A perfect storm - health inequalities and the impact of COVID-19

Health inequalities are largely due to the unfair and unjust inequalities in society in which people are born, live, work and age.

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The unequal distribution of the social determinants of health, such as education, housing and employment, drives inequalities in physical and mental health, reduces an individual’s ability to prevent sickness, or to take action and access treatment when ill health occurs. These inequalities are complex and embedded in society but they are also preventable. The dimensions of inequality are complex and overlapping as represented in the overlapping dimensions of health inequalities.

Health inequalities such as deprivation, low income and poor housing have always meant poorer health, reduced quality of life and early death for many people. The COVID-19 pandemic has starkly exposed how these existing inequalities - and the interconnections between them such as race, gender or geography, are associated with an increased risk of becoming ill with a disease such as COVID-19 (Coronavirus (COVID-19) Related Deaths by Ethnic Group, England and Wales: 2 March 2020 to 15 May 2020Disparities in the risk and outcomes of COVID-19).

Importantly, as a result of the pandemic, we are all more aware of what is meant by health inequalities and the ways in which they impact on people’s lives. Therefore, it is vital to act now and drive forward work programmes that reduce inequalities, prevent poor health and improve people’s opportunities for better health. It is vital too that the structural inequalities in our society – unemployment, overcrowded housing, and a lack of green space, as a few examples, are tackled because it is changes at the root cause that will reduce health inequalities in the long term.

Local government, aware of the circumstances of so many of their residents, is focussing on reducing these inequalities, working with the wider health system to enable recovery from the pandemic and to build sustainable and healthier futures.

This overarching briefing will describe the national literature on COVID-19 risk factors and the evidence to date on inequalities, drawing out key themes. It will examine both the impact of COVID-19 on inequalities and the impact of the pandemic restrictions on inequality. It will explore what steps councils are taking to reduce those inequalities.

Each of the supplementary briefings will examine these key themes in greater detail, introducing case studies from local authorities around the country that offer ideas and opportunities for supporting residents and reducing some of those inequalities.

Inequalities highlighted by COVID-19

The ongoing pandemic has (at the time of writing) killed more than 2 million people worldwide, more than 100,000 of them in the UK. It has infected 2.8 million people in the UK and that figure continues to rise.

Risks of contracting COVID-19 and its subsequent impact are both interconnected and cumulative. Those who are male, older, and from a black or ethnic minority group, with an underlying health condition, working in a higher risk occupation and living in a deprived area in overcrowded housing are at a greater risk of COVID-19 infection, of experiencing more severe symptoms and much higher rates of mortality (Disparities in the risk and outcomes of COVID-19).

In their essay, The COVID-19 pandemic and health inequalities, examining the implications of the COVID-19 pandemic for health inequalities, Bambra et al have called it a syndemic pandemic, describing it as an “intersectionality of multiple aspects of disadvantage coalescing to further compound illness and increased risk of mortality”.

In other words, COVID-19 has created a perfect storm of existing inequality and disease, leading to higher rates of infection and death amongst the most disadvantaged.

Economic impact

There is a robust evidence base showing that unemployment, poor quality work and low wages are hugely damaging for health and health equity.  The COVID-19 economic crisis is therefore going to lead to another health crisis and the people and geographical areas that are most likely to suffer these poor health effects are those that already had poor quality work and high levels of unemployment before the pandemic."
Build Back Fairer: The COVID-10 Marmot Review

The full economic impact of the pandemic continues to develop and its full force will unfurl over the coming months and years. Decisions due to be made in the March Budget, including the extension of the Coronavirus Job Retention Scheme (CIRS/furlough) and £20/week in Universal Credit payments will have a significant impact on people’s incomes.

Since April 2020 PAYE employee numbers have declined with the biggest losses in accommodation and food services, wholesale and retail, and manufacturing sectors.

Those who are self-employed together with others in insecure and non-traditional forms of employment have been hit hard. Between April and August, the self-employed experienced little economic recovery, with hours and incomes remaining significantly lower than the same time last year. Solo self-employed and older workers continue to be the most negatively affected (COVID-19 and the self-employed: Six months into the crisis).

Those who find work through apps – those most associated with the ‘gig economy’ -such as private hire drivers, parcel delivery drivers and food delivery drivers are least negatively affected. These workers tend to be younger and are more likely to be from a minority ethnic background than other self-employed workers. However, many consider their health to be at risk but continue working because of concerns about losing their job.

