotherapist from [poorer European country] who we are trying to care for. We are planning, casually, in the case of emergency, to give our flat and our office in [name of town] to someone to live in. (AT-T2-E01) Protecting people from hardships due to the secondary effects of economic closures was debated in relation to protecting the health of the most vulnerable. For example, the lack of restrictions in Switzerland in the first half of October were described by some participants as "dangerous" for the economy and the health care system alike. In the words of one participant in the UK: I think there's this fracture around, should we just try and do everything and go back to normal, and let old people die, or should we actually take this seriously? And on one side, it feels like there are people that see this, what I think is a false binary between the economy and the health of people. People see those things as inextricably linked. And if you don't take the health of people seriously, then the economy is going to go to shit anyway. In Ireland, some participants argued that closures, even if people and business suffered from them, ultimately served a "higher good" (IE-T2-V03). Similarly, in Italy participants reflected on the health of the population and the economic needs of certain groups of people as "a very dichotomous situation" (IT-T2-L04), and on the difficulty of finding a balance between these "two realities that are apparently in conflict with one another" (IT-T2-L01). Participants who expressed concern about the containment of the pandemic were also opposed to a full lockdown because of the economic consequences. Even participants who had been severely hit economically and expressed concern about potentially being ruined by further restrictions, acknowledged that "we cannot afford a surplus of patients in intensive care either," (IT-T2-L04). While experiencing hardship, many participants also reflected on degrees of relative privilege, in which economic wellbeing buffered personal wellbeing. Many participants commented on their own perceptions of personal privilege in relation to socioeconomic advantages, which both protected them from economic downfall and served as a protective factor for their health by enabling them to socially distance or work from home. As a participant in Ireland said, "I am well paid my job and I can afford to ride it out, but I don't think that everybody is as fortunate as I am," (IE-T1-G01). Other observations ranged from expressing empathy for those stuck in high-rise apartments with children, to one participant in Germany who described their own "luxury quarantine" situation in which they had plenty of space at home, a garden, and a job that could be done remotely (DE-T1-H03). Several participants in Switzerland expressed concerns about people losing their jobs, while describing their own professional situation as stable. Likewise, respondents in Austria reflected on the benefits of their personal situations in relation to those worse off, a sentiment also voiced by those in Ireland and the UK. These reflections were common across the socioeconomic spectrum, that is, individuals who had fewer economic resources also reflected on their relative privileges compared to others, in addition to those who were better off. More broadly, the relative financial and political stability of some European countries gave some participants reassurance. Participants in Germany, Switzerland, and Austria expressed an awareness that other regions in the world were worse off in the pandemic, contextualizing their local experiences within global inequalities such as the refugee crises, food insecurity, or child labor, which they noted would all become worse due to the pandemic. (4) Compounding discrimination and segregation of already disadvantaged social groups Ongoing debates online about the relationships between health, socioeconomic conditions, racial discrimination, gender inequality, and disproportionate burdens due to the pandemic were reiterated in the interviews. Particular concerns were noted by participants that those from already disadvantaged groups would be made worse off due to economic precarity, greater risk of health consequences, and additional forms of social discrimination. Participants in the UK referenced the effects of the pandemic on people from BAME (Black, Asian, minority ethnic) backgrounds, who also tended to have poor housing and hold low income jobs. One individual went on to discuss examples of racism and the risk of scapegoating these individuals for the spread of COVID-19 rather than focusing on protecting the vulnerable. Similar situations were experienced in Austria as an interviewee reported that: "I don't know, for example, people with a migration background … do they have information? … my friend, who runs a clinic together with her husband, said that these people did not know what was going on at the beginning, because they simply lacked the translation." (AT-T1-R05) Austrian and German participants shared racist incidents they had observed, and expressed concerns that racism was exacerbated during the pandemic. Several participants in Switzerland stated that they had observed or heard about stigmatizing behavior towards people supposedly coming from areas with high rates of infection at the time, such as China or Italy. An individual in the UK noted that while they had little need for public transportation, others who did were more exposed and had to take more risks when getting around, such as people living in BAME communities. Relating this kind of perceived differential risk to broader forms of inequality between northern and southern England, they went on to discuss how lack of remote work had other, cascading effects. However, when probed by the interviewer on how such questions related to