Policy responses to the pandemic need to take account of underlying social inequities

We welcome Bryn Nelson’s analysis of the potentially positive effects of public and policy responses to COVID-19,[i] particularly in providing an opportunity to reassess priorities. Nelson highlights the unanticipated benefits of recent behaviour changes – but we suggest the real revolution is a re-discovery of the health potential of state intervention. Governments worldwide have taken unprecedented steps to suppress viral spread, strengthen health systems, and prioritise public health concerns over individual and market freedoms,[ii],[iii] with reductions in air pollution, road traffic accidents and sexually transmitted infections a direct (if temporary) result of the embrace of collective over individual liberty.[iv] Aside from an outbreak of alt-right protests,[v] the usual accusations of ‘nanny state’ interference[vi] have been replaced by calls for centralised governance, funding and control on a scale unseen in peacetime.[vii]

While applauding this paradigm shift, it’s important to acknowledge both its partial nature and its extremely uneven impacts – positive or otherwise.  As Nelson notes, negative impacts of the current pandemic (such as unemployment and hunger) are ‘unquestionably troubling’, and while governments proclaim that “we’re all in this together”[viii] it’s already clear the virus disproportionately affects the poor, ethnic minorities and other socially disadvantaged groups.[ix],[x] Even more troublingly, the very measures intended to suppress viral spread are themselves exacerbating underlying social inequities.[xi],[xii] While a drop in traffic is very welcome, the edict to ‘work from home’ is disastrous for casually-employed service or retail workers;[xiii] and while social distancing may have reduced viral transmission in some groups, its benefits are less evident for those who are homeless,[xiv] in overcrowded housing[xv] or refugee camps.[xvi] In maximising the potential for COVID-19 to have positive effects, we must understand and address why its negative effects are so starkly mediated by class, ethnicity and (dis)ability.

Back in 2008, the WHO Commission on the Social Determinants of Health highlighted that population health and its social distribution are driven by the conditions in which people are born, grow, live, work and age, and that social injustice is the biggest killer of all.[xvii] This insight provokes serious questions about the unequal effects of this pandemic and its associated policy responses,[xviii] both positive and negative. Like Nelson, we hope the currently crisis will produce valuable lessons – most especially in understanding the need for collective action to create a healthier and more equal society.

There are three critical issues here. First, if governments are serious about “preventing every avoidable death”, [xix] COVID response strategies need to take account of their unequal impacts. While many states have acted swiftly to support businesses and wage-earners,4 these interventions are largely blind to class, gender and race. Unemployment and food insecurity have already increased[xx] with disproportionate effects on women and low-income workers,13 and growing income inequalities are predicted.[xxi] Charities report dramatic increases in domestic violence[xxii] with an estimated doubling in domestic abuse killings since the start of the lockdown.[xxiii] While COVID-19 is already more fatal in Black and minority ethnic groups,[xxiv] we have yet to see the extent to which the response will exacerbate existing racial inequities in employment, income and housing.[xxv] Governments must recognise – and ameliorate – inequalities in the negative effects of COVID-19.

Second, when developing strategies for transitioning out of lockdown, governments need to take account of the unequal impacts of any changes. The Scottish Government has signalled its intention to ease restrictions in ways that “promote solidarity… promote equality… [and] align with our legal duties to protect human rights”.23 Other governments should also consider how plans for lifting the lockdown can be tailored to minimize harm to already disadvantaged groups, and to ensure equal enjoyment of the associated benefits.

Finally, COVID-19 will produce a truly positive effect if the scale of the mobilisation to counter the pandemic can be matched by a sustained commitment to reducing social, economic and environmental inequalities in the longer term. Without such a commitment, we are perpetuating a situation in which many people live in a state of chronic vulnerability. This is bad for society, not only because it undermines social cohesion and trust,[xxvi] but because it places us all at increased risk.[xxvii] COVID-19 unmasks the illusion that health risk can be localised to the level of the individual, community, or even nation state.[xxviii]

If we’re serious about using this crisis to reassess our priorities, , we need to recognise the urgent need for change beyond individual ‘risky behaviour’. To paraphrase Rudolf Virchow, the promotion of health is a social science, and large-scale benefits come from political – not individual – change.[xxix] The genuinely positive effects of COVID-19 will come when we acknowledge the centrality of wealth redistribution, public provision and social protection to a resilient, healthy and fair society.12,[xxx] Only then can governments begin to claim that we’re “all in it together”.

Dr Sarah Hill is a Senior Lecturer in Global Health Policy Unit, School of Social & Political Science, University of Edinburgh and of SPECTRUM Consortium (Shaping Public Health Policies to Reduce Inequalities and Harm), UK

Professor Sharon Friel is the Director of SPECTRUM Consortium, UK and the Menzies Centre for Health Governance, School of Regulation and Global Governance (RegNet), Australian National University.

Professor Jeff Collin is a Professor of Global Health Policy in the School of Social & Political Science, University of Edinburgh and SPECTRUM Consortium.

A verion of this post originally appeared as a rapid response on the BMJ website in response to a feature article by Bryn Nelson entitled ‘The positive effects of covid-19’.

