Introduction This chapter examines the COVID-19 economic crisis, an economic shock of rare and extreme impact. COVID-19 has had a devastating impact on the world economy with huge reductions in productivity and national income, and record levels of unemployment (for example and 5.2 million people filed for unemployment benefit in just one week in April 2020 in the US). It is widely feared that the economic impact will be far greater than that of the global financial crisis of 2007/ 8, and that it is likely to be worse in depth than the Great Depression of the 1930s. Emerging contemporary data and research from previous recessions suggest that the economic fallout from the COVID-19 pandemic will have huge consequences for health and health inequalities. This chapter will provide an overview of the unequal impacts of COVID-19 in terms of the social and spatial distribution of the economic crisis. It will then use evidence from previous recessions (such as the global financial crisis of 2007/ 8) to explore the likely unequal health impacts and reflect on the role of social safety nets in preventing them.

An unequal crisis

The impact of COVID-19 on health inequalities will not just be in terms of virus-related infection and mortality, but also in terms of the health consequences of the policy responses undertaken in most countries. Traditional public health surveillance measures of contact tracing and individual quarantine were successfully pursued by some countries (most notably by Australia, South Korea and Germany) as a way of tackling the virus in the early stages. However, most other countries failed to employ this approach successfully, so governments worldwide were eventually forced to implement mass quarantine measures in the form of lockdowns and social distancing. These state-imposed restrictions, usually requiring the government to take on emergency powers, have 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.

Introduction

This book has documented the unequal impact of the COVID-19 pandemic. It has sought out the causes of the health inequalities that emerged from the pandemic, and located them in the syndemic of social inequality and the novel coronavirus. We have argued that the COVID-19 pandemic is unequal in four ways:

First, the pandemic is killing unequally (Chapter Two). In every country that has been affected by the pandemic, more people are ill, and there are more deaths from the disease, in the places where the most deprived people live. There are also significant inequalities across racial and ethnic groups. This is because of the interaction of the pandemic with existing social, economic and health inequalities.

Second, the pandemic is being experienced unequally (Chapter Three). Successive lockdowns designed to quickly halt the spread of COVID-19 when case numbers are rising rapidly have resulted in a significant increase in social isolation for nearly everyone; but the social and economic experiences of lockdowns have been unequal. Lower-income workers are more likely to experience job and income loss, live in higherrisk urban and overcrowded environments, and have higher exposure to the virus by occupying key worker roles.

Third, the pandemic is impoverishing unequally (Chapter Four). The pandemic has resulted in an unprecedented shock to the economy from which we have yet to emerge. Job losses, wage reductions, higher debt, and more poverty, as well as increases in the ‘deaths of despair’, are likely to follow, if previous economic downturns are any guide. However, the social and geographical distribution of these economic impacts will be unequal, with low-income workers, women and ethnic minorities once again bearing the brunt.

Fourth, the pandemic's inequalities are political (Chapter Five). The unequal impacts of COVID-19 were not inevitable: the pandemic was a predictable event, and the unequal effects could have been, and indeed in some countries were, mitigated or avoided through better preparation.

Introduction

In 1931 Edgar Sydenstricker identified inequalities in the 1918 Spanish flu epidemic, reporting a significantly higher incidence among the working classes. This challenged the widely-held popular, political and scientific consensus of the time that held ‘the flu hit the rich and the poor alike’. In the 2020 COVID-19 pandemic, there have been parallel claims made by politicians and the media: that we are ‘all in it together’ and that the COVID-19 virus ‘does not discriminate’. These claims fly in the face of the significant evidence that the pandemic does in fact kill unequally: COVID-19 deaths are twice as high in the most deprived neighbourhoods as in the most affluent; infection rates are higher in more deprived regions, among people with low incomes, and in urban compared to rural areas. There are also even more stark inequalities by ethnicity and race, with the death rates of minority ethnic communities in the UK, Canada and the US being more than twice as high as their majority White counterparts.

This chapter outlines these inequalities, drawing on historical and contemporary international evidence of inequalities in previous respiratory pandemics, ranging from the Spanish flu pandemic of 1918 to the H1N1 outbreak of 2009 and current estimates of social, ethnic and geographical inequalities in the COVID-19 pandemic. It also examines the causes of these inequalities in terms of the unequal burden of risk factors (such as diabetes and respiratory diseases) and the relationship to preexisting inequalities in the social determinants of health, arguing that COVID-19 is a syndemic pandemic. It concludes by reflecting on the longer-term implications of these health inequalities.

An unequal pandemic

In the very first stages of the pandemic (March to June 2020), it quickly became evident, from the experiences of a variety of countries, that there were significant social and ethnic inequalities in COVID-19 infections, symptom severity, hospitalisation and deaths.

COVID-19: the unequal pandemic

In December 2019, the first cases of an unusual ‘pneumonia’ were documented in the Chinese city of Wuhan. The novel disease, which seems to have jumped from an animal population into humans, was later named ‘SARS-CoV-2’ or ‘COVID-19’ (coronavirus disease 2019). The entire city of Wuhan, with a population over 11 million, was put under stringent quarantine by the Chinese government, with the lockdown eventually lasting 76 days. But by January 2020, the disease had spread to the US, Europe and the UK, and at the end of the month the World Health Organization (WHO) declared COVID-19 a ‘public health emergency of international concern’. By February, the first death attributed to coronavirus was reported outside of China, in the Philippines, and France announced the first coronavirus death in Europe. By the end of February, COVID-19 cases had been reported across all world regions and by mid-March, the epicenter of the COVID-19 pandemic had moved from China to Europe. By the end of March countries as varied as the UK, India, France and Norway had introduced emergency measures (social distancing and lockdowns) to try and contain the virus. The COVID-19 pandemic had begun.