inequality, the individual ultimately concluded that, "Life isn't fair," relating questions of education, class, and geographic location to a matter of chance (UK-T1-J02). Participants in Austria, Germany, and the UK reflected on the ways that the impact of the pandemic was affected by existing gender inequalities. Some were concerned that measures to counter the pandemic would exacerbate the greater burden carried by women in childrearing, citing concerns that women would assume additional childcare and homeschooling tasks, and experience greater professional disadvantages as a result. Worries about increased risk of domestic violence were also expressed, especially for families living in cramped conditions. Relatedly, many participants reflected on the unequal burdens across generations. In the interviews from October, the worries about children and impacts on the education had intensified as compared to April. An interviewee in Austria stated: I think it will be fatal for the children. I think it will also be very difficult for the mothers. And for women to recover, to gain a foothold, and I believe that the gender gap will widen. I believe that the consequences for children who simply do not have the educational support at home, and especially through the school system, will worsen. (AT-T2-E04) By contrast, one Swiss participant stated that their teenage daughter had found "a good way to deal with" home schooling and had wished for continued part-time home schooling after the pandemic (CH-T1-Z26). Immigrant children were assumed to be particularly affected, with participants mentioning the existing precarity of many immigrant families and the corresponding difficulty of navigating the pandemic situation. As an Austrian participant noted, "the serious consequences are enormous. A whole generation of migrant children who don't go to school for half a year. The effects will come to haunt us," (AT-T2-P04). Others in Austria, Germany, and the UK reflected on the lack of visibility of refugee concerns during the pandemic, citing a political climate where previously center-stage issues such as the refugee crisis had been sidelined by COVID-19. Some interviewees in the UK expressed concerns about younger relatives whose schooling had been disrupted, and described how the pandemic widened the existing "major gulf" between public and private education. They described the differences between the kind of pandemic schooling kids were getting in terms of attention, online classes, and material aspects. Others gave examples of situations where exceptions to strict public health measures were needed for familial circumstances, such as a family who had a child with down syndrome who required additional care. With the addition of the grandmother, the family would be over the limit of the "rule of six" in the UK, so the grandmother had to become the official caregiver of the child in order to comply with restrictions. Empathy was expressed with parents, in particular those with children with special needs. The societal effects of the pandemic were clearly perceived to fall along socioeconomic divisions. For example, one individual, who had been discussing how the pandemic exposed existing fault lines in UK society, ticked off a list of different aspects which made it easier for better-off individuals to weather the pandemic safely: … people that own their own properties. People that have secure employment. People that don't live in built-up urban environments. People that have a garden. People that can afford to have domestic support at home, either through one partner not working, or through actual paid-for work. People that can afford to buy ready meals, and order stuff, takeaway … they're less impacted than people on lower incomes with precarious employment, they may have lost their jobs. Where there isn't the spending capacity to homeschool. And where people are living in smaller spaces, maybe renting, and are expected to stay indoors, apart from to go out once a day … So, I think those are the fault lines that this exposes. And that's difficult in normal times as well for a lot of people, but I think it's been thrown into sharp relief through this whole process. (UK-T1-F06) The individual went on to lament the missed opportunity to discuss how to better support those who are truly vulnerable in society. They described how the conversations around mutual aid and the offers of help following the beginning of the pandemic were largely limited to people's own circles. The risk, the participant went on to note, was that established modes of crisis management became entrenched "through austerity and through policies that actually make a lot of people worse off," a pattern that would result in further stratification of COVID-19 burden. (5) Exacerbating socio-economic problems and calling for structural change Recognizing the ways that the pandemic was exacerbating existing socioeconomic inequalities, some individuals analyzed the present crisis brought about by the pandemic through the lens of the historical precedents. This analysis was made particularly forcefully by some UK participants. For one, the economic crisis had established roots following the financial crisis of 2009: It's clear that the coronavirus pandemic has just exposed fault lines that were already there … I think especially since austerity came about after the financial crisis, the problems that we're trying to deal with aren't new or different, they're just becoming more acute. This participant noted that while some of the community-minded efforts to provide support during the pandemic, such as neighborhood Whatsapp groups, were well-meaning, they were inadequate in the face of problems that are "complex, are deep-rooted, and hard to solve." This participant analyzed the present crisis through the lens of class