Coronavirus disease 2019 (COVID-19) has rapidly affected mortality worldwide1. There is unprecedented urgency to understand who is most at risk of severe outcomes, and this requires new approaches for the timely analysis of large datasets. Working on behalf of NHS England, we created OpenSAFELY-a secure health analytics platform that covers 40% of all patients in England and holds patient data within the existing data centre of a major vendor of primary care electronic health records. Here we used OpenSAFELY to examine factors associated with COVID-19-related death. Primary care records of 17,278,392 adults were pseudonymously linked to 10,926 COVID-19-related deaths. COVID-19-related death was associated with: being male (hazard ratio (HR) 1.59 (95% confidence interval 1.53-1.65)); greater age and deprivation (both with a strong gradient); diabetes; severe asthma; and various other medical conditions. Compared with people of white ethnicity, Black and South Asian people were at higher risk, even after adjustment for other factors (HR 1.48 (1.29-1.69) and 1.45 (1.32-1.58), respectively). We have quantified a range of clinical factors associated with COVID-19-related death in one of the largest cohort studies on this topic so far. More patient records are rapidly being added to OpenSAFELY, we will update and extend our results regularly.

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Factors associated with COVID-19-related death using OpenSAFELY.

Health professionals for a new century: transforming education to strengthen health systems in an interdependent world

The Coronavirus Disease 2019 (COVID-19) epidemic emerged in Wuhan, China, spread nationwide and then onto half a dozen other countries between December 2019 and early 2020. The implementation of unprecedented strict quarantine measures in China has kept a large number of people in isolation and affected many aspects of people's lives. It has also triggered a wide variety of psychological problems, such as panic disorder, anxiety and depression. This study is the first nationwide large-scale survey of psychological distress in the general population of China during the COVID-19 epidemic.

https://gpsych.bmj.com/content/gpsych/33/2/e100213.full.pdf

A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)30569-X.pdf

Structural racism and health inequities in the USA: evidence and interventions

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a transgenerational prospective observational study investigating influences on health and development across the life course. It considers multiple genetic, epigenetic, biological, psychological, social and other environmental exposures in relation to a similarly diverse range of health, social and developmental outcomes. Recruitment sought to enroll pregnant women in the Bristol area of the UK during 1990-92; this was extended to include additional children eligible using the original enrollment definition up to the age of 18 years. The children from 14541 pregnancies were recruited in 1990-92, increasing to 15247 pregnancies by the age of 18 years. This cohort profile describes the index children of these pregnancies. Follow-up includes 59 questionnaires (4 weeks-18 years of age) and 9 clinical assessment visits (7-17 years of age). The resource comprises a wide range of phenotypic and environmental measures in addition to biological samples, genetic (DNA on 11343 children, genome-wide data on 8365 children, complete genome sequencing on 2000 children) and epigenetic (methylation sampling on 1000 children) information and linkage to health and administrative records. Data access is described in this article and is currently set up as a supported access resource. To date, over 700 peer-reviewed articles have been published using ALSPAC data.

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Cohort Profile: The ‘Children of the 90s’—the index offspring of the Avon Longitudinal Study of Parents and Children

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(08)61690-6.pdf

Closing the gap in a generation: health equity through action on the social determinants of health

The final report of the World Health Organization Commission on the Social Determinants of Health (CSDH), published in 2008, affirmed that social injustice was killing on a grand scale, with a toxic combination of 'poor social policies and programmes, unfair economic arrangements, and bad politics' being responsible for producing and reinforcing health inequalities. It provided a comprehensive evidence-based discussion of pervasive inequalities of health in many countries, demonstrating the presence of a social gradient in health outcomes associated with the unfair distribution of the social determinants of health. The social determinants of health include the conditions in which people are born, grow, live, work and age, and the fundamental drivers of these conditions: the distribution of power; money; and resources. Following publication of the CSDH report and recommendations for action, the UK Government commissioned a Strategic Review of Health Inequalities in England. This article provides an overview and reflection on the findings from the CSDH and the Strategic Review of Health Inequalities in England, reviewing the case for putting fairness at the heart of all policy making. In the process, it highlights the need for action on the social determinants of health in order to address health inequalities and the social gradient in health outcomes.