[i] Nelson B. The positive effects of covid-19. BMJ 2020;369;m1785 doi: 10.1136/bmj.m1785

[ii] Oxford COVID-19 Government Response Tracker. Oxford: Oxford University, Blavatnik School of Government. https://www.bsg.ox.ac.uk/research/research-projects/oxford-covid-19-government-response-tracker (accessed 25 March 2020)

[iii] Kickbush I, Leung GM, Bhutta ZA et al. Covid-19: how a virus is turning the world upside down [editorial]. BMJ 2020; 369:m1336 doi:10.1136/bmj.m1336

[iv] Gostin LO, Gostin KG. A broader liberty: JS Mill, paternalism, and the public’s health. Public Health 2009; 123(3): 214-221

[v] BBC News. Coronavirus lockdown protests: What’s behind the US demonstrations? BBC [online], 21 April 2020. URL https://www.bbc.co.uk/news/world-us-canada-52359100

[vi] Calman K. Beyond the ‘nanny state’: Stewardship and public health. Public Health 2009; 123(S): e6-10

[vii] Economist. Building up the pillars of state [briefing]. The Economist, March 28th 2020.

[viii] Bell T. Sunak’s plan is economically and morally the right thing to do [opinion]. Financial Times, March 21 2020. URL https://www.ft.com/content/70d45e68-6ab6-11ea-a6ac-9122541af204

[ix] Office of National Statistics. Deaths involving COVID-19 by local area and socioeconomic deprivation: deaths occurring between 1 March and 17 April 2020. Statistical bulletin. London: Office of National Statistics.

[x] Van Dorn A, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet 2020 395(10232): 1243-4

[xi] Friel S, Demio S. COVID-19: can we stop it being this generation’s Great Depression? 14 April 2020. Insightplus, Medical Journal of Australia. URL https://insightplus.mja.com.au/2020/14/covid-19-can-we-stop-it-being-this-generations-great-depression/

[xii] Banks J, Karjalainen H, Propper C, Stoye G, Zaranko B (2020). Recessions and health: The long-term health consequences of responses to coronavirus. IFS Briefing Note BN281. London: Institute for Fiscal Studies. https://www.ifs.org.uk/publications/14799

[xiii] Sainato M. Lack of paid leave will leave millions of US workers vulnerable to coronavirus. Guardian [online], 9 March 2020. URL https://www.theguardian.com/world/2020/mar/09/lack-paid-sick-leave-will-leave-millions-us-workers-vulnerable-coronavirus

[xiv] Eley A. Coronavirus: The rough sleepers who can’t self-isolate. BBC [online], 22 March 2020. London: British Broadcasting Corporation. URL https://www.bbc.co.uk/news/uk-51950920

[xv] Lancet. Redefining vulnerability in the era of COVID-19. Lancet 2020 395(10230): 1089. https://doi.org/10.1016/S0140-6736(20)30757-1

[xvi] Hargreaves S, Kumar BN, McKee M, Jones L, Veizis A. Europe’s migrant containment policies threaten the response to covid-19 [editorial]. BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1213

[xvii] WHO Commission on the Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization.

[xviii] Joyce R, Xu X (2020). Sector shutdowns during the coronavirus crisis: which workers are most exposed? IFS Briefing Note BN278. London: Institute for Fiscal Studies. https://www.ifs.org.uk/publications/14791

[xix] Scottish Government. COVID-19 – A Framework for Decision Making. April 2020 Edinburgh: Scottish Government, 2020. URL https://www.gov.scot/publications/coronavirus-covid-19-framework-decision-making/

[xx] The Poverty Alliance. National organisations & the impact of Covid-19: Poverty Alliance briefing, 22nd April 2020. Edinburgh: The Poverty Alliance. URL https://www.povertyalliance.org/wp-content/uploads/2020/04/Covid-19-and-national-organisations-PA-briefing-22-April.pdf

[xxi] Crawford R, Davenport A, Joyce R, Levell P (2020). Household spending and coronavirus. IFS Briefing Note BN279. London: Institute for Fiscal Studies. https://www.ifs.org.uk/publications/14795

[xxii] Townsend M. Revealed: surge in domestic violence during Covid-19 crisis. The Guardian [online], 12 April 2020. URL https://www.theguardian.com/society/2020/apr/12/domestic-violence-surges-seven-hundred-per-cent-uk-coronavirus

[xxiii] Grierson J. Domestic abuse killings ‘more than double’ amid Covid-19 lockdown. Guardian [online], 15 April 2020. URL https://www.theguardian.com/society/2020/apr/15/domestic-abuse-killings-more-than-double-amid-covid-19-lockdown

[xxiv] Barr C, Kommenda N, McIntyre N, Voce Antonio. Ethnic minorities dying of Covid-19 at higher rate, analysis shows. Guardian [online], 22 April 2020. URL https://www.theguardian.com/world/2020/apr/22/racial-inequality-in-britain-found-a-risk-factor-for-covid-19

[xxv] Haque Z. Coronavirus will increase race inequalities [blog]. 26 March 2020. London: Runnymede Trust. URL https://www.runnymedetrust.org/blog/coronavirus-will-increase-race-inequalities

[xxvi] Wilkinson R, Pickett K. The Spirit Level. Why Equality is Better for Everyone. London: Penguin Books, 2010

[xxvii] Woodward A, Kawachi I. Why reduce health inequalities? Journal of Epidemiology & Community Health. 2000; 54(12):923-929.

[xxviii] Collin J, Lee K (2003). Globalisation and transborder health risk in the UK. London: The Nuffield Trust. https://www.nuffieldtrust.org.uk/research/globalisation-and-transborder-health-risk-in-the-uk-case-studies-in-tobacco-control-and-population-mobility

[xxix] Mackenbach J. Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea. J Epidemiol Community Health 2009; 63(3): 181-4 doi: 10.1136/jech.2008.077032

[xxx] Graham H. Unequal Lives. Health and Socioeconomic Inequalities. Maidenhead: Open University Press/McGraw Hill, 2007.



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