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Cited by 2,079Health disparities and outcomesEmployment and Welfare StudiesGlobal Public Health Policies and Epidemiology

The COVID-19 pandemic and health inequalities

Open access
Bambra, Clare, Riordan, Ryan, Ford, John, Matthews, Fiona·2020·Journal of Epidemiology and Community Health
DOI 10.1136/jech-2020-214401PMC PMC7298201
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Abstract

This essay examines the implications of the COVID-19 pandemic for health inequalities. It outlines historical and contemporary evidence of inequalities in pandemics—drawing on international research into the Spanish influenza pandemic of 1918, the H1N1 outbreak of 2009 and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates. It then examines how these inequalities in COVID-19 are related to existing inequalities in chronic diseases and the social determinants of health, arguing that we are experiencing a syndemic pandemic . It then explores the potential consequences for health inequalities of the lockdown measures implemented internationally as a response to the COVID-19 pandemic, focusing on the likely unequal impacts of the economic crisis. The essay concludes by reflecting on the longer-term public health policy responses needed to ensure that the COVID-19 pandemic does not increase health inequalities for future generations.

Integrity signals

Registry

Crossref · 10.1136/jech-2020-214401

Cites

50 of 50 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

17 of 50 cited sources checked · 6 supported · 1 flagged · accuracy not yet measured

  • Premisecitation

    Access to healthcare is lower in disadvantaged and marginalised communities, even in universal healthcare systems.

    “Similarly, access to healthcare is lower in disadvantaged and marginalised communities-even in universal healthcare systems.32”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [32] Todd A , Copeland A , Kasim A , et al. Access all areas? An area-level analysis of the relationship between community pharmacy and primary care distribution, urbanity and social deprivation in England. BMJ Open 2015;5:e007328. doi: 10.1136/bmjopen-2014-007328 source

      The Conclusions (page unavailable) report the opposite pattern for the access this study measured: a higher proportion of people in England’s most deprived areas live within a 20-minute walk of a GP premises. The Discussion’s principal findings likewise say GP-premises accessibility was highest in the most deprived areas. The paper measures proximity to GP premises and pharmacies, not healthcare access in general or access among all marginalised communities. (LLM, conf=0.87)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
  • Premisecitation

    In the 1918 pandemic across Sweden, there were inequalities in mortality between the highest and lowest occupational classes, particularly among men.

    “and across Sweden, there were inequalities in mortality between the highest and lowest occupational classes -particularly among men.7”
    Quote in the paperNot a substantial claim1 of 1 sources checked
  • Premisecitation

    In the 1918 pandemic, countries with smaller pre-existing social and economic inequalities, such as New Zealand, did not experience any socio-economic inequalities in mortality.

    “In contrast, countries with smaller pre-existing social and economic inequalities, such as New Zealand, did not experience any socio-economic inequalities in mortality.8 9”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [8] Rice G , Bryder L . Black november: the 1918 influenza pandemic in New Zealand . Christchurch: Canterbury University Press, 2005.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [9] source

      The Results (Univariate results, page unavailable) show no significant trend in mortality risk by occupational class among New Zealand military personnel; the paper also reports no significant occupational-class association in its fully adjusted model. But it does not establish that New Zealand had smaller pre-existing social and economic inequalities or that the country experienced no socioeconomic inequalities in pandemic mortality. The study was restricted to New Zealand military personnel in the Northern Hemisphere, so the claim generalizes beyond its population. (LLM, conf=0.87)

      Experimental — accuracy not yet measured
  • Premisecitation

    In the USA, financial issues were positively associated with influenza-like illnesses during the 2009 H1N1 pandemic.

    “Another study found positive associations between people with financial issues (eg, financial barriers to healthcare access) and influenza-like illnesses during the 2009 H1N1 pandemic in the USA.15”
    Quote in the paperNot a substantial claim1 of 1 sources checked
  • Premisecitation

    In the 2009 H1N1 pandemic, Mexico experienced a higher mortality rate than higher-income countries.

    “For example, globally, Mexico experienced a higher mortality rate than that in higher-income countries.12”
    Quote in the paperNot a substantial claim1 of 1 sources checked
  • May combine two claims. 21
  • Classified as probably not a substantial claim. 2

  • May combine two claims.

