In February the Institute for Health Equity published The Marmot review 10 years on. It examined trends in health inequalities in England over the last decade and found that regional and socioeconomic differences in health are large and growing. Life expectancy improvements are stalling and there has been a decline in the number of years some people can expect to live a healthy life.

The report shines a spotlight on how the circumstances in which we live – from the experiences of our early years to our working conditions, housing, education and support from local communities throughout our life, shape our health outcomes. It rightly demands urgent leadership from the government to address the existing health inequalities, which see a girl born in one of the most deprived areas being expected to live 19 fewer years in good health than one born in one of the least deprived areas.¹ The gap is similar for men, as shown in Figure 1. 

Looking back at news reports from 25 February 2020 – the day of the report’s publication – it is now apparent that the health inequalities news story of the decade – or indeed the century – was not the Marmot report, but the initial spread of COVID-19 through Europe. On that day there had been 11 deaths reported in Italy, cases confirmed in Austria and Switzerland and the UK government was debating the advice to give people returning from their ski holidays.² Like Bruegel’s Landscape with the Fall of Icarus, everyday life was continuing as a disaster began to unfold in the background.

Less than 2 months later, the landscape of the UK has changed irrevocably. Many thousands of families have lost loved ones and many millions of families face uncertainty and hardship, with a toll on their long-term health and wellbeing.

The measures taken to control the spread of the virus have wide-ranging implications for people’s income, job security and social contacts. These factors will in turn have a powerful influence on people’s ability to live healthy lives. Without consideration of the long-term health implications of the lockdown and likely economic shock, which stem from necessary measures to protect lives in the short term, the toll on the nation’s health risks going well beyond the number of people who will die with COVID-19. This toll will fall unevenly across our society. Mitigating its effects will require a thorough analysis of how health inequalities are intertwined with the course of the virus, as well as with the necessary government and societal response to halt its spread.

Existing health inequalities are linked to a greater severity of symptoms – and likelihood of death – for those contracting COVID-19.This was evident in early data from China and Italy which indicated that the effects of the virus were most acute for those that already suffered poor health.^3,4 This seems to be true for people in the UK too – of those who sadly died with COVID-19 in March 2020, 91% had at least one pre-existing condition.⁵

While this poses greatest risk for older people, it would be wrong to see the often cited ‘underlying health conditions’ as being solely age related. The risk of developing a long-term health condition, or multiple long-term conditions, is strongly patterned by where you live and your level of deprivation. Health Foundation research found in the least deprived fifth of areas, people can expect to have more than two conditions by the time they are 71-years-old. Yet in the most deprived fifth, people reach the same level of illness a decade earlier, at 61.⁶ Recent analysis has revealed the extent of the link between deprivation and risk of dying with COVID-19: adjusting for age, deaths in the most deprived areas of England have been more than double those in the least deprived.⁷

The uneven impact of the virus is highlighting a further inequality in our society – that of race and ethnicity. Recent headlines have shown the higher numbers of deaths among black and Asian communities,^8,9 and early data from intensive care units found a disproportionate number of patients with COVID-19 were black or from another minority ethnic background.¹⁰ Even when accounting for age and geography, there have been more deaths per capita in all ethnic minority groups (other than white Irish) than among white British people.¹¹ An inquiry has rightly been launched.¹²

The causes behind these patterns are likely to be complex and interlinked,¹³ but the search needs to start by recognising the economic disadvantage that is placing these communities at greater risk.¹⁴ Deep-rooted discrimination in British society creates systemic barriers to the conditions needed to live a healthy life, which contributes to poorer health outcomes among some within the black, Asian and minority ethnic communities in the UK (when compared to the outcomes of white British people).¹⁵ Given that your risk of dying with COVID-19 is strongly associated with experiencing existing poor health, this makes the virus potentially more dangerous for these groups. Also, while there is evidently variation in the lives of those from minority ethnic backgrounds, overall, workers who form part of the black, Asian and minority ethnic community are more likely to live in densely populated urban areas and are disproportionally represented in high-risk key worker jobs. This is particularly true in London, as shown in Figure 2, which has seen the largest number of COVID-19-related deaths of any region.¹⁶

As well as those with the poorest health being more likely to experience worse outcomes from COVID-19, the government measures to curb the spread of the virus are leaving many of these same people exposed to greater risks to their physical and mental health. These risks stem from increased exposure to the virus and from increased economic and social hardship during the lockdown.

