Essay The COVID-19 pandemic and health inequalities

1 1 Population health SciencesInstitute, Newcastle UniversityInstitute for health and Society,Newcastle upon Tyne, UK2 School of Clinical Medicine,Cambridge University,Cambridge, UKCorrespondence toClare Bambra, PopulationHealth Sciences Institute,Faculty of Medical Sciences,Newcastle University,Newcastle upon Tyne NE14LP, UK; 27 April 2020 Accepted 18 May 2020 Author(s)(ortheiremployer(s)) 2020. Nocommercial re-use. Seerights and by cite:Bambra C, RiordanR, Ford J,et al. J EpidemiolCommunity Health2020;74:964 COVID-19 pandemic and health inequalitiesClare Bambra,1 Ryan Riordan,2 John Ford,2 Fiona Matthews1 ABSTRACTThis Essay examines the implications of the covid -19pandemic for health inequalities . It outlines historical andcontemporary evidence of inequalities in pandemics drawing on international research into the Spanishinfluenza pandemic of 1918, the H1N1 outbreak of 2009and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates.

2 It then examines howthese inequalities in COVID-19 are related to existinginequalities in chronic diseases and the socialdeterminants of health , arguing that we are experiencingasyndemic pandemic . It then explores the potentialconsequences for health inequalities of the lockdownmeasures implemented internationally as a response tothe COVID-19 pandemic , focusing on the likely unequalimpacts of the economic crisis. The Essay concludes byreflecting on the longer-term public health policyresponses needed to ensure that the COVID-19 pandemicdoes not increase health inequalities for future 1931, Edgar Sydenstricker outlined inequalitiesby socio-economic class in the 1918 Spanish influ-enza epidemic in America, reporting a significantlyhigher incidence among the working the widely held popular and scientificconsensus of the time which held that theflu hitthe rich and the poor alike.

3 2In the covid -19pandemic, there have been similar claims made bypoliticians and the media - that we are all in ittogether and that the COVID-19 virus does notdiscriminate .3 This Essay aims to dispel this myth ofCOVID-19 as a socially neutral disease, by discuss-ing how, just as 100 years ago, there are inequalitiesin COVID-19 morbidity and mortality rates reflecting existing unequal experiences of chronicdiseases and the social determinants of health . Theessay is structured in three main parts. Part 1 exam-ines historical and contemporary evidence ofinequalities in pandemics drawing on interna-tional research into the Spanish influenza pandemicof 1918, the H1N1 outbreak of 2009 and the emer-ging international estimates of socio-economic, eth-nic and geographical inequalities in covid -19infection and mortality rates.

4 Part 2 examines howthese inequalities in COVID-19 are related to exist-ing inequalities in chronic diseases and the socialdeterminants of health , arguing that we are experi-encing asyndemic pandemic . In Part 3, we explorethe potential consequences for health inequalities ofthe lockdown measures implemented internation-ally as a response to the COVID-19 pandemic ,focusing on the likely unequal impacts of the eco-nomic crisis. The Essay concludes by reflecting onthe longer-term public health policy responsesneeded to ensure that the COVID-19 pandemicdoes not increase health inequalities for 1. HISTORICAL AND CONTEMPORARYEVIDENCE OF inequalities IN PANDEMICSMore recent studies have confirmed Sydenstricker searly findings: there were significant inequalities inthe 1918 Spanish influenza pandemic .

5 The interna-tional literature demonstrates that there wereinequalities in prevalence and mortality rates:between high-income and low-income countries,more and less affluent neighbourhoods, higher andlower socio-economic groups, and urban and ruralareas. For example, India had a mortality rate 40times higher than Denmark and the mortality ratewas 20 times higher in some South American coun-tries than in Norway, mortality rateswere highest among the working-class districts ofOslo5; in the USA, they were highest among theunemployed and the urban poor in Chicago,6andacross Sweden, there were inequalities in mortalitybetween the highest and lowest occupational classes particularly among contrast, countrieswith smaller pre-existing social and economicinequalities, such as New Zealand, did not experi-ence any socio-economic inequalities in urban rural effect was also observed in the 1918influenza pandemic whereby, for example, inEngland and Wales, the mortality was 30% 40%higher in urban is also some evidencefrom the USA that the pandemic had long-termimpacts on inequalities in child health studies have also demonstratedinequalities in the 2009 H1N1 influenza pan-demic.

