Covid-19, equity, and inclusiveness

In March 2020, as cases of covid-19 spiked around the world, we set out the requirements for an equitable response. We argued that honest, transparent communication on patients’ terms was vital; that free covid-19 testing and equitable sharing of health resources were essential to public health; that social distancing needed to be coupled with community support; and for robust sick leave policies for employees with covid-19 and paid time off for those affected by shutdowns. We argued congregate settings such as correctional institutions, homeless shelters, and refugee camps should be reconsidered where possible and adequately supported when necessary. Finally, we argued for adequate mental healthcare for essential workers and their families.1

The story of equity in covid-19, however, is a story of failure. Systems guaranteeing access to testing remain absent; in the US, despite major legislation, even patients with health insurance can still incur substantial costs for testing or be unable to physically access testing locations.2 Hoarding of health resources continues, most notably of vaccines by high income nations at the expense of everyone else.3 Sick leave policies remain inadequate while workers have seen an 8.8% global loss in working hours from unemployment, inactivity, and reduced working hours.4

Women, particularly those from marginalised communities, are disproportionally affected by loss of paid work and further burdened by increased unpaid labour, while at the same time making up most of the healthcare workforce.5 Congregate settings, in particular food processing plants, prisons, and detention centres, remain critical sites of transmission, illness, and death.6 Although some attempts have been made to mitigate the pandemic’s toll on mental health, efforts have been inconsistent, under-resourced, and may not target the most vulnerable groups.7 UN Women (the UN body for gender equality and the empowerment of women) has described increased violence against women and girls as a “shadow pandemic” exacerbated by both the effects of, and control measures for, covid-19.

These ongoing inequities are grounded in the historical marginalisation of communities and neglect of community health. In the context of this pandemic, however, they risk reinforcing disparities between those who survive this pandemic with affluence intact, and those who—even if they do not become infected—may be permanently disadvantaged and harmed by the lack of action to protect vulnerable people.

The arrival of vaccines will not relieve these inequities and may even exacerbate them. When, where, and how someone gets vaccinated are mediated by structural and systemic factors that created inequities in previous phases of the pandemic. People with limited or no internet connectivity are unable to access vaccine appointment websites, while those employed in (often low paid) service work may be unable to take time off to get vaccinated.

Increasing state and business interest in vaccine and immunity passports suggests we may be heading towards a time when ability to work, access goods and services, or even move within society will be contingent on vaccination or immunity. Those least able to access vaccines will once again be harmed most by the inequities of the pandemic response.8 The situation may become even more dire as high income countries continue their vaccine nationalism, enabling their economies to rebound while denying low and middle income countries vaccines for essential workers and vulnerable groups.