text:
Inequalities in healthcare disruptions during the COVID-19 pandemic: evidence from 12 UK population-based longitudinal studies
http://orcid.org/0000-0002-7975-4221Jane Maddock1,
http://orcid.org/0000-0001-5949-3899Sam Parsons2,
http://orcid.org/0000-0001-6154-1845Giorgio Di Gessa3,
http://orcid.org/0000-0003-3193-2452Michael J Green4,
http://orcid.org/0000-0003-2118-821XEllen J Thompson5,
http://orcid.org/0000-0002-0435-3562Anna J Stevenson6,
http://orcid.org/0000-0003-1953-2771Alex SF Kwong7,8,
Eoin McElroy9,
http://orcid.org/0000-0003-0427-1783Gillian Santorelli10,
http://orcid.org/0000-0002-2744-1194Richard J Silverwood2,
http://orcid.org/0000-0002-5662-0642Gabriella Captur1,
http://orcid.org/0000-0002-6211-2775Nishi Chaturvedi1,
http://orcid.org/0000-0002-4910-0489Claire J Steves5,
http://orcid.org/0000-0001-7808-4943Andrew Steptoe3,
http://orcid.org/0000-0002-5341-3461Praveetha Patalay1,2,
http://orcid.org/0000-0002-8198-5790George B Ploubidis2,
http://orcid.org/0000-0001-6593-9092Srinivasa Vittal Katikireddi4
1MRC Unit for Lifelong Health and Ageing, UCL, London, UK
2Centre for Longitudinal Studies, Social Research Institute, UCL, London, UK
3Department of Epidemiology and Public Health, UCL, London, UK
4MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, Glasgow, UK
5Department of Twin Research and Genetic Epidemiology, School of Life Course & Population Sciences, King's College London, London, UK
6Centre for Genomic and Experimental Medicine, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
7Division of Psychiatry, University of Edinburgh, Edinburgh, UK
8MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
9Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
10Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
Correspondence to Dr Jane Maddock; jane.maddock{at}ucl.ac.uk
Objectives We investigated associations between multiple sociodemographic characteristics (sex, age, occupational social class, education and ethnicity) and self-reported healthcare disruptions during the early stages of the COVID-19 pandemic.
Design Coordinated analysis of prospective population surveys.
Setting Community-dwelling participants in the UK between April 2020 and January 2021.
Participants Over 68 000 participants from 12 longitudinal studies.
Outcomes Self-reported healthcare disruption to medication access, procedures and appointments.
Results Prevalence of healthcare disruption varied substantially across studies: between 6% and 32% reported any disruption, with 1%–10% experiencing disruptions in medication, 1%–17% experiencing disruption in procedures and 4%–28% experiencing disruption in clinical appointments. Females (OR 1.27; 95% CI 1.15 to 1.40; I2=54%), older persons (eg, OR 1.39; 95% CI 1.13 to 1.72; I2=77% for 65–75 years vs 45–54 years) and ethnic minorities (excluding white minorities) (OR 1.19; 95% CI 1.05 to 1.35; I2=0% vs white) were more likely to report healthcare disruptions. Those in a more disadvantaged social class were also more likely to report healthcare disruptions (eg, OR 1.17; 95% CI 1.08 to 1.27; I2=0% for manual/routine vs managerial/professional), but no clear differences were observed by education. We did not find evidence that these associations differed by shielding status.
Conclusions Healthcare disruptions during the COVID-19 pandemic could contribute to the maintenance or widening of existing health inequalities.
Data are available upon reasonable request. Data for NCDS (SN 6137), BCS70 (SN 8547), Next Steps (SN 5545), MCS (SN 8682) and all four COVID-19 surveys (SN 8658) are available through the UK Data Service. NSHD data are available on request to the NSHD Data Sharing Committee. Interested researchers can apply to access the NSHD data via a standard application procedure. Data requests should be submitted to mrclha.swiftinfo@ucl.ac.uk; further details can be found at http://www.nshd.mrc.ac.uk/data.aspx. doi:10.5522/NSHD/Q101; doi:10.5522/NSHD/Q10. The ALSPAC study website contains details of all the data that is available through a fully searchable data dictionary and variable search tool: http://www.bristol.ac.uk/alspac/researchers/our-data. ALSPAC data is available to researchers through an online proposal system. Information regarding access can be found on the ALSPAC website (http://www.bristol.ac.uk/media-library/sites/alspac/documents/researchers/data-access/ALSPAC_Access_Policy.pdf). Data from the various BiB family studies are available to researchers; see the study website for information on how to access data (https://borninbradford.nhs.uk/research/how-to-access-data/). All USOC data are available through the UK Data Service (SN 6614 and SN 8644). All ELSA data are available through the UK Data Service (SN 8688 and 5050). Access to data from GS is approved by the Generation Scotland Access Committee. See https://www.ed.ac.uk/generation-scotland/for-researchers/access or email access@generationscotland.org for further details. The TwinsUK Resource Executive Committee (TREC) oversees management, data sharing and collaborations involving the TwinsUK registry (for further details see https://twinsuk.ac.uk/resources-for-researchers/access-our-data/).
We conducted coordinated primary analyses in 12 UK longitudinal population studies, and pooled results using a random effects meta-analysis.
Use of multiple studies increased statistical power to look at subpopulations such as ethnic minority groups across cohorts and allowed for greater examination of how inequalities were patterned by age.
Most studies were weighted to be representative of their target ages in the UK population, and findings were robust to excluding those that were not.
We did not adjust for whether respondents needed healthcare, so the inequalities observed may be at least partly attributable to inequalities in needing healthcare.
Data on prepandemic healthcare disruption were not available, so we could not tell if inequalities in healthcare disruption had widened or narrowed during the pandemic.
The COVID-19 pandemic has affected all aspects of society. Health systems worldwide have faced major disruption as they respond to large increases in demand arising from the COVID-19 disease.1–5 Furthermore, healthcare access has been reduced by governmental control measures and the public's fear of contracting infection.6 Disruptions may have both short-term and long-term health consequences as preventive treatments are foregone, disease surveillance is interrupted and disease diagnoses are delayed. While the disruption of health systems can impact the entire population, it has become apparent that not all groups have been affected equally. For example, recent evidence has demonstrated that both elective and emergency hospital admissions vary by socioeconomic deprivation and ethnic minority quintiles, with the more deprived areas showing a large fall in elective admissions, and areas with high ethnic minority populations showing larger falls in emergency admissions.5 Understanding the impacts of the pandemic on health systems and on equity of healthcare access is therefore a major policy priority.
In the UK, the National Health Service (NHS) provides free healthcare and prioritises equity of delivery. However, the UK's relatively high COVID-19 burden and associated repeated lockdown measures have raised concerns that the health system may not be providing accessible care to those who need it most. Recent reports from NHS Digital indicate a large increase in those waiting 12 months or more for elective treatments in February 2021 compared with March 2020.7 Furthermore, despite decreases in attendance at accident and emergency (A&E) services,4 the number of patients waiting over 12 hours for admission was 34% higher in January 2021 than January 2020. Disruption to pharmacological treatments has also been reported with delays in accessing medication.8 9 However, a comprehensive assessment of inequalities in healthcare disruption in the community is lacking.
It is well known that health systems do not meet the needs of all social groups equitably, with marked health inequalities by sex, ethnicity and socioeconomic position.10 11 For example, the inverse care law demonstrates that health service provision is often not allocated according to need, with more socioeconomically deprived areas relatively underserved.12 Given the barriers that some social groups face in accessing high-quality healthcare, there is considerable concern that disadvantaged groups (eg, ethnic minorities) will be disproportionately impacted by healthcare disruption during the COVID-19 pandemic, as some emerging evidence suggests.13 14
Harnessing multiple longitudinal studies allows inequalities to be studied in detail by improving statistical power and allows consistency of findings to be investigated. We therefore aimed to investigate inequalities in healthcare disruption during the COVID-19 pandemic in 12 population-based longitudinal studies, to help inform targeting of policy responses as we move out of the acute phases of the pandemic. We investigate healthcare disruptions (including prescription or medication access, procedures or surgery, clinical appointments) by sex, age, ethnicity, education and occupational social class and we explore whether associations differ by age, or for those who have been recommended to 'shield' due to clinical vulnerability.
The UK National Core Studies–Longitudinal Health and Wellbeing programme aims to draw together data from multiple UK population-based longitudinal studies to answer questions relevant to the pandemic response. By coordinating analyses within each study and statistically pooling results in a meta-analysis, we can provide robust evidence to understand healthcare disruptions during the pandemic.
Data were from 12 UK population studies which had conducted surveys both before and during the COVID-19 pandemic. Details of the design, sample frames, current age range, timing of the COVID-19 surveys, response rates and analytical sample size are available in online supplemental table S1 in supplementary file 4.
