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Breaking the vicious cycle of inequalities

When the effect becomes the cause

Giulia Cesaroni

Department of Epidemiology Lazio Regional Healthcare Service, Rome 1 Local Health Authority (ASL)

By December 2020April 26th, 2022No Comments
Disuguaglianze socioeconomiche
Photo by Lorenzo De Simone

Despite the overall health improvement of these years, socioeconomic inequalities continue to exist in this area: health is directly proportional to social advantage. Inequalities emerge with the use of any social stratification indicator- the level of education, employment, income, household conditions and individual or multifactorial indicators from the area of residence.

Where we stand today

The health divide based on socioeconomic conditions is present everywhere- in the northern and southern parts of the world just like in the north and south of Italy. The difference in life expectancy at birth between the more and the less educated Italians ranges between two years and a half in Emilia-Romagna to three years and six months in regions like Friuli Venezia Giulia, Lazio and Campania. There is a lower gap among women but it is still there nonetheless.

Inequalities are present from the start, from birth. The babies of women with low socioeconomic conditions weigh a bit less than those of women with high social status- the comparison is between babies of the same sex, at the same week of gestation and with moms of the same age. There are differences in the state of health between those who are less/more educated, employed/unemployed and between the deprivation categories of the area of residence; they appear at all stages of life, with a peak during working age.

Low socioeconomic conditions are associated with a higher prevalence of harmful lifestyles, a higher prevalence of chronic and acute illnesses and even a higher mortality- the main indicator of the health condition of the population. As people grow older it is normal to have more than one chronic condition at the same time. A Scottish study that was published on the Lancet a few years ago showed that the onset of chronic conditions happens 10-15 years earlier in more deprived areas than it does in wealthier ones. There are inequalities also around access to services. Whenever there is a new treatment procedure the wealthier classes immediately benefit from it. In our country all treatments are part of the standard of care, which lessens the gap, thanks to our universalistic National Healthcare Service. Fortunately different studies reported that, despite the different incidence of the illnesses, once people access the Italian National Healthcare Service for treatment there are similar short to medium-term outcomes among the various social classes.

The Covid-19 syndemic

Much has been done- and still is- to fill the gap, but we are going through a crucial time: we are dealing with a crisis that almost makes us forget about the one in 2008. According to the ISTAT (the Italian National Statistical Institute) in the second trimester of 2020 there were 850,000 fewer workers- mostly young people and women- compared to the same trimester of 2019. The same Covid-19 pandemic impacted population groups differently. Those who are most disadvantaged have living and working conditions that do not allow for much distancing to take place. During lockdown I had the opportunity to speak with a doctor from the A&E that encouraged his wife and children to move to their seaside house because of the risk he was exposed to at work. How many people on a low income have the option to self-isolate and keep the distance in case of infection or suspected infection?

In Italy more than 35,600 people died because of Covid-19. The serious manifestation of the disease and its lethality were much greater in patients who also suffered from chronic conditions such as chronic obstructive pulmonary disease, diabetes or cardiovascular pathologies. Chronic illnesses are more common in the less wealthy population groups, so much so that we started talking about a Covid-19 syndemic, chronic conditions and social determinants. The pandemic led to the suspension of clinics and their services. Delaying the diagnosis and treatment of a condition certainly had a different impact on the various social classes; this impact will have to be measured at some point. What we are forced to face, apart from the epidemic emergency, is also the economic crisis that some economists compare to the Great Depression of 1929.

There are 10 years left and we have clear guidelines on the direction we need to follow. Promoting social, economic and political inclusion implies reducing the inequalities that are present in the first place.

Where we need to head

The tenth objective for sustainable development outlined by the United Nations- the reduction of inequalities within and between countries- is a great challenge, given this situation. Such a goal requires the 40% income growth rate of the poorer population to increase steadily. We have until 2030 to promote social, economic and political inclusion. We need to guarantee equal opportunities by getting rid of discriminatory laws, policies and practices and we need to facilitate orderly and safe migration and mobility. There are 10 years left and we have clear guidelines on the direction we need to follow. Promoting social, economic and political inclusion implies reducing the inequalities that are present in the first place and- going back to the point about the indicators that are used to measure these- it means working on education, employment, income, household conditions, the environment we live in and- in order to help the workers of the National Healthcare Service- also health.