Social Inequalities in Health - a reflection after Covid-19


Globally, the COVID-19 pandemic has exposed the dire existence and effects of health inequalities. Stark variations in the environment an individual grows up in, their socioeconomic status, their occupation, their experiences and their education provokes severe differences in health between groups of individuals. Thus, these healthcare inequalities reflect a wider issue of unresolved socioeconomic inequalities in the UK - in this way, the pandemic has been described as a ‘syndemic’ whereby the severity of the virus and its associated disease is inextricably associated with existing epidemics which themselves are dependent on social determinants.


What inequalities have been seen during the pandemic?

In the UK, the newly-formed Inequalities in Health Alliance represents a burgeoning force appealing to the government to tackle the inequalities in medical issues and healthcare provision which have been amplified by the pandemic itself. The statistics are plentiful and sobering:

  • Up to May 2020, 25% of patients requiring intensive care support were of Black or Asian background [1]

  • The same groups represented 63% of the death of healthcare workers in the same period, despite representing just 21% of the NHS workforce [1]

  • The London Borough with the highest proportion of overcrowding (25.2%), Newham, was the same that saw the highest rate of COVID-19 death rates in May [2]


The causes for these and the numerous other inequalities identified are not simple, but the links between increased economic hardship, poor housing quality, nutrition, job security, stress, underlying health conditions and many other of those factors which go into making us ‘healthy’ are almost certainly at the heart of these issues.


What is social class and how is it qualified?

‘Social class’ describes superficial divisions in society based on a number of categories including income, living conditions, occupation and level of education. At a most basic level measurement of socioeconomic status can be divided into the oft-used three categories of working, middle and upper class. The superficiality and rigidity of the above classes have resulted in sociologists developing more nuanced scales such as the National Statistics Socio-economic Classification (NS-SEC). This is the official classification of socio-economic class in the UK and is based on occupation with consideration of a number of factors including an occupation’s security, autonomy and level of authority.

The NS-SEC categories - Rose D. and Pevalin D.


What are social inequalities in health and how are they qualified?

Social class inequalities in health are systematic differences between these categories in one or more aspects of health, reflecting inequalities in factors including nutrition, education and housing conditions which will often interact to exacerbate their individual effects. Tackling these inequalities in the UK has been a focus of NHS and government policy for several years but no clear solution has been found. Mortality and morbidity measurements may be used as inequality measures, both showing a stepwise gradient of ill-health from the higher to lower classes of either classification. Mortality is generally favoured, as morbidity values are dependent on the consulting and reporting habits of the classes. The influential Marmot review (2010) exposed existing social gradients in health, for example finding that the life expectancy of inhabitants of England’s poorest neighbourhoods is seven years less than that in the richest.

Up to May 2020, 25% of patients requiring intensive care support were of Black or Asian background

What causes health inequalities?

The Black Report (1980) was written by the UK government’s Department of Health and Social Security and represents the most holistic analysis of the reasons for health inequalities as well as claiming the inequalities had widened since the establishment of the NHS in 1948. It proposed four explanations for health inequalities: artefact, social selection, behavioural and material, concluding that the latter, reflecting differential exposure to hazards such as air pollution and poor housing, was the most important. Similarly, the Acheson inquiry (1997) identified six socioeconomic factors to be targeted by government departments to reduce health inequalities, including nutrition, education and housing. Despite NHS ideals of equity in healthcare provision, the ‘inverse care law’ is often quoted, stating ‘the availability of good medical care tends to vary inversely with the need for it’. Inequalities in material provision also have psychosocial effects whereby individuals can experience feelings of subordination and lack of support which adversely affect physiological processes, worsening existing ill-health. Marmot’s ‘status syndrome’ presents another psychological explanation, suggesting that autonomy - related to socioeconomic positions - is important in determining health inequalities.


How can we tackle these inequalities?


It is undeniable that part of the work tackling health inequalities falls to medical professionals themselves, despite the causes being more the responsibility of the government. For medical professionals to tackle these inequalities, fundamental starting points include ensuring equality in referral rates and drug prescription for key conditions as well as highlighting the health risks of a patient’s behaviours and environment. They must also advocate and inform for better health, particularly in communities most at risk from serious health conditions. Some medical professionals will likely play a greater role than others; General Practitioners, being ‘gate-keepers’ for the NHS, have the greatest exposure to the community and can best recognise and recommend local services for their patients, as well as noting which conditions and risk factors are prevalent in their communities. More widely, provisions must be put in place to ensure disadvantaged individuals can access and utilise healthcare services, including introducing specialised services where required and incentivising medical professionals to work in less prosperous areas such that their numbers reflect population need.


The wider needs of groups vulnerable to health inequalities must also be met, including those not confined to the medical sphere. Thus, medical professionals are not solely responsible for tackling these inequalities but must work closely with other sectors including employment, social service and education providers. Contemporary medical reforms must focus on improving socioeconomic conditions for the most disadvantaged and addressing upstream causes for inequality. A key challenge to consider is that the most disadvantaged individuals often will be the least likely to address their medical concerns with a professional, for example due to language barriers or limited access to services, and this requires consideration by local authorities and Care Commissioning Groups.


Conclusion...

We must endeavour to improve population health, requiring effective public and governmental participation. Tackling health inequalities requires a multifaceted approach and cannot be left to the medical sphere, although medical professionals are arguably in the best position to advocate for, inform on and begin to reduce these inequalities. Further, a distinction must be made between medical professionals as individuals and the NHS as a powerful economic and social entity with a duty to ensure all social classes are equal in healthcare provision.


References


[1] - Razai M S, Kankam H K N, Majeed A, Esmail A, Williams D R. Mitigating ethnic disparities in covid-19 and beyond BMJ 2021; 372:m4921 doi:10.1136/bmj.m4921

[2] - The Health Foundation, Emerging evidence on COVID-19's impact on health and health inequalities linked to housing, 2020

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