Our population of interest is the current UK population aged 16 years or older. The following studies are considered to be nationally representative samples of their target age groups: the Millennium Cohort Study (MCS)15; Next Steps (NS)16; the 1970 British Cohort Study (BCS70)17; the National Child Development Study (NCDS)18; the National Survey of Health and Development (NSHD)19 20; Understanding Society (USOC)21; and the English Longitudinal Study of Ageing (ELSA).22 We also included the Avon Longitudinal Study of Parents and Children (ALSPAC-G1)23; the parents of the ALSPAC-G1 cohort which we refer to as ALSPAC-G024; the Born in Bradford (BIB) study25 26; Generation Scotland: the Scottish Family Health Study (GS)27; and the UK Adult Twin Registry (TwinsUK).28 29 We present the results from all 12 studies in the main manuscript and results restricted to representative samples in online supplemental file 1.
We can further categorise these studies into age-homogenous birth cohorts (where all individuals were of similar age within each cohort) and age-heterogeneous studies (each covering a range of age groups). The age-homogenous studies include MCS, ALSPAC-G1, NS, BCS, NCDS and NSHD. The age-heterogenous studies include BIB, USOC, GS, ALSPAC-G0, TwinsUK and ELSA. Analytical samples were defined within each study based on respondents who had no missing data on at least one healthcare disruption outcome in a COVID-19 survey and on a minimum set of covariates (sex, ethnicity and age where relevant). Most studies were weighted to be representative of their target populations accounting for differential non-response.20 30 31 Weights were not available for BIB or TwinsUK. Studies were ordered for presentation by age of sample (youngest to oldest), with the age-homogenous cohorts first, followed by the age-heterogenous studies. Missing data within surveys were generally low, especially for healthcare disruption variables, but approximately 5%–10% of respondents across studies were excluded due to missing baseline covariates.
Below we describe the overall approach to measuring each variable in the analysis.
We assessed self-reported disruptions to prescriptions or medication access; procedures or surgery; and appointments (eg, with a general practitioner or outpatient services); and a combined variable indicating disruptions to any of the aforementioned. Any deviation from planned or existing treatment was coded as a disruption, regardless of the reason for the disruption. The wording of the questions was the same for MCS, NS, BCS70, NCDS and NSHD. There was variation in how the questions were asked in the other studies. Full details of the questions and coding used within each study are available in online supplemental file 2. ALSPAC did not have information about prescriptions or medication access. BIB did not have information about procedures or surgery. TwinsUK did not have information about procedures or surgery or appointments. Where multiple pandemic survey waves had been included, we coded for any disruptions reported up to and including the most recent. This meant at least 7 months of follow-up for most studies (GS had five and ELSA had four, while ALSPAC had the longest follow-up period at 9 months). Online supplemental table S3 shows how the prevalence for any experience of each disruption accumulated across the six USOC surveys. The majority of those who experienced each type of healthcare disruption had already experienced it by the end of May 2020.
Indicators of inequality
We assessed inequalities associated with key sociodemographic characteristics, that is, sex, age, ethnicity, education and occupational social class. For age, we considered age groups categorised as: 16–24; 25–34; 35–44; 45–54; 55–64; 65–74; and 75+ years. Depending on the level of detail of ethnicity available, we examined both a binary (white (including white minorities) vs ethnic minorities (excluding white minorities)) and a finer categorisation of ethnicity (white, south asian, black, mixed, other asian, other ethnic minority). For education, we distinguished between degree or equivalent; A-level or equivalent (ie, post-compulsory schooling qualifications); General Certificate of Secondary Education (GCSE) or equivalent (ie, qualifications for completing compulsory schooling); and fewer or no qualifications. We also examined occupational class with the following categories (based on different coding schemes in different studies): professional/managerial; intermediate; routine/manual; and other (which included never/long-term non-employed and, in some studies, respondents who could not be classified elsewhere). Respondents' education and occupational class were not available in the MCS or ALSPAC-G1, so we considered parental education or household social class. For full details, see online supplemental file 2.
We decided a priori to examine modification by age and clinical vulnerability to COVID-19 to see whether inequalities varied by life stage or were particularly acute for those with higher healthcare needs and at higher risk from COVID-19 harms. For moderation by age, the age-heterogeneous studies split their samples into the age bands covered, while age-homogeneous cohorts were included within the appropriate age bands (see above for banding). In the UK, clinically extremely vulnerable people were advised to stay at home ('shield') during the pandemic. Respondents were directly asked whether they had received a letter from the NHS advising them to stay at home and protect themselves. Specific survey questions can be found in online supplemental file 2.
Other variables
The following covariates were also included where relevant and available within each study: UK nation (ie, England, Scotland, Wales or Northern Ireland); household composition (based on partnership status and whether there were children in the household); and prepandemic self-reported health (good vs poor).
Within each study, distributions of sociodemographic characteristics and healthcare disruption were examined. Then, each healthcare disruption outcome was regressed on each indicator of inequality (ie, sex, age, ethnicity, education and occupational class). Unadjusted associations are included in online supplemental file 3. Since our aim was primarily to describe inequalities, we focus on presenting associations with minimal adjustment only for sex, age and ethnicity when applicable. To assess whether associations were independent of other related factors, we also provide results in online supplemental file 3 for any healthcare disruption which additionally adjust for education, occupational class, UK nation (where appropriate), household composition and prepandemic self-reported health. Moderation by age and shielding status was assessed using stratified models.
Results were then meta-analysed for each outcome for the full sample, and within age and shielding strata. We used a random effects meta-analysis with restricted maximum likelihood. For stratified results, a test of group differences was performed using the subgroup meta-analysis command. We report heterogeneity using the I2 statistic (0% indicates low variation between estimates across studies, while values closer to 100% indicate greater heterogeneity).
Finally, in sensitivity analyses we restricted the meta-analyses to representative studies (MCS, NS, BCS70, NCDS and NSHD, USOC and ELSA). Meta-analyses were conducted in Stata V.16.32
The distribution of demographic and socioeconomic characteristics within each study is presented in table 1. A total of 68 912 participants were included in the coordinated analysis. Due to study design, participants from BIB were all female, as were the vast majority (89.4%) from TwinsUK. The age ranged from 16 years in BIB and USOC to 90+ years in TwinsUK and ELSA.
Per cent (and n) distribution of demographic and socioeconomic characteristics by study
Overall, the prevalence of any healthcare disruption ranged from 6.4% in TwinsUK to 31.8% in USOC (figure 1). Table 2 shows that disruptions to medical appointments were most common, ranging from 3.5% (ELSA) to 28.4% (USOC). Disruptions in prescriptions or medication access varied from 0.8% (ELSA) to 10.4% (GS). Disruptions to procedures or surgery were least common ranging from 0.7% (MCS) to 16.8% (ELSA).
Per cent prevalence (and 95% CIs) of healthcare disruptions during the pandemic by study
Prevalence (and 95% CIs) of any healthcare disruption by study. Sources: Millennium Cohort Study (MCS); Children of the Avon Longitudinal Study of Parents and Children (ALSPAC-G1); Next Steps (NS); 1970 British Cohort Study (BCS70); National Child Development Study (NCDS); National Survey of Health and Development (NSHD); Born in Bradford (BIB); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); UK Adult Twin Registry (TwinsUK); English Longitudinal Study of Ageing (ELSA). Studies are ordered by age homogeneity/heterogeneity and mean age of respondents at the time of the interview. Samples for each study were restricted to respondents with non-missing information on healthcare disruptions and valid information on sex, social class, education and (where applicable) age and ethnicity. All information about how data were collected and variables were coded is available in online supplemental file 2.
The following sections describe the results adjusted for sex, age and ethnicity when applicable. Unadjusted results and results adjusted for education, occupational class, UK nation (where appropriate), household composition and prepandemic self-reported health can be found in online supplemental file 3. The associations were largely robust to further adjustment.
Sex and healthcare disruptions
Across all studies, females were generally more likely to report any healthcare disruptions than males (see online supplemental table S4 for details).
Pooled results from the meta-analysis demonstrate that females had increased odds of any healthcare disruption compared with males (OR 1.27; 95% CI 1.15 to 1.40; I2=54%, figure 2, online supplemental file 3). Similar associations were observed for disruptions to appointments (OR 1.33; 95% CI 1.17 to 1.52; I2=60%). The association between sex and disruptions to procedures and medications crossed the null (online supplemental file 3 and figure 2).
