Resilient and equitable recovery from the covid-19 pandemicBMJ 2022; 376 doi: https://doi.org/10.1136/bmj.o311 (Published 04 February 2022) Cite this as: BMJ 2022;376:o311
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The emergence and the impact of the covid-19 pandemic have been driven by the interactions of multiple determinants such as ecology, socio-economic status, inequality, and politics leading many commentators to write about how we should consider covid-19 to be a syndemic rather than a pandemic.
Covid-19 has uncovered deeply rooted social inequities and brought racial injustice to the forefront of public health and political attention. Several studies have shown that ethnic minority populations had a greater risk of covid-19 infection and mortality.1 This disproportionate impact of covid-19 on ethnic minorities is partly explained by socio-economic factors,2 however, as Razai et al have written, cultural and structural racism are also causes.3 In the US, underpinned by long-standing structural and societal inequalities, living and working conditions predispose US minority communities to worse outcomes from pandemic.4
This pandemic is further complicated by man made disasters. Politicising and ignoring science has hampered the rollout of timely and effective control measures5 while political conservatism in the US inversely associates with perceived health risk and adoption of health protective behaviours.6 Furthermore, hate speech has triggered anti-Asian racism and xenophobia in the US7 resulting in an increased level of post-traumatic stress disorder among Asian and Asian American young adults, who reported verbal or physical assault.8
Around one million excess deaths occurred in 2020 in 29 high income countries, and men have higher age standardised excess death rates than women in almost all countries.9 A study on excess mortality spanning 79 high, middle- and low-income countries shows that the privatisation of healthcare, an underfunded health sector, and slow covid-19 containment and mitigation actions are key drivers of excess deaths.10 Timely activation of comprehensive responses, adapting health systems’ capacity, preserving health systems’ resources, and reducing health systems’ vulnerability all contribute to effective country responses.11
However, untimely and ineffective containment measures against covid-19 have resulted in surges of cases and have overwhelmed healthcare systems around the world. This has knock-on impacts on access to non-covid essential health services, such as services for acute myocardial infarction, stroke, accident and trauma. A study in the US shows substantial and higher concentration of excess deaths from non-covid-19 causes among men and ethnic minorities, especially Black and non-Hispanic males, than covid-19 deaths.12 Lack of insurance coverage and overwhelmed health systems are causes of excess deaths from covid-19 and non-covid-19 conditions further widening the socio-economic divide of the pandemic.
This collective evidence from the pandemic should guide us on why we need to achieve a resilient and equitable recovery and how we might do this. We suggest the following:
Firstly, we must roll out covid-19 vaccination to at least 70% of world’s population by 2022. This is currently hampered by the global inequity in access to a covid-19 vaccine and the emergence of variants of concerns. As of 22 January 2022, only 14.4% of the population in Africa had received at least one covid vaccine compared with 77% in high- and upper-middle-income countries.13 Global solidarity and commitment can make this happen; though the vaccine pledge made at the G7 Summit in Cornwall, UK in June 2021, will only reach low-income countries by 2023.14 This will prolong the pandemic as low-income countries continue to fight covid-19 outbreaks, allowing the emergence of new variants and spread across the world due to international travel. Low vaccine coverage causes slower economic recovery in emerging markets and developing economies.15 Continued research and development of new vaccines effective for new variants are critical measures.
Secondly, thinking of the covid-19 pandemic as a syndemic should help us to focus our efforts on minimising the various determinants which exacerbate the consequences of covid-19 on marginalised and underserved populations. This requires bold leadership across various governments in support of structural reform which addresses inequity through universal social protection, housing, labour, and employment policies. Universal health coverage ensures equitable access by all to healthcare services either in normal and emergency situations. A resilient and equitable recovery requires an equal development path, and comprehensive policy packages on education, healthcare, digital technology and infrastructure.
Thirdly, we must strengthen health systems capacity in terms of preparedness for future epidemics or pandemics. This requires active surveillance of coronavirus and other high impact viral families including influenza, filo- and flavi-viruses in bats and other wildlife worldwide. We must strengthen our diagnostic capacities to detect, sequence and share genomes which strengthen global preparedness and alert.16 We must invest in our healthcare workforce capacity, notably epidemiologists and public health officers to respond to outbreaks, as well as frontline clinicians.
Recovery from the covid-19 pandemic requires effective governance for health and solidarity at a global level and leadership, good governance, and full involvement of people disproportionately affected by the pandemic.
Competing interests: none declared
Acknowledgment: This paper is part of the BMJ collection launched at the Prince Mahidol Award Conference 2022 “The World We Want: Actions Towards a Sustainable, Fairer and. Healthier Society”
Provenance and peer review: commissioned, not peer reviewed