#MSCOVID19: inequality

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We all focus on the obvious risk factors that predict who will and who won’t die of severe COVID-19, but the one that needs a deep think is deprivation the main social determinant of health. The latest data that has just been released from the ONS (Office for National Statistics) is a grim reminder that survival during COVID-19 is not only dependent on physical factors but social factors as well. In reality, the physical and the social are inseparable from each other because they depend on each other, for example, living in a poor area often means poor access to outdoor areas that promote physical activity. If you are interested in reading more on this I would suggest reading Micheal Marmot’s book ‘The Health Gap: The Challenge of an Unequal World‘.

I work at the Royal London Hospital, where our local patch consists of three boroughs Whitechapel, Hackney and Newham. It was quite alarming that Newham had the highest age-standardised COVID-19 rate with 144.3 deaths per 100,000 population followed by Brent with a rate of 141.5 deaths per 100,000 population and Hackney was third with a rate of 127.4 deaths per 100,000 population. 

The following are the headline figures from the ONS:

  • Between 1 March and 17 April 2020, there were 90,232 deaths occurring in England and Wales that were registered by 18 April; 20,283 of these deaths involved the coronavirus (COVID-19).
  • When adjusting for size and age structure of the population, there were 36.2 deaths involving COVID-19 per 100,000 people in England and Wales.
  • London had the highest age-standardised mortality rate with 85.7 deaths per 100,000 persons involving COVID-19; this was statistically significantly higher than any other region and almost double the next highest rate.
  • The local authorities with the highest age-standardised mortality rates for deaths involving COVID-19 were all London Boroughs; Newham had the highest age-standardised rate with 144.3 deaths per 100,000 population followed by Brent with a rate of 141.5 deaths per 100,000 population and Hackney with a rate of 127.4 deaths per 100,000 population.
  • The age-standardised mortality rate of deaths involving COVID-19 in the most deprived areas of England was 55.1 deaths per 100,000 population compared with 25.3 deaths per 100,000 population in the least deprived areas
  • In Wales, the most deprived areas had a mortality rate for deaths involving COVID-19 of 44.6 deaths per 100,000 population, almost twice as high as the least deprived area of 23.2 deaths per 100,000 population.

On average the most deprived areas of the country had more than double the death rate than people in the least deprived areas. In the MS Academy webinar on Wednesday on ‘Preparing to get COVID-19’, I said there was nothing you could do about poverty or your level of deprivation in the short term, but maybe this is the wrong attitude to have. Although inequality is political and something the government needs to challenge with legislation there are lots of things we as individuals can do to tackle the problem.

To tackle inequality and its effect we need to start locally. Be mindful of its presence and how it impacts on health. Try to invest in local community projects and make everyone feel part of a community. It is remarkable to see how this is happening on such a large scale across the country in response to COVID-19. We need to make sure it continues post-COVID-19. We now realise the value of community that goes beyond the GDP of the country. Community and looking after each other and the health benefits of doing so are much more valuable than GDP.

As part of our ‘Raising the Bar‘ initiative, I am co-leading the workstream with Dr Helen Ford (Leeds) on the Social Determinants of Health and how they impact on the treatment and outcomes for pwMS. Our motto is that ‘no patient with MS should be left behind’. We have some interesting ideas that we are exploring with the wider MS community and would appreciate any input and help from you. The one that worries me the most at the moment is food security. We know that many pwMS in the UK are poor and many have problems paying for food and that the COVID-19 epidemic has exacerbated this. So if you know someone in your community with MS who is vulnerable please drop them a line and simply ask is there anything you can do to help. A friendly voice or helping with a food parcel delivery from the local food bank may be all that is required.

We have a grant application being processed at the moment to try and get an online platform set-up to help pwMS, who are part of Barts-MS, connect in a meaningful and helpful way. When I look at the statistics of COVID-19 from our local Burroughs we need this to happen sooner rather than later. 

When the dust settles post-COVID-19 I suspect that high-income countries with the greatest inequality will have the highest per capita death rates. At the moment it looks like the US and the UK are heading for the top of the leaderboard and it comes as no surprise that the US and UK have relatively high Gini* indices compared to other high-income countries.

Some pundits argue that the relatively poor response of the UK and US to COVID-19 has more do with our slow response and preparation, despite knowing that a SARS pandemic was likely in the near future. Others argue is that it relates to our partisan political systems and that other democratic system, for example in most of Europe,  make for less combative politics and a more common-sense consensus that is responsive to the needs of the people rather than vested interest groups. Whatever the reason or reasons for the lacklustre response of the UK compared to other European countries to COVID-19 we are going to have to make sure we become a more compassionate society post-COVID-19 and aspire to be a more inclusive society.  Do you agree?