    Premisecitation

    Housing impacts health inequalities materially through costs and psychosocially through insecurity.

    “Housing also impacts health inequalities materially through costs (eg, as a result of high rents) and psychosocially through insecurity (eg, short-term leases).34”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [34] source

      The Introduction (page unavailable) says housing tenure may affect health psychosocially: home ownership may provide greater security than renting, while debt may cause anxiety. It does not identify high rents as a material pathway or short-term leases as the source of insecurity, and it qualifies the tenure effect rather than asserting it outright. (LLM, conf=0.84)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Poor quality housing is associated with health outcomes; 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.

    “For example, 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.34”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [34] source

      The Introduction says cold and damp housing may cause or exacerbate respiratory conditions, and that some housing-related hazards can cause injuries. The Results identify overcrowding as a housing-risk category, but the passages do not link it specifically to higher infection rates or household-accident injuries. The paper also does not specifically identify asthma as an outcome of damp housing. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the USA, inequalities in premature mortality and infant mortality by income and ethnicity decreased during welfare expansion (1966-1980) and increased during Reagan-Bush period (1980-2002).

    “For example, inequalities in premature mortality and infant mortality by income and ethnicity in the USA decreased during the period of welfare expansion in the USA ('war on poverty' era 1966 to 1980), but they increased again during the Reagan-Bush period (1980-2002) when welfare services and healthcare coverage were cut.46”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [46] source

      The ‘Post-treatment reduction of clinical risk’ and ‘Duration of Follow-Up’ sections discuss antimalarial treatment trials, not US mortality inequalities. Searches for premature and infant mortality by income and ethnicity, the war on poverty, and the Reagan–Bush period found no passage addressing the claimed trends. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Before COVID-19, life expectancy among poorest groups was declining in UK and USA, and health inequalities in some European countries were increasing over last decade.

    “COVID-19 has laid bare our longstanding social, economic and political inequalities -even before the COVID-19 pandemic, life expectancy amongst the poorest groups was already declining in the UK and the USA and health inequalities in some European countries have been increasing over the last decade.50”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [50] Forster T , Kentikelenis A , Bambra C . Health inequalities in Europe: setting the stage for progressive policy action, Foundation for European Progressive Studies and the Think Tank for Action on Social Change (TASC). 2018. Available https://www.feps-europe.eu/component/attachments/attachments.html?task=attachment&id=168 source

      The “Healthier but Still Unequal” section (page not provided) reports widening life-expectancy gaps in Denmark and in England between 2010 and 2015, supporting the claim that health inequalities increased in some European countries before COVID-19. It does not establish that life expectancy itself declined among the poorest groups in the UK or USA; the search for that claim found no such passage. (LLM, conf=0.88)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    In the 1918 Spanish influenza pandemic, there were inequalities in prevalence and mortality rates between high-income and low-income countries, more and less affluent neighbourhoods, higher and lower socio-economic groups, and urban and rural areas.

    “The international literature demonstrates that there were inequalities in prevalence and mortality rates: between high-income and low-income countries, more and less affluent neighbourhoods, higher and lower socio-economic groups, and urban and rural areas.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    After the GFC, UK areas with higher unemployment had greater increases in suicide rates; inequalities in mental health increased with most deprived experiencing largest increases in psychiatric morbidity and self-harm.

    “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.43”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [43] source

  • May combine two claims.

    Premisenone given

    The COVID-19 pandemic is occurring against a backdrop of social and economic inequalities in existing non-communicable diseases (NCDs) as well as inequalities in the social determinants of health.

    “The COVID-19 pandemic is occurring against a backdrop of social and economic inequalities in existing non-communicable diseases (NCDs) as well as inequalities in the social determinants of health.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    In England and Wales, BAME people accounted for 34.5% of 4873 critically ill COVID-19 patients (ending April 16, 2020), higher than the 11.5% seen for viral pneumonia between 2017 and 2019.

