The end of 2020 brought with it a new round of restrictions to curtail the growth in COVID-19 cases in several European countries, including the UK, Germany and Italy. As these restrictions – and the high number of infections and death – continue into 2021, it is critical to remember that COVID-19, and policies to address it, do not impact all population groups equally.
The equity implications of policies to address COVID-19 should be given greater consideration. It is well documented that it was the austerity measures taken to address economic effects of the 2008 financial crisis, rather than the crisis itself, that caused health inequities to grow and life expectancy to fall.
The World Health Organization Regional Office for Europe (WHO EURO) has recently inaugurated a pan-European commission to rethink policies in light of pandemics. Each wave of COVID-19 impacts (Figure 1) will exacerbate disadvantages for those already facing greatest exclusion and marginalization. Policy responses to these three interconnected crises must be designed with equity implications at the forefront.
In order to address health inequities, universal policies that provide a minimum of protection for everyone are needed. Interventions should also be targeted to address the structural determinants of inequities facing those most disadvantaged in society. These need to be part of efforts to build back better.
The first, most immediate impact of COVID-19 remains the direct health crisis resulting from the spread of this novel pathogen. To address the pandemic, governments around the world adopted unprecedented measures to limit social interactions and ensure physical distance between individuals. These measures resulted in closures of borders and an almost complete halt to economic activity in many countries, which led to a second crisis – an economic crisis.
To offset this, governments introduced, and continue to introduce, economic rescue packages, which were extraordinary and unprecedented. As a result of the economic crisis, the GDP in most countries has shrunk and unemployment is rising. Social impacts of COVID-19 include increases in domestic violence, growing mental health issues related to isolation, as well as the longer-term effects of educational policies such as the closure of schools.
The third wave, therefore, entails a social crisis, bringing about broader consequences on the societal fabric and on health determinants such as education and employment.
In relation to the direct health impacts of the pandemic, it has rapidly become apparent that those already facing disadvantage are at greater risk of contracting the disease and of having worse health outcomes.
For example, major ethnic disparities have been reported in the UK, and in Germany and Spain, outbreaks have been reported in meat processing factories and among temporary workers who live in precarious conditions. Disadvantaged groups in Europe are thus going to have to build resilience against the health crisis, the emerging economic crisis, and the succeeding social crisis.
As the COVID-19-related economic crisis is building through Europe, equity-blind economic rescue packages are likely to further deepen health inequities and the disproportionate effects of the economic crisis on those already facing marginalization and exclusion. For example, undocumented migrants or temporary workers are more likely to lose their employment or experience a reduction in income. They are less likely to have secure housing in which to quarantine themselves or have social networks that can support their physical and mental health during the economic crisis.
Equally, the gendered impacts of COVID-19 policies are well established, such as the effects of school closure measures on women’s productivity and the increase in domestic violence as a consequence of physical distancing rules that reduce time spent outside of the home.
An extensive body of research illuminates the policy conditions required to reduce differences in health, and shows that inequalities are bad for the health of everyone. What this body of evidence also shows is that to address inequities, universal policies that provide a minimum level of protection for everyone are needed. These may include a social protection floor or a universal basic income, as well as targeted interventions that address those facing the greatest disadvantage in society – known as proportionate universalism.
Universal COVID-19 response policies that do not take into account the pathways through which different determinants of health shape risk differently will fail to address disadvantage. Countries were late to recognize and address the structural determinants producing inequities in risk of infection and access to quality healthcare in the initial health crisis caused by COVID-19. With cases climbing again, governments must now consider health equity impacts as an essential dimension of policies to combat COVID-19 and its social and economic impacts.