in the UK, noting that many of the small-scale, solidaristic efforts in response to the pandemic were responding to needs of those in their own socio-economic group, while those who were most in need continued to lack the support they needed. Entire sectors of society have been "neglected, left behind, and ignored by the government's approach to the recovery after the financial crisis. And I think they're being largely ignored and neglected in their response to the pandemic at the moment. So, it's just the continuation of a trend." (UK-T1-F06). Other participants in the UK also linked austerity and privatization to the pandemic crisis, noting the dissonance of efforts such as clapping for the National Health Service (NHS) by the same individuals who had worked to dismantle the NHS. Instead of performative gestures, they called for reflection on what sorts of social structures needed to be strengthened in order to better respond to the COVID-19 crisis (UK-T1-P01). By contrast, reflections of this nature were notably not offered by participants from some of the other countries, such as Switzerland. Interviewees repeatedly cited the crisis brought about by COVID-19 as a potential catalyst for change because existing forms of structural inequality had been made more apparent. In both direct and indirect ways, participants described through their own struggles how the measures that protected some people from infection placed others at risk. Even those participants who considered themselves to be relatively well-off noted that those who were most protected by pandemic measures, such as staying home to socially distance and work remotely, were those who were least at risk financially. In the words of one participant in Ireland, "one of the biggest protectors against coronavirus is actually wealth" (IE-T1-G01). They went on to observe that the price of the crisis will be borne by those who have the fewest resources. Several participants in Italy offered a similar reflection, saying that a principal effect of the pandemic restrictions is that "the rich will be richer and the poor will be poorer" (IT-T1-M04). In the subsequent interview in T2, they continued their observation that, "with these further restrictions, the social gap between the well-off and the worse-off will become wider, to the detriment of the society as a whole" (IT-T2-M02). If wealth was understood to be a protective factor in enduring the COVID-19 pandemic, then for some the pandemic was a moment of opportunity in which such inequalities in wealth should be addressed. One participant in the UK called for a "massive redistribution of wealth," which would help society to "adjust its morals, what it places value in." The participant continued: You need events like this to happen, because it affects everyone equally and if there ever was chance for a big correction or people's principles and values and redistribution of money, then an event like this might just do that. Similarly, one participant in Switzerland reflected, "we needed this crisis to uncover social inequalities," (CH-T1-H01). Participants observed the lesser impact on those who were already well-off prior to the pandemic. As one participant in Germany noted, "the longer it lasts, the stronger the effects will be" (DE-T1-Z01), and several respondents in Austria expressed a desire for a universal basic income. Another person described it as a "shameful" development, by which those who "are at the top" were buffered from the consequences (DE-T1-Z09). By the second round of interviews in October 2020, several participants expressed concerns that the pandemic had increased the gap between the rich and the poor not only in their respective countries, but also globally. Our interview data shows health and wealth were intertwined in people's experiences in a twofold manner: First, living and working conditions were clearly linked to a greater risk of being exposed to the virus, and to different responsibilities and pressures (e.g. time and place for homeschooling, loss of income, difficulty of complying with restrictions). Second, existing social and economic disadvantages were made worse by the pandemic. Often when participants began recounting how they had been affected in one area of their life, such as changes in their mental health and wellbeing, the story soon bled into other areas of their life, such as occupational uncertainty, difficulty paying bills, or loss of social contacts. Across the board, already difficult situations were made more challenging, whether the postponement of cancer treatment, a divorce, or worries about remote education. Participants who had more resourceswhether financial, social, or were in good healthwere more able to endure the plethora of difficulties brought by the pandemic. As participants shared the ways their lives had been changed, their responses repeatedly illustrated that while COVID-19 was a problem, it was never the only problem. In sum, participants' experiences illustrated that virtually all aspects of life have bearing on health. While this has been articulated in critical studies of health, and on a largely abstract level in policy discussions and epidemiological modelling (Galanis and Hanieh, 2021) , this study illustrates both how health and wealth became intertwined during the pandemic, and some of the ways that the pandemic led people to realize just how health and wealth were intertwined in their own lives. Respondents' statements suggest that many people have an intuitive understanding of the alignment of health and economic wellbeing, which was heightened by the circumstances of the pandemic. In a situation in which many governments and media were playing out the protection of "our economies" against public health, respondents articulated through their own experiences that protecting health