    “With regard to ethnic inequalities in COVID-19, data from England and Wales have found that people who are black, Asian and minority ethnic (BAME) accounted for 34.5% of 4873 critically ill COVID-19 patients (in the period ending April 16, 2020) and much higher than the 11.5% seen for viral pneumonia between 2017 and 2019.20”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] Intensive Care National Audit and Research Centre . Report on COVID-19 in critical care 17 April 2020 . London: Intensive Care National Audit and Research Centre, 2020.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • Rests on an assumption: 14% of the population of England and Wales are from BAME backgrounds.

  • May combine two claims.

    Premisecitation

    In Chicago (ending April 17, 2020), 59.2% of COVID-19 deaths were among black residents and the COVID-19 mortality rate for black Chicagoans was 34.8 per 100 000 compared to 8.2 per 100 000 among white residents.

    “For example, in Chicago (in the period ending April 17, 2020), 59.2% of COVID-19 deaths were among black residents and the COVID-19 mortality rate for black Chicagoans was 34.8 per 100 000 population compared to 8.2 per 100 000 population among white residents.21”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] Chicago Department of Public Health . COVID-19 death characteristics for Chicago residents. 2020. Available https://www.chicago.gov/city/en/sites/covid-19/home/latest-data.html (accessed 18 Apr 2020).

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    Lower-paid workers, particularly in the service sector, are more likely to be designated as key workers, required to go to work and rely on public transport, increasing their exposure to COVID-19.

    “For example, lower-paid workers (where BAME groups are disproportionately represented)-particularly in the service sector (eg, food, cleaning or delivery services)-are much more likely to be designated as key workers and thereby are still required to go to work and rely on public transport for doing so.All these increase their exposure to the virus.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    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.

    “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.35”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [35] source

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    People with existing chronic conditions are less likely to receive treatment and diagnosis as health services are overwhelmed by dealing with the pandemic.

    “People with existing chronic conditions (eg, cancer or cardiovascular disease (CVD)) are less likely to receive treatment and diagnosis as health services are overwhelmed by dealing with the pandemic.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The COVID-19 crisis will have huge economic, social and health consequences.

    “Just like the 1918 influenza pandemic (which had severe impacts on economic performance and increased poverty rates), the COVID-19 crisis will have huge economic, social and-ultimately-health consequences.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisereasoning

    Minority ethnic groups, people living in areas of higher socioeconomic deprivation, those in poverty and other marginalised groups generally have a greater number of coexisting NCDs, which are more severe and experienced at a younger age.

    “Minority ethnic groups, people living in areas of higher socioeconomic deprivation, those in poverty and other marginalised groups (such as homeless people, prisoners and street-based sex workers) generally have a greater number of coexisting NCDs, which are more severe and experienced at at a younger age.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    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.

    “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 (particularly in deprived urban areas) and lower access to communal green space.27”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [27] Bambra C . Health divides: where you live can kill you . Bristol: Policy Press, 2016.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Premisecitation

    Sudden economic shocks lead to increases in morbidity, mental ill health, suicide and death from alcohol and substance use.

    “Previous research has found that sudden economic shocks (like the collapse of communism in the early 1990s and the global financial crisis (GFC) of 2008 41 ) lead to increases in morbidity, mental ill health, suicide and death from alcohol and substance use.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [41] Stuckler D , Basu S . The body economic. why austerity kills . London: Thomas Allen, 2013.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationreasoning

    The health consequences of the COVID-19 economic crisis are likely to be unequally distributed, exacerbating health inequalities.

    “So, the health consequences of the COVID-19 economic crisis are likely to be similarly unequally distributed-exacerbating heath inequalities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The prevalence and severity of the COVID-19 pandemic is magnified because of the pre-existing epidemics of chronic disease, which are themselves socially patterned and associated with the social determinants of health.

    “The prevalence and severity of the COVID-19 pandemic is magnified because of the pre-existing epidemics of chronic disease-which are themselves socially patterned and associated with the social determinants of health.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    The Gypsy/Roma community has a smoking rate two to three times the European average and increased rates of respiratory diseases and other COVID-19 risk factors.

