The results of the covid-19 pandemic will likely only make health inequalities worse. But can this crisis be an opportunity for real change?

The news that people living in the poorest parts of the country are dying from covid-19 at double the rate of people in affluent areas should not come as a surprise. Health and social inequality has existed across the world for many decades. Earlier this year, Michael Marmot’s 10 year review of health inequalities¹ showed that the situation in England is getting worse. This is mirrored by the global situation where 10% of the population live on less than $1.90 per day.² The likely global economic recession as a result of the covid-19 pandemic will only make these inequalities worse. Therefore the challenge of addressing health inequalities could be seen as an increasingly impossible task. But, if our strategic planning during and after the pandemic is well judged, some of the worst effects might be mitigated.  

Why even think about health inequalities when health systems are currently, rightly focussed on dealing with the covid-19 pandemic? It is important because evidence is emerging that there is inequality in covid-19 related mortality, based on existing ethnic and socioeconomic inequalities. It is therefore imperative that we pay attention to existing health inequalities to help prevent morbidity and mortality from covid-19 and non covid-19 related illnesses.

A simultaneous focus on health preservation and illness management is critical during this pandemic. We know that cardiovascular disease is a driver of health inequality and remains the main cause of mortality globally. So maintaining a focus on cardiovascular prevention, treatment, and rehabilitation across all health systems is essential, even during this pandemic. Early statistics suggest a disproportionate number of people from ethnic minorities are being admitted to intensive care units or are dying from covid-19. The reasons for this are not yet clear, but may be partly caused by existing social and health inequalities. It is plausible that a combination of social factors and the higher prevalence of cardiovascular risk factors such as hypertension, diabetes, obesity and physical inactivity make disease progression in these patients infected with covid-19 take a more malignant course. Can we develop capacity and capability to help treat and prevent cardiovascular disease in these populations now, and then sustain it as we emerge post-covid in order to reduce this inequality in the long term?

Can we strengthen and sustain a focus on public health after covid-19? Health outcomes are only partly related to health services, so we must explore the strength of public health initiatives and messages to ensure we focus on social determinants of health to avoid widening inequality. For example, smoking accounts for circa 50% of variation in life expectancy.³ Can we strengthen and use current public health messaging about smoking cessation to reduce the immediate adverse impact of covid-19, and subsequently reduce health inequality post-covid? 

We must be mindful that generating and tackling waiting lists can exacerbate health inequalities. Therefore, in a recovery period, when waiting lists will inevitably rise, how can we ensure that clinical prioritisation is based upon need? In the NHS, it might be time to switch from 2 weeks waits and 18 week referral to treatment standards, and replace them with simple clinically prioritised categories of urgent and routine appointments across health providers and to define in real time what those waiting times are for each organisation. Transparent waiting times could provide patient choice and enable those most in need to obtain treatment and overcome the inverse care law of provision being inversely proportional to need.⁴ Postcode lotteries and unequal access to healthcare based on where you live, widen and exacerbate existing health and social inequalities. It is time to truly transform and integrate care and to reduce delays to diagnostics and specialist care based upon need. 

In terms of seeking healthcare for covid-19 and non covid-19 related illness, awareness, access, acceptability and acquisition, are all vitally important. All people must be made aware that health services still exist to treat symptoms, particularly those relating to cancer and cardiovascular disease. Whilst the rapid deployment of technology and virtual consultation has been an excellent by-product of the pandemic, we must ensure those who do not have access to necessary technology or are not health literate, are not disadvantaged. All people must be able to access services and should not be deterred from doing so. During this pandemic a policy of “no visiting” in most hospitals inevitably makes hospitalisation a daunting experience and might have deterred some patients from seeking admission, yet these barriers can be somewhat mitigated with technology or compassionate and informed exemption. 

Finally, government policies must appreciate the impact of deprivation on health. While more affluent populations are able to stockpile food and buy in bulk, poorer populations cannot. Unemployment is rising due to the economic impact of covid-19 and this disproportionately affects those on lower incomes or on zero-hours contracts. Poorer housing, with shared washing facilities, makes it harder to avoid cross contamination or achieve physical distancing. While richer populations enjoy wifi and technology to remain connected and have access to larger gardens, or more green spaces, no such luxuries exist for poorer populations.

The consequences of unemployment, deprivation of education, inadequate nutrition, deteriorating mental health and much more, will hit the most vulnerable populations the hardest, during and after lockdown. As we emerge from the pandemic, it seems likely that wider health inequalities will exist. Politicians and health and social care leaders must start planning now to mitigate the disproportionate impact of covid-19 on the most vulnerable populations. As policies emerge and health systems plan recovery frameworks during and after covid-19, it is essential that an equality impact assessment is a central tenet to each policy to ensure health inequalities drive recovery, restoration and reset. That is, if we are serious about addressing health inequalities and not letting a good crisis go to waste.

Kiran CR Patel, Chief Medical Officer and Consultant Cardiologist, University Hospitals of Coventry and Warwickshire

Andy Hardy, Chief Executive Officer, University Hospitals of Coventry and Warwickshire

Competing interests: none declared

 

1. Marmot. M. Health equity in England: the Marmot review 10 years on; BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m693 (Published 25 February 2020) Cite this as: BMJ 2020;368:m693
2. Prydz E and Joliffe D. Estimating international poverty lines from comparable national thresholds. World Bank Group report March 2017.
3. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020; 382: 1199–1207.
4. Jha P and Peto R. Global Effects of Smoking, of Quitting, and of Taxing Tobacco N Engl J Med 2014; 370:60-68