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Fair society, healthy lives

A person's mental health and many common mental disorders are shaped by various social, economic, and physical environments operating at different stages of life. Risk factors for many common mental disorders are heavily associated with social inequalities, whereby the greater the inequality the higher the inequality in risk. The poor and disadvantaged suffer disproportionately, but those in the middle of the social gradient are also affected. It is of major importance that action is taken to improve the conditions of everyday life, beginning before birth and progressing into early childhood, older childhood and adolescence, during family building and working ages, and through to older age. Action throughout these life stages would provide opportunities for both improving population mental health, and for reducing risk of those mental disorders that are associated with social inequalities. As mental disorders are fundamentally linked to a number of other physical health conditions, these actions would also reduce inequalities in physical health and improve health overall. Action needs to be universal: across the whole of society and proportionate to need. Policy-making at all levels of governance and across sectors can make a positive difference.

Social determinants of mental health

Objective To summarise the evidence on the effect of psychological coping styles (including fighting spirit, helplessness/hopelessness, denial, and avoidance) on survival and recurrence in patients with cancer. Design Systematic review of published and unpublished prospective observational studies. Main outcome measures Survival from or recurrence of cancer. Results 26 studies investigated the association between psychological coping styles and survival from cancer, and 11 studies investigated recurrence. Most of the studies that investigated fighting spirit (10 studies) or helplessness/hopelessness (12 studies) found no significant associations with survival or recurrence. The evidence that other coping styles play an important part was also weak. Positive findings tended to be confined to small or methodologically flawed studies; lack of adjustment for potential confounding variables was common. Positive conclusions seemed to be more commonly reported by smaller studies, indicating potential publication bias. Conclusion There is little consistent evidence that psychological coping styles play an important part in survival from or recurrence of cancer. People with cancer should not feel pressured into adopting particular coping styles to improve survival or reduce the risk of recurrence.

https://www.bmj.com/content/bmj/325/7372/1066.1.full.pdf

Influence of psychological coping on survival and recurrence in people with cancer: systematic review

figures are, we should not see them as representing simply a problem for low-income countries. When the CSDH published its report in 2008, we highlighted the health inequalities in the Scottish city of Glasgow (also shown in Fig. 1). In the richest part of Glasgow, life expectancy for men is 82 years; in the poorest part, it is 54 years (Hanlon et al., 2006)—eight years shorter than the average in India. If we define poverty as living at two dollars a day or less, then approximately 40% of the world’s population lives in poverty. By this definition, no one in Glasgow lives in poverty. Despite this, men living in the poorest part of Glasgow have dramatically worse health than the Indian average. Inequalities in health are a problem for all of us in countries with low income, middle income, and high income. Such dramatic inequalities in health should not be taken as a counsel of despair. Change can be dramatic. In the 1960s, life expectancy in sub-Saharan Africa was not greatly different from that in South Asia. Over the next four decades, health improved markedly in South Asia and in other parts of Asia, but improved very little in sub-Saharan Africa. This is illustrated for specific countries in Fig. 2 (United Nations Population Division, 2009). In 1970, life expectancy was the same in Zambia and Vietnam. Subsequently, life expectancy improved only modestly in Zambia and then again declined. By contrast, there was continued and dramatic improvement in Vietnam. Health improvements take place at different rates, and the There are major inequalities in health within and between countries. The Commission on Social Determinants of Health (CSDH) was set up by the World Health Organization to bring together the evidence on these inequalities and on what would work to make a difference. The CSDH concluded that a toxic combination of unfair economic arrangements, poor policies and programs, and bad governance was responsible for most of the inequalities that we see in the world (Commission on Social Determinants of Health, 2008). The CSDH was informed by and deliberated on reports produced by nine knowledge networks. The CSDH did not put emphasis on any specific disease diagnosis. That said, there has been a great deal of interest from groups concerned with specific manifestations of illness, including mental and physical health, communicable and noncommunicable diseases, and violence. One of the knowledge networks, priority public health conditions, was constituted by colleagues at WHO Geneva. Their recent work shows the importance of social determinants of health to those concerned with specific causes of morbidity and mortality publication (Blas and Kurup, 2010). We are delighted therefore that leaders in dental research wish to consider the topic of social determinants of health. We start with the general picture of inequalities in health between and within countries and move to more specific considerations of dental health.

Ruth Bell

Papers

Closing the gap in a generation: health equity through action on the social determinants of health

Fair society, healthy lives

Social determinants of mental health

Influence of psychological coping on survival and recurrence in people with cancer: systematic review

Social Determinants and Dental Health