Chronic disease, health equity and COVID-19

Chronic disease is driven – and made worse – by social and economic inequities; disadvantaged communities and groups experience higher rates of chronic disease and poorer health outcomes. Emerging evidence from the US, UK and China indicates that populations with a higher prevalence of chronic disease and associated risk factors such as tobacco smoking and obesity are also more likely to experience severe outcomes and death due to COVID-19. It suggests that chronic disease prevention and addressing health inequities must be a critical component in the post-pandemic response.

The coronavirus pandemic is a public health emergency for Australia and the world. This new strain of coronavirus, SARS-CoV-2, causes the disease known as COVID-19. This coronavirus is particularly concerning because it spreads easily, impacts significantly on the health system, and a vaccine is not currently available.

The coronavirus pandemic is also worrying because some populations have a greater risk of experiencing more severe illness from COVID-19. Much has been written about the risks from COVID-19 for older people. There is also is emerging evidence that people with chronic disease and associated risk factors are more likely to experience severe outcomes or death from COVID-19.

COVID-19 and chronic disease

The data emerging from countries such as China, Korea, Italy and the US suggests that chronic disease may be associated with more severe outcomes from COVID-19, though we note the full picture is still evolving. 

Evidence from China indicates that irrespective of age, a person with a chronic disease is at increased risk of dying from COVID-19. Similar evidence has come from an Italian study where half the patients who died of COVID-19 had hypertension. Another study from China found though 20% of admissions to hospital with COVID-19 were patients with a chronic disease, this group made up nearly 60% of those progressing to intensive care.

There is also emerging data about the major risk factors for chronic disease and the likelihood of experiencing more severe outcomes from COVID-19. Early reports from England and the USA suggest that obesity is a risk factor for severity of COVID-19 – even for younger populations. Smoking is also associated with COVID-19 severity.

Furthermore, public health emergencies like COVID-19 can exacerbate existing social and economic vulnerabilities and widen inequities in health. This has consequences for chronic disease prevention and management.

As researchers working in chronic disease, systems thinking and public health policy, we propose that reducing inequity and preventing chronic disease should inform our post-pandemic response in Australia.

Another kind of epidemic: inequities in health and chronic disease

Prior to the current pandemic of COVID-19 Australia was already experiencing a different type of epidemic – that of chronic disease. One in two Australians has a chronic disease or condition such as diabetes, cancer, asthma and cardiovascular disease. A third of our population is affected by obesity and 14% of Australian adults smoke daily. And while many prevention interventions are cost-effective only 1.3% of Australia’s health budget is invested in chronic disease prevention.

Chronic disease in Australia has a clear social gradient. Disadvantaged communities and groups experience much higher rates of chronic disease and poorer health outcomes. Australians living in the poorest suburbs experience the highest rates of obesity, diabetes, heart disease and other chronic conditions, as well as economic exclusion and social isolation.

While our effective public health response has meant that Australia’s COVID-19 rate is currently low, we remain concerned about the growing evidence that links chronic disease with worse outcomes from this coronavirus. For a significant proportion of the population, COVID-19 is already exacerbating existing health and economic inequalities.

Our post-pandemic response must include priority measures to alleviate the acute magnification of existing social and economic inequities, and to address the structural and systemic drivers of our underlying epidemic of inequities in health.

The 2008 Marmot Review sets out key areas for addressing inequities in the UK, and many of these policy priorities are relevant for an Australian context. By applying principles such as ‘proportionate universalism’ we can ensure all in the population will benefit, but with greater benefit for those experiencing greater disadvantage.

Our post-pandemic priorities must include alleviating poverty, social exclusion, low levels of education, poor housing, low levels of workforce participation and lack of access to services.

Retaining policy measures that address poverty, such as increasing Newstart (JobSeeker) is a promising action to address both acute and longer-term socio-economic disparities in Australia.

Other important policy measures include ensuring a fair and equitable education system for children and young people, particularly during times of crisis like COVID-19. This is important because lower levels of educational attainment are associated with increased risk for poor health such as cardiovascular disease.

The other key area in the Marmot Review is to strengthen and invest in prevention. Actions to promote health and prevent chronic disease require a systems approach that can have co-benefits for other areas of public policy. These actions include promoting healthier urban design with improved walkability, liveability and social engagement. COVID-19 has reminded us of the importance of investing in liveable neighbourhoods – but this needs sustained investment and planning by local, state and territory governments.

Prioritising healthy, equitable and sustainable food systems is another priority action for prevention. Policy measures include ensuring that fresh food and produce continue to be exempted from the GST. This is particularly important to help address problems such as food insecurity in Australia.

We also need to continue investing in health-promoting laws and regulations, such as tobacco taxes and warning labels. This is particularly important given that Australia’s smoking rates vary amongst different groups depending on level of disadvantage, and tobacco use still causes about 21,000 preventable deaths every year in Australia.

Reducing inequity and preventing chronic disease will not stop pandemics like COVID-19, but by addressing the inequities highlighted by COVID-19 we can build a healthy and fair Australia.

‘Chronic disease, health equity and COVID-19’ was published first by Intouch Public Health, 30 April 2020.