6 For example, globally, Mexico experi-enced a higher mortality rate than that inhigher-income terms of socio-eco-nomic inequalities , themortality rate from H1N1in the most deprived neighbourhoods of Englandwas three times higher than in the was also higher in urban comparedto rural , a Canadian study inOntario found that hospitalisation rates forH1N1 were associated with lower educationalattainment and living in a high study found positiveassociations between people with financial issues(eg, financial barriers to healthcare access) andinfluenza-like illnesses during the 2009 H1N1pandemic in the studies on cycli-cal winter influenza in North America have alsofound associations between mortality, morbidityand symptom severity and socio-economic statusamong adults and 17964 Bambra C,et al.

7 J Epidemiol Community Health2020;74:964 968. on February 20, 2022 by guest. Protected by Epidemiol Community health : first published as on 13 June 2020. Downloaded from Just as in 1918 and 2009, evidence of social inequalities isalready emerging in relation to COVID-19 from Spain, the USAand the UK. Intermediate data published by the Catalonian gov-ernment in Spain suggest that the rate of COVID-19 infection issix or seven times higher in the most deprived areas of the regioncompared to the least , in preliminary USAanalysis, Chen and Krieger (2020) found area-level socio-spatialgradients in confirmed cases in Illinois and positive test results inNew York City, with dramatically increased risk of deathobserved among residents of the most disadvantaged regard to ethnic inequalities in COVID-19 , data fromEngland and Wales have found that people who are black, Asianand minority ethnic (BAME) accounted for of 4873 criti-cally ill COVID-19 patients (in the period ending April 16, 2020)

8 And much higher than the seen for viral pneumoniabetween 2017 and 14% of the population ofEngland and Wales are from BAME backgrounds. Even morestark is the data on racial inequalities in COVID-19 infectionsand deaths that are being released by various states and munici-palities in the USA. For example, in Chicago (in the period endingApril 17, 2020), of COVID-19 deaths were among blackresidents and the COVID-19 mortality rate for black Chicagoanswas per 100 000 population compared to per 100 000population among white will likely be aninteraction of race and socio-economic inequalities , demonstrat-ing the intersectionality of multiple aspects of disadvantage coa-lescing to further compound illness and increase the risk 2.

9 THE SYNDEMIC OF COVID-19 , CHRONIC DISEASE ANDTHE SOCIAL DETERMINANTS OF HEALTHThe COVID-19 pandemic is occurring against a backdrop ofsocial and economic inequalities in existing non-communicablediseases (NCDs) as well as inequalities in the social determinantsof health . inequalities in COVID-19 infection and mortality ratesare therefore arising as a result of a syndemic of COVID-19 , inequalities in chronic diseases and the social determinants ofhealth. The prevalence and severity of the COVID-19 pandemicis magnified because of the pre-existing epidemics of chronicdisease which are themselves socially patterned and associatedwith the social determinants of health . The concept of asyndemicwas originally developed by Merrill Singer to help understand therelationships between HIV/AIDS, substance use and violence inthe USA in the syndemic exists when risk factors orcomorbidities are intertwined, interactive and cumulative adversely exacerbating the disease burden and additively increas-ing its negative effects: A syndemic is a set of closely intertwinedand mutual enhancing health problems that significantly affectthe overall health status of a population within the context of aperpetuating configuration of noxious social conditions [24p13].

10 We argue that for the most disadvantaged communities, COVID-19 is experienced as a syndemic a co-occurring, syner-gistic pandemic that interacts with and exacerbates their existingNCDs and social conditions (figure 1).Minority ethnic groups, people living in areas of higher socio-economic deprivation, those in poverty and other marginalisedgroups (such as homeless people, prisoners and street-based sexworkers) generally have a greater number of coexisting NCDs,which are more severe and experienced at at a younger age. Forexample, people living in more socio-economically disadvan-taged neighbourhoods and minority ethnic groups have higherrates of almost all of the known underlying clinical risk factorsthat increase the severity and mortality of COVID-19 , includinghypertension, diabetes, asthma, chronic obstructive pulmonarydisease (COPD)