COVID-19 reveals the injustices that underlie health inequities: what are the implications?
By David Nabarro. Originally published by Imperial College London on 6 April 2021.
The COVID-19 pandemic has laid bare the social injustices that are holding back equity in health and care.
People living in poverty and deprivation are some of the hardest to reach and easiest to leave behind.
This means poor people are absorbing much of the brunt of the pandemic’s impacts, faced with challenges that leave them among the worst affected by the virus and exacerbating the struggles they already carry.
First there is the issue that they will find it harder to get tested, because they might not have access to the Internet or the skills to use it, or due to language barriers. Then there are concerns held over contact tracing, with poor people often less willing to take part as they fear the consequences for others and the negative connotations.
It can also be very difficult for people with limited means to adopt public health measures such as physical distancing because of their circumstances, such as factory staff who work in close confines with others. And then if a person who works in a low-paid job is told to isolate on sick pay, which might be only a proportion of what they would usually take home, then of course they would do anything they can to avoid this and risk spiralling debt.
Lockdowns tend to make poor people poorer
Movement restrictions in response to COVID-19 – often described as “lockdowns” – have an uneven impact on working people. Those in the informal sector or gig economy find it much harder to keep income coming in as they are mostly unable to work from home, and they depend on being able to move about to earn their income. We are seeing this all over the world, not just in the UK: lockdowns make poor people poorer. This is why lockdowns should only be used as a last resort to reduce the intensity of an outbreak, offer space for planning and implementation of measures needed to interrupt virus spread, and implement measures needed to stop outbreaks from surging.
Added to this is the reality that poor people tend to get a raw deal when it comes to accessing both health care and vaccines, leaving them more vulnerable to the virus and its far-reaching effects. Being poor and being from a minority ethnic background unfortunately tend to come hand in hand, meaning that ethnic minorities tend to be particularly affected by injustices that affect their access to care.
This is the harsh reality of many people’s lives. Those of us who are committed to making a difference must drive awareness of ways in which inequities affect access to, and outcomes of, health care. Decision-makers should use these lessons as an opportunity not only to ensure that their responses to the crisis are fair, but also to reduce health and care inequalities that will help advance justice in all societies.
From my perspective, improving poor people’s access to effective health care requires us to focus on health equity as a priority, whenever decisions are made.
This involves some critical steps.
Identify, include, prioritise: essential steps to tackling inequality
Decision-makers could be more explicit that tackling inequity is key to containing infectious diseases. Naming the issues that need to be addressed, identifying the people who are most affected, and then prioritising the individuals, groups and communities who are most at risk. Simply put, being poor increases the COVID-related risks that people face.
This means that the rights of all people, including the right to health, have to be prioritised. The rights of poor people need to be protected and that means that they need the space and opportunity for these rights to be realised. They must be able to articulate their needs, be heard, participate in seeking solutions, and expect accountability from service providers. They must receive the attention they need and be able to share their perspectives.
Rights-based approaches make it more likely that the needs of poorer people, and their specific circumstances, will be prioritised as interventions are planned and implemented. If the interests of poorer people are not prioritised, it is likely that the people themselves will be left further behind. This prioritisation is relevant both to COVID-19 outcomes and health outcomes in general.
Listening to all people, especially to those with limited means, appreciating their needs, and prioritising responses that reflect their realities, are vital and necessary when seeking to tackle inequality. Once the needs of poorer people are prioritised and responses are planned, decision-makers will appreciate that working together with a focus on the issues being addressed, and where they occur, is likely to have the most sustainable impact. This will require a constant process of acting, learning, and adapting. It may not feel right the first time. That is inevitable, especially when the needs of those who are hardest to reach are prioritised.
Committing to a fairer future
By listening to those with the greatest needs, appreciating their realities and prioritising them in responses, decision-makers ensure that interventions have a greater likelihood of successfully reducing inequities in a manner that is proactive, people-focused and thoughtful. This is not simply a tick box exercise: there are rarely single and scalable solutions for the inequities.
Working to ensure that people who are the hardest to reach are brought into the centre of action is challenging. It is important to meet them where they are, sense the rhythm of their lives and value their perspectives on what matters.
And so today, this World Health Day, let us all commit to focusing on the needs of all people, with a view to fairer and more sustainable futures. Futures where all people, no matter their background or circumstance, are able to enjoy all their rights, especially to good health and care, food and nourishment, and all basic needs. Because as the pandemic has shown us, we are not safe unless we are all safe; we are all in this together.
Dr David Nabarro is Co-Director of the Institute of Global Health Innovation (IGHI) and WHO Special Envoy on COVID-19.