COVID-19 and the inequalities industry

The COVID-19 pandemic has examined forensically the way people live their lives throughout the world and exposed the weaknesses in the measures that are supposed to protect the most vulnerable. Inequalities in living and working conditions that lie behind the determinants of life expectancy have once again come to the fore and we have been brought face to face with the stark reality that those who have been dealt the most meagre hands in life’s game of chance have been those most likely to succumb to the coronavirus. The poor, particular social and ethnic groups, together with those living in the most disadvantaged areas at home and abroad have been singled out for infection, death and chronic morbidity. None of this should surprise us.

Our knowledge of the impact of inequality on health, wellbeing and life expectancy goes back a long way and can be dated to the Chadwick Report on the Sanitary Conditions of the Labouring Classes in England, published in 1842 and by the novels of Charles Dickens who documented the lives of ordinary people in novels such as Hard Times.^1,2 Chadwick’s report was made possible by the advent of routinely collected vital statistics on birth and death and paved the way for academic studies on poverty and inequality that persists to the present day.

Landmarks in the evolution of what was to become a British tradition, were the publication of studies by Liverpool shipowner and social reformer, Charles Booth, and by York industrialist, researcher and social reformer, B. S. Rowntree. ³ Booth reported that of over 4000 poor individuals, 62% were paid low or irregular wages, 23% had large families or suffered from illness, and 15% squandered their earnings, drank excessively or refused to work. Rowntree’s studies in York between 1899 and 1901 concluded that 30% of people there lived in poverty and that they needed 21 shillings per week to stay out of poverty, defining for the first time the notion of a ‘poverty line’. ⁴

Since those days, the study of poverty and inequality has become a well-trodden path with contributions by many of the leading figures in British academia. By the time the Black Report on Inequalities in Health was published in 1980, contributors to the genre had included luminaries such as Richard Titmus, Bryan Abel-Smith, Ann Cartwright and Julian Tudor Hart.^5–9 In recent years it has assumed the characteristics of an academic industry with questionable impact on the living conditions and life chances of the most disadvantaged.

The Black Report, under the chairmanship of Sir Douglas Black, President of the Royal College of Physicians of London, documented the inequalities that existed in the mortality experience of men and women in different social classes in different parts of the country and between different racial groups. Commissioned by a Labour Government but received by an incoming Conservative administration, a clumsy attempt was a made to bury the report by only releasing 200 poorly photocopied drafts over a bank holiday weekend. The unintended consequences were to generate widespread publicity resulting in the publication of a paperback version, which went on to enjoy huge sales. ⁹

Despite this, a protracted period of an antagonistic government in which the use of the term ‘inequalities in health’ was banished from government circles in favour of the vague ‘variations’, coupled with a lack of focus in the recommendations led to a dearth of practical follow-up action. ¹⁰ However, an untoward consequence of government efforts to play down the significance of such inequalities paradoxically marked an acceleration in the academic efforts dedicated to describing and documenting the ongoing injustice of widening social inequity.

One of the authors of the report Black Report was Professor Jerry Morris my head of department at the London School of Hygiene and Tropical Medicine, who with a deep-seated reluctance to sleep anywhere but in his own bed, dispatched me to Scandinavia to present the findings to the National Boards of Health in Sweden and Finland. Among the audience in Stockholm was health policy analyst, Goran Dalhgren, who, stimulated by the report was to go on to spend the remainder of his career researching health inequality in partnership with Margaret Whitehead. Dalhgren and Whitehead’s ‘Rainbow’ model of health determinants would prove to be an enduring expression of the whole systems interventions necessary to impact on the continuing social injustice of profound health inequality, something that ironically was much less in evidence in the Scandinavian countries whose values and policies ensured that by and large nobody had too much and nobody too little. ¹¹

Following the publication of the Black Report, there ensued a range of regular contributions usually describing the persistence of inequalities in health in the United Kingdom. The election of the Blair government in 1997 saw outgoing Chief Medical Officer Sir Donald Acheson chairing a renewed Independent Inquiry into Inequalities in Health, published in 1998 and feeding in to the new administration’s ambitions for a public health strategy led by the country’s first Minister for Public Health, Tessa Jowell. ¹²

Since Jerry Morris and Sir Donald’s deaths, Sir Michael Marmot has assumed some of the mantle of this work with an extensive output of research and documentation aimed at influencing policy makers. ¹³ In 2009, Wilkinson and Pickett added to the rational arguments for tackling inequalities at a societal level by demonstrating that more equal societies also do better economically, an insight that might have played better in the United Kingdom during the pandemic when some pundits and politicians seemed to frame sound public health interventions as being in opposition to a thriving economy. ¹⁴

The Acheson Report informed the implementation of policies including that of child enrichment and parental support programme, ‘Sure Start’, based on American President Kennedy’s ‘Head Start’ Programme and aimed at the 20% most disadvantaged families, supported by ‘Sure Start’ and ‘Healthy Living Centres’, especially in designated ‘Spearhead’ districts and boroughs where disadvantage was most acute. These initiatives began to have an impact, but were short lived being mostly abandoned following the return of the Conservatives to power in 2010.

Since the advent of the COVID-19 pandemic, it has not only become clear that the neglect of the British public health system over the past 10 years meant that the country was ill-prepared to handle and control the challenge presented but that the abandonment of efforts to reduce social inequalities rendered a significant part of the population especially vulnerable with predictably dire consequences.^13,15,16

It is said that every system is perfectly designed to achieve the results that it does. This observation seems undoubtedly to apply to the alleviation of inequalities in health where structural causes call for structural change.

Lessons from history teach us that change is possible even in the United Kingdom where a comprehensive set of measures was implemented by Lloyd George’s administration following the damning report on the physical condition of the working classes in 1906, which led to fears that the country would be unable to muster an armed force to contain German military ambitions. ¹⁷ To achieve meaningful change it is necessary to move beyond academic analysis to political commitment and leadership. This was demonstrated in the far-reaching achievements of the campaigning Health of Towns Association movement in the 1840s and has been recognised by the World Health Organization in its Healthy Cities Programme today. This global initiative stresses the importance of political leadership at the municipal level in tackling inequality and achieving the United Nations Sustainable Development Goals. ¹⁷

It remains to be seen whether a government that has now replaced the use of ‘Inequalities’ with ‘Disparities’ and has replaced Public Health England, its National Public Health Agency, with a body called the U.K. Health Security Agency, complete with para-military uniform for its staff, will be able to achieve its vague ambitions for ‘levelling up’ or whether it will go the same way as its predecessors ‘big society’. One glimmer of hope on the horizon is the emergence of a new National Inequalities Alliance that seeks to use the aftermath of the pandemic as a platform for lasting change. ¹⁸