Associations between female (compared with male) sex and healthcare disruption. Sources: Millennium Cohort Study (MCS); Children of the Avon Longitudinal Study of Parents and Children (ALSPAC-G1); Next Steps (NS); 1970 British Cohort Study (BCS70); National Child Development Study (NCDS); National Survey of Health and Development (NSHD); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); UK Adult Twin Registry (TwinsUK); English Longitudinal Study of Ageing (ELSA). Adjusted for age and ethnicity where applicable.
There were differences in the association between sex and healthcare disruption when stratified by age (p<0.001, online supplemental file 3). The odds of having any healthcare disruption for females was highest among 16–24 year-olds (OR 2.22; 95% CI 1.63 to 3.02; I2=0%, Supplementary File 3). An association between sex and healthcare disruption was observed up to age 54 years but there were no clear associations among those aged 55 years and above. There was no evidence that the association between sex and healthcare disruption differed by shielding and non-shielding groups (Supplementary File 3).
Age and healthcare disruptions
A higher prevalence of having any healthcare disruption was observed among older participants of the national birth cohorts where the same questionnaire was used (figure 1). This age difference was also observed among the ALSPAC studies and for other age-heterogenous studies as seen in online supplemental table S4.
The meta-analysis including age-heterogenous studies was supportive of age differences for any healthcare disruptions (eg, OR 1.39; 95% CI 1.13 to 1.72; I2=77% for 65–75 years vs 45–54 years) (figure 3, online supplemental file 3). Disruptions seemed less likely in younger age groups and more likely among older age groups, though some estimates cross the null and had high heterogeneity, which may be because of few studies in specific age categories (figure 3, online supplemental file 3). Associations for disruptions to medical appointments and procedures or surgery showed these age differences more clearly (figure 3, online supplemental file 3).
Associations between age (compared with 45–54 year-olds) and healthcare disruption. Sources: Born in Bradford (BIB); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); UK Adult Twin Registry (TwinsUK); English Longitudinal Study of Ageing (ELSA). Adjusted for sex and ethnicity where applicable.
There were no clear differences in the association with age and any healthcare disruption by shielding status. However, for those who were shielding, CIs were wide (Supplementary File 3). The magnitude for the association of healthcare disruption among 75 year-olds and above vs 45–54 year-olds was higher among the non-shielding group (OR 1.61; 95% CI 1.17 to 2.22; I2=79%) compared with the shielding group (OR 0.83; 95% CI 0.51 to 1.37; I2=83%, Supplementary File 3).
Ethnicity and healthcare disruptions
Among the studies that had data on ethnicity, between 7.8% (BIB) and 31.9% (USOC) of the white groups reported healthcare disruption. Between 8.3% (TwinsUK) and 23.6% (GS) of ethnic minority groups reported having any healthcare disruption (online supplemental table S4).
In meta-analysis, ethnic minorities compared with white groups had increased odds of any healthcare disruption (OR 1.19; 95% CI 1.05 to 1.35; I2=0%, figure 4 and Supplementary File 3). This association was less clear for specific domains of healthcare disruption (figure 4, online supplemental file 3). Among the studies that had a finer categorisation of ethnicity, only the black ethnic groups had clearly raised odds for any healthcare disruption compared with white groups (OR 1.38; 95% CI 1.03 to 1.84; I2=0%). Associations with healthcare disruption were less evident for other ethnic groups but were imprecisely estimated (figure 4, online supplemental file 3).
Associations between ethnicity (compared with white groups) and healthcare disruption. Sources: Millennium Cohort Study (MCS); Children of the Avon Longitudinal Study of Parents and Children (ALSPAC-G1); Next Steps (NS); Born in Bradford (BIB); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); UK Adult Twin Registry (TwinsUK); English Longitudinal Study of Ageing (ELSA). Panels illustrate findings for some larger ethnic groups separately and the final panel presents results for all non-white ethnic minorities combined. Adjusted for age and sex where applicable.
There were no major differences in associations between ethnicity and any healthcare disruption by age, though this may simply be due to low power as CIs were wide (Supplementary File 3). The clearest associations with ethnic minority groups were within the age ranges of 35–44 and 45–74 years (OR 1.31; 95% CI 1.01 to 1.71; I2=0% and OR 1.61; 95% CI 1.16 to 2.22; I2=0%). The mixed ethnicity group was also at particular risk for disruption in the 16–24 years age range (OR 2.50; 95% CI 1.25 to 5.02; I2=0%). The magnitude for the association between any healthcare disruptions among ethnic minority groups versus white groups was higher among those who were shielding (OR 1.56; 95% CI 1.01 to 2.39; compared with OR 1.06; 95% CI 0.86 to 1.31 for non-shielding). This observation was consistent across more granular ethnicity categories, but CIs were wide (Supplementary File 3).
Education and healthcare disruptions
There was no clear pattern in the prevalence of healthcare disruption across education levels. For example, in USOC 29.7% of those with any healthcare disruption had a degree or equivalent and 39% had no school-leaving qualifications. In TwinsUK, 9.9% of those with any healthcare disruption had a degree or equivalent and 6.1% had no school leaving (online supplemental table S4).
In meta-analysis, we did not observe clear associations between education level and healthcare disruption, other than that those without school-leaving qualifications had raised odds of disruptions to procedures or surgery (OR 1.26; 95% CI 1.11 to 1.44; I2=0%; Supplementary File 3 and figure 5). We did not observe differences by age or shielding status (Supplementary File 3).
Associations between education (compared with degree level) and healthcare disruption. GCSE, General Certificate of Secondary Education. Sources: Millennium Cohort Study (MCS); Children of the Avon Longitudinal Study of Parents and Children (ALSPAC-G1); Next Steps (NS); 1970 British Cohort Study (BCS70); National Child Development Study (NCDS); National Survey of Health and Development (NSHD); Born in Bradford (BIB); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); UK Adult Twin Registry (TwinsUK); English Longitudinal Study of Ageing (ELSA). Adjusted for age, sex and ethnicity where applicable.
Occupational class and healthcare disruptions
The prevalence of any healthcare disruption ranged from 9.7% (BIB) to 25.7% (USOC) among the professional/managerial social class and from 9.3% (BIB) to 27.6% (USOC) for the manual/routine social class (online supplemental table S4).
Results from meta-analysis show that those in a more disadvantaged occupational class were more likely to report any healthcare disruptions (eg, OR 1.17; 95% CI 1.08 to 1.27; I2=0% for manual/routine compared with professional/managerial, figure 6, online supplemental file 3). The OR was greatest for the other occupational class category (OR 1.51; 95% CI 1.12 to 2.04); however, the I2 was also large (80%). "The large I2 implies considerable between study heterogenity. It is worth noting that two of the four individual studies (MCS and ELSA) that did not show clear associations for this category were at the extremes of the age range considered. Similar associations were seen for domains of healthcare disruption, with the largest inequalities seen for access to medications. We did not observe differences by age or shielding status (Supplementary File 3).
Associations between occupational social class (compared with professional/managerial) and healthcare disruption. Sources: Millennium Cohort Study (MCS); Children of the Avon Longitudinal Study of Parents and Children (ALSPAC-G1); Next Steps (NS); 1970 British Cohort Study (BCS70); National Child Development Study (NCDS); National Survey of Health and Development (NSHD); Born in Bradford (BIB); Understanding Society (USOC); Generation Scotland: the Scottish Family Health Study (GS); parents of ALSPAC (ALSPAC-G0); English Longitudinal Study of Ageing (ELSA). Adjusted for age, sex and ethnicity where applicable.
There were no major differences in the results after restricting to representative samples (Supplementary file 1).
Our study demonstrates marked inequalities in healthcare disruption during the COVID-19 pandemic by harnessing data from 12 UK longitudinal studies. Females were more likely to report healthcare disruptions than males, especially at younger ages (<55 years). This inequality was observed for each healthcare disruption type including prescription medication, procedures or surgery and appointments as well as a combined measure for any of these disruptions. Older adults were especially likely to report disruptions to medical appointments and procedures and surgeries compared with their younger counterparts. Ethnic minority (excluding white minorities) groups were more likely to report healthcare disruption compared with white (including white minorities) groups. Furthermore, when stratifying results by shielding status, the magnitude for the association between any healthcare disruptions among ethnic minority groups (compared with white groups) was higher among those who were shielding. In studies where a finer breakdown of ethnicity was possible, black ethnic minority groups had the most clearly increased odds of disruption compared with white ethnic groups. Occupational class was also found to be associated with healthcare disruption with those in a routine/manual occupation or other (which included never/long-term non-employed) being more likely to experience healthcare disruption than those in a managerial/professional occupation. No clear association between education and healthcare disruption was found in the main, age or shielding status-stratified analyses.
