MRC/CSO Social and Public Health Sciences Unit

Published 14th May 2020

By Ruth Dundas and Alastair Leyland. Dundas and Leyland's work focuses on population health, in particular measuring, understanding and reducing inequalities in health and mortality.

In recent weeks, the UK and devolved governments have announced many measures to protect the population from the COVID-19 pandemic. The concern is that the virus will spread, overwhelm the NHS capacity to respond, reduce economic output as workers become ill, and kill large numbers of people. Taking urgent and radical action according to the precautionary principle is entirely appropriate to address this threat. However, for at least the past 40 years, health inequalities have been known to be killing people on a huge scale in the UK^1-5 (over 850,000 premature deaths over 15 years in England⁶) and the responses by different governments to tackle this has been markedly different to the pandemic response (Table 1). A question has to be asked as to whether the government responses to each are in proportion to the scale of the challenges, and if they are different, why they are different.

Table 1 – Examples contrasting the characteristics of responses to COVID-19 and health inequalities in UK

Characteristics of response	COVID-19 pandemic	Health inequalities
Timeliness	Immediate – COVID-19 cases reported in China 22/01/2020, UK Government initial response immediate advice on travel to Wuhan, China 22/01/20207 62 days from initial report of cases to full implementation of mitigating effects (schools & business closed, stay at home)	Black Report in 1980, Acheson in 1998, 5 years later research showed limited policies implemented to reduce inequalities10 Introduction of targeted resource allocation for NHS in England in 1999 leading to reduction in mortality amenable to healthcare (2001-2010)11 Changes to benefits and welfare policy (1997-2010) leading to reductions in child poverty12
Volume of evidence	Covers a period of 62 days (from 22/01/2020-23/03/2020) [Reported by WHO on 22/01/20, first response from UK Government on 22/01/2020, UK Government announces “lockdown” on 23/03/2020]	13Covers a period of 40 years – reports from Black 1980, Acheson 1998, Wanless 2003, Leyland 2007, Marmot 2010
Statements of response	Daily briefings by WHO Director General covering reports of cases, deaths and WHO recommendations to minimise harm to populations. Daily briefings and reports from Government ministers, DHSC & PHE	No daily briefings Black report published on August Bank Holiday Monday in 198014
Quality of evidence	Case fatality rate is unknown but estimated to be 3.4% worldwide8  and 1.6% in UK9; likely to be overestimated as the denominator of cases is unknown, those tested for the virus is a subset of all those with the virus.	Overall and all cause mortality are well described by deprivation measures. The population at risk (total population and population by deprivation measures) and deaths (all cause and cause specific) are high quality measures reported by ONS and NRS.
Language used	COBRA committee convened Briefing by CMOs/media appearances (radio, newspaper articles)	Health Inequalities task force Annual reports from CMOs

While any death is a tragedy and will have ripple effects through a community, the responses to COVID-19 and health inequalities are out of alignment with the extent of the health problems. Inequalities in health and mortality are unjust and have been on both the political and research agenda for over 30 years. It is acknowledged that reducing inequalities in health is difficult – it requires a multiagency approach to tackle the social determinants of health such as poverty, welfare, employment, housing, pollution, education¹⁵ - but just because something is difficult to do, does not mean we should discount it.

It is not just the contrasting response of Governments to these different problems that is concerning. The differential reaction shapes the media coverage, which in turn shapes the public’s understanding and the potential for future effective action.

We are not arguing that the scale of government response to the pandemic is inappropriate. Instead, we argue that the inequalities challenge is at least as important and thereby should demand a similar urgency and seriousness of response. There may be many factors that could explain why they do not. Health inequalities are something of a ‘long emergency’ rather than a sudden and novel event. Do we need a new headline-grabbing abbreviation (e.g. ‘INEQUAL2020’) to reframe the urgency of the health inequality crisis?

If political action was to be taken in proportion to the impact on premature mortality, comprehensive action on health inequalities should be prioritised at least to the same extent as the pandemic. This would mean urgent responses from the Prime Minister, Chief Medical Officers, civil servants, business and others. We wait in anticipation.

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References

1. Department of Health and Social Security (1980) Inequalities in Health: report of a research working group. London: DHSS
2. Acheson D. (1998). Independent Inquiry into Inequalities in Health Report. The Stationary Office. London
3. Wanless D. (2002). Securing our future health: taking a long-term view. Final report. HM Treasury. London.
4. Leyland AH, Dundas R, Mcloone P, Boddy FA. (2007). Inequalities in Mortality in Scotland, 1981-2001. Occasional paper (Medical Research Council (Great Britain). Social and Public Health Sciences Unit).
5. Marmot M, Goldblatt P, Allen J, et al. (2010). Fair Society, Healthy Lives : strategic review of health inequalities in England post 2010, Institute of Health Equity. London.
6. Lewer D, Jayatunga W, Aldridge RW, Edge C, Marmot M, Story A. Premature mortality attributable to socioeconomic inequality in England between 2003 and 2018: an observational study. Lancet Public Health 2019; 5(1): 33-41.
7. Department of Health and Social Care and Public Health England. DHSC and PHE statement on coronavirus. 2020a https://www.gov.uk/government/news/dhsc-and-phe-statement-on-coronavirus accessed 11/03/2020
8. WHO Transcript of WHO Director-General's opening remarks at the media briefing on COVID-19 - 5 March 2020 (https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---5-march-2020) accessed 11/03/2020
9. Department of Health and Social Care and Public Health England. Guidance - Number of coronavirus (COVID-19) cases and risk in the UK (updated 10 March 2020) 2020b https://www.gov.uk/guidance/coronavirus-covid-19-information-for-the-public accessed 11/03/20
10. Exworthy M, Blane D, Marmot M. Tackling health inequalities in the United Kingdom: the progress and pitfalls of policy. Health Serv Res. 2003;38(6 Pt 2):1905–1921. doi:10.1111/j.1475-6773.2003.00208.x
11. Barr B, Bambra C, Whitehead M. (2014) The impact of NHS resource allocation policy on health inequalities: England 2001-2011. BMJ 2014; 348: g3231.
12. Taylor-Robinson D, Whitehead M, Barr B. (2014). Great leap backwards: the UK’s austerity programme has disproportionately affected children and people with disabilities. BMJ 2014; 34: g7350.
13. See references 1-5
14. BMJ 2002;325:661doi: https://doi.org/10.1136/bmj.325.7365.661
15. Lynch J. (2017). "Reframing inequality? The health inequalities turn as a dangerous frame shift." Journal of Public Health 39(4): 653–660.

First published: 13 May 2020