A long-term collaborative approach to addressing health inequality

addressing health inequality
© Andrii Yalanskyi

Christine Hancock, Founder and Director at C3 Collaborating for Health, discusses the ongoing issue of health inequality that COVID-19 has exposed, and how to ensure healthy lives for all

In February 2021, the UK government achieved its target of vaccinating the most vulnerable groups of the population against COVID-19, which included care home residents and staff, health and care workers, all those 70 years of age and over and clinically extremely vulnerable individuals. (1) The vaccination programme has been widely regarded as a success – by mid-February more first doses per 100 people had been administered in the UK than any other country of comparable population size. (2)

Whilst it is acknowledged that COVID-19 will remain endemic in the global population for the foreseeable future, vaccination will bring us all closer to living more normal lives again. However, we, at C3 Collaborating for Health (C3) are not celebrating just yet. From our experience working alongside communities to promote sustainable healthy behaviours, we know that there is more to do.

C3 seeks to address the leading risk factors for chronic diseases by promoting three behaviour changes which are: improving what we eat and drink; stopping smoking, and increasing physical activity – we do so by building multi-sector collaboration. Global policy has driven prevention higher up the health agenda, as reflected in the UN’s Sustainable Development Goals of 2015 and in particular SDG 3: to ensure healthy lives and promote well-being for all at all ages. (3) However, at the start of the COVID-19 pandemic, we at C3 were anxious that our prevention message could not be heard.

Discriminative disease

In early 2020, as the pandemic began to take hold in Europe, it was described as an indiscriminate disease. However, as more and more evidence emerged, it became clear that this simply was not true. People infected with COVID-19 suffering from chronic conditions such as obesity, type 2 diabetes, cardiovascular and respiratory diseases, were observed to suffer from significantly worse health outcomes and ultimately higher fatality rates.

In February 2020 the pandemic was making its way through northern Italy – the first region outside of China to face the catastrophic effects of COVID-19. The rest of Europe – and the world – watched with horror as healthcare professionals and healthcare systems struggled to cope with overwhelming numbers of seriously unwell patients. By July 2020, it was established that 66% of Italians who died after contracting the virus were known to have suffered from high blood pressure. (4)

In April 2020 the French newspaper Le Figaro published a compelling analysis of body mass index (BMI) – a metric for measuring obesity – which described obesity as the principal risk factor for requiring ventilation in COVID-19 patients; a month later this was supported by scientific evidence showing a significant association between obesity and admission to intensive care. (5) In the UK obesity was cited as a risk factor for Prime Minister Boris Johnson, whose illness with COVID-19 during the first wave necessitated admission to intensive care. (6) In May 2020, the modifiable risk factors of both high BMI and smoking, and their correlation with the severity of COVID-19 illness, were evidenced in a UK population study of over 400,000 people. (7)

However, the undisputed evidence of risk factors for chronic disease and the presence of co-morbidities cannot be recognised in relation to COVID-19 outcomes alone, but instead must be considered in the wider context of health inequality, which tragically pre-dates the pandemic. Indeed, the mainstream media has shone a spotlight on issues relating to inequality and inequity, and the impact of the social determinants of health, (which include housing, employment, access to food, and transport), yet health inequality is not of the pandemic’s making – and for all of us working in public health, the course of the pandemic has been tragically unsurprising.

This synergy observed between health inequalities and poor COVID-19 outcomes supports the resurgence of a 1990s academic term ‘syndemic’ – attributed to the American medical anthropologist Merrill Singer. Commentary in The Lancet, in 2020 by its editor Richard Horton, characterised Singer’s notion as biological and social interactions that increase risk of harm or worsen health outcomes. The commentary goes on to suggest that the vulnerability of older people, ethnic minority communities, and key workers who are commonly in poorer paid employment, and often with less welfare protection, evidence that a biological solution alone will not suffice. (8)

Health inequalities were well documented by Michael Marmot over a decade ago, in which the concept of a social gradient was examined – the lower a person’s social position, the worse their health. (9)

We are yet to understand how far-reaching the pandemic’s impact will be on a national and global scale as evidence continues to emerge of the struggles faced by people from lower socioeconomic groups. These challenges have included cramped and insecure housing, insecure employment, a lack of green space for physical activity and a lack of technological equipment to facilitate home-working or home-schooling.

In a letter published in the Financial Times in November 2020, C3’s Founder and Director, Christine Hancock, provided a vivid picture of the issues C3 encounters in its work with communities that included the issues of child poverty and holiday hunger, high obesity rates, and unemployment. We at C3 believe that a long-term approach to addressing these complex issues requires collaboration with all sectors of society and political parties – and working with communities.

Currently, C3 is working with seven communities in the North of France and the South of England via an EU funded project ASPIRE (Adding to Social capital and individual Potential In disadvantaged REgions). This multi-partner project aims to address the complex issues of obesity and unemployment; C3 is one of 16 organisations that have come together to tackle the issues holistically via its community engagement programme.

In summary, while we at C3 recognise and applaud the UK government’s success in the COVID-19 vaccine roll-out, the issue of health inequality that COVID-19 has exposed will not be solved via vaccines alone, but instead requires multi-sector collaboration that encompasses the health, food, education, employment, transport and housing sectors – an approach that addresses the social determinants of health.


  1. Gov.UK COVID-19 vaccination first phase priority groups. 2021 [cited 24.02.2021]. https://www.gov.uk/government/publications/covid-19-vaccination-care-home-and-healthcare-settings-posters/covid-19-vaccination-first-phase-priority-groups
  2. Baraniuk C. COVID-19: How the UK vaccine rollout delivered success, so far. BMJ. 2021; 372.
  3. United Nations. Sustainable Development Goals, Knowledge Platform [Internet]. 2020 [cited 18.05.2020]. https://sdgs.un.org/goals/goal3
  4. Statista. Most common comorbidities observed in coronavirus (COVID-19) deceased patients in Italy as of July 22 2020. 2020 [cited 24.02.2021] https://www.statista.com/statistics/1110949/common-comorbidities-in-covid-19-deceased-patients-in-italy/
  5. Caussy C. Prevalence of obesity among adult inpatients with COVID-19 in France. The Lancet Diabetes Endocrinol 87. 2020: 562-4.
  6. What can Boris Johnson expect in intensive care? The Financial Times. 2020. [Cited 08.04.2020]
  7. Ho FK, Celis-Morales CA, Gray SR, Katikireddi SV, Niedzwiedz CL, Hastie C, et al. Modifiable and non-modifiable risk factors for COVID-19, and comparison to risk factors for influenza and pneumonia: Results from a UK Biobank prospective cohort study. BMJ Open. 2020;10(11).
  8. Horton R. Offline: COVID-19 is not a pandemic. Lancet. 2020; 396 (10255): 874. https://doi.org/10.1016/S0140-6736(20)32000-6
  9. Marmot M, Bell R. Fair society, healthy lives (Full report). Vol. 126, Public Health. 2012. https://doi.org/10.1016/j.puhe.2012.05.014


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  • C3 Collaborating for Health

    C3 brings together different communities to create health changes that make it easier to stop using tobacco, improve diet and do more physical activity.

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C3 Collaborating for Health
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Founder and Director
C3 Collaborating for Health
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