From Lessons to Enduring Legacies: Building Upon COVID-19 Health Equity Science

The COVID-19 pandemic exposed and exacerbated existing health inequities globally. ¹ In England, as in many other nations, the SARS-CoV-2 virus disproportionately affected certain populations, revealing stark disparities in risks and outcomes. ² Addressing these disparities necessitated a shift from mere documentation to delivering actionable and culturally competent insights and interventions, guided by the principles of health equity science. ³ We describe the experience of London in applying health equity science alongside effective leadership, partnerships, and governance to translate evidence into action and accelerate the public health impact during the COVID-19 pandemic. We explore the opportunities to create lasting legacies for public health research and practice from our pandemic experience, many of which will be relevant and applicable to public health practice in the United States.

The early and rapid emergence of health inequalities in COVID-19 incidence, testing uptake, diagnoses, hospitalizations, intensive care unit admissions, and mortality in the initial phase of the pandemic in England^4,5 led the then–Secretary of State for Health and Social Care and Chief Medical Officer in England to commission Public Health England (PHE) to conduct research on disparities in COVID-19 risks and outcomes to inform the pandemic response. The goal of the PHE reports^6,7 was not to passively document disparities but to understand why these health inequalities occurred and to actively inform interventions that reduce and eliminate them. This endeavor required defining the populations that were experiencing disparities (eg, by age, sex and gender, race and ethnicity, socioeconomic status, geographic location) and framing research questions that centered actionable outcomes through combining quantitative and qualitative methodologies.

A key commitment of the PHE investigation was engaging communities and strategic partners in the research, dissemination, and design of disease prevention and control interventions. This engagement was imperative to ensure that the research and programmatic activities reflected the needs and priorities of diverse communities and to increase the cultural competence of interventions. ⁸ The PHE reports’ 7 recommendations were designed to facilitate early, effective, and urgent response and implementation by policy makers, academics, practitioners, and affected communities. Strengthening community-based participatory research was seen as essential to achieving this goal and advancing health equity science.

With subsequent waves of the pandemic, COVID-19 health equity science quickly moved to studying and addressing the social and structural determinants of health, such as income inequality, housing overcrowding and insecurity, structural racism, and access to health care, which played a crucial role in shaping vulnerability to COVID-19 and in informing policy interventions.^9-12 Individuals living in overcrowded, substandard housing were more likely than those not living in these conditions to be exposed to the virus and experience worse outcomes, which were further exacerbated by limited access to health care resources. ¹³

Similarly, there was increasing recognition during the pandemic of the role played by structural racism and discrimination as drivers of health inequities that negatively affect employment, education, and health care access and contribute to unequal access to resources and opportunities, which ultimately affected health outcomes. ¹⁴ Health equity science undertaken during the pandemic response enabled a transparent and concerted action to name and address these structural factors through new strategic frameworks for action, better governance, leadership and accountability, and community mobilization and engagement in service design and response.^15,16

Another important challenge was the need to shine a light on racial and ethnic disparities while avoiding harmful myths and stereotypes. This required recognizing race and ethnicity as social constructs, rather than biological determinants of health, that ensure a robust framing of socioeconomic determinants and working with affected communities on messaging and framing. ¹⁷ Public health practitioners and policy makers were keen to ensure a more holistic approach to understand the nature and drivers of the challenges being experienced by socioeconomically vulnerable communities, including how racism and structural discrimination interacted with other social determinants of health to shape racial and ethnic health disparities. Using appropriate terminology and data disaggregated by relevant subpopulations was vital to accurately capturing and understanding nuanced patterns of disparities. ¹⁸

Choosing the right metrics to measure disparities was also critical, whether describing variations in the uptake of COVID-19 testing, contact tracing, or vaccination programs or characterizing the distribution and determinants of disease. ¹⁹ As the pandemic progressed and data quality improved, we were able to focus on disaggregating data by relevant subpopulations within broader categories (eg, disparities among various socioeconomic groups within races and ethnicities), allowing for a more nuanced understanding of the issues and ensuring that interventions remained relevant and effective. ²⁰

Promoting the visibility of underrepresented groups was critical in the pandemic response and in the postpandemic recovery. A range of people and interventions, such as community champions and outreach workers, community participation research, asset-based community development, community engagement, and mobilization, were used to actively seek out and include perspectives from communities that were experiencing disparities and ensuring their voices were heard and their needs were addressed.^21,22 Similarly, codesigning and conducting research with communities, rather than simply studying them, helped foster greater trust and ensured research questions were relevant to their lived experiences. ²³ Public health practitioners committed to more robust and sustained dissemination of policy updates and research findings in accessible formats and languages to better engage and empower communities to advocate for solutions that address their needs.

So effective were these approaches that steps have been actively taken to continue funding support for these infrastructures to ensure the lessons learned can be applied to the pandemic recovery and other public health programs. In London, the London Health Equity Partnership ²⁴ and London Inspire (https://www.inspireblackhealth.london/home) programs are two such legacies that have been instrumental in enhancing the city’s response to mpox outbreaks, influenza preparedness, and, most recently, the resurgence of measles. ²⁵

While the principles of health equity science provide a powerful framework for understanding and addressing health disparities, their effective implementation requires committed leadership combined with robust and inclusive governance for delivery. Leadership and governance play a crucial role in translating health equity scientific knowledge into concrete actions, ensuring resources are allocated equitably, and fostering accountability for achieving health equity goals.

Our experience in the pandemic response and subsequent recovery highlighted the importance of visible and engaged leadership for health equity that was inclusive, transparent, and accountable. Including representatives from communities experiencing health disparities on decision-making bodies, including regional and local community advisory boards and citizen science initiatives, and codesigning research projects with community partners were critical for ensuring that diverse voices were heard.

In London, the combined visibility and proactivity of the Mayor of London, health and care system leaders, and wider leadership coalitions representing academic, business, voluntary, and community sectors were critical to raising awareness and advocating for a prioritization of health equity. The creation of a London Health Equity Group of the London Health Board (https://www.london.gov.uk/programmes-strategies/health-and-wellbeing/london-health-board) and strong health equity workstreams in other regional partnership bodies (London Partnership Board ²⁶ ) ensured ongoing and integrated focus on inequalities across response partners. These efforts included leadership commitment to health inequalities, dismantling the systems that perpetuate health disparities, and supporting evidence-based policies that address the root causes of health disparities, informed by research conducted using principles of health equity science. ²⁷

London’s health and care leaders also played key roles in making data and decision-making processes accessible to the public, fostering trust, and ensuring accountability. This work included publishing data on health disparities disaggregated by relevant subpopulations, holding public briefings, and providing clear explanations for policy decisions. Finally, system leaders supported greater accountability by establishing clear metrics and targets for achieving health equity goals, and holding all partners accountable for their progress at the London Health Board and other subregional and local governance groups. ²⁸ This accountability required regular monitoring and evaluation of interventions, with adjustments made as needed based on data and community feedback.

In conclusion, the principles of health equity science provide a powerful roadmap for understanding and addressing health disparities. To effectively address these disparities, we must move beyond mere documentation and embrace the principles of health equity science. By conducting actionable research, focusing on drivers of inequity, using appropriate measures and terminology, and promoting the visibility of underrepresented groups, we can design and implement interventions that tackle the root causes of these disparities and achieve health equity for all. However, effective implementation requires a supportive environment fostered by robust governance and committed leadership. By prioritizing equity in governance structures, encouraging leadership that champions evidence-based policies and collaboration, and nurturing open communication, we can ensure that the knowledge generated by health equity science translates into tangible improvements in the health and well-being of all.