The common factor among all self-employed people is the lack of any safety net if they are ill and the patchy availability of government support. As the Institute for Fiscal Studies (IFS) Deaton review reported:

“The Self-Employment Income Support Scheme (SEISS) provided extremely rough justice: while it overcompensated many by entitling them to 80 per cent of previous profits irrespective of how large a hit they took from the pandemic, it also offered no possibility of support at all to around 2 million people with self-employment income who were either newly self-employed, or reported profits of more than £50,000 in the previous year, or had total self-employment income that had represented less than half their income”.
The IFS Deaton Review of Inequalities: A New Year Message

National and to some extent local government needs to meet the challenge of supporting those who are in non-traditional forms of employment if we are to tackle this form of inequality.

The greatest decrease in employment over the last year has been amongst young people (aged 16-24) who are more likely to work in those sectors of the economy which have been hardest hit. Students in higher or further education have been unable to access part time work, typically in the hospitality sector, to support themselves, while those not in education have had fewer jobs available to them than before the pandemic, and COVID-10 restrictions have led to a reduction in the availability of apprenticeships and training schemes.

Geography, deprivation and poverty

Across England, COVID-19 all-cause mortality rates are higher in more deprived areas, which is evidence that there are underlying health inequalities driving poorer outcomes.

View the age-standardised COVID-19 mortality rates (per 100,000) for March to July 2020 and IMD average rank, upper tier local authorities in England (Build Back Fairer: The COVID-19 Marmot Review)

A PHE report into the disparities of COVID-19, found that early on in the pandemic, diagnosis rates by local authority were highly clustered. Authorities, which are mostly urban, in London, the North West, the West Midlands and the North East had the highest rates. A similar geographic pattern was seen for death rates.

After London, cases peaked in the East and West Midlands. Leicester, for instance has been in a lockdown of sorts since July 2020 but its rates remain high. It is a city with dense areas of deprivation, a high ethnic minority population with multigenerational housing and a number of workplaces such as clothing factories and food production companies where transmission has been hard to control.

There have long been marked regional differences in life expectancy, particularly among people living in more deprived areas. As the Marmot report, Build Back Fairer, notes, differences both within and between regions have tended to increase over the years of austerity. For both men and women, the largest decreases in life expectancy were seen in the most deprived 10 per cent of neighbourhoods in North East England and the largest increases in the least deprived 10 per cent of neighbourhoods in London.

These regional differences were played out during the course of the pandemic with the North East and North West severely affected by the virus in the early days of the pandemic and again in the early autumn.

The introduction of the tiering system was an attempt by government to apply restrictions proportionately to those areas worst affected by the virus. This meant that areas with higher case rates also experienced knock on effects of greater economic impacts as hospitality and non-essential shops were closed, people were furloughed or lost their jobs. Thus inequalities were exacerbated.

Multigenerational and overcrowded housing

Urban areas including London with greater density of population were hit hard, reflecting the deprivation that comes with crowded housing and homes of multiple occupancy. The more deprived a local authority, the higher the COVID-19 mortality rate has been (Build Back Fairer: The COVID-10 Marmot Review).

Overcrowded living conditions and poor-quality housing are an obvious consequence of low income and deprivation, adding to the higher risks of infection and mortality from COVID-19.

Ethnicity

A review by Public Health England, Disparities in the risk and outcomes of COVID-19, explored the extent that ethnicity impacts upon risk and outcomes. It found that people of Black, Asian and other minority ethnic (BAME) groups may be more exposed to COVID-19, due to occupation, population density, use of public transport, household composition and housing conditions and therefore are more likely to be diagnosed with the disease.

The complexity of these interconnecting factors means that there is no simple one size fits all solution to reduce health inequalities amongst those in our black, minority and ethnic communities. In addition, BAME is not one homogenous group and the impact of COVID-19 is different for different ethnic populations. 

For many Black and minority ethnic people, especially in poor areas, there is a higher incidence of chronic diseases and multiple long-term conditions with these conditions occurring at younger ages than others. Many of the pre-existing health conditions that increase the risk of having severe COVID-19 infection (such as diabetes and obesity) are more common in BAME people and many of these conditions follow socioeconomical patterns.

Age

Older people face significant risk of developing severe illness if they contract COVID-19 due in large part to physiological changes that come with ageing. Compared to people under 40 years old, the chances of dying from COVID-19 are 70 times higher for those over 80 and 50 times higher amongst those aged 70-79 (Disparities in the risk and outcomes of COVID-19).  Older people are more likely than younger people to have underlying health problems. High risk conditions include chronic neurodegenerative diseases such as dementia, cardiovascular diseases and diabetes. For this reason, older people have been urged to stay at home during the pandemic, a restriction which has had its own effects on their health.