and "the economy" are two sides of the same coin. If some restrictions, aimed to limit the spread of the virus and prevent hospital overload result in significant economic struggles, this is likely to expand the spread of the pandemic and to burden the healthcare system with further health and mental health issues. On the other hand, if keeping some business activities "open" has the effect of expanding and prolonging the pandemic, this is also to the detriment of the economy as well as peoples' health. These tradeoffs were felt firsthand by the participants we spoke with. In reflecting on the "false dichotomy" between saving lives or livelihoods, Prasad et al., argue that this binary illustrates the "hegemony of the 'medical' over the 'social', and is symptomatic of the blind-spotting in policy to health and social inequity." (Prasad et al., 2020) Instead, public health frameworks are needed that give the same weight to the social determinants of healthsuch as vulnerability, differential risk, and local contextual factorsas immediate, medical consequences of COVID-19. After witnessing the indirect effects of the pandemic, it is clear that treating a virus as the only threat to human health is deeply problematic (Redfield, 2020 ). Yet, it is also evident that the supposed primacy of "the economy" over health is equally fraught. Our findings illustrate that the COVID-19 pandemic is not one crisis, but manywhat we have termed the "second pandemic" following our participants' insight, or what others have affirmed as a "syndemic pandemic." (Bambra et al., 2020; Gravlee, 2020) . The term 'syndemic' describes the intertwining of risk factors or comorbidities that mutually reinforce each other to amplify the consequences of the pandemic. This was seen as participants described how the crisis affected the distribution of tangible resources such as income, but also less tangible resources such as feelings of security, and the ability to retain a degree of autonomy in crisis. Some participants engaged in a sociological analysis of how COVID-19-related health risks were shaped by factors such as where one lived, what one did for work, or larger histories of extraction, blue-collar labor, availability of resources or economic policy a decade ago. In reporting observations of risk-taking and compliance with public health guidelines, participants noted that one's ability to comply was determined in great part by broader socio-economic and geographic circumstances. There was an understanding that COVID-19 did not affect all members of society equally (Clouston et al., 2021) , with participants across all countries expressing concern for women shouldering more of the burden at home, for school-aged children who were isolated, or for people of color who were at greater risk of being exposed to COVID and of being subject to racist attacks in relation to the pandemic. The accounts of many of participants suggested that socio-economic disadvantage is a big risk factor for contracting COVID-19; this is supported by studies illustrating that socio-economic disadvantage is both a social and medical risk factor. Disadvantaged and underserved groups are: (1) at a higher risk of getting infected with COVID-19; (2) if infected, at higher risk of developing severe conditions; (3) if facing severe infection, at higher risk of not receiving adequate medical assistance. This has resulted in disproportionally high infection and death rates among certain segments of the population, both across and within countries (Marmot et al., 2020; Center for Disease Control, 2021; Ray, 2020) . Those who have fewer opportunities to isolate themselves from others, those with pre-existing health conditions, those who have lost jobs or must work even if infected, are at greater risk from suffering the cumulative effects of the pandemicpoints that our participants illustrated through their own lives and their observations of those around them. In this sense, our data empirically illustrate the ways that the mutually-reinforcing, overlapping forms of disadvantage, combine and reverberate through the COVID-19 syndemic. The reduction of poverty and the mitigation of inequalities emerges as a crucial elements of any strategy to increase pandemic preparedness, a point that was made in calls by participants to use this COVID-19 pandemic as a moment to work for structural change. To this end, government support to mitigate the economic effects of the pandemic came up frequently, and marked some of the most notable differences between countries in the responses. In some cases, participants were critical of a perceived lack of support from the government (e.g., Italy), while in other cases, participants were positive about the ease of receiving government support (e.g., Austria and Switzerland, with limited exceptions). This was also one area where clear differences between the April/May and October/November interviews emerged. In the spring, many participants called for more support or were uncertain about eligibility for programs they had heard about on the news. By October, participants described established programs, noting how government income assistance or other programs had been crucial in getting through the prior months. Yet, government support in mitigating the effects of the pandemic was nonetheless fraught. For example, the critique of governmental decisions in setting precedents for the impact of the COVID-19 crisis was most pronounced in the UK case, with several individuals offering keen analyses of how the recent history of austerity had predisposed particular segments of the population to be worse-off when the pandemic hit (Marmot et al., 2020) . While this kind of direct analysis and linkages to past events was not as present in other countries, there were nonetheless clear examples of how those