Preparing for COVID-19’s aftermath: simple steps to address social determinants of health

While many face a loss of life, a great many more face a loss of livelihood. ¹

For many countries across the world, we are seeing unprecedented economic declines and, in some cases, the largest collapses in business activity ever recorded.^2–6 Unlike the 2008 global financial collapse, which took at least 4–5 years before we reached a reasonable steady state for our citizens, ⁷ the current crisis affects nearly all sectors of our economy with several companies already going out of business.

Recovery from COVID-19’s aftermath will take years

While we wait to recover economically, we know from the 2008 global financial collapse that we will see a large increase in social and health needs including worsening living standards, well being reductions, decreased educational achievement, increased rates of suicide and increase in poor mental health, many of which will stem from unemployment.^8–12 All of these social and health needs will likely precipitate an increase in inequalities and social fragmentation. ⁹

Designing a response to deal with these issues is not straightforward because of the myriad societal elements that will affect and be affected by the responses and the unpredictability of the effects. ¹³ We are dealing with complex systems that are non-linear and are not reversible ¹⁴ – we will not be able to return to our pre-COVID state. Further to this, COVID-19’s aftermath presents us with a situation of fundamental uncertainty where we will be unable to know or predict the probability of alternatives or outcomes. ¹⁵

In the face of these fundamental uncertainties, what should we do?

Studies by Gigerenzer and other behavioural economists have shown that in complex and uncertain situations, simple rules known as heuristics can consistently outperform complex algorithms based on big data models. Heuristics are conscious and unconscious strategies for making decisions in ways that are adapted to the structure of the decision maker’s local environment. The study of heuristics has shown that ignoring complexity of the environment can reduce effort and can also lead to more accurate judgements. Some classic examples of heuristics include ¹⁵ :

1/N rule: allocating resources equally to each of N alternatives can outperform optimal asset allocation portfolios

Satisficing: exploring alternatives and selecting the first one that exceeds your aspiration levels can lead to better choices than by chance.

The heuristic we see being used by governments across the world is to pump money, about USD five trillion globally to date, into their economies to help businesses and individuals to maintain their livelihoods. ¹⁶ Despite the massive increase in debt across the world, which will likely continue to increase as COVID-19’s negative impact continues unravelling, this is likely the right response because as Draghi, former President of the European Central Bank, points out, it is the role of the state to step in during emergencies and protect its citizens and the economy against shocks that the private sector cannot remedy. ¹

These trillions, though helpful, are necessary but not sufficient to keep our citizens, populations and societies healthy if they are not spent on the right things.

As public health experts such as Rose, Wilkinson and Marmot have been telling us for many decades, it is the social determinants of health (e.g. housing, education, transportation, access to jobs, nutritious food, clean air, clean water, support to prevent/recover from substance abuse, etc.) that determine 70–80% of our health outcomes.^17,18

Adopting a heuristic approach to take simple steps can go a long way to supporting our citizens during the tough times to come. In response to the 2008 global financial collapse and the recession the UK faced afterwards, the UK’s Faculty of Public Health recommended several actions to mitigate negative health impacts including: active labour market programmes; family support programmes; control of alcohol prices and availability; primary care people at high risk of mental health problems; debt relief programmes; training for healthcare professionals to discuss patients' finances and provide information on benefits; and coordinated responses across health, social and financial services to facilitate early interventions for at-risk populations. ¹⁹

Recovering from COVID-19 will not be easy and it will be painful. But understanding where we can and cannot make an impact will help us to take simple steps in areas we can control so that we can optimise the way we spend our limited resources and ensure as peaceful and efficient a recovery from COVID-19 as possible.