COVID-19 and Inequality

We know from the ‘Marmot Review 10 Years On’ that people in more deprived areas spend more of their shorter lives in ill-health than those in less deprived areas and the amount of time people spend in poor health, has increased across England since 2010. 

Social inequalities in health are impacting COVID-19 morbidity and mortality. Social determinants of health including poverty, physical environment, employment, and social support networks can have a considerable effect on COVID-19 outcomes. According to the Office of National Statistics, people in deprived areas of the UK are dying of COVID-19 at double the rate of affluent areas.

Those in crowded accommodation, often seen in deprived areas, are at a higher risk of viral transmission because of crowded living space and up until recently, scarce access to COVID-19 screening and testing.

Smoking is widely known to contribute to the difference in life expectancy between the rich and the poor in the UK. According to ASH, smoking rates between low socio-economic and high socio-economic groups can vary as much as 5.9% and 21.1%. Smoking and exposure to secondhand smoke has been linked to adverse outcomes in COVID-19. A review by the Lancet revealed that current or former smokers were more likely to have severe COVID-19 symptoms than non-smokers, as well as increased risk of intensive care unit admission, the need for ventilation or COVID-19 related mortality.

Malnutrition causes substantial physical and mental health risk, including the lowering of immune response, which has the potential to increase the risk of infectious disease transmission. School closures have increased food insecurity for children living in poverty who would normally participate in school lunch programs. Loss of employment and an increase in job seekers allowance, employment support allowance and universal credit claims is likely to increase the number of families falling below the poverty line.

Poverty makes it harder for parents to follow parenting recommendations. Families living in poverty do not always have the right IT equipment to support the current programs of home learning and do not necessarily have access to the internet. Support for homeschool is harder in cramped accommodation, particularly in multi child households. The low levels of access and support for homeschooling of those families in low socio-economic groups is likely to increase the risk that poor children will grow up to be poor adults, further adding to our increasing health inequalities.

The disruption to health services could lead to thousands more excess deaths as programs such as childhood vaccinations against infectious diseases are interrupted, cancer screenings are delayed, and routine surgery is cancelled leading to a worsening quality of life and a rise in avoidable deaths.   

The isolation of families can exacerbate domestic abuse, as perpetrators are more likely to be at home with the victim, and the traditional routes to help and support such as schools, GPs and workplaces may be closed. Isolation also means that there are less opportunities to identify the early warning signs of abuse as new domestic abuse cases emerge. The impact of physical, sexual, and psychological violence can result in a range of negative and harmful effects on the health, well-being, and outcomes in life for victims and their children.

Physical and sexual abuse can cause short term, long term and permanent injury. Psychological abuse can lead to a variety of problems such as low self-esteem, disturbed patterns of eating and sleeping, lack of confidence, depression, extreme anxiety, alcohol and substance misuse, self-harm and suicide. The longer term social and economic consequences of violence can include homelessness, loss or separation from family friends, isolation, loss of employment, debt, and destitution.

Alcohol misuse is the biggest risk factor for death, ill-health, and disability among 15-49-year-olds in the UK, and the fifth biggest risk factor across all ages. Alcohol habits can be formed quickly but can be hard to break. If people start drinking at risky levels now, not only do they face the risk of immediate harms (such as accidents, fires, arguments and conflict) but also the risk of their alcohol consumption rising over the medium to long term. Alcohol’s effects on mental health are particularly concerning during lockdown, when there is already a great deal of stress. With only an estimated 18% of dependent drinkers receiving treatment before COVID-19, more will need to be done to increase access to structured treatments and programs. 

COVID-19 has also highlighted the dangers of obesity. In a study of nearly 17,000 hospital patients with Covid-19 in the UK, those who were obese, with a body mass index (BMI) of more than 30, had a 33% greater risk of dying than those who were not obese. There is a risk that obesity levels could increase as a result of lock-down as more people are confined to their homes, with many in low socio-economic groups having little access to outdoor space. People may eat more due to boredom or in response to the higher levels of stress, engage more in sedentary activities such as watching television and get less sleep as their daily routines change. Obesity is known to cause health issues relating to a weak heart or lungs, poorly-functioning kidneys and type 2 diabetes as well as affecting a person’s immune system, making it more difficult for an obese person to fight off viruses such as COVID-19.

We can only hope that what we have learned about the effects of COVID-19 disproportionately affecting the poor and disadvantaged will mean that the impact of social conditions on health will receive a fresh focus and there will be increased funding for prevention programmes.