Those on lower incomes are more likely to have continued travelling into work. Less than one in ten of the lower half of earners say they have the option to work from home during the lockdown, compared with half of the highest earners.¹⁷ Many low earners have also been classified as key workers, particularly in retail and food,¹⁸ and though their continuing to work has been for the wider social good, they have at times been given inadequate protection.¹⁹ As well as increasing their risk of exposure by working outside the home, and for some needing to travel on public transport systems, low earners can also be returning to cramped housing conditions, putting their wider household at greater risk.

It is not just the virus that presents an increased health risk in the current circumstances. The government response, while saving lives in the short term, is already having economic consequences for those at the sharp end of inequalities. Where they are not in key worker roles, many millions of families, who were already struggling to get by, are facing reduced or non-existent incomes. Those on low wages are seven times as likely as high earners to have worked in a sector that has been shut down.²⁰ This insecurity can be expected to have immediate impact on the mental health of those affected. The response is also contributing to an increase in food insecurity. Rising prices and reduced access to fresh food exacerbates the difficulties some families already face in putting a healthy meal on the table – preliminary research indicated that the number of adults who were food insecure in Britain had quadrupled after the lockdown.²¹ Children are perhaps even more acutely affected. The Trussell Trust reported a 122% rise in emergency food parcels given to children from food banks in their network during the second half of March 2020, compared to the same period in 2019.²² Headlines have also highlighted an increase in domestic violence since lockdown, as people are living in confined environments.²³

One of the starkest contrasts in people’s experience of lockdown can be seen between those with affordable, secure and good-quality homes (and gardens) and those burdened with high rents, insecure tenancies and limited or no access to outdoor space.²⁴ As well as the quality of the accommodation affecting their general wellbeing, those in the rental sector are likely to be facing different economic consequences. The option of mortgage holidays will provide some short-term alleviation for those who own their homes.  However, renters remain extremely vulnerable. As the average renter spends a third of their income on housing – compared with 17% of homeowners – they are likely to find themselves struggling to meet payments, increasing their risk of eviction if they are unable to address arrears built up when current measures which suspend evictions are lifted.²⁵ The ensuing housing insecurity and increased housing costs in the coming months is likely to negatively impact people’s physical and mental health.^26,27 As Figure 3 shows, this issue is likely to disproportionately affect those in ‘shut down’ sectors (those most likely to be affected by the lockdown, as they cannot operate under current social distancing rules²⁸) and key workers.

People in different parts of the UK are experiencing these economic impacts of the lockdown unevenly. Preliminary analysis indicates that cities in the north of England are likely to be worst affected, with a greater share of workers unable to shift to remote working.²⁹ We are also seeing early but significant impacts on small towns that rely on tourism, as high-street spending has been hit particularly hard in these areas.³⁰ For those living in these towns, the extent of the financial impact will worsen if the lockdown restricts the tourist pounds that usually accompany the summer months. This regional variation risks widening regional health inequalities, as the immediate financial pressures tip families into periods of uncertainty and stress.

Beyond the immediate harm caused by COVID-19 itself and the accompanying lockdown, there will be longer term implications of the measures taken to control the spread of the virus.

