What does coronavirus tell us about health inequalities - and what needs to be done?

It now seems extraordinary that once upon a time –  a long four weeks ago or so – coronavirus was being referred to “the great leveller”. How much has changed.

Shocking data from the Office for National Statistics (ONS) shows that death rates for the poorest in the UK are twice as high as those for the most well-off. 

There are clearly a number of complicated factors at work here, and much more needs to be done to understand exactly what is going on. But in many ways, as shocking as these figures are, they are not a surprise.

Of the 3,912 deaths involving COVID-19 that occurred in March 2020, 91% were of people with at least one pre-existing health condition. Of those pre-existing conditions, the most common was ischaemic heart disease, which accounted for 14% of all deaths involving COVID-19. Chronic lower respiratory disease was present in 13% of all COVID-19 deaths and diabetes in 10% of deaths of people aged 50-59. 

We know that these underlying conditions present in COVID-19 deaths, and the risk factors that lead to them, are more common with increasing level of deprivation. In the poorest fifth of the population, a quarter of men aged 50 and over have ischaemic heart disease compared with just under ten percent in the wealthiest fifth.  There are similar disparities for respiratory disease (26% vs 14% in men), diabetes (23% vs 11% in men) and other conditions. We know too that having two or more diseases is more common in people of lower socioeconomic status.

It is clear then that our baseline levels of health have played a key role in the nation’s COVID-19 outcomes and that this has had the greatest impact on the poorest in society. Perhaps not quite as bad yet as our American cousins, who were described in a recent article in the New York Times as generally "too diseased." But might these baseline levels of health ultimately account for the differences in outcomes that are being seen between countries? The current Government has re-committed to the vital target of five extra years of healthy, independent life – and to closing the gap in disability-free life expectancy between rich and poor. When this crisis has passed, it is essential that the government recognise that greater commitment to prevention can improve people’s health and keep them out of high-risk groups.

This means higher levels of regulation and financial disincentives that will help individuals make healthier choices and tackling the barriers to exercise experienced by so many. But it also means addressing the wider structural determinants of health including poor housing, poor jobs, pollution and access to healthy food. The consequences of neglecting primary health prevention have been laid bare by the current crisis but good health is important even when we’re not in the midst of a pandemic. 

In some ways, none of this should come as a surprise. In prophetic language in January 2019, the NHS Long Term Plan stated that “incidence and mortality rates for those with respiratory disease are higher in disadvantaged groups and areas of social deprivation, where there is often higher smoking incidence, exposure to higher levels of air pollution, poor housing conditions and exposure to occupational hazards.” And they pledged to improve “upstream prevention of avoidable illness and its exacerbations. So, for example, smoking cessation, diabetes prevention through obesity reduction, and reduced respiratory hospitalisations from lower air pollution.” One can’t help but wonder how many lives could have been spared had these steps been enacted sooner. As we move forward, primary prevention to improve the nation’s health must be a priority.