Image Source: Satoshi Kambayashi, The Economist
We are “all in it together.” The COVID-19 virus “does not discriminate,” various media sources reported politicians asserting at the start of the pandemic in March 2020. However, recent evidence from multiple global studies irrefutably dispels the myth of the COVID-19 pandemic as a great equaliser and instead points to the pandemic augmenting existing inequalities. Michael Marmot, director of the Institute of Health Equity at University College London said “The pandemic has exposed and amplified underlying inequalities in society. Health inequalities are the result. Tackling the social causes of health inequalities is even more urgent now.”
The inequalities that the COVID-19 crisis has exposed have been accumulating for over a decade. Inequalities in income have been increasing since around 1980: about 20 times as much of the increase in global wealth has gone to the richest 1% of people as to the poorest 50% since 1995. This increasing economic inequality has been mirrored in increasing health inequalities. Before 2020, life expectancy amongst the most impoverished groups was already declining in the UK and the USA, and in some European countries, health inequalities have been increasing over the last decade. Health Equity in England: The Marmot Review 10 Years On, published in 2020, has documented three concerning patterns since 2010: a slowdown in an increase of life expectancy, a continuing increase in inequalities in life expectancy between more and less deprived areas and increased regional differences, and a decline in life expectancy in women in the most deprived areas outside London.
However, COVID-19 seems to have amplified these inequalities. The global picture shows that the greater the inequality in income within a country, the greater the number of excess deaths in 2020 and 2021 which are a strong estimate of mortality from COVID-19.
Government data from various countries suggests that the rate of COVID-19 infection is higher in the most deprived areas compared to the least deprived and in all countries affected by the pandemic, evidence suggests that there have been more deaths from the disease in the most deprived areas. In Brazil in 2020, the risk of catching and dying from COVID-19 correlated with a social risk score based on the ability to social distance. People living in areas with a higher social risk score caught and died from COVID-19 at higher rates. In the UK, The Office for National Statistics (ONS) published COVID-19 mortality rates alongside the Multiple Deprivation Indices (measures deprivation of an area based on average income, employment rate, education level and crime rates) which showed, with a clear gradient, that the more deprived an area, the greater the number of deaths. The Nuffield Trust in London added to this data by showing that deprivation also affected mortality for a range of other chronic health conditions.
During the peak of the first wave of COVID-19, the death rate in areas of England that scored highest for deprivation was double that of the least deprived areas. This appears to be because of existing social and economic inequalities, particularly in access to adequate housing and education or employment and the resulting health inequalities make disadvantaged populations more vulnerable to various health inequalities. Lower-income workers are more likely to experience job and income loss, live in higher-risk urban and over-crowded areas and housing and have higher occupational exposure to COVID-19 by occupying key-worker roles. They may also have poorer access to healthcare.
The world’s economy has also been severely impacted by COVID-19. World Bank data has revealed that the world’s poorest people have had the largest financial losses. By the end of 2022, an estimated 75 million more people will be in extreme poverty (living on less than US$1.90 daily) than was forecast before the pandemic. The COVID-19 economic crisis has had huge social and ultimately health consequences. These health consequences will often be experienced disproportionately by people living in deprived areas and so the health consequences of the COVID-19 economic crisis are likely to be unequally distributed, exacerbating existing health inequality. The post-COVID-19 global economic slump is likely to make the health equity situation even worse, particularly if there is a return to the health-damaging policies of austerity. It is essential that government policy responses are implemented so that the pandemic does not increase health inequalities for future generations.
But is inequality harmful? For the first time in its 70-year history, UNICEF distributed food parcels in London in 2020 because of food insecurity caused by the economic impact of COVID-19. However, inequality is more than a purely economic condition. Inequalities place us in a hierarchy, making people more conscious of their status and reducing social mobility. Inequality engenders feelings of inferiority in people with a low social status and life in disadvantaged environments produces feelings of powerlessness and threat resulting in chronic stress that results in both physical and mental health problems. More unequal societies also have more antisocial behaviour, higher violent crime rates and consequent imprisonment, lower levels of paediatric well-being and development and more disease and death. Additionally, some economists have argued that inequality impairs our ability to tackle the climate crisis. Piketty and Wisman have both argued that inequality increases the political power of the wealthy who cause the most environmental pollution while being impacted by it the least. This is a warning we cannot afford to ignore.
There are a plethora of measures that we can implement to move towards a just and sustainable post-covid world. Implementation of progressive taxation and regulation of illicit financial flows e.g. national taxation policies ensuring high-income earners pay most tax and making corporations pay tax in the countries they operate would help reduce income inequality. Reducing vulnerability in living and employment conditions such as public housing, progressive labour laws, social security pensions, childcare at workplaces, parental leave and school meals would provide social and economic security. Expanding employee ownership of companies would also be beneficial. Implementation of policies to address structural racism and discrimination would help lessen social inequality e.g. affirmative action laws and policies, and anti-racism training. Strengthening the public sector provision of healthcare, the cessation of further healthcare privatisation and increasing resources to areas and communities that are currently underserved would ensure that good quality healthcare is accessible to everyone. Additionally, investing in human resources for health including community health workers through implementing fair wages and increasing training/recruitment from the local area to ensure retention, would further reduce healthcare disparities. By democratising the decision-making about healthcare services and medical technologies at community, national, and global levels, the public would have more faith in the service. Overall the most important mitigation strategies are the strengthening of social and economic policies across government that act on factors influencing health and carefully considering the effect on child health in all policies.
Historically, pandemics have been experienced unequally with higher rates of infection and mortality among the most disadvantaged communities, particularly in more socially unequal countries. The COVID-19 pandemic is no different. The nature of the virus as it interacts with existing social inequalities in chronic disease and the social determinants of health results in the amplification of these inequalities. Inequality is important as more equal societies have increased social cohesion and reduced chronic disease and antisocial behaviours. Improved social protection including more generous welfare measures, progressive taxation and economic measures and investment in access to good healthcare are all likely to benefit any population and may even mitigate the effects of the next pandemic.