Unmet health needs

As the NHS diverts resources to the crisis, there are consequences for people with existing health needs. The paring back of routine care means that preventative services have been put on hold, such as cancer screening in Scotland.³¹ Management of some existing long-term conditions is also on hold, as GP surgeries pause non-urgent and non-essential routine care in England³² and English hospitals pause routine operations.³³ And while it is encouraging that the message about reducing demand on the NHS is getting through, there is a downside. Initial data is showing that there have been lower presentations for heart conditions, suggesting there will be a shadow of unmet need once the immediate crisis subsides.³⁴

Financial hardship

The crisis will also have lasting implications for a group of people who would never have expected to face serious financial hardship. With over a million registering for Universal Credit in the first week of lockdown and many more redundancies and social security claims expected, there is a new group of unemployed people emerging. Hopefully this will be short term, but for some there will be a long and difficult journey back to financial security. These journeys are likely to take their toll on people’s health and wellbeing, as they expose a previously secure group to the hardships of limited budgets and reduced living conditions.

There is strong evidence that employment and fair pay is good for people’s health and wellbeing– it provides access to basic living standards and can expand social networks.³⁵ In contrast, poverty and insecure work have well-established negative impacts on people’s health through the effects of deprivation and social isolation. Children who live in poverty will face barriers to living a healthy life and are more at risk of experiencing adverse childhood experiences that have long-term impacts on health.

Education and social mobility

Beyond financial hardship, other aspects of the lockdown will erode people’s wellbeing and long-term health. School closures are likely to disadvantage children with fewer opportunities for home learning.³⁶ For those taking exams in 2021 this could have a defining impact on their future options. Education is key to social mobility – it improves access to good jobs, higher wages and financial security. If the lockdown creates barriers to these for disadvantaged young people through its impact on education, there will be consequences for their future chances of living healthier lives.

Another aspect of lockdown affecting young people in the UK are job losses, as those aged 25 and younger are more than twice as likely to work in a sector that has been forced to close.³⁷ The transition to adulthood is critically important for young people’s future health and joblessness at this stage presents a challenge, particularly for those living in areas with limited opportunities.³⁸

The role of business, local government and others

While the national government shapes the macro environment in which the crisis is managed, wider society also plays a critical part. The response of businesses and large employers in their efforts to protect staff has been varied. In some cases, businesses acted faster than government to reduce the risk to employees and customers.^39,40 In others, there has been public outcry at what has appeared to be putting business interests ahead of social good, despite the government support available.^41,42,43

This highlights the importance of business having concern for their workforce and their role in ensuring job quality, which matters for health – people in low-quality jobs are twice as likely to report their health is not good.⁴⁴ The pandemic has also shown the vital role that charities and community groups play in our social fabric. This sector, often invisible alongside the state infrastructure, are the first line of support for some of the most vulnerable in society. In many places their contributions will make the difference between individuals facing hardship and suffering, and communities being resilient in the face of adversity.

Local government, including directors of public health, are playing a vital and often unacknowledged role working alongside businesses, public institutions (including the NHS), charities and community groups to provide support to disadvantaged people during the crisis. However, over the past decade central government has significantly shifted expenditure away from the services and infrastructure that help people stay healthy and towards addressing problems that could have been avoided in the first place.⁴⁵ For example, between 2013/14 and 2018/19 public spending on local children’s services in England fell overall. While spending in 2019/20 now exceeds the past 2014/15 peak there has been a significant shift in focus from preventative services provided during the early stages of a child’s life to reactive services, including care for children in need or those who are ‘looked after’.⁴⁶

This has limited the resources available to local governments for preventative work on health inequalities. One example of an area in urgent need of investment is the public health grant to local authorities, cut by 22% on a real terms per head basis since 2015/16. The grant covers vital services such as sexual health, drug and alcohol and children’s services, as well as enabling directors of public health to influence the wider determinants of health at local level.

The period of lockdown is just the initial phase in a series of challenges to health inequalities in this country. With predictions of a 35% loss of real GDP in the current quarter⁴⁷ there may be long-term consequences for millions of households. The government will face difficult trade-offs – weighing up whether to take the costly actions required to protect those facing greatest disadvantage or risk a further widening of the inequalities that have characterised the last decade. In making these decisions, it should be remembered that the health and wellbeing of the population is one of any nation’s greatest assets, essential to a successful economy and thriving society. Allowing health inequalities to become further entrenched would not simply be an injustice for the individuals affected. It could seriously undermine our future prosperity.⁴⁸

The COVID-19 pandemic has presented the UK with societal challenges not seen since the Second World War. Without the right action, its legacy will be more of the creeping inequalities that have characterised the last decade and which, in the long term, will take their own toll on the nation’s health. However, we have already seen community spirit increase in the immediate response to the crisis,⁴⁹ and, as our interdependence becomes clearer, there may be greater public support for collective action to protect the most vulnerable in the future. This pandemic could be a watershed moment in creating the social and political will to build a society that values everyone’s health now and in the long term.

