Section 6: Inequalities and COVID-19

In the year when COVID-19 entered our lives, the link between inequalities and poor health outcomes has become increasingly clear. As we are still in the pandemic phase, we are unable to fully quantify the impact of COVID-19 in Gateshead, but there are some early observations to make about the likely impacts on local people.

Recently published data suggests that the most deprived areas of England have twice the rate of deaths involving COVID-19 than the most affluent. But COVID-19 is not unique in this respect: inequalities in mortality have long been evident. Indeed, deaths from suicide, conditions such as liver disease and cancer as well as overall mortality rates, all show that death rates for people living in the most deprived areas of the country are higher than those in the least deprived. (Nuffield Trust. Mortality rate for different conditions, per 100,000 people (Published 06/05/2020))

Gateshead is the 47th most deprived local authority in England, out of 317 local authorities. Around 32,700 (16%) people in Gateshead live in one of the 10% most deprived areas of England. (Gateshead JSNA)

As the chart shows, not only do all causes of death lie below the equality line, most death rates for the most deprived areas are around twice those in the least deprived. 

Advising people to self-isolate risks serious social and psychological harm. Quarantine of people exposed to an infectious disease is associated with negative psychological effects, including post-traumatic stress symptoms. (Douglas MK, Srinivasa; Taulbut, Martin; McKee Martin; McCartney, Gerry. Mitigating the wider health effects of covid-19 pandemic response. BMJ. 2020;369. (opens new window))

The effects are exacerbated by prolonged and multiple isolation episodes, fear, frustration, boredom, financial loss, bereavement and stigma. When quarantine is voluntary, the effects are less and impact is also mitigated with clear and rapid communication and when the period is short, and people are protected from financial loss. This has not been the case with COVID-19 and we know that for many the pandemic has had a very negative impact on their mental health and wellbeing.  

We know that exposure to poor quality housing is associated with certain health outcomes, for example, damp housing can lead to respiratory diseases such as asthma while overcrowding can result in higher infection rates and increased risk of injury from household accidents.  

Housing also impacts health inequalities materially through costs and psychosocially through insecurity. Lower socio-economic groups have a higher exposure to poor quality or unaffordable, insecure housing and therefore have a higher rate of negative health consequences. These inequalities in housing conditions may also contribute to inequalities in COVID-19. For example, deprived neighbourhoods are more likely to contain houses of multiple occupation and smaller houses with a lack of outside space, as well as have higher population densities and lower access to communal green space. (The COVID-19 Pandemic and health inequalities. 2020: jech2020-214401 - Bambra C, Riordan R, Ford J, Matthews F. (opens new window))  

Evidence suggests that COVID-19 may have a disproportionate impact on people from Black, Asian and minority ethnic (BAME) groups. The relationship between ethnicity and health is complex and likely to be the result of a combination of factors. People of BAME communities are likely to be at increased risk of acquiring the infection. There are many reasons for this; BAME people are more likely to live in urban areas, in overcrowded households, in deprived areas, and have jobs that expose them to higher risk. People of BAME groups may also face barriers in accessing services that are created by, for example, cultural and language differences.

BAME communities are also likely to be at increased risk of poorer outcomes if they acquire COVID-19. For example, people of Bangladeshi and Pakistani background have higher rates of cardiovascular disease than people from White British ethnicity, and people of Black Caribbean and Black African ethnicity have higher rates of hypertension compared with other ethnic groups. Data from the National Diabetes Audit suggests that type II diabetes prevalence is higher in people from BAME communities. 

COVID-19 has affected different sections of the population to different degrees. As the pandemic goes on, we are becoming more aware of groups who are at risk for many different reasons.

PHE looked at the numbers and rates of death for people with learning disabilities between 21 March and 5 June 2020. COVID-19 accounted for 54% of deaths of adults with learning disabilities in residential care in the review period, slightly less than for people with learning disabilities generally, but still much more than in the general population. (Research and analysis. COVID 19 deaths of people identified as having learning disabilities: summary. Published 12 November 2020)

We also know that during the COVID-19 lockdown that social stress coupled with restricted movement and social isolation measures, has resulted in increased levels of gender-based violence.

Many have been forced to 'lockdown' at home with an abusive partner while services to support survivors are being disrupted or made inaccessible. Our understanding of the impacts of COVID-19 will become clearer in the future as we are better able to analyse and understand the data and experiences of different groups.  

The longer-term and largest consequences of the 'lockdown' for health inequalities will be through political and economic choices. Economists fear that the economic impact will be far greater than the financial crisis of 2007 / 2008, and they say that it is likely to be worse in depth than the Great Depression.

