Avoiding a legacy of unequal non-communicable disease burden after the COVID-19 pandemic

2020 was a difficult year for health. The COVID-19 pandemic brought a widespread but deeply unequal health burden, etched along racial and ethnic lines, reflecting longstanding socioeconomic inequalities. As the pandemic swept the world, these inequalities became differences in exposure to the virus and differences in pre-existing non-communicable disease (NCD) burden associated with an increased risk of severe COVID-19. The confluence of these factors—the spread of a novel infectious agent, the prevalence of NCDs that exacerbated disease severity, and the patterns of social inequality underpinning both—have led to the apt description of COVID-19 as a syndemic.

When we speak of the unequal impact of the COVID-19 pandemic, we are usually referring to differences in COVID-19 outcomes. However, it is becoming increasingly clear that the inequitable health consequences of the pandemic run deeper than COVID-19-related morbidity and mortality alone. In the short-term, these have included non-COVID-19 mortality increases for heart disease, diabetes, and dementia,¹ substantial declines in mental health outcomes, particularly for those with the least assets,² and cancellations of elective surgeries, including those for urgent cancer care.

As we enter 2021, we are now facing the risk that the health inequities wrought by COVID-19 will have long-tail, greater consequences for the burden of NCDs for decades to come. COVID-19 was accompanied by a recession in many countries, occasioned by the economic fallout from the spread of the virus and efforts to contain it. This burden was not shared equally, and there is ample evidence that the COVID-19 recession has widened socioeconomic gaps.³

Since so much of health is socially determined, and the NCD burden is borne disproportionately by those with access to fewer salutary resources, the longer-term consequences of the pandemic on social inequality³ stand to lead to more NCDs among those groups already facing comparatively high levels of morbidity and mortality. In other words, social inequalities led to a disproportionate NCD burden that worsened COVID-19, and COVID-19 is worsening social inequalities that will, if we fail to act, lead to a greater and more disproportionate NCD burden. In some cases, policy choices might exacerbate these effects. Importantly, in the COVID-19 moment, vaccine distribution choices offer the opportunity to acknowledge these disparities by prioritising marginalised groups with higher COVID-19-relevant NCD comorbidity burdens, or risk disproportionately favouring high-income groups in better health within each age cohort.

The role of physical-distancing policies, particularly in their effects on unemployment and schooling, merit particular consideration in this regard. In the USA, the employment rate among high-wage (>US$60 000 per year) workers has largely recovered to pre-pandemic levels, while the rate among low-wage (<$27 000) workers remains 20% lower than in 2019.⁴ Involuntary job loss has been associated with a more than doubling of risk of subsequent stroke,⁵ a reduction in attendance for necessary medical examinations,⁶ and increasing levels of alcohol and substance abuse.⁷ These risks compound existing inequalities in health, as African Americans and Hispanic or Latino Americans, who already have shorter life expectancy and poorer population health overall due to longstanding socioeconomic disparities, are also overrepresented among the recently unemployed.

The disruption to education outcomes similarly exacerbates existing inequalities, with long-term implications for NCDs in particular. Students from Black, Hispanic, and Indigenous communities in the USA have disproportionately fallen behind in their academic achievement as a result of school closures.⁸ Participation in online maths coursework and documented student progress in maths are about 20% lower among low-income families compared with before the pandemic.⁴ Over the longer term, differences in educational attainment are associated with substantial differences in adult mortality.⁹ The European Centre for Disease Prevention and Control released a summary of the evidence on school closures, and, beyond disruptions in learning, notes a range of health impacts, disproportionately large for children who were already marginalised or vulnerable. These health impacts include increased anxiety and depression, increased risk of domestic violence, decreased nutrient intake, and increased food insecurity.¹⁰

These examples suggest that both the pandemic and some of the measures adopted to contain it are exacerbating future health inequalities and could increase NCD health gaps for years, and even decades, to come. COVID-19 has demonstrated both the crucial role of prevention, and, when prevention fails, the unacceptable high cost in lives and overburdened health systems that follows. How then do we act to prevent the long-term NCD-related consequences of the pandemic? We suggest that the moment calls for three approaches (panel ).

Panel. Recommendations for avoiding a legacy of unequal NCD burden from the COVID-19 pandemic.

• •Improve the use of data in monitoring and predicting the long-tail effects of social determinants on the prevalence of non-communicable diseases (NCDs)
• •Prioritise the health needs of marginalised groups on the basis of such data and predictions
• •Embed these insights in real-time decision-making and accountability frameworks to reduce the inequitable burden of NCDs

First, social inequality has been at the core of poor health pre-COVID, is reflected in inequalities in health outcomes during the pandemic, and will continue to be the driving force of NCDs in its wake. It therefore seems clear that the social determinants of health must be considered as foundational to NCD prevention and centrally embedded in government policy at all levels. This approach will require difficult decisions to be made that balance the urgency of managing COVID-19 with the importance of addressing the social determinants that will otherwise be exacerbated by it.

Second, we need access to better data to monitor the social determinants of health and their effects. Monitoring the changes in society and inequality that COVID-19 is exacerbating is a crucial means of predicting the downstream consequences for NCDs. This approach will require efforts at the intersection of data science and social determinants, including expansion of the definitions of health data to better include measures of social inequality, consideration of ways in which existing data are being underutilised, and the development of predictive models of future disease burden that take these data into account.

Third, these data must be embedded in real-time, accountable decision making that seeks to act to mitigate these disparities. The convergence of forces that constitute the social determinants of health requires a convergence of decision makers with a collective responsibility to reduce future health burdens, informed by data on the foundational causes of health. This approach will by necessity include honest interrogation of the decisions made now to mitigate the pandemic in ways that acknowledge the long-term consequences of worsening inequalities with respect to NCD burden.

The full burden of the COVID-19 pandemic remains to be revealed, but it is clear that the health burden of the pandemic is not being equally felt. Inequalities in NCD burden contributed to COVID-19 health inequities, and the consequences of efforts to mitigate COVID-19 stand to further widen NCD gaps. It falls to us as researchers and policy makers to act quickly to centre the role of social determinants in health production, through faster, more responsive data collection, and to use those data to inform decision making that aspires to narrow NCD health gaps in the years and decades to come.