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I was talking to a colleague recently when she suggested that the success of North Korea’s COVID-19 management was due to a policy ordering anyone who tested positive to be shot. While this was clearly, at least I hope, a callous and morbid joke. It made me wonder. How close does this fabricated utilitarian approach mirror health policy in the world currently? Public health data shows that segments of society ‘took the bullet’ during this pandemic. Disproportionally affected, they would call it, but the results don’t stray that far from pre-pandemic trends to be disproportionate, merely an intensified version of what was already there. (1)

For instance, in Britain, before they were sharing social inequality with the rest of the planet, they were perfecting it at home. One remarkable pommie gent by the name of Sir Michael Marmot studies this like it’s his job and has concluded that the determinants for health lie outside the healthcare system. He proposes they are instead founded in inequalities in the way we grow up, interact, work, and age in society. These Social Determinants of Health are widely accepted and currently used worldwide to inform government policy in all sectors to achieve better health outcomes. I would encourage you to read more but, for the purposes of this article, know that they are: early life, stress, the social gradient, social exclusion, work and unemployment, social support, addiction, food, and transport. (2)

British COVID policy centered around suppression and mitigation factors to control the spread of infection. Population-wide social distancing and personal protective equipment use in combination with at-home isolation of positive cases, and closures of school, and university campuses until vaccination high enough to immunize the population is reached. (3) And while these measures appeared to be responsible in the moment, the damage to the social determinants of health was already long done. A previous decade of public policy focused on austerity, cuts to social services and local government funding, combined with new stressors of lost income, crowded housing, and dangerous working conditions for those down the social gradient. Excess mortality was inevitable. Special mention should be made of the Black, Asian, and minority ethnic (BAME) population in the UK. Even after accounting for regional differences, residence type, socioeconomic factors, and health measures such as pre-existing conditions, men of black African ethnicity were 2.2 times more at risk of death from COVID-19 than those of white ethnicity in the first wave and black African women were 1.5 times more at risk than white women in the first wave. (4)

School and early years settings closures have compounded issues of equality in education leaving experts worried about intergenerational effects on poverty. (4) In England, high-income families spent an average of 30% more time on home learning than those from other income brackets and BAME children had proportionally higher attendees of schools reporting a need for intensive catch-up support. The UK government speaks of returning to normality with the catchcry of Build Back Better. Public health advocates like Marmot are calling to have inequities in society addressed, more succinctly, to Build Back Fairer. (1)

Then there is Sweden. Those brave Vikings. No masks. Virtual lockdowns. The true outlier in approaches to COVID-19 management. Far removed from the large-scale social distancing measures of the UK and many other nations. Even so, Sweden and the UK experienced similar outcomes of amongst the highest per capita COVID-related mortality rates in Europe. One study modelled a theoretical outcome where if the UK and Sweden had swapped COVID management policies there would have been a respective doubling and halving of mortality cases. (5) The Swedes live in different circumstances to the Brits evidently. The public health agency of Sweden is an independent agency rather than a government division. Allowing for greater autonomy of epidemiologists to make decisions and for the development of their nationwide experiment. Keeping schools and society open. Relying on voluntary public behavior changes. (6)

One case where these measures in Sweden failed monumentally is in protecting its elderly, living in long term care facilities, resulting in over 3000 deaths. The quality of care in these facilities, which are provisioned not by a national body but instead by 290 different municipalities, was called into question after the fact. Further research showed the mortality was 7 times higher than what would be expected in US or other Scandinavian countries facilities. This failure to predict the risks, or modern day Ättestupa by The Public Health Agency, resulted in 50% of all of Sweden’s COVID deaths in the first wave of the pandemic. (7) Even in a country lauded for high quality of living, COVID finds the gaps in the system. And while the contrasting British model of governance is faulted for being too centralized, the case for strong national regulation in health care is evident here. (4)

As we look back and evaluate the management of this pandemic, the stark view of human loss due to inefficiencies in healthcare systems and public policy will become more apparent. So as we move on to reach for zero net emissions and to rebuild economies from here, how willing are we to invest in skill development and education of the disenfranchised, dare I say even the redistribution of wealth? Do we take equity into the equation, or watch fellow humans die of red tape?


References

  1. Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. Build Back Fairer: The COVID-19 Marmot Review. The Pandemic, Socioeconomic and Health Inequalities in England. London: Institute of Health Equity 2020
  2. Marmot M, Wilkinson R. Social determinants of health: the solid facts. Copenhagen, Denmark: World Health Organization; 2003.
  3. Ferguson N, Laydon D, Nedjati-Gilani G et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College London 2020, doi: https://doi.org/10.25561/77482.
  4. Suleman M, Sonthalia S, Webb C, Tinson A, Kane M, Bunbury S, Finch D, Bibby J. Unequal pandemic, fairer recovery: The COVID-19 impact inquiry report. Health Foundation 2021, https://doi.org/10.37829/HF-2021-HL12
  5. Mishra S, Scott JA, Laydon DJ, Flaxman S, Gandy A, Mellan TA, et al.. Comparing the responses of the UK, Sweden and Denmark to COVID-19 using counterfactual modelling. Scientific Reports 2021;11(1).
  6. Anell A, Glenngård A. H, & Merkur S. Sweden health system review. Health systems in transition 2012; 14(5), 1–159.
  7. Ballin M, Bergman J, Kivipelto M, Nordström A, Nordström P. Excess Mortality After COVID-19 in Swedish Long-Term Care Facilities. Journal of the American Medical Directors Association 2021;22(8):1574–80.e8.
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