Health inequalities: the urgent call to Build Back Fairer

In spring 2020 Prime Minister Boris Johnson was admitted to hospital with COVID-19. Members of the British government described the virus as a “great leveller” on the basis that it affects people from all walks of life. The fallacy of this claim has become painfully clear over the last ten months. In fact, it couldn’t be further from the truth.

December 2020 saw the publication of the latest report by Sir Michael Marmot and the UCL Institute of Health Equity (Build Back Fairer: The COVID-19 Marmot Review), which provides an overview of the inequalities in COVID-19 mortality and the broader effect of the pandemic on the nation’s health. The title of the report is key: “Building Back Better” has become a core part of the government’s narrative, however it is critical that we build back fairer too.

The report sets out the urgent need to rebuild society based on the principles of social justice. COVID-19 has exposed and amplified deep inequalities within England, bringing into sharp focus the systemic link between ill health and deprivation. We know, for example, that the mortality risk for the virus has been much higher for individuals living in more deprived areas (more than double for people living in the least deprived areas) and/or overcrowded or poor-quality housing. The risk has also been much higher for BAME communities: between 2 March and 15 May 2020, black males were 3.3 times more likely to die from a COVID-19-related death than white males, partially reflecting the fact that BAME communities are disproportionately represented in more deprived areas and high-risk occupations. 

COVID-19 has also shone a light on the strong correlation between low income and many frontline occupations which provide essential services, such as care work, nursing, and working in supermarkets. These individuals put themselves at risk daily yet too often they are not recognised or rewarded properly for the contribution that they make to society. By way of example, the report states that 60% of care workers in England earn less than the real living wage whilst one in ten social care workers are on zero hours contracts.

All in all, the inequalities in mortality rates for COVID-19 follow a similar social gradient to that for all causes of death (i.e. the more deprived a certain area is, the shorter the life expectancy will be). This reflects the strong influence of the social determinants of health (also referred to as “the causes of the causes”). In short, the difference in health outcomes between individuals is not simply down to their genetics, behaviour and medical care access, but also due to the socio-economic conditions (e.g. employment, education, food availability and living conditions) in which different people are born, grow, live, work and age – all of which play a huge part in determining their overall “health”. 

Poverty fundamentally limits options, including the option to choose whether to eat healthily or to live in an unpolluted area. Improving health and wellbeing is inherently easier for some individuals and communities than for others. 

This connection between health outcomes and socio-economic conditions is not “new news”, but the pandemic has laid bare the severe impact which such factors can have on an individual’s health. On top of this, as the report states, the societal responses to contain the pandemic (tier systems, lockdowns, etc.) have and will continue to widen health inequalities further, making the need for radical change all the more pressing. To take just a few examples from the report:

• Low-income groups and part-time workers are most likely to have been furloughed, experiencing 20% wage cuts on already low wages.
• Children from more disadvantaged families have been disproportionately harmed by closures of early years settings and schools, including due to less access to online learning, private tutoring and educational resources.
• Food poverty among children and young people has increased significantly (put in the spotlight by Marcus Rashford’s sustained campaign for free school meals for children).

But why has England fared so incredibly badly in the wider international stage in response to the pandemic? 

In late January, the number of deaths in the UK from COVID-19 passed 100,000. Whilst many of us have to some extent stopped engaging with the rising figure out of horror and disbelief, we must not turn away from the shocking scale of this number. What is more, England not only has one of the highest excess mortality rates in Europe, but the economic impact has been one of the worst suffered.

On this question, the report points back to the findings of Sir Michael Marmot’s previous report, The Marmot Review 10 years on (published in February 2020), which catalogued what had happened to health and health inequalities within the previous decade. The truth is that England was already in very poor health before COVID-19 took hold. Since 2010, life expectancy had stagnated (amongst developed countries the rate was only slower in Ireland and the USA), health inequalities were increasing (both between regions and socioeconomic groups) and life expectancy was declining in the most deprived areas. ONS data from 2016-2018 showed that men living in the most disadvantaged communities in England were living 9.5 years less than those living in the wealthiest areas whilst females were living 7.5 years less; an increase for both sexes since 2013-2015. In addition, the gap in years spent living in “good” health between the least and most deprived areas was 18.9 years for men and 19.4 years for women.

A number of causes will have contributed to this situation, but one factor is beyond doubt: the conditions for good health have not been sufficiently prioritised over recent years, which has in turn contributed to the increase in inequalities within economic and social conditions. 

Government policies of austerity have brought cuts to public health funding and local government, negatively impacting services which support health such as social care, housing, education, youth services and green space. This left the nation exposed and vulnerable to the effects of a global pandemic.

Health and wellbeing are a fundamental measure of society’s prosperity, enabling individuals to thrive and participate towards a strong economy, but the persistent focus on economic growth across much of the world in recent decades has failed to properly take this into account. Thankfully, the limitations (and dangers) of measuring a country’s performance by its GDP are increasingly recognised and a shift towards prioritising other factors (including health and the environment) is beginning to take hold in some places - see, for example, New Zealand’s Wellbeing Budget of 2019. But the pandemic has demonstrated that this recalibration cannot happen soon enough in England.

It is time to put population health back front and centre. This means not just treating the surface-level symptoms of poor health but also working to address the underlying social determinants and the health inequalities arising from these, which can be significantly reduced if targeted effectively. It also means valuing and appropriately compensating all members of society for the contribution which they provide. We will then move closer to an equitable society where everyone can enjoy good health and achieve their full potential. 

Tessa is an On Purpose London October 2020 Associate, currently working in the Population Health and Inequalities team at King's Health Partners on a programme to reduce health inequalities and improve health outcomes within South East London.