    “Similarly, the Gypsy/Roma community-one of the most marginalised minority groups in Europe-has a smoking rate that is two to three times the European average and increased rates of respiratory diseases (such as COPD) and other COVID-19 risk factors.29”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] European commission . Roma health report: health status of the Roma population in the member states of the European union . Brussels: European Commission, 2014.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationcitation

    These housing conditions will likely increase COVID-19 transmission rates, as was the case with H1N1 where strong associations were found with urbanity.

    “These will likely increase COVID-19 transmission rates-as was the case with H1N1 where strong associations were found with urbanity.13”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

  • Probably not a substantial claim: may not pass S4 (based).

    Premisereasoning

    Lockdowns have in common a significant increase in social isolation and confinement within the home and immediate neighbourhood.

    “These state-imposed restrictionsusually requiring the government to take on emergency powershave been implemented to varying levels of severity, but all have in common a significant increase in social isolation and confinement within the home and immediate neighbourhood.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Reduced access to healthcare contributes to inequalities in chronic disease and is likely to lead to worse outcomes from COVID-19 in more disadvantaged areas and marginalised communities.

    “This reduced access to healthcare-before and during the outbreak -contributes to inequalities in chronic disease and is also likely to lead to worse outcomes from COVID-19 in more disadvantaged areas and marginalised communities.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    There will likely be a post-COVID-19 global economic slump, which could worsen health equity, especially if austerity is implemented again.

    “It seems likely that there will be a post-COVID-19 global economic slumpwhich could make the health equity situation even worse, particularly if health-damaging policies of austerity are implemented again.”
    Quote in the paperSubstantial claim
23 of 23

  • The paper relies on this without support.

    14% of the population of England and Wales are from BAME backgrounds.

    “Only 14% of the population of England and Wales are from BAME backgrounds.”

  • The paper relies on this without support.

    Most countries failed to pursue traditional public health surveillance measures and were forced to implement lockdowns.

    “While traditional public health surveillance measures of contact tracing and individual quarantine were successfully pursued by some countries (most notably by South Korea and Germany) as a way of tackling the virus in the early stages, most other countries failed to do so, and governments worldwide were eventually forced to implement mass quarantine measures -in the form of lockdowns.”
2 of 2

Claims other papers make about this one

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Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Conclusion attributes 1918 inequalities to COVID-19

    Minor

    The conclusion says inequalities both then and now arose through COVID-19. Earlier, the paper identifies the historical inequalities as occurring during the 1918 Spanish influenza pandemic, not the COVID-19 pandemic.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Lacobucci G . GPs in deprived areas face severest pressures. BMJ . 2019;365:l2104.

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Authors
Bambra, C., Riordan, R., Ford, J., & Matthews, F.
Affiliations
  • Newcastle University (GB)
  • University of Cambridge (GB)
Corresponding author
Bambra, Clare
ORCID
Venue
Journal of Epidemiology and Community Health
Publisher
BMJ
Published
2020-06-13
Volume
74
Issue
11
Pages
964-968
ISSN
  • 0141-7681 (ISSN-L)
  • 0143-005X
  • 1470-2738
DOI
10.1136/jech-2020-214401
PMC
PMC7298201
OpenAlex
W3034285292
Cited by
2,079
References
48
Citations by year
2026: 136 · 2025: 161 · 2024: 278 · 2023: 353 · 2022: 515 · 2021: 462 · 2020: 79 · 2019: 1 · 2014: 1
FWCI
176.19
Type
journal article
Language
en
Open access
Licence
bmj.com/coronavirus/usage (tdm)
Locations
  • Journal of Epidemiology & Community Health (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (submittedVersion)
  • Repository@Hull (Worktribe) (University of Hull) (submittedVersion, cc-by)
  • HighWire Press Open Archive (submittedVersion)
Funders
National Institute for Health Research (NIHR200173)
Topics
  • Social Sciences › Health › Health disparities and outcomes
  • Health Sciences › Health Professions › General Health Professions › Employment and Welfare Studies
  • Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Global Public Health Policies and Epidemiology
Keywords
COVID-19 pandemic, health disparities, syndemic, social determinants of health, socioeconomic disparities, ethnic inequality, regional disparities, economic impact of lockdown
MeSH terms
Betacoronavirus, COVID-19, SARS-CoV-2, Humans, Pneumonia, Viral, Socioeconomic Factors

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