The direct burden of COVID-19 on health services across the globe has been colossal and remains so in some countries, with prioritisation of patients with COVID-19, leaving less capacity and resources for non-COVID-19 healthcare. Furthermore, associated repeated lockdown measures are also likely to decrease healthcare access and availability with a decrease in the number of people attending A&E services,4 and reports of difficulties accessing medication.9
Our findings are consistent with current evidence from a smaller subset of the studies examined here, suggesting that females are more likely to experience disruption to planned surgery, medical procedures or other medical appointments during lockdown.13 Furthermore, our results show that older adults were more likely to report healthcare disruption as compared with their younger counterparts, especially disruptions to medical appointments and planned procedures or surgeries. This finding is consistent with current UK evidence indicating that older adults experience more delays and disruption to health services.33–36 Black ethnic minority groups were also found to be at increased risk of healthcare disruption compared with white ethnic groups—an issue of particular concern given prepandemic ethnic inequalities in healthcare.37 The inequalities by occupational class we found are consistent with prior evidence of socioeconomic healthcare inequalities reported in the UK in the past decade,38 and highlight that these have still been present in the COVID-19 pandemic. Associations with occupational class were clearer than those for education, which is also an indicator of socioeconomic position but may have been a more distal influence.
The sex inequalities observed in this study could partially be explained by a disproportional increase in childcare responsibilities for women,39 which may have made it more difficult to access healthcare. However, in this study we adjusted for household composition and associations for sex were robust to further adjustment on this variable.
Our results also show that older adults were more likely to report healthcare disruption than younger adults. There are many reasons why older people may have experienced an increase in healthcare disruption during the COVID-19 pandemic compared with younger people, including fear of becoming infected while visiting a care facility, difficulties engaging in telemedicine (using technology to deliver care)33–35 and greater frailty, resulting in more healthcare utilisation and subsequent disruption.36
One explanation for the inequality in healthcare disruption among black ethnic minority group may be due to adverse effects of loss of income, unstable housing, increased psychological distress and reduced community support brought about by lockdown restrictions. Another explanation could stem from a disproportionate representation of ethnic minority populations among key workers, who are subjected to increased and antisocial working hours.
The analysis brings together data from 12 longitudinal studies with rich and sensitive information on healthcare disruption. This study is strengthened by the coordinated investigation in multiple longitudinal studies with differing study designs, different target populations and varying selection and attrition processes. Our combined approach provides the largest sample size available to prospectively investigate differences between ethnic groups, within representative population-based samples. What's more, though using non-response weights available, the proportion of ethnic minority groups within most studies is representative of the UK population. Moreover, the use of multiple studies increased statistical power to look at subpopulations such as ethnic minority groups across cohorts and allowed for greater examination of how inequalities were patterned by age. While not all 12 studies were representative of the population of interest, removing them in sensitivity analyses did not change our conclusions. Our novel approach to coordinated analyses harnessing multiple data sets therefore allowed research questions to be addressed which would not otherwise be possible.
Differences between studies in a range of factors including measurement of healthcare disruption, timing of surveys, design, response rates and differential selection into the COVID-19 sweeps are potentially responsible for heterogeneity in estimates. However, despite this heterogeneity, the key findings were consistent across most data sets. Furthermore, this heterogeneity can be informative, for example, by virtue of mixing age-specific and age range studies, we identified that sex inequalities were stronger at younger ages. The definition of healthcare disruption used may also have contained a range of disruptions of greater or lesser severity, and there may have been further inequalities in the severity of disruptions experienced; however, we were not able to assess this using the available data. We also could not assess prepandemic inequalities in healthcare disruption, though other studies have indicated massive increases in the prevalence of healthcare disruption (at least in part from the supply side with non-urgent procedures cancelled to reduce risk of infection transmission), and that inequalities related to geographic measures of deprivation (rather than individual-level measures as used here) have widened during the pandemic.5 40 41
We have focused on our aim of identifying who experienced greater disruptions in healthcare, rather than on adjustment for confounders to estimate causal effects of the exposures in question.42 Nevertheless, many of the associations we observed were robust to adjustment for a wider range of related variables, but bias due to residual confounding cannot be ruled out. Importantly, we did not condition our analyses on healthcare need. Many of the inequalities we observed for healthcare disruptions may be due to inequalities in health, with those who have greater health needs being more likely to require healthcare that could be disrupted. Accounting for differences in need could have masked inequalities in healthcare disruptions that are caused by inequalities in health and could have made it less clear which groups have been more likely to experience disruption during the pandemic. Restricting analyses to those who needed care could also induce bias if there were unmeasured determinants of both need and disruption.43 Nevertheless, another study of the USOC data analysed here that did restrict analyses to those needing care still found income-related inequalities in healthcare disruption, and most of the associations we observed were robust to adjustment for prepandemic self-assessed health.44
Impact of healthcare disruption
Disadvantaged groups such as females, older adults, black ethnic minority groups and those in routine/manual occupations have had elevated odds of healthcare disruption in the first 8–10 months of the COVID-19 pandemic.
Delays and disruptions to treatment could have ongoing implications for patients' physical and mental health.45 Action is needed to remedy these inequalities, and efforts to ensure continuity of care during pandemic-related disruptions may need to be more clearly targeted to those who most need that care. Actions to alleviate healthcare disruption inequalities critically rely on better understanding the causes. For example, barriers to accessing care, such as working hours or fear of infection, may require measures to make care more accessible outside of working hours, or to increase public confidence that patients can attend safely.
As healthcare access resumes, given the forgone delays in treatments and the subsequent backlog of postponed surgeries,46 these groups may require prioritised support to address unmet needs experienced during the pandemic.
There have been clear inequalities in disruptions to healthcare during the COVID-19 pandemic in the UK. Females (especially those aged 54 or younger), older adults, ethnic minorities and those in disadvantaged occupational classes have been more likely to experience healthcare disruptions. These are groups who usually experience worse health, so considering the massive increases in the prevalence of healthcare disruptions related to COVID-19, these inequalities in disruption have clear potential to maintain or even exacerbate existing health inequalities.
Ethics statement and data access details for each study can be found in online supplemental table S2 in supplementary file 4.
The contributing studies have been made possible because of the tireless dedication, commitment and enthusiasm of the many people who have taken part. We would like to thank the participants and the numerous team members involved in the studies including interviewers, technicians, researchers, administrators, managers, health professionals and volunteers, including: Generation Scotland: Drew Altschul, Chloe Fawns-Ritchie, Archie Campbell, Robin Flaig; ALSPAC: Daniel J Smith, Nicholas J Timpson, Kate Northstone; Understanding Society: Michaela Benzeval; TwinsUK: Deborah Hart, María Paz García, Rachel Horsfall, Ruth C E Bowyer; Centre for Longitudinal Studies: Matt Brown, Lisa Calderwood, Emla Fitzsimons, Alissa Goodman, Aida Sanchez; NSHD: Andrew Wong, Maria Popham, Karen MacKinnon, Imran Shah, Philip Curran. We are extremely grateful to all the families who took part in this study, together with the interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. We are additionally grateful to our funders for their financial input and support in making this research happen.
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Twitter @_JaneMaddock, @di_gessa, @green_mjg, @EllenJoT, @RJ_Silverwood, @gabycaptur
JM, SP, GDG, MJG and EJT contributed equally.
Contributors SVK, GBP, JM, SP, GDG, MJG and EJT conceptualised the study and design. SVK, GBP, JM, SP, GDG, MJG, EJT and RJS designed the methodology. JM, SP, GDG, MJG, EJT, AJS, ASFK, EM and GS conducted the formal analysis. JM, SP, GDG, MJG and EJT drafted the manuscript. All authors contributed to critical revision and provided final approval of the manuscript. The project was supervised by GBP and SVK. Funding was acquired by PP, SVK, GBP, RJS and NC. JM, SP, GSG, MJG, EJT, ASFK, EM, GS, GBP and SVK are responsive for the overall content and guarantor.
