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Health inequalities, COVID-19 and healthcare professionals

Professor Sir Michael Marmot, director of the UCL Institute of Health Equity, reflects on the impact of the COVID-19 pandemic on health inequalities.

‘We have lost a decade. And it shows’ sums up my report Health equity in England: the Marmot review 10 years on, published in February 2020. The report examined progress in health and health inequalities in the 10 years since the publication of the Marmot Review, Fair society, healthy lives.

Three features of health in England on the eve of the pandemic gave cause for alarm. First, a slowing of the increase in life expectancy. For a century, life expectancy had been increasing by about 1 year every 4 years. This rate of increase slowed dramatically, beginning in 2010, and more or less ground to a halt. Second, there is a social gradient in health – the more deprived the area of residence the shorter the life expectancy. This gradient became steeper. Perhaps more importantly, years spent in ill-health went up, and the social gradient in disability-free life is even steeper than that for life expectancy. The increase in inequalities in life expectancy plays out regionally. For people living in neighbourhoods in the least deprived decile, there is little difference among regions of England, and life expectancy shows a modest increase. Particularly for women living in the poorest decile, there are large regional differences – lower life expectancy in the north compared with the south. For this poorest decile, life expectancy is rising in London and going down in virtually all other regions.

In the 2010 Marmot Review, we examined the evidence on causes of health inequalities as a basis for recommendations as to what to do. We took as an assumption that universal health coverage, via the NHS, was an accepted goal, and focused on the social determinants of health, summarising actions in the following six domains:

  • Give every child the best start in life
  • Education and life-long learning
  • Employment and working conditions
  • Having sufficient income to lead a healthy life
  • Healthy and sustainable communities
  • Taking a social determinants approach to prevention

Progress on most of these has stalled or gone into reverse since 2010. For example, child poverty has increased and spending on education per pupil has declined by 8%. The general policy context is that public expenditure has declined from 42% of GDP to 35%; and the cutbacks in spending by local government have been imposed in a regressive way: the more deprived the area the bigger the reduction.

Then comes COVID-19. Far from the great leveller, mortality from COVID-19 follows the social gradient. COVID-19, of course, is caused by a virus. But the ‘causes of the causes’ are the same social conditions that give rise to the social gradient in health, more generally. In addition, there are specific causes that amplify inequalities such as employment in frontline occupations and living in crowded multi-generational households. These last two, along with deprivation, account for much of the excess mortality from COVID-19 in groups from BAME backgrounds.

Healthcare professionals have a vital role to play in combating health inequalities, in addition to the essential provision of healthcare services. We have highlighted five activities related to the social determinants of health: education and training; seeing the patient in broader perspective; the health service as employer, and the role of anchor institutions; working in partnership; and advocacy.

As a new initiative, the Inequalities in Health Alliance has great potential to change the national conversation on health inequalities and lead to actions that will improve the lives people are able to lead and achieve a fairer distribution of health.


This blog post is part of a series published to mark the launch of the Inequalities in Health Alliance.