* The Gini index or coefficient is a measure of the income or wealth distribution of a nation’s people and is the most commonly used measurement of inequality. A Gini index of zero is perfect equality where everyone has the same income. A Gini index of one (or 100%) represents maximal inequality where only one person has all the income or consumption, and all others have none. 

CoI: none

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

20 comments

  • These areas in London are highly populated, families, sometimes large families living in small flats in blocks, social distancing must be very hard.

    Also those living in HMO’s, must find it hard to have enough safe personal space. Sharing kitchens and bathrooms. I lived in a HMO once, it had one bathroom containing the only toilet, for 4 residents to use.

    • Thanks for the insight, but this highlights why the lived-environment in deprived areas explains the high infection and death rate. This is no different to what happened in the plague.

      • I grew up in Hackney when it really was deprived. There was no disability discrimination act, I couldn’t get a hospital appointment for an MS diagnosis, hardly any charities around to help the poor. Now Hackney has gentrified and people may see residents being deprived. In the three boroughs you mention, there are multigenerational households not necessarily due to being poor, but because BAME residents tend to stay close to their families and tend to care for their elderly. This is cultural and they have a rich source of closeness. If you look to the suburbs you will see wealthy BAME families living together. There are very vulnerable people living with relatives that are still essential workers. You could be living on the streets and still die in the Royal Free Hospital in Hampstead. Look around the ethnic grocers provide fresh fruit and veg, much cheaper than supermarkets. My friend from a BAME background sadly passed away recently not from Covid. The borough she lived in is classed as deprived, but she had a good job and owned her own lovely home. She died in a hospital in another borough. So I hope when the epidemiologists look at this, it’s not based on prejudiced assumptions.

  • I live in Haringey, in a very deprived ward. However there are also a lot of people like me – middle class, middle income, often working in the public sector who live here because it’s the closest to our work in central London that we can afford to live.

    I have a masters degree in Food Policy from City University and wrote my dissertation on household food security in the UK. I work for a local authority but have been excluded from the covid-19 redeployment pool due to my MS. Other colleagues are working to get emergency food parcels to people who need them.

    Enter the wonderful community I live in. I have been able to turn my skills to helping set up a food co op locally. The first day was yesterday. People subscribe to a veg box, we order and sort the vegetables, and any extra cash goes towards a few extra boxes to those in need in our neighbourhood (whether boxes or donating vegetables to community cooking schemes making meals for vulnerable people).

    The first day was yesterday and we will expand the scheme next week.

  • Add to the ‘combative’ approach what has been done to working conditions in the UK. Gordon Brown’s raid on pensions has at a stroke created incredibly damaging long-term uncertainty for much of the working population. The only secure pensions are in the public sector, but everyone working in health, education, social services, the police etc. pays for them in blood. Micro-management led by well-nigh impossible government targets make ongoing worker stress, workplace bullying and poor mental health a fact of life. And the legacy of Thatcher’s Britain is that the safety nets of council housing and regulated services such as Fire and Rescue are gone, ensuring that the poor will always be at the mercy of market forces – think Grenfell Towers.. The wonder is that the NHS has somehow survived and I just hope that the scars on society left by the pandemic run so deep that no politician will again dare to tamper and tinker. I believe an old Chinese curse is: ‘May you live in interesting times’…

  • Whatever the reason or reasons for the lacklustre response of the UK compared to other European countries to COVID-19 we are going to have to make sure we become a more compassionate society post-COVID-19 and aspire to be a more inclusive society. Do you agree?

    I haven’t a clue what this means. Probably a cut and paste from an article written by a Guardian journalist in their flat in Notting Hill.

    Sounds like you want a society where everyone earns the same wage, everyone lives in the same size house and everyone wears the same clothes.

    Let’s imagine I’ve just arrived on the Kent coast on a small boat with my four children. I’m escaping Afghanistan (for whatever reason), I speak no English and have limited job skills. I eventually arrive in Tower Hamlets. What do you think I am entitled to? A detached house? Benefits of £50,000? Free healthcare, education…. ? Would you be happy if the state paid for the rent for all of us to live next door to you in leafy Clapham? Would you mind if we tagged along when you next dine at The Ivy? Are you prepared to pay 90% tax to pay for this utopian society? Would you be happy to be paid the same salary as a nurse? Would your next trip to the theatre feel the same if the row behind you was occupied by a group of tattooed oiks, swearing, eating cheese and onion crisps and watching TikTok videos on their phones? How inclusive do you want to be? Be careful what you wish for.