Funding This work was supported by the National Core Studies, an initiative funded by UKRI, NIHR and the Health and Safety Executive. The COVID-19 Longitudinal Health and Well-being National Core Study was funded by the Medical Research Council (MC_PC_20030). Understanding Society is an initiative funded by the Economic and Social Research Council and various government departments, with scientific leadership by the Institute for Social and Economic Research, University of Essex, and survey delivery by NatCen Social Research and Kantar Public. The Understanding Society COVID-19 Study is funded by the Economic and Social Research Council (ES/K005146/1) and the Health Foundation (2076161). The research data are distributed by the UK Data Service. The Millennium Cohort Study, Next Steps, the 1970 British Cohort Study and 1958 National Child Development Study are supported by the Centre for Longitudinal Studies, Resource Centre 2015-20 grant (ES/M001660/1) and a host of other cofunders. The 1946 NSHD cohort is hosted by the MRC Unit for Lifelong Health and Ageing funded by the Medical Research Council (MC_UU_00019/1 Theme 1: Cohorts and Data Collection). The COVID-19 data collections in these five cohorts were funded by the UKRI grant: Understanding the economic, social and health impacts of COVID-19 using lifetime data: evidence from 5 nationally representative UK cohorts (ES/V012789/1). The English Longitudinal Study of Ageing was developed by a team of researchers based at University College London, NatCen Social Research, the Institute for Fiscal Studies, the University of Manchester and the University of East Anglia. The data were collected by NatCen Social Research. The funding is currently provided by the National Institute on Aging (Ref: R01AG017644) and by a consortium of UK government departments: Department for Health and Social Care; Department for Transport; Department for Work and Pensions, which is coordinated by the National Institute for Health Research (NIHR, Ref: 198-1074). Funding has also been provided by the Economic and Social Research Council (ESRC).The UK Medical Research Council and Wellcome Trust (grant reference: 217065/Z/19/Z) and the University of Bristol provide core support for ALSPAC. A comprehensive list of grants funding is available on the ALSPAC website (http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf). TwinsUK receives funding from the Wellcome Trust (WT212904/Z/18/Z), the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London. TwinsUK is also supported by the Chronic Disease Research Foundation and Zoe Global. Generation Scotland received core support from the Chief Scientist Office of the Scottish Government Health Directorates (CZD/16/6) and the Scottish Funding Council (HR03006). Genotyping of the GS:SFHS samples was carried out by the Genetics Core Laboratory at the Wellcome Trust Clinical Research Facility, Edinburgh, Scotland, and was funded by the Medical Research Council UK and the Wellcome Trust (Wellcome Trust Strategic Award 'STratifying Resilience and Depression Longitudinally' (STRADL); reference: 104036/Z/14/Z). Generation Scotland is funded by the Wellcome Trust (216767/Z/19/Z). Born in Bradford (BIB) receives core infrastructure funding from the Wellcome Trust (WT101597MA), and a joint grant from the UK Medical Research Council (MRC) and UK Economic and Social Science Research Council (ESRC) (MR/N024397/1), and one from the British Heart Foundation (BHF) (CS/16/4/32482). The National Institute for Health Research Yorkshire and Humber ARC and the Clinical Research Network both provide support for BIB research. SVK acknowledges funding from an NRS Senior Clinical Fellowship (SCAF/15/02), the Medical Research Council (MC_UU_00022/2) and the Scottish Government Chief Scientist Office (SPHSU17). ASFK acknowledges funding from the ESRC (ES/V011650/1). EJT acknowledges funding from Wellcome Trust (WT212904/Z/18/Z). GBP acknowledges funding from the Economic and Social Research Council (ES/V012789/1). GC acknowledges funding from British Heart Foundation Special Programme Grant SP/20/2/34841
Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.
Competing interests SVK is a member of the Scientific Advisory Group on Emergencies subgroup on ethnicity and COVID-19 and is cochair of the Scottish Government's Ethnicity Reference Group on COVID-19. NC serves on a data safety monitoring board for trials sponsored by AstraZeneca.


A pretty little Italian girl skips outside to peer up at the unexpected drone of aeroplanes, unaware of the danger as her neighbour, an eccentric opera singer, fervently prays for her teenage son. It is the start of WWII. An age difference of thirteen years separates the little girl Mariolina Martore and the army officer Eugenio Piergiovanni, but their lives are destined to intertwine.
Mariolina is a timid but stalwart child who lives with her mother and grandmother. During the war years, they endure bombings, cold, hunger, and disease in Torino, Northern Italy.
In contrast, Eugenio, a teenage soldier, is captured and spends six years in African prisoner-of-war (POW) camps—one of which boasted 63,000 prisoners at one time. Eugenio's transition into adulthood during captivity, as told through his diaries, makes for bittersweet humour as he strives to find laughter in sad situations.
Goodbye to Italia is a non-fiction romantic story of Italian drama, courage, and humour. So as to stay true to the retelling by my mamma and papa, and to capture the essence of living through those times, the chapters in the first half of the book interchange between the two diverse characters, Mariolina and Eugenio, as they come of age.
This wasn't my life to begin with. It wasn't my body either. I inherited both, and more, from Mouse. Mouse created me. She had created another life when she was four so she knew how. That's what people with Dissociative Identity Disorder do. You see, terrible things happened to Mouse when she was very young, so she decided to simply stop growing up when she was eight. Her body aged but she didn't. At eleven, when something even more despicable happened, Mouse froze herself in time, leaving her life, body, and name to me. Mouse remains an afraid and damaged young girl, living in The Deep inside of us. But don't worry, she isn't alone. My name is Jade and I am an alternate personality – the main personality but an alternate nonetheless. I live in this body with Mouse and the other alters: Peter, Neil, Jane, Zen, Nancy, Ray, and Lucy. For over twenty years there had been no more splitting, no one new. Then Anne came along, making alter number ten. This book is the first part of our journey integrating Anne into her new life. It was her idea to write about it and both our ideas to dedicate this book to Mouse … Our Frozen Mouse – the author of us all.
Twins David and Dennis Pischke's lives change forever when their father dies, and a man damaged by the war arrives at their farm near the isolated town of Moosehorn, Manitoba. Boleslaw Domko quickly works his way into their lives and their mother's bed.
"Where Children Run" opens with one of their earliest memories—the day Domko throws their infant stepsister against the wall. In this first-hand account, the Twins recall years of neglect, starvation, and enslavement; horrific beatings and candlelit nights spent in the nearby St. Thomas Lutheran Church. Neighbors intervene, but their efforts provide only temporary relief as the children's mother—also living in fear—refuses to press charges.
The brothers vow that if they survive, they will someday expose their tormentor and members of their mother's religious organization who turned a blind-eye to their suffering. This is their story—told with stark honesty and in heart-wrenching detail.
"Where Children Run" is a timeless, unforgettable book about survival; and a powerful testament to the strength and adaptability of the human spirit.
What was it like to be a Jewish teenager in Europe during World War II? One who couldn't escape or hide but who faced the Nazis head on and survived? Abe-vs-Adolf is the captivating tale of a boy who made it through nine different concentration camps, losing everything but his determination to live. Abe Peck was only fourteen when the Germans invaded Poland, took over his community and forced his family into a rundown ghetto. Over the next five horrific years, as a prisoner and slave in camps like Auschwitz and Buchenwald, Abe endured unimaginable cruelty. What got him through the relentless horror and atrocities? His only way to beat Adolf Hitler was to live to tell about it. As the sole living Holocaust survivor from his entire town, Abe is the only one left who can tell us what really happened to his civilized society when evil took over.
"Walt and Lee Jourdan have created something special. The voice of the book resides in Walt's voice-similar to Jake Lamotta's "Raging Bull" and Louie Armstrong's autobiography. Five Stars" ~ Paul Croshaw, Writer/Director.
Little Walt is a nine-year-old Colored boy in 1937 Oakland, California. The Great Depression is in full swing, offering little opportunity for Little Walt to do more than shine shoes and sell magazines to help his family make ends meet.
Big Walt, his father, quit school after eighth grade, but applied his resourcefulness to own and operate several businesses, including a boarding house, barber shop, cab company, gas station, a baseball team, a used car lot, and an illegal gambling house.
Little Walt had to use his own resourcefulness to break the mold, and he went on to achieve success on the gridiron, as a sailor in the Korean War, and in a society bent on maintaining a culture of subservience for African Americans.
But it was not to be a smooth upward trajectory for Little Walt. He struggled to maintain focus after family tragedies, and faced many obstacles, both cultural and personal, as he endeavored to raise a family – ultimately ending in a place no one could have predicted when he lugged his shoeshine box ten miles a day as a nine-year old boy.
Forewords by Randall Cunningham, NFL MVP, and Susan Toler Carr, daughter of the first Black NFL official.
Award-winning film and television writer, producer and director David Brady's work is best known in Canada, but not stranger to U.S. and European audiences. He has been the President of four film and television production companies. All of his work has been critically acclaimed, including two Golden Globe Nominations for Best Foreign Picture, Best Actor. Productions he has produced have 7 Canadian Academy Awards, a Banff Television Festival nomination and nearly a dozen US Film & Video Awards. He has produced for such networks as The Disney Channel, Discovery, The Smithsonian Channel, TLC, CBC, CTV, France 5, Fox Tel to name just a few.
His road to success was filled with childhood trauma that led to substance abuse and massive debt. His book provides a simple 8 Step formula to help you find a solution to the effects of growing up in an alcoholic or dysfunctional family.
