By Sara Arber and Robert Meadows

There is a long tradition of studying class inequalities in health in the UK, from the 1980 Black Report (1) onwards, but to date there has been surprisingly little attention to class inequalities related to the coronavirus (CV-19). This blog outlines some of the ways that class is implicated in the initial spread of the virus. It also points towards likely longer-term implications in terms of greater inequalities in health both by class and between ‘rich’ and poorer countries.

Class inequalities in primary transmission of CV-19

The initial spread of CV-19 into western countries appears to have involved at least three class-related routes: (i) Business people travelling to work in China and then returning to their own countries; (ii) Infected business people and their families (or other relatives) travelling abroad for work or going on holiday to other countries, particularly to ski resorts in northern Italy, France and Austria; (iii) Cruise ship passengers. Individuals who represent these initial infection routes, the ‘seeds’ for CV-19 infection in western countries, were primarily middle or upper-middle class – those who travel abroad for work, and those with the financial resources to go skiing, holiday abroad, or have holidays on cruise ships.

Class inequalities in mortality among the ‘first wave’ with CV-19

Class therefore appears critical in terms of the characteristics of those initially infected with CV-19. There is also reason to suspect that class has a very different relationship to (i) the likelihood of getting appropriate medical care and recovering from CV-19 infection, and (ii) the characteristics of those who are subsequently infected with CV-19 in the ‘second’ wave.

Once infected with CV-19, individuals who recover may be more likely to be middle class or more affluent, particularly in more unequal societies and in poorer countries. This is for a number of reasons – including having the knowledge and ‘cultural capital’ to seek medical treatment at an appropriate time, and having the financial resources to get tested, access good healthcare facilities and receive appropriate treatment. The high death toll in Iran is likely to be disproportionately among the poorer classes, with government ministers, professionals and the middle class more likely to receive timely and adequate medical care. The authors are unaware of any studies examining class inequalities in recovery rates from CV-19 or any significant attempt to capture this data. This is a serious omission.

A key goal of the NHS is to provide equal care for all irrespective of class, gender, age and ethnicity. However, many countries have a division between private health care and usually much lower standard ‘public’ health care, such as the US and throughout the developing world. This is compounded in countries with health insurance systems and where poorer citizens are less able to afford health care insurance. Unlike in the UK and most of Europe, in countries with greater inequality in access to health care, there is likely to be much higher death rates among those with less financial resources and/or only access to public hospitals. We are ignorant at present about whether there will be class inequalities in the death rate among those currently infected with CV-19 in the UK, but we can be sure that class inequalities in mortality are likely to be considerably greater in many societies, such as the USA and in the developing world. However, the greatest class inequalities in CV-19 infection and mortality are likely yet to come.

Class inequalities in secondary transmission of CV-19 in the UK

As we enter the ‘delay’ phase, it is important to understand the characteristics of people most likely to be infected in the second wave of CV-19 infections. The primary UK advice for reducing the likelihood of infection in the UK is ‘self-isolation’, to ‘work from home’, ‘social distancing’ and restriction of social and other contacts (2). But, there are massive socio-economic inequalities in the ability to, and quality of life of people who, self-isolate.

Here socio-economic resources have a huge influence. It is obvious that having a larger house allows people to more effectively and easily self-isolate. Such people will not only have more rooms in which to spend the recommended weeks of ‘self-isolation’, but will also have more resources in the home, technology and equipment to occupy or ‘entertain’ themselves during the long periods of self-isolation. Whether or not you have a garden represents a fundamental class-divide in terms of being able to effectively self-isolate and still allow safe outdoor activity, exercise and sunlight – all things recommended as important by Public Health England (2). Resources that are taken for granted by many, such as having a large freezer, may be fundamental to the ability to ‘stock up’ on food and be able to effectively self-isolate. Similarly, having the financial resources to buy (or have already bought) bulk quantities of everyday food products to store is class-divided. Do we know whether there are class divides in those who now queue waiting for supermarkets to open or to restock?

‘Self-isolation’ is difficult for anyone, but those more likely to break the ‘self-isolation’ rules and thus become infected with CV-19 in the second phase are more likely to be socio-economically disadvantaged – people living in more cramped conditions, poorer quality housing and still needing to regularly go out for food stuffs. This is especially likely among the less advantaged living in inner cities. Indeed this may be the case for the ‘second hot spot’ of CV-14 deaths in the West Midlands (3) – an area with more disadvantaged communities (4).