Carers have borne an enormous burden throughout the pandemic, whether through separation from the individual they care for, or from a sharp increase in their caring responsibilities as other services and support became unavailable. A Carers UK survey of nearly 6,000 current and former carers reported that 64 per cent  of informal carers had not been able to take any breaks at all in the last six months; 58 per cent  of carers had seen their physical health impacted throughout the pandemic, while 64 per cent  said that their mental health had worsened (Caring behind closed doors: six months on).

Among the young, COVID-19 is exacerbating the impact of inequalities on their mental health as socialising with friends, engagement with sport and education are curtailed. Loss of schooling impacts more on those who are already socially disadvantaged, and without access to devices to do online classes. Poor families may struggle to provide meals and heating at home all day, while a lack of space in the home makes studying difficult. The restrictions on sport outside the elite sports groups will have a lasting effect on the development, self-esteem and future achievements of many young people. The longer the pandemic restrictions are needed the more the inequalities gap will widen between those who are socially deprived and those who are not.

There is too, a risk of increased generational divide. While older people have been at greater risk from the disease, they report being financially better off whilst young people have borne the brunt of job and income loss (Review of Inequalities: A New Year’s message).

Long COVID, which is recognised as a syndrome of longer-term effects on the health of some people who have had COVID-19 is beginning to be of concern for all age groups. The effects of long COVID will lead to new inequalities for people and exacerbate existing disparities.

Gender

According to WHO (Gender and COVID-19 Advocacy Brief) there is limited availability of sex and age disaggregated data in relation to COVID-19, thus hampering analysis of the gendered implications of disease and the development of appropriate responses. It has called for member states to collate this data so that the impacts of COVID-19 can be better understood.

In addition, sex-disaggregated COVID-19 data does not report or account for gender identity, therefore data are absent on the impact of COVID-19 on transgender and non-binary people (The Sex, Gender and COVID-19 project).

Despite the limited availability of data, it is becoming clear that COVID-19 affects men and women differently and there are a range of inequalities issues that councils can pick up to support their residents. Men and women are contracting COVID-19 in more or less equal numbers but men are more likely to die from it. Figures reported in November 2020 found that for every 10 women that died of COVID-19 globally, 14 men died (Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions).

Work is still ongoing to understand the reasons for this, some of which may be biological. However, it is likely that social, cultural and psychosocial issues play a part, ranging from attitudes to risk, engagement with health services and expectations around employment.

One of the starkest pre-existing inequality outcomes for women is that among those in the most deprived 10 percent of areas, life expectancy fell between 2010–12 and 2016–18 (Place based approaches for reducing health inequalities).

Occupation

According to ONS data, (Coronavirus (COVID-19) Related Deaths by Occupation, England and Wales - Office for National Statistics) between the 9 March 2020 and 28 December, there were 7,961 deaths involving COVID-19 in the working age population.

The inequalities posed by occupation with regard to the risk in exposure and risk of COVID-19 mortality are clear. Those working in health and social care public facing jobs that involve lots of public and professional contact clearly have a higher risk of infection.  For example, doctors, nurses, carers and other health care professionals. And then there are essential jobs that cannot be done from home such as taxi drivers, bus drivers and other transport workers, manual labourers and retail staff.

There is a strong association between occupation, ethnicity and gender. Some ethnic groups are more likely to work in jobs that have a higher occupational risk than those from a white background. Amongst women, the highest rates of death were found in nurses, care workers and home carers of which 13.2 per cent  are from Black ethnic backgrounds (Related Deaths by Ethnic Group, England and Wales: 2 March 2020 to 15 May 2020).

Among security guards and related occupations, which are considered to be those with the highest infection risks, 15 per cent  of staff were from Black ethnic backgrounds followed by 11 per cent  from Bangladeshi or Pakistani background.

The Institute of Fiscal Studies in a recent analysis using labour force statistics also found that a working age person of Black-African ethnicity is 50 per cent  more likely to be a key worker than a white British working-age person and nearly three times as likely to be a health and social care worker.

Those of Indian ethnicity make up only 3.2 per cent  of the working-age population, but more than 14 per cent  of doctors.

