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why the poor and disadvantaged are more likely to die

Anxious politicians want to make the case that COVID-19 doesn’t discriminate, in order to frame the fatalities as effecting us equally. As the BBC’s Emily Maitlis made clear in her brave denunciation of this point of view on the 9th April 2020, such arguments are highly misleading. Early on in the pandemic, the news of deaths of under-protected London bus drivers, higher mortality rates amongst BAME doctors, health workers and BAME individuals, alongside the deaths of older people in care homes, all pointed to the social patterning of fatalities from COVID-19. This point has now been confirmed beyond a reasonable doubt. The disadvantaged will suffer most from this pandemic, they are more likely to die and less likely to be able to protect themselves from becoming ill. The newly released data from the Office for National Statistics show that those living in our most deprived communities are twice as likely to die. This is shocking, but entirely predictable, and has a recent epidemiological history.

Firstly, we make a caveat. As statistician David Speigelhalter pointed out recently, it will not be until next year that we can make a complete assessment of the deaths from COVID-19 and the increasingly significant number of excess deaths resulting from the lockdown which are a function of those either not seeking, or not getting, appropriate medical attention for cardiovascular and other chronic diseases. Conversely, we also need to factor in the improvements to health resulting from reduced air pollution, accidents and other factors. However, putting this caveat aside, there is increasing clarity about the profile of fatalities and the patterns preceding them. Men appear to be more likely to die, as do older people and those from BAME backgrounds, but the largest numbers are those with pre-existing or underlying conditions, including those experiencing obesity. For example, on the worst day for fatalities to date (10 April), of the 980 deaths reported all but 56 had ‘underlying conditions’ (less than 6%). The link between COVID-19 and underlying conditions is well-known but what is rather less reported is how much these “underlying conditions” are socially determined with a sharp social gradient and a link to the consequences of austerity and long-term patterns of social disadvantage. In simple terms, it is the poorest and most disadvantaged that are more likely to die from COVID-19 and there is a brutal logic to this, the clues to which have emerged over the last few decades.

Since 2015, UK researchers have been pointing, with alarm, at the increasing numbers of excess deaths, with over 30,000 reported that year. Various explanations were offered (flu, cold weather) but the study team showed that none of these fully accounted for what they were seeing,  saying, “while the evidence is not conclusive, the analysis does suggest that failures in health and social care could be the possible cause for the rise in deaths”. Another study in 2017 resulted in the widely quoted figure of 120,000 excess deaths due to austerity measures. Whilst there have been critiques of these studies, there is a growing and plausible body of evidence that the political path chosen in the aftermath of the financial crisis of 2008 has meant that the price has been paid, both economically and with their lives, by the poorest and most disadvantaged in the UK.

But it was not just excess deaths. Evidence began to emerge of the stalling of life expectancy that began in 2011. Michael Marmot’s update of the scale of health inequalities in the UK earlier this year confirmed this pattern. For some sections of the population, life expectancy has begun to decline and the decline in the improvements in cardiovascular mortality, stroke, chronic respiratory disease and others, that had been achieved in previous years, has now ground to a halt. It is precisely these chronic diseases which appear to make up the majority of the “underlying conditions” found in the COVID-19 mortality picture. Some of the reporting at the time referred to “deaths of despair”; deaths resulting from suicide and drug and alcohol abuse as well as cardiovascular disease and strokes increasing among middle-aged Britons. Also commented upon was, “Shit life syndrome” – something  GPs see regularly: people facing chronic and catastrophic social circumstances of poverty, disadvantage and neglect and which also underpins the COVID-19 patterns.

We know from the work of social epidemiologists such Richard Wilkinson and Kate Pickett that there is a social gradient in all of these chronic conditions meaning that there is an excess of people with these conditions from poorer and disadvantaged groups. It is worth noting that for poorer people, the burden of multi-morbidity also happens at an earlier age and these may well make up the younger cohort of those dying from COVID-19. As David Spiegelhalter noted, one of the crueller effects of the virus may be to compress a year’s worth of mortality (that is, those most likely to have died in the course of a year) into a few short weeks. Putting that into the context of the social gradient, it is the deaths of the least advantaged that will have been brought forwards and this appears to be confirmed in the recent ONS analysis.

But there is more. The other side of the social patterning of fatalities, are the health behaviours and health advantages of those from more affluent groups. Owen Jones has already written about the practical ways in which the middle-classes are protected from the worst impacts of the virus; being less likely to be laid off, able to work from home and have access to facilities like computers and high-speed internet, being less likely to be renting and living in sub-standard, overcrowded accommodation, and having better access to gardens, parks or green spaces. But what we also know is that alongside the social gradient in chronic disease, there is a social patterning of health-promoting behaviours. From lower levels of smoking to lower body mass indexes, improved patterns of nutrition and exercise, we know that more socio-economically advantaged groups are more likely than those at the bottom to be able to perform healthy behaviours. The explanations for this are complex, but what is clear is that the greater the resources at an individual’s disposal (financial, educational, practical, personal networks of influence), the better the health outcome. This is, if you like, one of the iron laws of public health, but it is absent from much of the reporting on COVID-19 to date.

We have written in our work about the ways that worsening social inequalities wrought by the socio-economic and political changes of the last few decades fundamentally impact the lives of those living in the UK. For example, broader socio-political discourses shame the disadvantaged and render dependency of any sort as illegitimate. At a moment in which we are increasingly dependent on the proper functioning of the welfare state and dependent on each other for making the lockdown work, we need to acknowledge how the political decisions of the past have brought us to this point. History is always written on the body. The deaths of despair, shit life syndrome and the social gradient in ‘underlying conditions’ contrast with the ‘natural’ social advantages of the better-resourced groups in the population. In short, this means that the crisis will deepen already entrenched inequalities. There has to be some political acknowledgement of this simple fact. What the world is going to be like when we emerge from the COVID-19 pandemic is not an inevitability. Our newfound solidarity and awareness of mutual dependency can shape a different world, where the poorest and most disadvantaged do not face worse health outcomes as a result of broader political choices. It is down to the sort of world we demand and that is one in which the health damages of the past are recognised and not repeated.

About the Authors: Paul Bissell is a Professor of Public Health & Dean of the School of Human & Health Sciences, University of Huddersfield. Paul is a medical sociologist with an interest in health inequalities @BissellHuman. Marian Peacock is a Senior Lecturer in Public Health, Edge Hill University.  Marian is a public health sociologist with an interest in how narrative approaches can help with understandings of the consequences of inequality. Sara MacDonald is a Senior Lecturer in Primary Care, University of Glasgow. Sara is a primary care-based sociologist with interests in healthcare access, experiences of health and illness and inequality @saramacdonald13.