Article Text

Download PDFPDF

Inequalities persist in Europe—and COVID-19 does not help
  1. Elizabeth Breeze
  1. Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London, UK
  1. Correspondence to Dr Elizabeth Breeze, Faculty of Epidemiology and Public Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK; elizabeth.breeze{at}

Statistics from

Recent evidence of continuing inequalities by educational level in disability in Europe is disappointing. Further socioeconomic measures might reveal greater inequalities. Conclusions are limited by differences in wording used to establish disability. Assuming that there is inequity behind these inequalities, this, along with the adverse effects of the COVID-19 pandemic, reinforces the need for multisectoral action, collaboration and cooperation.

Rubio Valverde et al1 show us that inequalities in disabilities in Europe have not improved between 2002 and 2017. They included a wide age range (30–79 years) and 26 countries. They used two surveys, the European Union Statistics on Income and Living (EU-SILC) and the European Social Survey. The disability measure was the Global Activity Limitation Indicator (GALI), a self-report of being limited in activities ‘people usually do’ in the past 6 months.2 The former survey indicated an increase in gap between low and high education groups, with the more educated experiencing reduced prevalence of disability, and the latter survey no discernible trend. Inequalities have been the subject of discussion for decades so it is disappointing to find this.

Three aspects of the paper caught my attention. This is one of a long series of analyses by Mackenbach and his team which use education as the socioeconomic indicator. Their reasons for doing this are that they judge educational measures to be most comparable across countries, that it may be a starting point for several pathways and reverse causation is unlikely.3 However, it may not be the socioeconomic indicator most strongly related to disability and may underestimate the importance of socioeconomic status. For example, in the English Longitudinal Study of Ageing, absolute differences in healthy life expectancy were greater for wealth categories than for education or social class whereas in the USA’s Health and Retirement Study both wealth and education were strong.4 Marmot’s example of a Glasgow male shows how education, occupation and material resource all play a part.5

Marmot is also talking about ‘equity’ whereas Rubio Valverde’s paper refers to inequality. To know that there are these inequalities is the starting point but the prompt to action is inequity. Not a new topic, of course, but one that has become highly visible with the COVID-19 pandemic. The WHO report judges that ‘failure to anticipate and avoid the resulting unwanted scenarios in the short and medium terms has led to a major risk both of exacerbating health, social and economic inequities in the long term and of giving rise to new vulnerabilities within the population’6 (p 1). People with learning and other disabilities have been at higher risk of death. In England, as of November 2020, 60% of COVID-19 deaths were to people with disabilities.7 COVID-19 is leaving some people with reduced long-term health which may lead to reduced earning capacity or mobility6 (p 33). Also, new hardship is arising because of the economic and social restrictions. The corollary of the two-way impact of socioeconomic inequities on the pandemic and the pandemic on the inequities is the need for multisectoral policies affecting people’s access to essential care and health services, providing economic security and ensuring that decision-making is an inclusive process6 (p 14). We need ‘commitment to social justice and putting equity of health and wellbeing at the heart of all policy making’8 (p 64). Marmot is addressing socioeconomic inequity and those relating to ethnicity, age and gender.

The third aspect of the paper is the variability between countries and between surveys in the graphs of disability prevalence over time. Both the levels and shapes vary. Rubio Valverde et al highlight this and, not finding clear geographical patterns, fall back on overall averages. Some of this heterogeneity arises from variation in the GALI wording used in EU-SILC and they have tried to take some account of this. There are now several multicountry studies and families of cohort studies which aim to harmonise measures within their group; methods are being developed to harmonise when measures are different9 but Rubio Valverde’s paper highlights how differences in measurement can hamper conclusions about risks. Being self-report, and depending on what people consider to be usual, one can expect some variation by culture and age and gender. However, it is likely that some of it arises from the context in which people live: their country’s health services, policy and environment. It would be instructive to learn more about this and see what we can learn from each other. During the pandemic, countries have taken very different paths to deal with the SARS-CoV-2 virus and its effects. Collaborative research is common in epidemiology. In the economic and political world, sometimes it feels as if the terms ‘cooperation’ and ‘collaboration’ are undervalued. My wish is to see them given greater prominence.



  • Contributors EB drafted the article and is accountable for all aspects of the writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.