Has COVID-19 increased inequality in mortality by income in the Netherlands?

Bram Wouterse*, Joana Geisler, Marlies Bar, Eddy Van Doorslaer

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

3 Citations (Scopus)
10 Downloads (Pure)


Background In the Netherlands in 2020, COVID-19 deaths were more concentrated among individuals with a lower income. At the same time, COVID-19 was a new cause that also displaced some deaths from other causes, potentially reducing income-related inequality in non-COVID deaths. Our aim is to estimate the impact of the COVID-19 pandemic on the income-related inequality in total mortality and decompose this into the inequality in COVID-attributed deaths and changes in the inequality in non-COVID causes.

Methods We estimate excess deaths (observed minus trend-predicted deaths) by sex, age and income group for the Netherlands in 2020. Using a measure of income-related inequality (the concentration index), we decompose the inequality in total excess mortality into COVID-19 versus non-COVID causes.

Results Cause-attributed COVID-19 mortality exceeded total excess mortality by 12% for the 65–79 age group and by about 35% for 80+ in the Netherlands in 2020, implying a decrease in the number of non-COVID deaths compared with what was predicted. The income-related inequality in all-cause mortality was higher than predicted. This increase in inequality resulted from the combination of COVID-19 mortality, which was more unequally distributed than predicted total mortality, and the inequality in non-COVID causes, which was less unequal than predicted.

Conclusion The COVID-19 pandemic has led to an increase in income-related inequality in all-cause mortality. Non-COVID mortality was less unequally distributed than expected due to displacement of other causes by COVID-19 and the potentially unequal broader societal impact of the pandemic.
Original languageEnglish
Article numberjech-2022-219845
Pages (from-to)244-251
Number of pages8
JournalJournal of Epidemiology and Community Health
Issue number4
Early online date8 Feb 2023
Publication statusPublished - 18 Apr 2023

Bibliographical note

Funding Information:
We are grateful to the Institute for Public Health (RIVM) and the Smarter Choices for Better Health (SCBH) Initiative of Erasmus University Rotterdam (EUR) for financial support.

Publisher Copyright:
© 2023 Author(s). Published by BMJ.


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