David received an MFA from York University in Toronto and was an undergraduate and graduate student at Simon Fraser University in Vancouver, BC. David has been on the faculties of three universities, York and Ryerson University in Toronto and Capilano University in North Vancouver, British Columbia.
In the Service of Community an Honored Elder: The Honorable Judge Perry Brooks Jackson traverses the life of Judge Jackson, the first African American judge in Ohio, from birth to his death and beyond, noting his challenges and achievements and continued significance. The book is an Indie Book Award finalist in two categories: Autobiography/Biography and African American. It is also a Readers' Favorite finalist in the category of biography.
Six years into a clinical career, anonymous mental health worker, Clyde Dee, starts work in a notorious Section 8 housing project. Getting to the bottom of what's going on in a fractured system, Clyde finds himself mysteriously compelled to break the codes of standard drug war conduct. After six months of uncanny threats and coincidences, he decides to go off a low dose of anti-psychotic medication. Stopped by police in an effort to exit the country, he ends up incarcerated in a State Hospital for three months and released to the streets. In the years that follow, Clyde moves through American disparities and cultural delusions, facing some of his worst fears come true.
Clyde's story reveals both the innards of "Schizophrenia" and how a person can learn to make peace with the forces that are following them around. With the mob breathing down his neck, Clyde is able to overcome homelessness, underemployment, and harassment. He is able to morph into someone who is fighting to gain attention for his successes in treating others who are in the throes of a "psychotic"
New York City. 1968. I was 24. I had just graduated from college. I applied to VISTA (Volunteers in Service to America) as a possible deferment from the Army and Vietnam. I was young and I thought I knew everything. I figured if they had VISTA in any state they had to have VISTA in every state. I requested an assignment in Hawaii.
Kirkus Reviews said Sleetmute is "incredibly entertaining" and also "Resnicoff's encounters fascinate not only because they introduce readers to a world few have ever seen, but also because he's a gifted storyteller. He channels his 24-year-old self's confusion and naïveté in a way that is by turns hilarious, endearing and often quite moving".


The right exercise prescription can increase your resilience, reduce depression and anxiety, help manage your mood and help you sleep instead of worrying about all the things that could keep you up at night. All of these benefits are great for you – but also for your assisted reproductive treatment. Bonus!
With the stress that comes with fertility treatment it pays to increase your self-awareness of your mental well being and your ability to 'bounce back'. Knowing how you cope with stressful situations can help you recognise that you may need to develop strategies to keep you on track when faced with the challenges of fertility treatment. Take the brief resilience coping scale quiz to find your resilience score.


Despite their heroics during World War I, the British officers of the Royal Air Force did not believe that Indians were capable of waging war from the air.
They were considered inferior, and the fledgling Indian Air Force (IAF) was equipped with outdated machines and forced to operate in impossible working conditions. Harjinder Singh, a determined orphan, entered this military world in mid-1930s as a lowly sepoy, and yet thanks to his courage, determination and sheer skill, he enjoyed a meteoric rise over three decades of service, becoming one of the leading figures of the IAF - a thrilling career that spanned World War II, Indian independence and the carnage of Partition. Using an extensive collection of personal diaries, notes and letters with a thread of humour throughout, Spitfire Singh unleashes this untold story - one of mutual respect forged and strengthened across lines of religion, caste, creed and race.


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Economy|The Promise of Today's Factory Jobs
Economic Scene
The Promise of Today's Factory Jobs
By Eduardo Porter
To hear Mike Bink, one might believe American manufacturing is about to recapture its lost glory.
Master Lock, which has made locks in Milwaukee since 1921, has brought 100 jobs back from China over the last year and a half. And Mr. Bink, who has worked at the plant for 33 years and heads the United Auto Workers local, is sure more will follow. "They are making a lot of capital investment; buying a lot of new equipment," he said. "That will create more jobs."
Master Lock's story dovetails nicely with the budding upturn in manufacturing employment, which has rekindled hope across a Rust Belt pummeled by 30 years of job loss. Nationwide, factories have added 400,000 jobs in the last two years, the first sustained bout of growth since the 1990s, replacing about a fifth of the positions lost during the recession. Other companies, from Otis to General Electric, are bringing home jobs once thought lost for good.
Mr. Bink's enthusiasm has echoed from the factory floor all the way to Washington. During his State of the Union Message, President Obama wove Master Lock's tale of repatriated jobs into a narrative of recovery that could serve him well in November. "We have a huge opportunity, at this moment, to bring manufacturing back," the president said. "But we have to seize it."
To do so, his administration has proposed a piñata of tax breaks and incentives intended to transform the incipient movement into a new golden age for factory jobs.
Things have not looked this promising for manufacturing jobs in a long while. Rising costs in China — where the government is letting the currency gain against the dollar and wages are rising at a double-digit pace — are making it more attractive for American companies to produce at home. Expensive oil adds to the cost by pushing up the price of freight.
Yet a revolution in manufacturing employment seems far-fetched. Most of the factory jobs lost over the last three decades in this country are gone for good. In truth, they are not even very good jobs.
As much as the administration needs a jobs strategy, one narrowly focused on manufacturing is unlikely to deliver.
Much of the anxiety about factory jobs is based on the misconception that job losses have been due to a sclerotic manufacturing sector, unable to compete against cheap imports. Until the Great Recession clobbered the world economy, manufacturing production was actually holding its own. Real value added in manufacturing, the most precise measure of its contribution to the economy, has grown by more than two thirds since its heyday in 1979, when manufacturing employed almost 20 million Americans — eight million more than today.
American companies make a smaller share of the world's stuff, of course. But what else could one expect? Thirty years ago China made very little of anything. Today its factory output is almost 20 percent of world production and about 15 percent of manufacturing value added.
Maurcie Johnson, left, and Diandre Jackson stacked locks at the Master Lock plant in Milwaukee in January.Credit...Andy Manis/Bloomberg News
What's surprising is how little the United States lost in that time. American manufacturers contribute more than a fifth to global value added.
Manufacturers are shedding jobs around the industrial world. Germany lost more than a fifth of its factory jobs from 1991 to 2007, according to the United Nations Industrial Development Organization, about the same share as the United States. Japan — the manufacturing behemoth of the 1980s — lost a third.
This was partly because of China's arrival on the world scene after it joined the World Trade Organization in 2001. Since then, China has gained nearly 40 million factory jobs. But something else happened too: companies across the developed world invested in labor-saving technology.
Consider Master Lock. Its Milwaukee plant is operating at capacity for the first time in 15 years, before it started sending work overseas. It is producing much more stuff than it did back then. But it is doing so with 412 workers — about 750 fewer than it had 15 years ago.
"They used to throw bodies at something to get the job done," said Ron McInroy, the U.A.W.'s head for the region encompassing Milwaukee. "Now they look at the best utilization of manpower and the best utilization of machines."
So it is across the economy. In his forthcoming book, "The New Geography of Jobs," the University of California, Berkeley, economist Enrico Moretti points out that the average American factory worker makes $180,000 worth of goods a year, more than three times what he produced in 1978, in today's dollars.
It may not matter to factory workers who lost their jobs. Whether forced out because an employer moved production to China or because a fancy new machine makes it easier to compete against a rival in China, the job is gone.
Still, the distinction is important. Without an understanding of the forces at work, policy makers' attempts to bolster manufacturing could backfire.
One thing is clear. Most of the jobs lost to China and other poor countries cannot "come back." They don't pay anywhere near enough. And they don't exist here anymore anyway.
The factory jobs we really want will be fewer and will require more education. But they will pay more.
Credit...Source: United Nations; Credit: The New York Times
Remember agriculture? In the 1960s, plant scientists at the University of California, Davis, developed an oblong tomato that ripened uniformly, and its engineers developed a machine to harvest it with one pass through the fields. By the 1970s the number of workers hired for the tomato harvest in California had fallen by 90 percent.
In the book "Promise Unfulfilled," Philip Martin, an economist at the university, says that in 1979 the worker advocacy group California Rural Legal Assistance sued the university for using public money on research that helped agribusiness at the expense of farm workers. And in 1980, Jimmy Carter's agriculture secretary, Bob Bergland, declared that the government wouldn't finance any more projects aimed at replacing "an adequate and willing work force with machines."
It's hard to say that workers won this battle, however. After Mr. Bergland pulled the plug, research on agricultural mechanization came to a near-halt. Yet farm work today remains probably the worst paid, most grueling job in the United States.
A tricky thing to understand is that most jobs in the United States are created in areas of the economy not exposed to global competition. They are nannies and doctors, lawyers and roofers. In a recent study, the Nobel laureate Mike Spence and Sandile Hlatshwayo of New York University found that the part of the economy that does not have foreign competitors added 27.3 million jobs from 1990 to 2008. The sector that competes in global markets added virtually none.