Mental health

In its report on the impact of COVID-19 on BAME communities, Overexposed and under-protected the devastating impact of COVID-19 on BME communities, the Runnymede Trust points out that some issues affect people across the spectrum regardless of their ethnicity. Mental health is one of those issues. Poor mental health is strongly associated with social and economic circumstances, which in turn impacts on health inequalities. (PHE check ref) Poor mental health also affects people’s physical health, their ability to learn and to work. The risks to mental health as a result of COVID-19 have been widely reported and may prove to have the greatest long-term effect on people’s health as a result of the pandemic. This impact on mental health can be seen across the generations each age cohort having its own particular issues.

There are the long-term psychosocial needs of children and young people but also there is the more immediate risk around safeguarding as a result of lockdown and the breakdown of usual routine for children.

Learning disabilities

COVID-19 has had a particularly severe impact on those with a learning disability with rates of death estimated to be as high as 692 per 100,000 of the population between March and June 2020, some 6.3 times higher than the general population after adjusting for other factors such as age and sex.

A report by Public Health England examined data from The English Learning Disabilities Mortality Review (LeDeR) and NHS England’s COVID-19 Patient Notification System (CPNS) which records deaths in hospital settings (COVID-19 deaths of people identified as having learning disabilities). It found 451 per 100,000 people registered as having a learning disability died with COVID-19 between 21 March and 5 June, a death rate 4.1 times higher than the general population after adjusting for other factors such as age and sex. But as not all deaths in people with learning difficulties are registered on these databases, researchers estimated the real rate may have been as high as 692 per 100,000, 6.3 times higher.

Digital exclusion

One of the positive outcomes of COVID-19 has been the explosion of access to services online. In the main this has been received positively by residents. They have attended consultations online via phone or zoom calls, with GPs, nurses and sexual health clinics. It has enabled people to obtain contraception, medicines and advice. However, the downside of this for say young people living at home, is the potential lack of privacy (medicines arriving via the post or consultations being overheard), while for those who are not equipped with access to the internet, are excluded altogether from this new type of access.

Vaccination uptake: Delivery of the COVID-19 vaccination programme is being led by the NHS with local government helping to identify and establish vaccination centres, provide support staff to help run the centres and most of all, advising and leading on vaccinating those vulnerable groups who may not be registered with primary care and are out of sight of usual processes.

All too often, those who are reluctant to be vaccinated are likely to be most at risk of contracting COVID-19 and experiencing severe illness perhaps as a result of their existing poor health, their living conditions or in relation to their ethnicity.

There has been much said and written about vaccine hesitancy with work being done to understand and overcome the reluctance of minority groups and vulnerable people to be vaccinated.

What local government is doing

There is wide recognition that a system wide approach is required to have an impact on the severity of health inequalities people face. Joint working between the civil, service and community sectors as illustrated below can enable system wide impact. Health inequalities are now on the agenda of every integrated care system as they bring together partners from health, social care, the voluntary sector and public health.

View the components of the population intervention triangle in Place based approaches for reducing health inequalities.

References
  1. Office for National Statistics, Coronavirus (COVID-19) Related Deaths by Ethnic Group, England and Wales: 2 March 2020 to 15 May 2020
  2. Public Health England, Disparities in the risk and outcomes of COVID-19 GOV.UK, 2020
  3. Bambra C, et al. J Epidemiol Community Health 2020, The COVID-19 pandemic and health inequalities
  4. Marmot, Health Foundation, Build Back Fairer: The COVID-10 Marmot Review 
  5. Centre for Economic Performance, COVID-19 and the self-employed: Six months into the crisis 2020
  6. Johnson P, Joyce, R, Platt, L, (2021) IFS Deaton Review of Inequalities: A New Year’s message; Institute for Fiscal Studies, Nuffield Foundation
  7. Office for National Statistics, Why Have Black and South Asian People Been Hit Hardest by COVID-19? 
  8. Carers UK (2020) Caring behind closed doors: six months on
  9. WHO (2020) Gender and COVID-19 Advocacy Brief 
  10. Global Health 5050, (International Center for Research on Women (ICRW), African Population and Health Research Center (APHRC) The Sex, Gender and COVID-19 project
  11. Griffith DM, Sharma G, Holliday CS, Enyia OK, Valliere M, Semlow AR, et al. Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions
  12. PHE (2019) Place based approaches for reducing health inequalities
  13. Office for National Statistics, Coronavirus (COVID-19) Related Deaths by Occupation, England and Wales - Office for National Statistics
  14. Office of National Statistics “Coronavirus (COVID-19) Related Deaths by Ethnic Group, England and Wales: 2 March 2020 to 15 May 2020
  15. Runneymede Trust Overexposed and under-protected the devastating impact of COVID-19 on BME communities
  16. PHE (2020) COVID-19 deaths of people identified as having learning disabilities