The positive effects of COVID-19 and the social determinants of health: all in it together?
We welcome Bryn Nelson’s analysis of the potentially positive effects of public and policy responses to COVID-19, 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, , 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. Aside from an outbreak of alt-right protests, the usual accusations of ‘nanny state’ interference have been replaced by calls for centralised governance, funding and control on a scale unseen in peacetime.
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” it’s already clear the virus disproportionately affects the poor, ethnic minorities and other socially disadvantaged groups. , Even more troublingly, the very measures intended to suppress viral spread are themselves exacerbating underlying social inequities. , While a drop in traffic is very welcome, the edict to ‘work from home’ is disastrous for casually-employed service or retail workers; and while social distancing may have reduced viral transmission in some groups, its benefits are less evident for those who are homeless, in overcrowded housing or refugee camps. 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. This insight provokes serious questions about the unequal effects of this pandemic and its associated policy responses, 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”, 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 with disproportionate effects on women and low-income workers,13 and growing income inequalities are predicted. Charities report dramatic increases in domestic violence with an estimated doubling in domestic abuse killings since the start of the lockdown. While COVID-19 is already more fatal in Black and minority ethnic groups, we have yet to see the extent to which the response will exacerbate existing racial inequities in employment, income and housing. 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, but because it places us all at increased risk. COVID-19 unmasks the illusion that health risk can be localised to the level of the individual, community, or even nation state.
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. 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, Only then can governments begin to claim that we’re “all in it together”.
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Competing interests: No competing interests