Achieving this will require action that goes beyond suppressing the virus and meeting the needs of the most vulnerable in the weeks and months ahead. Once the emergency response is over, the government urgently needs to start thinking longer term, implementing a national cross-departmental health inequalities strategy that would lay the foundations for a new social compact.

At the heart of a new social compact must be:

• An enhanced role for the state in providing social protection: As already set out, living in poverty can have long-lasting negative implications for people’s health. It is therefore vital that the social security system is strengthened to protect people from severe deprivation, thereby safeguarding their health and wellbeing in times of acute need and in the long term. Steps such as abolishing the two-child limit and setting benefit rates at a level that provides an adequate standard of living will be important to reduce hardship and prevent a projected rise in child poverty.
• Significantly increased public spending on prevention, with targets set and preventative spending tracked: Action ought to be taken to remedy the government’s shift from investing in prevention to spending on treatment. This needs to play out at all levels of public expenditure but must address the underfunding of local government over the last decade. While local councils have been provided with additional funding to enable them to respond to the COVID-19 pandemic, the crucial role they play in protecting health and wellbeing must be acknowledged and supported over the longer term.
• Better quality of jobs for workers who have been undervalued and underpaid: With the pandemic raising questions around the people and jobs that our economy rewards and protects, its aftermath should be seized as a key moment to ensure employers give greater consideration to job security, job design, management practices and the working environment – as well as pay.
• Measures to improve the quality, security and affordability of housing: It is vital that changes to the local housing allowance made during the pandemic, which have already increased the housing available to those at risk of homelessness, are maintained beyond the immediate crisis.^50,51 Improving the quality of available housing should also be a priority, as should steps to increase housing affordability and security for those who have been pushed into hardship they never would have expected.
• Action on the systemic barriers facing black, Asian and minority ethnic groups: It is important that the inquiry into the disproportionate impact of COVID-19 on black and Asian communities generates meaningful longer-term work to address the root causes of persistent health inequalities among these communities, including discrimination.
• Sustained support of the voluntary and community sector: While the government has announced some emergency funding for the voluntary and community sector,⁵² additional support is needed at a time when these organisations will play a more vital role than ever in rebuilding local communities – working alongside other sectors including the NHS, local government and business.
• Economic development to create the widespread conditions that enable people to live healthier lives: The pandemic has highlighted groups of people who are particularly vulnerable to economic shocks. Economic development by local, regional and national government can be designed to make these groups more secure through promoting social cohesion, equity and participation, encouraging access to products and services that are good for people’s health and ensuring environmental sustainability. This is the topic of an upcoming Health Foundation report.

COVID-19’s impact through the lens of inequalities

Attempting to understand the impact of the COVID-19 pandemic on societal inequalities is currently like looking through a kaleidoscope. There are so many separate, interconnected and constantly changing elements that it may never be possible to see the full picture. But one thing is certain, unless these current events are viewed through the lens of inequalities, we risk ending up in a place of even greater injustice than where we started.

As The Marmot review 10 years on showed, deprived communities in England have seen vital physical and community assets lost, resources and funding reduced, community and voluntary services eroded and public services cut over the past decade. All of this has damaged health and widened inequalities. Looking ahead to the aftermath of the pandemic, lessons from the past decade of austerity must be learned.

Time will tell, but there is a real risk that if we do not learn these lessons, those who currently face most disadvantage will eventually pay the highest price – even as they have kept things going for the rest of us. One can only hope that the shared recognition of this creates a collective desire to ensure that health inequalities, as persistent as they are avoidable, are finally addressed.