    • Let’s start with food, education, the lived environment and health services. The rest will fall into place.

      For example, one of my east-end patients with SPMS lives on the third floor of a tower block. She is dirt poor and eats a tea-and-toast diet. She is too scared to leave her flat and gets about maybe once a month. She is lonely and socially-isolated. Her daughter and grand-daughter live in the midlands and she sees them may once or twice a year. This is what I am talking about; existence on the edge. We need to start small and local.

      • All children get an education. The inequality come from having a private system alongside the state system. The private school system has privileges beyond just small classes and nice skiing trips – most doctors, journalists and lawyers are privately schooled. It’s all about connections and the old school tie network.

        https://www.businessinsider.com/most-uk-journalists-doctors-barristers-private-schools-2017-7

        Most of the Cabinet are ex private school. Even your hero Mr Corbyn was privately educated. Would you support the state taking over private schools so that all children got the same quality of education? This would be the real leveller but the establishment (politicians, journalists, BBC, law, medicine, military) would never allow it.

        COI none – went to a state comprehensive school

        • I went to a private school but my marks were good enough to get into a good single sex state school. I think the outcome would have been the same for me, I just would have started working life with less student debt.

      • My friends all lived in tower blocks not far from the London hospital. We went to an inner city comprehensive. No privileged upbringing some extremely poor. Ended up teachers, scientists, nurses etc. I don’t remember classes being separated by rich and poor. Yes I’ve been there with not enough money to eat.

  • The mainstream media has a lot to answer for in all this. Journalists who simply summarise Government policy without analysing it and subjecting it to proper scrutiny, newspapers which reinforce negative stereotypes of people without employment and dependent on benefits as lazy and even corrupt, an increasingly disproportionate number of members of the media coming from the priviledged classes. It all ensures that the inequalities of the status co are perpetuated. Wish there was an easy way to change this.

  • Are the death rates from COVID-19 and poverty directly correlated? Countries with the highest populations and lowest GNPs, or lowest per capital income, would be expected to have the highest death rates. I suspect that sub-Saharan Africa, Latin America and S.E. Asia would be susceptible due to inadequate healthcare. How is it that the U.S. would have higher death rates from COVID-19 than : South Sudan, Niger, Malawi for example? From the Johns Hopkins COVID-19 website poor countries have very low death rates per 100k. Is this just a case of under reporting and inability to monitor patients?

  • If evidence was needed that deeply-rooted nastiness is embedded in Whitehall look no further than the changed face of the benefit claims system. We have moved from DLA, which was based on professional judgements of clinicians to PIP, where the decision-makers are outsourced, paid by results i.e. reducing claims paid. It was accepted as ‘modernising and ‘simplifying’ by society – as has been said, convinced by the media of massive fraud inherent in the system. In fact, DLA fraud has since been calculated at .05% and now the number of appeals after flawed PIP judgements is so great that govt has been forced to admit that the promised savings to the system overall have not happened. The Panorama documentary exposed the mindset of some working in DWP, truly shocking….. but not as shocking as a political system that set this up. It would have been more honest for the government to come clean and admit it couldn’t afford the bill – perhaps means-test everything rather than stigmatise the disabled and vulnerable as scroungers.

  • These stats are deaths in a hospital, not a care home or at home or in the community, from what I understand. I wonder about this, and population age in these parts of London, perhaps the Covid-19 patients are slightly younger here, than other parts of the UK, they may not be care home residents, and pass away in hospital, where numbers have been recorded .

  • Hi Prof G,

    This was a really helpful video and I learnt a lot from watching it all. Thank you for this.

    BW,

    F

  • Where do you start?

    I think that we need to use this as an opportunity to reset our society.

    The big problem with the far left ideas above is that you pretend that they are new ideas. I see a media, TV, movies & music that has pushed these ideas for decades. I don’t see them working so far. I don’t agree that poverty is a political issue – it is an issue of self reliance.

  • Re. Mental health. There’s several telephone help lines open during the Covid-19 outbreak:

    Samaritans, Mind, Rethink, and Shout.

  • For those who are too shy to sing, the vocal warm up exercises are fun to do. Lots of five or ten minute YouTube videos are available, on vocal warm ups.

  • In this country there two serious contributors to social and economic poverty, private schools and a first past the election system. They are both very divisive. Eliminate those and many problems will disappear within a generstion.

By Prof G

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