who were worse off overall were at greater risk during the crisis. Speaking to the same participants over six months allowed us to follow up on how personal situations had changed throughout the course of the pandemic. Some who described being in precarious financial situations in April had benefitted from government support. Others found themselves in even more dire situations, unable to pay the bills or with exhausted savings. Difficult health situations, such as those who were already at high risk due to preexisting or chronic health problems, had been made more challenging due to cancelled treatment, or the inability to access social support networks. Yet in general, there was not as pronounced a difference between the two time periods as we might have expected. Those who had been less affected early in the pandemic were also doing relatively well by the time of the second interview. For example, like the participant who described their own situation of a "luxury quarantine," some were still benefiting from their accumulated resourcesof space, time, remote work, savings in the banklater in the pandemic as well. Similarly, those who had fewer resources when the pandemic began were having an even harder time six months later. Such findings are supported by reports illustrating the large percentage of people who have no savings to buoy them through moments of crisis (Blundell et al., 2020; Fessler and Schürz, 2017) . We suggest that one of the reasons that there was no dramatic difference between the two periods has to do with the fact that most of the inequalities addressed in the interviews are rooted in deeper economic and social structures; that is, the stratification of relative advantage and disadvantage seen in participant experiences largely preexisted the pandemic. In addition to formalized mechanisms of aid from the government, participants reported acts of community support, ranging from Whatsapp groups among neighbors to organize shopping, to clapping for the NHS in the UK, to the sewing of masks and other protective materials for healthcare workers. Yet, some participants also expressed skepticism of the widespread discussion of how the pandemic may have prompted an increase in solidaristic social action, noting with disdain that community efforts were not accompanied by political change. Some asked where the outpouring of support was for those who had been dealing with food or housing insecurity for years (Blundell et al., 2020) . Indeed, while the pandemic has strengthened some forms of solidarity (e.g. public healthcare (Prainsack, 2020) ), it has also made societal dividing lines more visible (Lindström, 2020) across generations, genders, economic levels, and engendered racialized narratives of blame. Following our analysis of 482 interviews across six European countries, our data confirm that socio-economic inequalities have not only been revealed, but also reinforced and exacerbated, by the COVID-19 pandemic. Our participants perceived those who were already underserved, discriminated against, or in precarious economic and working conditions, to be disproportionately impacted by the pandemic both in terms of health and wealth, with these two domains being deeply entwined in their effects. The often cited dichotomy between strategies that oppose the health of the population to economic needs, does not correspond to any 'real life' division in our data. Instead, people saw economic struggles also causing major health issues, and vice versa. Governmental and transnational support have been implemented to mitigate both the health-and wealth-related consequences of the pandemic, such as reinforcements of healthcare systems and subsidies for those whose earnings have been reduced. These mechanisms and instruments of support, although essential for preventing even worse scenarios, can only patch up some of the most pressing and evident needs. Our data show that the things people struggled with the most were due to more deep-rooted structures that impacted the range of possibilities and resources available to some during the pandemicwhat we advance as the "second pandemic." In other words, while ad-hoc measures to mitigate the risks and effects of the crisis partially alleviated economic problems for people, structural factors such as housing, working conditions, good access to digital tools and information infrastructure, social networks, and health conditions in general seem to have had a bigger impact on people's ability to cope. If, as articulated by one of our participants, "the biggest protector against coronavirus is wealth," then a different, and more equal, distribution of wealth and resources could better mitigate the detrimental effects of the pandemic, both in terms of population health and economics. 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The Pandemic, Socioeconomic and Health Inequalities in England The Inequality Virus: Bringing Together a World Torn Apart by Coronavirus through a Fair Health equity and social justice Covid Is a Great Unequaliser Solidarity in Times of Pandemics Bridging a false dichotomy in the COVID-19 response: a public health approach to the 'lockdown' debate Impact of the COVID-19 pandemic on quality of life and mental health in children and adolescents in Germany Why Are Blacks Dying at Higher Rates from COVID-19? Brookings The danger of a single threat How Politics Makes Us Sick: Neoliberal Epidemics Kinderarmut: Eine Unbearbeitete Großbaustelle Arzte Offentlichen Gesundheitsdienstes Ger The authors are grateful for the funding provided for this study by the following institutions: European also grateful for the support and collaboration of the SolPan research commons, from which the study design, interview guides, coding frameworks, and collectively shared data set across 9 countries emerged.