This doesn't mean the administration should ignore manufacturing. We need world-class, innovative industries that compete in global markets. They won't add a ton of jobs precisely because they must stay lean to compete. But they will pay for those jobs.
The 33,000 Apple workers in Cupertino, Calif., sustain 171,000 additional jobs in the metropolitan area, Mr. Moretti estimates.
This pattern suggests, however, that a jobs strategy should take care not to blunt the edge of our most competitive firms. If outsourcing sharpens their edge on world markets, punishing then for doing so could destroy American jobs.
More important, perhaps, manufacturing is not the nation's only cutting-edge industry. Many of the most innovative firms are not manufacturers but service companies. Apple is very competitive. But so are the companies that design applications running on its iPhones and iPads. Hollywood studios and marketing companies are big exporters. These firms need highly trained workers and pay high wages.
Mr. Moretti says each job in an "innovation" industry, broadly understood, creates five other local jobs, about three times the number for an average job in manufacturing. Two of them are highly paid professional positions and three are low-paid jobs as waiters or clerks.
Innovation — not manufacturing —has always propelled this country's progress. A strategy to reward manufacturers who increase their payroll in the United States may not be as effective as one to support the firms whose creations — whether physical stuff or immaterial services — can conquer world markets and pay for the jobs of the rest of us.

redpajama_set_name: RedPajamaCommonCrawl


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Democrats propose a new path for immigrants protected by DACA and TPS
AL DIA News
With the so-called Dream and Promise Act, the Democratic majority in the House of Representatives aims to solve the situation of thousands of immigrants in the country.
by Yamily Habib
Democrats propose a new path for immigrants...
Let's make it clear beforehand: any proposal introduced by a coalition of representatives - even if approved in the House - goes through a long process of modifications to be negotiated in Congress.
That is to say, that even when Democrats have all the intentions of opening a path towards citizenship for millions of immigrants, the journey to make it a reality is quite arduous.
However, gestures such as the introduction of the Dream and Promise Act on Wednesday indicate a strong determination on the part of the Democratic Party not only to keep promises but also to maintain a clear message and a marked distance from the presidential rhetoric.
After winning the majority in the House during the mid-term elections, the new Speaker of the body, Nancy Pelosi, promised in December, "to approve legislation that grants the so-called Dreamers a path to citizenship," arguing the need to antagonize, "the Republicans' destructive anti-immigrant agenda."
Three months later, under the authorship of the representatives Lucille Roybal-Allard (D-CA), Nydia M. Velázquez, Yvette D. Clarke (D-NY), Steny Hoyer (D-Md.) and Pelosi herself, the Democratic party has taken the first step towards the fulfillment of the promise.
H.R.6 combines the former Dream Act, "with a proposal to allow some immigrants with temporary humanitarian protection to apply for permanent legal status," explains Vox.
Among them are the undocumented youth who arrived in the country as children (Dreamers), protected under the Deferred Action Program (DACA), and citizens from countries destroyed by natural disasters or wars and who have Temporary Protection Status (TPS).
The Trump Administration has threatened both programs since the beginning of its management, putting millions of immigrants at risk of being deported.
"We are not going to allow Donald Trump to send them back, and we are not going to ask them to live in a constant state of fear and uncertainty," Rep. Velázquez said at a press conference.
Similarly, the proposal poses a path to citizenship for thousands of Liberians under the Deferred Enforced Departure (DED), according to NBC News.
However, this is not the first time that Democrats have tried to approve such a measure.
With a House-majority in 2010, the representatives approved the so-called DREAM Act, but didn't get the necessary votes in the Senate to transform it into law.
Thanks to the current divisionism regarding the immigration issue and the intransigence on the other side of the aisle regarding a bipartisan approach, it's possible that this new proposal - which is also much more ambitious – won't be approved either.
However, it demonstrates a new strength behind the Democratic commitment that has been growing in recent years and, with presidential primaries at the gates, seems to guarantee that immigration will be the bone of contention in 2020.
More in Immigration
New migrant caravan shows no improvement in living conditions in the Northern Triangle
Cuban immigrants: caught between Trump's foreign policy and his election campaign
Federal ruling definitively blocks funds for Trump's border wall
One Year After Jakelin Caal's Death, Little Has Changed for Immigrants in U.S. Custody
New Democratic majority in the House is determined to save DACA
DACA to the Supreme Court: the day is here
"Home is Here," a new campaign to save DACA


Projects |Projects – Aquila Resources Inc.
Aquila is focused on developing high-grade poly-metallic assets in the Great Lakes Region.
Aquila's three assets, the Back Forty Project located in Michigan's Upper Peninsula, Bend Project and Reef Project, are found along the mineral-rich Penokean Volcanic Belt. The area hosts multiple deposit types including VMS, magmatic copper-nickel and stratiform copper. The Upper Peninsula is home to other projects, including Lundin Mining's Eagle Mine and Highland Copper's White Pine North and Keweenaw projects.


The cycle The Viola in My Life was begun in July 1970 in Honolulu (composed especially for Karen Phillips, resident performer at Hawaii University) and consists of individual compositions utilising various instrumental combinations with the viola.
The attention demanded by Feldman's music – so soft that it can almost not be heard – is so uniform that it suggests the idea of a surface. We are never quite sure where the sounds are coming from. Time, articulated in most music by rhythm, is perceived as being static. Each sound floats in space, is entirely independent of what has gone before and what has yet to come. Sounds do not progress but merely accumulate in the same place.
The Viola in My Life is a gorgeous succession of delicate sounds in which Feldman, through the interaction of sound and silence, conjures up a desolate magic on a plane where time is somehow altered, transformed.


Italian glass car boot finds, or are they?
Topic: Italian glass car boot finds, or are they?
A similar Alrose vase is on Ebay, there is no label on mine.
The bohemian urn has a lot of irregular scratches to the base if that's any help dating it. Shame there isn't any other way to date glass.
The vase on ebay doesn't really look like the pieces in the Pina book in any case. There's the optic ribbing for one thing, and secondly the ebay one looks modern (i.e. new) to me.
With luck someone on the Murano board will be able to help.
Re: Italian glass car boot finds, or are they?
Here's a selection of their glass. You might like to have a peek.
Unless I'm very much mistaken, I'm sure there are a few in there that I've seen on this board. This glass seems to be common around my area.
Here's another one that I've had.
I knew I'd seen these before on a U.K. website - http://www.jazzitupjewellery.com/cat336_1.htm?source=overture Although it doesn't actually say where they were made.
Its interesting that yours had a Cello sticker. I've got a large vase with a Cello sticker and haven't been able to find out anything about it. I came to the conclusion that it was most likely Polish.
None of my items have a Cello sticker on them but I did see something like one with a Cello sticker on it. It may have been in a shop called "Collectables". It sells lots of things, not just glass.
Just to add to the list, similar glass by Makora which is also in Krosno.
I've found a vase on ebay which is identicle in shape to my vase. I'm just wondering if anybody can identify the maker by the label?
The glass flowers on the link Anne provided are Chinese. I received an e-mail from the manufacturer wanting me to carry them on my website.
Go here and click on the colored glass links.


Copy and paste the Jet's Pizza coupon best gift for your loved ones code in the box next to clinique free gift macys 2017 the product and click "Apply" or "Submit".
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MagLiteracy
Share the literacy love.
Literacy ends poverty. With magazines for every reading age, interest, and language, magazines and comics are the most powerful literacy engines on the planet. Our passion is to create the largest literacy marketplace in the world!
The seed for MagLiteracy.org was planted in 1994, while organizing community hunger relief efforts. Realizing that homes without food, a basic necessity, had very few reading materials – a major factor contributing to a cycle of illiteracy and poverty for children and families – we knew that magazines and comics were special and untapped for literacy. In fact, two-thirds of U.S. children in poverty live in homes with zero books. So, MagLiteracy.org set out to share the reading materials that we all love to feed children and families hungry to read.
The Magazine Publishers Family Literacy Project – a 501(c)(3) charity – was launched in time to celebrate the United Nation's International Literacy Day in 2004 with a mission to deliver the joy of reading magazines and comics to at-risk children and families, while strengthening their literacy skills and self-esteem. Since then, we've supplied new and recycled magazines and comics to hundreds of thousands of at-risk children and families across the U.S. and around the globe. Our earliest successes were made possible by financial support from Austin Kiplinger and his family, generous annual grants from Foster Printing, and sponsorship from the Majeski Foundation, Pretium Partners, Prince Sports, and Stacie Jones, a Harlem Subway Sandwich Shop owner.