Previous research has found that sudden economic shocks like the global financial crisis lead to increases in morbidity, mental ill health, suicide and death from alcohol and substance use. These health impacts were not shared equally though - areas of the UK with higher unemployment rates had greater increases in suicide rates and inequalities in mental health increased with people living in the most deprived areas experiencing the largest increases in psychiatric morbidity and self-harm. Unemployment is disproportionately experienced by those with lower skills or who live areas with fewer employment opportunities. (Pub Med - Mitigating the wider health effects of covid-19 pandemic response. BMJ. 2020;369. (opens new window)) We also know that unemployment is likely to disproportionately affect the at-risk groups, women, young people and the poor.  

A recent report warns that despite the measures put in place by government to protect jobs, unemployment is set to rise further and faster than during any recession on record. There were over 400,000 Universal Credit claims in a week at the end of March, a figure over seven times higher than the year before. The number of claims is nearly five times higher than the peak in claims for Jobseekers Allowance - the main unemployment benefit at the time - during the height of the great recession in 2009. (The Edge Foundation (June 2020) The Impact of Covid-19 on Education) 

Analysis suggests that the gains of five years of jobs growth - during which employment increased to a record high - have been reversed in just one month. The analysis found that unemployment had already increased by half - from 3.9% to 6%, and that is likely to go higher still. 

The economic pain inflicted by COVID-19 will be felt unequally across the UK. Compared to the UK as a whole, the North East and the North West of England both have a higher proportion of employment in 'shutdown sectors' - which have had to significantly reduce operating in recent weeks to slow the spread of the virus, such as retail and manufacturing.  

Access to healthcare is lower in our disadvantaged and marginalised communities, and amongst rural communities. In England, the number of patients per general practitioner is 15% higher in the most deprived areas than that in the least deprived areas. (The COVID-19 Pandemic and health inequalities. 2020: jech2020-214401 - Bambra C, Riordan R, Ford J, Matthews F. (opens new window)) This reduced access to healthcare, before and during the outbreak, contributes to health inequalities.

People with existing chronic conditions are less likely to receive treatment and diagnosis during the pandemic as health services have had to focus on the COVID-19 emergency. We expect that there will be significant knock on effects caused by COVID-19 delays to elective surgery, cancer treatment and ongoing management of long-term conditions.  

The closure of our schools will potentially increase educational inequality, as it is most likely to impact the most disadvantaged young people through their time in education and into the workplace.

In Early Years education, even in normal circumstances, the poorest children are already 11 months behind their better-off peers before they even start at school. There are significant risks of both short term and long-term impacts on the most disadvantaged children, who may not have a suitable home learning environment. Extra support will be needed for many children when returning to school. (The Edge Foundation (June 2020) The Impact of Covid-19 on Education.)

Ensuring access to technology and online resources is a challenge. Previous research (Cullinane C & Montacute R (2018) Pay as you go? Sutton Trust. A) found that 34% of parents with children aged 5 to16 reported their child does not have access to their own computer, laptop or tablet that they can use to access the internet on at home. There are also concerns regarding online learning in higher education, where exams and courses have largely been replaced with online lectures and tuition. This mode of learning may put students who do not have access to technology or a suitable workspace at a disadvantage.

Childcare support is critical during this time for single, working mothers, however, many informal networks of support have been restricted during this time. (OSF Changes in income, time use and well-being before and during the UK COVID-19 lockdown. 2020. (opens new window))

Adverse outcomes may occur amongst young people in terms of educational and social outcomes among families that lack study space, access to home computing and parental support and lack of food provision from schools. Some may be at risk of online abuse or exploitation.

Early research (Child and Adolescent Mental Health During Covid-19) suggests that the pandemic and subsequent measures are having significant impacts on the mental health of children and young people. This group are already at higher risk of developing mental health issues compared with adults. Children may be experiencing increased anxiety and stress about the virus, and school closures and social distancing measures have led to a loss of structure and social contact. Such circumstances, coupled with reductions in support services, could lead to a range of poor mental health outcomes. 

Children and young people from certain groups (such as those from poorer households, young carers and those with disabilities) are already disproportionately affected by higher levels of mental health issues. For example, one study found that children from the poorest 20% of UK households are four times as likely to have serious mental health difficulties by the age of 11 as those from the wealthiest 20%. Experts express concern that the COVID-19 outbreak may widen these mental health inequalities, as well as increasing the overall prevalence of mental health issues in children.

Women make up almost 80% of the health and social care workforce and as such they are most exposed to COVID-19. This has impacted on women's mental well-being and inequalities, particularly amongst women who are single mothers. Single mothers are less likely to own houses, cars, and the most at risk for depression.

The complexity of these many stresses on family life and the impact of these inequalities, will become apparent in the future.

Section 7: Recommendations