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men 2017, Hurricane Maria struck Puerto Rico. The official death toll as a result of the storm is 64. But be aware of the longer-term consequences (devastated infrastructure, overwhelmed hospitals) and the death toll rises into the thousands. When we look closely at these numbers, we also see something else: two months later, mortality had increased dramatically for the lowest socioeconomic group, somewhat for the middle group, and less for the highest group. A large external shock had highlighted the underlying inequalities in society.
This has been the case with Covid-19. Inequalities in health and social conditions that lead to poor health have been revealed and amplified by the pandemic and the response to it. Now, with vaccines working, there is talk of Britain returning to “normal”. But the “normal” that existed in February 2020 is not acceptable. The Covid-19 pandemic should be seen as an opportunity to build a more just society.
A new report that my colleagues and I at UCL published today uses evidence to suggest how we can do this.
In February 2020, just a month before the UK entered a national lockdown, we published a review of what had happened to Britain’s health and health inequalities in the 10 years since 2010. The outlook was bleak : stagnation of life expectancy and increasing inequalities between socioeconomic groups. and regions. Most notable was the reversal of a long-term trend of improving health year after year: a woman living in the most deprived area of North East England, or in other areas outside of London, was less likely to live a life long and healthy in 2019 than I would have had 10 years ago. We made a series of recommendations, addressing the social determinants of health, on how things could and should improve.
So, Covid-19 changed the world dramatically. But in England the changes have been fully consistent with its state before the pandemic. The comparatively poor management of the pandemic in England was similar to the improvement in its health that lagged behind that of other rich countries in the previous decade.
There are four possible explanations: the quality of governance and the political culture, which did not prioritize conditions for good health; the continuing increase in economic and social inequalities, including an increase in poverty among families with children; a policy of austerity and the consequent cuts to the financing of public services that were markedly regressive; and a poor state of health of the nation.
Addressing these four is at the core of what needs to be done to achieve change.
A striking feature of the pandemic is the way the risk of death from Covid-19 is unevenly distributed across the country – the more deprived the area, the higher the death rate. This looks a lot like the picture of all causes of death. Another is the high death rate for members of ethnic minority groups, Asians, and blacks. Much of this excess risk can be attributed to living in more deprived areas, working in high-risk occupations, living in crowded conditions and, in the case of the Bangladesh and Pakistani groups, a higher prevalence of relevant pre-existing conditions.
Structural racism means that some ethnic groups are more likely to be exposed to adverse social and economic conditions, in addition to everyday experiences of discrimination, leading to “resilience theft,” as Bristol Mayor Marvin Rees put it. The spread of the Black Lives Matter protests in the UK has increased the visibility of these issues.
Building a more just society will involve addressing this root cause of social injustice, in addition to the social and economic inequalities that are so pervasive. We must also accept the growing recognition, around the world, that economic growth is a limited measure of societal success. We would do well to learn from the example of the New Zealand Treasury, which in 2019 put wellness at the center of the government’s mission.
Our new report is called Build Back Fairer. One objection to our proposals has to do with money. Reversing cuts in children’s centers, funding per student in schools, local government, social care for adults and the health service, will mean public spending. So will paying care workers a living wage and having more generous safety nets that don’t send families into extreme poverty. At a time of huge national debt, can the country afford it?
Britain has tried the austerity experiment. It didn’t work, if health and well-being are the indicators of success. Phrases like “maximize the nation’s credit card” are neither helpful nor based on sound economics. In a time of zero interest rates, with a tax rate that is at the lowest extreme among European countries, and with control of its own currency, a nation can borrow and can tax for the purpose of building a more society. fair, it can even print money (quantitative easing).
We shouldn’t wonder if we can afford to make our children’s well-being ranked 27th out of 38 rich countries, or pay for free school meals during the holidays so that eligible children don’t go to bed hungry. Social justice requires it.
The issues we raise are not unique to England. In the United States, for example, growing economic inequalities and high mortality associated with race and ethnicity are also very evident. From March to September 2020, the wealth of the 643 billionaires in the US was estimated to have increased by 29%, a staggering $ 845 billion (£ 630 billion). During the same period, the hourly wage of the bottom 80% of the workforce was reduced by 4%. Inequalities in Britain may be less dramatic, but it is clear that our own level of inequality is not compatible with a just and healthy society.
To emerge from this pandemic in a healthier state, we need a commitment on two levels. First, for social justice and for putting equity in health and well-being at the center of all policies. Reduce spending regressively: the poorer the area, the steeper the cut – it is unfair and is likely to worsen health inequalities.
The pandemic has shown that when the health of the public is seriously threatened, other considerations become secondary. Lasting social and economic inequalities mean that the public’s health was threatened before and during the pandemic, and will continue to be after. Just as we needed better management of the nation’s health during the pandemic, we also need national attention to health inequalities and their causes.
The second level is to take specific actions to create healthier lives for everyone throughout life: from reducing child poverty levels to 10%, to ensuring that wages (or benefits for those who cannot work) are sufficient. to lead a healthy life, to create the conditions for older people to lead meaningful lives.
The evidence is clear. Much can be done to improve people’s quality of life. Health inequality is a solvable problem. We are all interested in rebuilding more fairly.
• Michael Marmot is Professor of Epidemiology at University College London, Director of the UCL Institute for Health Equity, and Past President of the World Medical Association
