by Katherine Smith
20th December 2021

In the six months since we published The Unequal Pandemic: COVID-19 and Health Inequalities, we have given over 40 talks on the topic. Interest has come not only from fellow academics but also from policy makers (including some in the US Senate and the Scottish Parliament), from medics, from public health advocates and graduate students.

We have presented the findings to audiences in Austria, Germany, Norway, Spain, Switzerland, and in multiple locations in the USA and the UK as well as, most recently, to the 10th Global Conference on Health Promotion. Given the importance of the topic, and how wide ranging readership has been, we felt it was essential to ensure the book was accessible to everyone. So we are delighted that the book has now become open access and freely available to all.

As we were writing the book, we could see media coverage of the pandemic beginning to shift from policy claims that we were ‘all in it together’ to concern about unequal morbidity and mortality rates and the unequal impacts of the policy responses (especially the ‘lockdowns’ that have occurred in many countries). These disparities were unsurprising to anyone familiar with health inequalities and the social determinants of health, or to those who had studied the unequal impact of historical pandemics such as the 1918 ‘Spanish flu’. However, the tragic toll of these inequalities, as well as the renewed public and policy interest, meant we felt it was essential to bring together emerging data and evidence to illustrate just how unequal, and unjust, the toll of the pandemic was. In so doing, our book dispels any myth that COVID-19 is an ‘equal opportunity’ disease and shows that, just as 100 years ago, the pandemic is experienced unequally across societies.

The book delves into international data and accounts, arguing that COVID-19 and inequality are a ‘syndemic’ in which pre-existing inequalities are worsening the impact of the pandemic, while many policy responses are exacerbating and deepening inequalities. In sum, we argue that three facts explain the unequal impact of the pandemic:

The pandemic kills unequally: COVID-19 deaths are twice as high in the most deprived neighbourhoods of England than in the most affluent, and infection rates are higher in the more deprived regions such as the north-east of England and in urban areas. There are also significant inequalities by ethnicity and race, with the mortality of ethnic minorities in the UK considerably higher than expected, and the death rates of black Americans in US cities such as Chicago far higher than for their white counterparts. This is because of the interaction of the pandemic with existing social, economic and health inequalities.

Pandemic policies are experienced unequally: the COVID-19 ‘lockdowns’ have resulted in a significant increase in social isolation and confinement within the home and immediate neighbourhood for an average of 10–12 weeks. The social and economic experiences of this lockdown are unequal, as lower-income workers are more likely to experience job and income loss, live in higher-risk urban and overcrowded environments, and have higher exposure to the virus by occupying key worker roles.

The pandemic impoverishes unequally: COVID-19 and the lockdowns have resulted in an unprecedented shock to the economy with widespread predictions of the worst recession for 300 years. This economic devastation is resulting in job losses, wage reductions, higher debt and more poverty, as well as increases in the ‘deaths of despair’. However, the social and geographical distribution of these economic impacts is unequal – with low-income workers, women and ethnic minorities bearing the brunt.

Crucially, we argue that these inequalities are political and not inevitable. The pandemic was a predictable (indeed, a predicted) event and its unequal effects could have been mitigated or avoided through better preparation. The original inequalities leading to these unequal impacts were a result of prior political choices, including choices around the design and accessibility of healthcare systems, social support systems, housing quality, employment regulations and the distribution of wealth. Once the pandemic hit, it was up to policy makers whether to prioritise addressing the unequal impacts of the pandemic or not. Governments responded differently and those countries with higher rates of social inequality and less generous social security systems are experiencing a more unequal pandemic.

In writing the book, it was sometimes hard not to feel despondent or angry as we encountered countless stories of tragedy and injustice, many of which could have been prevented with different policy decisions. Yet, as we looked across studies trying to assess the unfolding consequences of the pandemic, we were struck by the frequency with which researchers and journalists were arguing that there are also opportunities for progressive policy change. Hope can be difficult in times of darkness but it can also be a political act, enabling people to start to imagine a better future – a future with fewer inequalities and untimely deaths. With this in mind, we close the book by outlining five reasons to be hopeful:

1. In opening the door to economic policies that had previously been ‘off the table’, the pandemic might pave the way for more progressive economic reforms.

2. In the context of concern that we had entered a ‘post-truth’ era, the emphasis now being placed on scientific expertise offers opportunities for ensuring that researchers and other academic experts can play a more meaningful role in social and policy debates.

3. Where public trust in policy declines, we may see efforts to rejuvenate democratic engagement via reforms and innovation.

4. There have already been some positive environmental impacts as air and car travel reduced, showing that we can make the kinds of changes needed to address climate change if we really want (or need) to.

5. Our global connections are highlighting the futility of inequalities (as I write this blog, the emergence of the omicron variant underlines the repeated warnings that ‘we are not safe until everyone is safe’).

Hoping, of course, is insufficient: we must act; but hope allows people to believe that a better future is possible. And this is a first step.

Katherine Smith is Professor of Public Health Policy at University of Strathclyde.


The Unequal Pandemic cover.The Unequal Pandemic: COVID-19 and Health Inequalities by Clare Bambra, Julia Lynch and Katherine E. Smith is available to order on the Policy Press website for £7.99 or  download free via OAPEN.

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