With favorite new magazines and comics sponsored by local businesses and consumers, and surplus and gently read, recycled magazines and comics rescued from throughout the supply chain, and with generous support from publishers, printers, paper companies, logistics and shipping companies, newsstand suppliers, and consumers – MagLiteracy.org puts wonderful reading materials into the hands, homes, and hearts of children and families who want to learn and love to read.
Reading is where it all begins. We've accomplished much, but there are so many more at-risk readers to reach.
How we do literacy
Consumers love to share their deep enthusiasm for favorite media, and publishers love to create readers for good. Like a food bank feeding the mind, we establish and manage the partnerships and logistics across the entire publishing supply chain – from paper companies and printers to publishers and consumers – that deliver desired magazines and comic books from where they are located to literacy programs, and into the hands, homes, and hearts of eager at-risk readers.
Consumers and businesses donate funds to buy bulk copies and subscriptions for at-risk readers.
Consumers buy newsstand magazines and comic books to read, and then recycle them for literacy.
Consumers and businesses recycle magazines and comic books from home, work, and school. Our first recycling project was organized by a classroom of kindergarten students for children in a nearby homeless shelter.
Publishers recycle back issues for literacy, tell our stories, print PSA display ads, and partner on gift promotions.
Grassroots volunteer teams find literacy needs in their communities, raise funds, and deliver magazines and comic books to meet literacy needs via our online literacy marketplace and literacy newsstands.
Read our stories to learn more.
Contact us with questions or ideas.
Join us to iMAGine what's possible and to make it so.
Join teams
Recycle magazines & comics
Get magazines & comics for literacy
MagLiteracy, Powered by WordPress.com.


View Poll Results: Which is good if you do VGA?
Well Where are you placing? ?
Thanks for the suggestion! Aha!
Exhaust is very trouble, too.
I am now, SSDx4 in RAID0 + HDDx1 we plan to build the system.
I'm looking for the location of SSD.
What tool will I need?
Also what fan size will fit there?
Looks like its comming out really nice! Very sweet looking build, I want to se the ending result!
I disbelieve in separation. I close my eyes to see you.
This is for you, everything I am. This is for you, take it from me.
Breathe me in. I am forever. Deep within I am eternal.
I will return to you. I am with you always. I will never turn away from you.
You are welcome to to the HSB with 14cm fan!
Last edited by Psydrop; 12-03-2009 at 08:14 AM.
Nice build so far, waiting for some more updates!
Nice work noeru! My next pc will be built in a 800D and you are answering me many questions with your photos ;-) Thanks!
Thank you, I'm now waiting for the arrival of several pieces of parts.
I would go with having them in the 5.25" bay.
In the top of case should be outlet of hot air (hot air goes up) nad in the bottom or lover parts should be air intake. That's a better solution IMO.
Looking good! I was wondering how to fit two rads in that box and this has given me some great ideas. Awesome job with the modifications, very clean.
I guess that mobo will be also watercooled. So then it produces much less hot air (radiation) then only AC mobo. The difference will not be much different 2-3*C.
The best will be to try both solutions while checking temps.
In my case i got intake in the bottom and air outlet in the top and it works.
Thank you for your valuable opinions!
Unified treatment of the black cable very very thanks MDPC!
Last edited by noeru; 12-11-2009 at 05:51 PM.
And I'm not used to fill the hole mesh cable to the back panel, but Eternal Hot air to dissipate it is important for me.


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Printmaking, Sculpture, and Installation
Leslie Friedman on a Subway Billboard!
This Fall, Philadelphia's Artists Take to the Streets
MADE IN PHILLY: Now on a Block Near You
50 Works of Art Take Over Advertising Spaces Throughout Philadelphia and Celebrate the City's Creative Renaissance
Philadelphia, PA – The Center for Emerging Visual Artists and leading sponsors The John S. and James L. Knight Foundation, Greater Philadelphia Tourism Marketing Corporation, and With Art PhiladelphiaTM are proud to announce the launch of Made in Philly in conjunction with the 2013 Philadelphia Open Studio Tours. The campaign showcases the extraordinary quantity and quality of visual art being produced in Philadelphia and connects each work displayed to the neighborhood (even block) where it was created. Beginning the first week in September, look for large-scale artwork images on bus shelters, rail platforms, and billboards across the city…and in October, visit the studios of the artists who made them. For more details on the campaign and the 2013 Tours, visit philaopenstudios.org.
At the York and Dauphin stop of the Blue Market-Frankford Subway line, a billboard showing the work of Leslie Friedman will be on display on the platform. The Coke Zero Cans depicted in the ad were in fact made 8 blocks from the subway station at her studio in Viking Mills, an old factory building in New Kensington. Known for her brightly colored, Pop inspired installations, Friedman's work is exhibited in Philadelphia and outside the city both nationally and internationally. The cans were last shown at Space 1026 in July 2013 in a show entitled "Tastier."
Click Made_In_Philly_Press_Release for the full press release.
September 7, 2013 September 7, 2013 Categories: News
Title Magazine Reviews 'Tastier'
NAPOLEON at Traction Company: As first as exactly


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You are here: Home » Featured » Artist Updates: Old Dominion, Robby Johnson, The Cadillac Three
Artist Updates: Old Dominion, Robby Johnson, The Cadillac Three
Jessica Nicholson • November 14, 2016
Old Dominion Supports Rock The Cradle, Hats Off For High Hopes Charities
Rock The Cradle, an event created by Music Row executives Connie Bradley and Troy Tomlinson to raise money for Saint Thomas Midtown Hospital's Beaman Neonatal Intensive Care Unit, celebrated its seventh year on Tuesday, Oct. 25 at Loveless Barn in Nashville, Tenn. The event featured a special performance by American Music Awards nominee Old Dominion, and included a cocktail reception, dinner, silent and live auction for attendees.
This year's Rock The Cradle raised more than $100,000 for obstetrics care and cutting-edge technology in the Beaman Neonatal Intensive Care Unit, and also provides financial assistance to those patients with urgent needs.
"My baby was born and swept right into the NICU," shares Old Dominion lead singer, Matthew Ramsey. "I know first-hand the fear and stress that comes along with that. It takes a special type of person to take care of the little ones who need extra attention, as well as comfort the families. They are truly angels. Playing Rock The Cradle was a no brainer for us. It was an honor to be able to help and give back in our own way."
Old Dominion's Trevor Rosen and Matthew Ramsey also performed at the benefit concert Hats Off For High Hopes last night (Nov. 13) at the Ryman Auditorium. Joining them were hitmakers including Shane McAnally, Josh Osborne, Tim Nichols, Matt Jenkins, Marv Green and Lee Thomas Miller.
Pictured (L-R): Lee Thomas Miller, Matt Jenkins, Shane McAnally, Tim Nichols, Trevor Rosen, Josh Osborne, Marv Green, Matthew Ramsey, Gail Powell, Executive Director of High Hopes, Cheryl Dean, Public Relations and Marketing Coordinator. Photo: Tausha Dickinson
Robby Johnson Releases Deluxe Edition Of Debut Album Don't Look Back
Celebrating the start of the holiday season, Robby Johnson has released three new songs in a deluxe edition of his debut album, Don't Look Back, which was initially released in early 2016.
Johnson's Don't Look Back (Deluxe Edition), is being distributed online and at retail stores worldwide via a freshly inked deal with Sony Music. The bonus tracks included are "Ring, Ring, Ring," "I Got Your Back," and his breakout single, "South Of Me." With a purchase of the deluxe edition before the end of this year, fans will also be gifted Johnson's recordings of two Christmas classics: "Happy Xmas (War Is Over)" and "Rudolph, The Red Nosed Reindeer."
The Cadillac Three Teams With Monster Energy For The Black Roses Tour
The Cadillac Three will launch The Black Roses Tour – as part of the Monster Energy Outbreak Tour Series – on Jan. 19 in Memphis, Tennessee, crossing the U.S. to the final stop in Sacramento, California on March 17. The 28-city headline run follows The Cadillac Three's successful fall tour in Europe, summer trek with Florida Georgia Line and the release of their new album Bury Me In My Boots (Big Machine Records). Tickets will go on-sale this Friday, Nov. 18 at 10 a.m. local time in each city.
Special guests Aubrie Sellers, Brent Cobb, Ray Wylie Hubbard and Quaker City Night Hawks will alternate as support on select dates. For the full tour dates, see below and for tickets, visit: thecadillacthree.com/tour.
Jessica Nicholson serves as the Managing Editor for MusicRow magazine. Her previous music journalism experience includes work with Country Weekly magazine and Contemporary Christian Music (CCM) magazine. She holds a BBA degree in Music Business and Marketing from Belmont University. She welcomes your feedback at jnicholson@musicrow.com.
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