Links between Health and Social Inequality in Germany
“Disadvantaged groups face elevated health risks”

Health inequalities suddenly became the focus of a broader public debate during the pandemic in Germany. Jan Paul Heisig, Professor for Sociology at the Freie Universität Berlin, analyses these inequalities and their links to persistent social inequalities in the German society.

By Jan Paul Heisig

“Social distancing” was among the first of numerous new terms that we have learned during the pandemic, although many have observed that “physical distancing” would be a better label: While the virus may force us to reduce physically proximate interactions, we need to continue having meaningful interactions with other human beings, which are essential to our well-being.

The pandemic has not only forced us to distance ourselves from each other in a spatial sense. However, it has also spotlighted the enormous - socially created - distances that exist between people in terms of their economic circumstances and living conditions as well as in terms of their individual health status and access to care. These inequalities have fundamentally shaped how people experienced the pandemic, and many kinds of inequalities have been reinforced as some workers have lost their jobs or closed their businesses, while others experienced greater demand for their work than ever. Some could easily evade the coronavirus by working from home, while others faced continued exposure on the job.

In Germany, social inequalities in the economic impact of the pandemic were high on the agenda early on and, while not perfect, a large number of measures such as extensions of unemployment benefits cushioned the financial impact of the crisis. It took the public longer to realise how unequally health risks were distributed. This may have to do with the fact that the pandemic was initially concentrated in relatively affluent regions and neighbourhoods: the first major breakouts in March 2020 were driven by people returning from their skiing holidays in the Austrian Alps, a rather expensive pleasure with the corresponding affluent clientele. The widespread perception that the German healthcare system ensures high-quality care for everyone - despite some privileges for those insured with private companies rather than the larger statutory scheme - may also have contributed to the general impression that the health impact of the pandemic would be distributed rather equally.

An unequal health impact

Social scientists and epidemiologists, however, warned early on that disadvantaged and vulnerable groups – people with low income, low education, and/or immigrant origins - would face elevated health risks from the pandemic. The following months would prove them right, with data increasingly indicating that rates of infection and death were higher in disadvantaged regions and neighborhoods with high poverty or unemployment rates. That being said, evidence on the unequal health impact of the pandemic in Germany remains less clear than for many other high-income countries. This is largely because there is no information of socio-economic position or ethnicity in German mortality statistics and because administrative data from health insurance and other sources are fragmented and difficult to access. The available evidence therefore mostly comes from comparisons of districts and other administrative units, which may hide a lot of important variation within these entities. Nevertheless, despite these limitations of the empirical evidence, social inequalities in the health impact of the pandemic did become a subject of broader public debate during the second wave between September 2020 and March 2021.

The pandemic has thus put health inequalities higher on the public agenda, at least for a while. Much of the debate has centred on differential infection risks due to work-related exposure or crowded homes that affect the risk of household transmission, and it remains true that differential infection risks are a major factor. What has received less attention is that higher hospitalisation and mortality rates among disadvantaged groups are also the result of higher vulnerability due to pre-existing conditions and lower overall health. The pandemic has further exacerbated inequalities in health and mortality, but it is crucial to recognise that it could only do so because there are substantial inequalities in vulnerability even in high-income countries with universal healthcare systems such as Germany. These inequalities translate into large mortality differentials even in non-pandemic times, with a 2019 study on life expectancy at birth estimating that those who would spend their lives in the highest income group (≥ 150 per cent of German median which is approximately 2240 Euros per month for a single person) could expect to live for an additional four to five years (women) or even eight to nine years (men) compared with those who would spend their lives in the lowest income group (< 60 per cent of German median which is approximately 900 Euros per month for a single person).

The need for a global response

Taking the lessons from the pandemic seriously means that we need to recognise and tackle the structural inequalities that lead to these inequalities in health. The pathways linking socio-economic position to health and mortality are complex and much research remains to be done. At the same time, we know enough to take action now. An increasing number of social scientists and epidemiologists see chronic stress, captured by the concept of allostatic load and caused by the experience of adversity, disadvantage and uncertainty, as one major source of health inequalities. This view suggests that health inequalities cannot be tackled by health care alone, but requires a more comprehensive approach that encompasses social and economic policies. That does not mean that health care is not important. It is - and we therefore need to better understand how access, utilisation, and quality of care depend on socio-economic position, gender, and ethnicity. Inequalities in health care provision have multiple sources, including underutilisation on the part of disadvantaged groups but also outright discrimination by at least some medical practitioners. Another key factor is a lack of attention to social and ethnic diversity in medical training and clinical trials. Many medical “best practices” may be (inadvertently) tailored towards higher-status and majority groups, paying insufficient attention to the specific physiological and social needs of lower-status and minority groups. All these considerations point to the need for a long-term agenda that reduces health inequalities through both greater research and intervention efforts.

I began my discussion of health inequalities during the pandemic with the situation in Germany, but health inequalities are a global challenge. This is true in a double sense:  in a within-country sense, as health and mortality differentials between higher and lower strata exist in all countries; but also in a between-country sense, as there are vast differences in health and mortality between the rich countries of the global North and the poorer countries of the global South. A truly comprehensive effort to tackle health inequalities will therefore be a global one, but the experiences during the pandemic do not exactly give reason for hope that such an approach is a realistic scenario. Many bad decisions and mistakes have been made during the pandemic, but the failure to achieve fair and comprehensive access to vaccines on a global scale may well be the most shameful and consequential one. The coronavirus has been a pandemic in the most emphatic sense of the word, spreading to and affecting the lives of humans all over the planet. One would hope that such a global experience can instill a sense of solidarity and shared humanity. So far there is little to suggest this is the case, but it is never too late for a change. Our efforts to fight the pandemic must finally start to follow the imperative of global solidarity, particularly when it comes to vaccination, and any long-term agenda to reduce health inequalities needs to take a global perspective as well.