In many countries redressing health inequalities within the population has become a feature of policy documents. International agencies like the World Health Organisation has units & experts on the social determinants of health & equity. Yet when a crisis like the pandemic caused by the SARSCOV2 virus occurs we observe that the social and structural factors that shape health fall to the wayside. Experts on these issues do not feature among the emergency committees, little-to-no mention is made of health inequalities in strategic documents (ex: WHO: A coordinated global research roadmap).
The message is clear: we want to hear from virologists at a time like this, not population scientists!
In the end, who managed to highlight the huge health inequalities in Covid19 infection, severity & mortality? It was not those of us who have worked on these issues for years, who were shouting into the storm. It was the media.
The news media highlighted the stark death rates among Black Americans, among ethnic minorities in the UK. It seemed this was also happening in France, where data on ethnicity do not exist so are inferred from geographic differences in death rates. Gradually, in some countries, the data are becoming available, like analyses produced by the Office of National Statistics in the UK, or from the USA, like this working paper by J.T. Chen & N. Kreiger. These analyses show that socially disadvantaged members of our populations are dying in disproportionately high numbers from Covid19.
Many of us have had to try & collect data ourselves or find some way of linking datasets, in difficult circumstances. To do so means having to convince funders & authorities again & again that data on occupation, housing, ethnicity, education, income are important to properly understand a disease like Covid19. If our authorities seemed to care about health inequalities at some point before, they had forgotten all about them now.
We have to keep repeating that social & structural factors need to be considered when formulating public health measures and interventions during a crisis. They are vital if we are to understand and prevent the long term consequences of this crisis for health. Simply put, if we do not take structural & social factors into account when studying Covid19 we are not “doing” good science, and we are not going to be able to respond appropriately in public health.
We have relied on using our prior knowledge of health inequalities to explain the risks of exposure & infection for those with certain occupations, or who live in more crowded housing. We have had to remind our health authorities & colleagues that virtually all the risk factors for severe forms of Covid19, smoking, obesity, cardiovascular diseases, diabetes… are socially patterned. It is at the intersection of structural domains of power, between gender, class & ethnicity/ race, where inequalities play out the most starkly.
Now is not the time for those of us working on health inequalities to stay quiet. What is playing out at different levels of government policy today will affect us for generations. We need to look at this in terms of the life course. We must insist that health inequalities are thought through in all policies.
Preventing health inequalities in a time of pandemic: A health in all policies framework
I formulated a framework for thinking through public health prevention in order to integrate health inequalities (see table). I used the classic prevention sequence of primordial, primary, secondary & tertiary prevention. The primordial factors are essential and need to be watched closely given the impending economic recessions. If we don’t make sure they are set-up, funded and maintained, then we have no chance to mitigate the effects of external insults to come, including the effects of the climate crisis. This is simply a question of human rights and social justice. Human rights to basic needs: water, sanitation, education, food, shelter, information… must remain the number one priority.
In no particular order: We must advocate for universal health care & social care. Access to screening, treatments and long term care for the elderly. We saw in this crisis that worker’s rights are a key issue, they must be provided with paid sick leave, parental (maternity/ paternity) leave and protection from the hazards of their occupations. Those who are not employed in the formal sector must be catered for through social security or a universal basic income. Affordable clean housing with adequate space must become a political priority, it is a basic human right. Education must be accessible to all without exception. When they’re at school children and adolescents must be able to get a decent meal and their school supplies without financial burden. Child care must be made affordable to all families who need it to make sure there are no gender inequalities around work.
I’ll end with my current battle. If we care about something we need to measure it. For this reason, data must be collected systematically on social & socioeconomic factors and linked to health-related factors. This must be done through transparent data governance, and if required, overseen by an ombudsman. The data must be made accessible to policymakers and scientists.
We must advocate for an equitable social model and an environmentally sustainable economy. Opportunities lie ahead to put people ahead of profit, and we need to get into the arena to fight for them.