Class differences in ‘working from home’ and impacts of school closures

Currently, working from home is recommended in the UK wherever possible, in order to reduce the likelihood of CV-19 infection. But the potential ability to ‘work from home’ varies enormously according to type of job, with those in managerial, administrative and office-based work more likely to have a job that is conducive to (or compatible with) the ability to ‘work from home’, than those working in manufacturing industries or skilled trades. However, the feasibility and effectiveness of ‘working from home’ also various directly with socio-economic factors associated with the size of house and facilities available in the home – whether there is a spare room or is ‘home working’ done on the kitchen table? As well as whether the household already has broadband, PCs, laptops, a printer and the other necessities for ‘home working’.

With the closing of schools and nurseries, except for children where both parents are defined as ‘key workers’, the ability to ‘work from home’ is compounded by having to look after children. This is obviously much more problematic in small houses/flats and where there is no garden.

The requirement for parents to look after children at home is going to be challenging for most parents, but this is especially so for parents with fewer socio-economic resources. The expectation of schools, who have sent parents suggested ‘online work’ in order to ‘home school’ their children, is predicated on the family having broadband and owning at least one (but preferably 2-3) computers and parents being digitally literate. A ‘digital divide’ already confronts many poorer families (5). Social inequalities between families will be further compounded as those with less digital literacy and equipment will have less ability to ‘home school’ their children, as well as being unable to purchase essentials online and benefit from online activities during self-isolation.

Thus, policies of ‘home working’, self-isolation, and home schooling for children are more problematic for socially disadvantaged groups, and for these groups may thus lead to greater social contact with others in the public sphere and higher rates of CV-19 infection.

The future global divide in CV-19 mortality?

The CV-19 pandemic began in China, and spread to western countries (particularly Europe and the USA) through the more geographically mobile middle and business classes. By mid-March, there were very low numbers of CV-19 infections and deaths in Africa, south America and other poorer countries (although numbers were growing). CV-19 infections to date have largely been the result of (ie seeded by) people travelling to these countries from Europe – whether for holidays, work, returning from education in the west, or involved in NGOs/charities – and who were carrying the CV-19 virus.

In these poorer countries, the societal implications of the CV-19 pandemic are likely to be even greater than in developed societies, such as Italy, Spain, and the UK. If the health care system in Italy and the UK ‘can’t cope’ with providing intensive care treatment for the seriously ill with CV-19, there is little hope that access to such intensive medical care will be available for the majority of the population in Africa or other poorer countries. Thus, the consequences of the pandemic will likely be many times graver for the global south, because of their lack of health care resources and personnel. This higher mortality rate will be compounded in many countries, especially in Africa, by the large number of people living with HIV or who are malnourished, both groups of whom are more likely to become seriously ill or die from CV-19 if they become infected.

The guidance to self-isolate in the UK and Europe, and which was mandatory and very effective in China, is likely to be impossible in poor countries, except among the wealthy elite. In Africa, many people live in shanty towns, do not have running water or latrines, therefore the ‘preventive’ measures of ‘self-isolation’, social distancing and to ‘wash your hands’ will be ludicrous. Therefore, we might expect CV-19 infections to spread faster and more lethally than in the west.

A sobering conclusion

We will not know for months, or perhaps years, how the mortality rates for CV-19 vary between classes (or ethnic groups) within countries, nor will we know the differences in mortality rates between countries. However, it seems likely that mortality rates in poorer countries will be much greater than in richer countries, often with devastating consequences.

It is a cruel irony that the initial spreaders (or seeds) of the CV-19 pandemic were business people and the affluent (in other words, the middle class), but that the greatest causalities of the pandemic will be the poor and disadvantaged in western countries, and especially the populations of poorer countries.

1. Townsend P. and Davidson N. (eds) 1982. Inequalities in Health: The Black Report, Penguin Books, Harmondsworth.
2. https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people (accessed 22.3.20)
3. https://www.thetimes.co.uk/article/covid-19-west-midlands-emerges-as-coronavirus-hotspot-hzpkf3fs2 (accessed 21st March 2020)
4. Jones, D., Lowe, P. and West, K., 2019. Austerity in a disadvantaged West Midlands neighbourhood: Everyday experiences of families and family support professionals. Critical Social Policy, p.0261018319840923. 5. Friemel, T.N., 2016. The digital divide has grown old: Determinants of a digital divide among seniors. New Media & Society, 18(2), pp.313-331.

Dr Sara Arber is Emeritus Professor of Sociology and Dr Robert Meadows is Reader in Sociology at the University of Surrey.

Please note: Blog entries reflect the personal views of contributors and are not moderated or edited before publication. However, we may make subsequent amendments to correct errors or inaccuracies.