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.