COVID-19 is now a global phenomenon, affecting all parts of the world and all parts of society, radically altering how we live and interact. Everyone, from all walks of life, has been affected by the pandemic. But, as this book will show, some people have been – and will be – far more affected than others: COVID-19 is an unequal pandemic.

High-profile early cases of the virus included powerful and wealthy individuals such as Prince Charles, UK prime minister Boris Johnson, and Hollywood actor Tom Hanks. This gave the impression, often reinforced in claims made by politicians and the media, that when it came to COVID-19 we are ‘all in it together’, and that the COVID-19 virus ‘does not discriminate’. In one sense, this is true: the virus, once contracted, can bring serious illness or death no matter how wealthy or powerful the ‘host’.

In 1931 Edgar Sydenstricker identified inequalities in the 1918 Spanish flu epidemic, reporting a significantly higher incidence among the working classes. This challenged the widely-held popular, political and scientific consensus of the time that claimed ‘the flu hit the rich and the poor alike’. In the 2020 COVID-19 pandemic, there have been parallel claims made by politicians and the media: that we are ‘all in it together’ and that the COVID-19 virus ‘does not discriminate’.

This book aims to dispel the emerging myth of COVID-19 as an ‘equality of opportunity’ disease, by outlining how, just as 100 years ago, the pandemic is experienced unequally across society. COVID-19 and inequality are a syndemic: a perfect storm. Drawing on international data and accounts, the book will argue that the pandemic is unequal in four ways:

The pandemic kills unequally: COVID-19 deaths are twice as high in the most deprived neighbourhoods of England as in the most affluent; infection rates are higher in the more deprived regions, such as the northeast of England, and in urban compared to rural 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 are far higher than for their White counterparts. This is because of the interaction of the pandemic with existing social, economic and health inequalities.

The pandemic is 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 lowerincome 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.

Introduction

This chapter explores the ‘collateral damage’ caused by COVID-19 and subsequent policy responses designed to contain the spread of the virus. While Chapters One, Two and Four focus on some of the direct health and economic consequences of the pandemic, this chapter brings together evidence concerning the inequalities in the multitude of less direct impacts of lockdown policies, highlighting the complex interconnections between the pandemic and our lives: the syndemic pandemic. For the most part, these indirect impacts are, like the health and economic impacts, deeply concerning and unequally spread; those who are less well-off are also often less well protected and so bear the brunt of the ‘collateral damage’. However, as we will see in Chapter Six, there are also some glimmers of hope when it comes to considering the indirect impacts of the pandemic, especially when we consider potential coalitions for progressive change.

The chapter is organised around Figure 2.2, so it starts by considering the impacts that are most obviously related to health because they are most proximal (for example, the impacts on NCDs and other health conditions) and then moves out, through the various layers of the rainbow. It closes by considering the uncertainties around how the pandemic might reshape the macro-level political, economic and social conditions in which we live and work (a theme which is picked up again in Chapters Five and Six). Since the evidence on collateral damage is new and emergent, the geopolitical focus of the chapter is diverse, drawing in examples in ways that reflect this growing evidence base, though the UK (where a wealth of relevant research has already been published) features throughout.

It is necessary, therefore, to keep in mind the variations in policy responses across different contexts. While some countries (such as the UK) had repeated lockdowns in which people were asked to stay at home and in which schools and nurseries were closed (initially and subsequently en masse but with more sporadic closures in response to outbreaks in between), other countries (such as Sweden) took a more laissez-faire approach, merely restricting large public gatherings but keeping schools and childcare open.

Syndemic pandemic: black swan, white swan, or grey rhino?

In the second century CE, Roman poet Juvenal likened finding the perfect woman to seeing a black swan in the wild: both were considered so unlikely as to be impossible. But after Dutch navigator Willem de Vlamingh encountered a swan with all black feathers while exploring southwestern Australia in 1697, the black swan instead became a metaphor for erroneously assuming that something is impossible based on the limited facts at one's disposal – in this case, the observation that in Europe, all swans were white. By 2020, ‘black swan’ had come to symbolise for market investors an event with serious effects that is nevertheless so rare as to be unpredictable, based on the current state of knowledge. So when the Silicon Valley venture capital firm Sequoia Capital referred to the COVID-19 pandemic as a ‘black swan’ in a memo issued on 5 March 2020, everyone knew what they meant: something terrible and unpredictable had happened, and all we could do now was figure out how to deal with the consequences.

But, much like the actual black swan ‘discovered’ by Willem de Vlamingh, COVID-19 was quite predictable to those who were paying attention to all of the available facts. Scientists had been warning for decades that the combination of climate change and human encroachment on natural habitat made it not only possible but likely that a pandemic disease would cross over from an animal population to humans. The spread of SARS, MERS, Ebola, swine flu, avian flu and Zika should all have prepared us for this possibility. If anything, the COVID-19 pandemic was a white swan, not a black one.

The threat of growing inequities resulting from COVID-19, on the other hand, was more like a ‘gray rhino’, a metaphor coined by strategist Michele Wucker: that is, a threat that is predictable – not to say obvious – in light of existing warnings and visible evidence; is quite dangerous; and is also avoidable.