The Office for National Statistics (ONS) has released new statistics on deaths involving COVID-19 by local area and socioeconomic deprivation.
Prof Dave Gordon, Director of the Bristol Poverty Institute and Director of the Townsend Centre for International Poverty Research, University of Bristol, said:
“There are a range of reasons why the death rates in the 30% of the most deprived areas are more than twice as high as in the richest areas. Firstly, people in poorer areas are more likely to get a Covid-19 infection. They are more likely to be key workers (for example, care assistants, shop assistants, building workers, bus drivers, delivery drivers, etc) so they are more likely to come into contact with infected people than their peers in richer areas who may be able to work from their homes. Many key worker jobs are low paid and therefore these key workers often live in deprived areas. People in deprived areas are more likely to have to rely on public transport than people in richer areas and thus come into contact with infectious people. They are also more likely to have worse internet connections and not be able to afford the premium on grocery home delivery services so will need to go out to shop for food more often than than people in richer areas. Deprived areas tend to have higher population densities than richer areas therefore people in these areas are more likely to have contact with an infected person when they leave their homes for exercise, medical care, food shopping, etc. The higher the population density the more difficult maintaining social distancing is likely to be.
“Secondly, people in poor areas who have a Covid-19 infection are more likely to die. There is a higher risk of severe disease and death from a Covid-19 infection if you have underlying health condition such as hypertension, diabetes, cardiovascular disease, chronic respiratory disease and cancer. People in deprived areas are more likely to suffer from these particular underlying health conditions than people in richer areas, for a range of reasons, such as greater pollution levels, greater stress levels, greater inflammation levels, greater risk of H. Piori infections in childhood, etc. The Inverse Care Law unfortunately still affects the NHS in the UK – the quality of health care is inversely related to health need i.e. deprived areas on average have worse health care than richer areas.
“It is very disappointing but not surprising that more people are dying of Covid-19 infections in deprived areas, given the reasons listed above. However, what is a surprise is that the inequality in death rates between richer and poorer areas from Covid-19 are so much greater than deaths from other causes. In the most deprived 30% of areas people are more than twice as likely to die from Covid-19 infections compared with people in the richest 10% of areas in both England and in Wales – so this is not just a ‘London effect’. So far the Public Health response to the pandemic has not targeted or tried to shelter people living in deprived areas – this is clearly needed given these new ONS statistics.
“These data tell us about death rates from Covid-19 by area deprivation level but they do not tell us who is dying in these ‘poor’ and ‘rich’ areas. The assumption is that poor people are more likely to die of Covid-19 than rich people but these data do not prove this. They of course also do not tell us why there are much higher death rates in poorer areas but we can make an educated guess as to the causes.”
Prof Noel McCarthy, Warwick Medical School, said:
“This pattern is likely to be influenced by a range of factors. Certainly the circulation of infection, which is higher in densely populated urban areas could contribute. Deprived populations live, on average, more in urban than in rural areas. This likely means that they are more likely to have been infected due to their urban setting independently of deprivation. London, the midlands and urban parts of the North West had higher levels of infection contrasting with, for example the South West. There may also be a higher risk of spread among deprived populations linked to deprivation. The intensity of spread is likely to be higher in crowded households as one mechanism. Additionally, staff in many public facing frontline activities, in particular social care, are relatively poorly paid. This increases the risk of exposure to infection outside the home affecting the risk for all in that household.
“On average deprived populations have a higher proportion of minority ethnic members. The unexplained increase in poor outcome among these groups will contribute to an analysis looking at rates linked to deprivation that does not take account of the ethnic mix in each area.
“Lastly there may be additional effects of social deprivation on the risk of mortality following infection, although it is not possible to tell this from these data and analyses. This is because, firstly, it is not possible to separate increased risk of infection and increased risk of death following infection in these data, and secondly the potentially important role of ethnicity in generating these patterns cannot be separated. Further analyses including ethnicity and accurate estimates of the different rates of infection across the UK would be needed to estimate any risk directly produced by deprivation itself.”
Prof Keith Neal, Emeritus Professor of the Epidemiology of Infectious Diseases, University of Nottingham, said:
“Higher rates in deprived areas are not surprising given that known risk factors for more severe COVID-19 disease are more common in these areas. Greater population density could also be expected to contribute. Because it is age standardised the younger population of London has been factored into the analysis.
“Two of the other stand out features of the report are figure 2 showing how London is much more severely affected than other regions and figure 6 how rates are correlated with population density. Population density is a well-recognised association with the spread of respiratory pathogens.
“The epidemic may have started earlier in London than other parts of the country and if so it would mean the epidemic was more widespread prior to control measures which could also be a factor in more deaths in London.
“This work has major potential implications for lifting restrictions in non-conurbations before conurbations (major urban areas).”
Prof Carl Heneghan, Director of the Centre for Evidence-Based Medicine, and Professor of Evidence-Based Medicine, University of Oxford, said:
“Today’s figures show deprived areas have double the mortality rates for COVID-19 further signifying the strong link between deprivation and premature mortality.
“In 2017, for instance, 16% of premature male deaths in England were in the most deprived areas, compared with 6% in the least deprived. 
“Concentrated areas of high poverty that include Newham, Hackney and Brent, the areas most affected by COVID, have higher rates of non-communicable disease such as cardiovascular disease  that increase the risk of severe illness and deaths from COVID-19. These areas also suffer from poor housing, nutrition & higher incidence of health conditions that might act to lower immunity. ”
Prof Sarah Harper, Clore Professor of Gerontology, University of Oxford, said:
“We know that not only are mortality rates higher in the more deprived areas of the UK than the less, but also that morbidity – or ill health – is generally higher as well. Given that COVID19 mortality seems to be associated with underlying health issues it is therefore not an unlikely assumption that this might lead to higher death rates in these areas.
“There are various reasons for these high levels of morbidity or ill health which are complex but seem related to environmental or life course factors such as stress, diet, smoking, exercise, education and mental wellbeing, for example. These are in turn often related to economic factors, such as poverty.
“However this is likely to be but one of several factors, and factors such as access to health services both before the pandemic as well as now might also play a part – though we really need to collect good data before we make that assumption.”
“I cannot comment on the role of ethnicity as there is no information about the ethnic breakdown. This may of course have an influence, due to the concentrations of BAME populations in our deprived areas. But my view at this stage is that we do not have sufficiently robust data nor understanding on this factor.”
Dr Tom Wingfield, Senior Clinical Lecturer and Honorary Consultant Physician, Liverpool School of Tropical Medicine, said:
“It has long been recognised that poverty is associated with difficulties accessing healthcare services and poor health. In turn, poor health can further compound poverty, sometimes through disability and loss of work. This vicious cycle is referred to as the “health-poverty” or “medical-poverty” trap. The health-poverty trap is exhibited in diseases such as diabetes, ischaemic heart disease, and chronic lung disease, and also in infections including tuberculosis and pneumonia.
“Sadly, it appears that Covid-19 is no exception. The ONS analysis shows that Covid-19 looks to have a greater impact on poorer people: rates of death from Covid-19 are higher in more deprived areas of the UK. Although evidence is still emerging, it is highly likely that these findings will be replicated in other settings, especially low- and middle-income countries.
“We can’t allow this to continue. It is vital that we address the social determinants and consequences of illness, including Covid-19, and reduce the horrifying inequities that exist in our society in the UK and beyond. This will only be achieved by a concerted approach that targets the root causes of these social ills: reducing poverty, closing the gap between the rich and poor, providing universal healthcare and basic education, ensuring we are all fed and well nourished, and guaranteeing social protection for all those in need in times of sickness or unemployment.”
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