It has become clear that whilst we may all be in the same storm with COVID-19, we are not all in the same boat.
COVID-19 is not just a viral disease – it is also a socially determined disease. Taken separately, each stage of COVID-19 including the risks of infection; hospitalisation; admission to intensive care and death are all significantly determined by social and economic factors.
Most of the causal pathways to increased mortality risks for lower socio-economic groups, BAME populations, the vulnerable and the least resilient communities are hidden in plain sight. They have been clearly delineated in iconic reports by Sir Michael Marmot.
The consequences in this pandemic of historical failures to address structural inequalities has now been quantified.
The Office of National Statistics (ONS) has reported the stark COVID divide between rich and poor. Those in the wealthiest 10% of the population have a rate of 25.3 COVID19 deaths per 100,000 population, but in the poorest 10% of the population it is 55.1 COVID19 deaths per 100,000. Double the risk.
ONS also report sharp differences in occupational mortality. Compared with the rate among people of the same sex and age in England and Wales, men working in the lowest skilled occupations have the highest rate of death involving COVID-19. Men working as security guards have one of the highest rates, with 45.7 deaths per 100,000 and taxi drivers and chauffeurs (36.4 deaths per 100,000). Data published by the Oxford Centre for Evidence Based Medicine suggests that BAME communities also have higher rates of excess deaths from COVID-19. These vary across different ethnic groups. Excess deaths (observed vs. expected) are around 1.5 times higher than expected for the Indian population, 2.8 times higher for the Pakistani population, and 3 times higher for Bangladeshis. Excess deaths are 4.3 times higher for the Black African population, 2.5 times for the Black Caribbean population, and 7.3 times higher for ‘Black Other Background' individuals. Excess deaths are 1.6 times higher for the ‘Mixed Any Other Background' population.
Whitehead, Barr and Taylor-Robinson at Liverpool University argue this evidence confirms that despite central government messaging, we are in fact not all in this together. The less privileged are bearing the brunt of the pandemic. Barr suggests one way to look at it is that we have three compounding drivers of inequality at play with COVID19: differential exposure to COVID 19 risks, differential vulnerability and differential consequences.
Inequalities in health arising from the way society is organised have persisted despite the scientific knowledge of what would be needed to fix them. This is largely because the policy choices implied by the evidence have not been the preference of incumbent governments who have not ‘followed the science' to fix the problem. Yet the COVID-19 crises has revealed an ever increasing public preference to confirm shared values that ‘all lives matter and every single life matters as much as every other life'. This renewed appetite for equality has been evident both in public opinion surveys and in the massive volunteering movement evident during the crises. In this, the public has shown willing to mobilise the ‘organised efforts of society' to show kindness and empathy in communities and to make things fairer for those shielding or isolated.
Yet whilst the public are willing to do what it takes to demonstrate a greater commitment to equality, there is a slow response from central government and as the inequalities continue, so will the risks to us all.
As the national Test Trace and Isolate (TTI) system evolves from its rushed and consequently shaky start, the 2.8m UK workers in the gig economy who may have to suddenly self-isolate if they are a contact of a confirmed case will have to forgo two weeks' income just to comply with self-isolation requests. Monthly paid salaried staff will be protected, their self-isolation treated as paid sick leave. There is no furlough payment at the moment for self-isolation. This increases the risk of non-compliance in those in the most precarious employment but it also risks a wider societal ‘long tail of the pandemic'. The injustice is that workers in the gig economy have been amongst those most exposed, largely because they have been the workers who have kept society functioning in lockdown.
This structural inequality will make societal recovery more prolonged. It will increase deaths as individuals on the lowest pay find themselves unable to comply with TTI protocols and so continue to spread the disease. Spain has established a national minimum income scheme both to deal with this issue and to mitigate longer term economic impacts of the crises.
The need to address inequality is also significant for the future stages of the pandemic, including the exit and recovery phases. Many of the poorest communities will be the most vulnerable to employment and income collapse as the pandemic subsides. As we click gradually through the lockdown lifting measures, many SMEs will find that their business model simply does not provide enough income if customers have to continue to be socially distanced. Many employees will find themselves moving off furlough into unemployment- and this is likely to hit the poorest communities and BAME communities hardest and longest.
We need a long term equality strategy for the future that saves livelihoods as well as lives. This will need to focus on those most at risk and those who have paid the biggest price to keep us all going during the COVD19 pandemic.
Dominic Harrison is director of public health and wellbeing at Blackburn with Darwen Council
Twitter: @BWDDPH
Leaving gig economy workers without self-isolation income will 'increase deaths'
