On the 4th March this year I returned from 4 weeks in rural Scotland, where I had very limited internet access, to find a world somersaulting around Covid-19.
My immediate reaction was relief that I retired from being a Director of Public Health in 2012. I remember only too well the way in which the H1N1 influenza virus 2009-10 affected my work for months, with daily briefings, and contingency planning. For example, I spent days working on ways to create capacity in the community for people well enough to be discharged from hospital but not able to go home for some reason. The contingency never arose, and this is an intrinsic aspect of emergency planning: anticipating what might go wrong, planning what to do and hoping it is not required.
Meanwhile my leadership role on the ‘day job’ was squeezed into the remaining time available. To illustrate, a core element of this work focussed on an eight-point action plan to address significant inequalities in life expectancy geographically within the patch:
- two designed to improve decision-making and audit processes by including explicit consideration of equity;
- three concerned lifestyle issues such as drinking, eating/ exercise, smoking;
- mental health and wellbeing
- financial inclusion, and
- targeted community-based work.
This was before a decade of austerity scoured out capacity from Local Authorities and their community services. Work in these complex areas continues today, although reducing inequalities is no longer a government target.
The Covid-19 virus for most people causes a mild infection, which you might not know you have had. But current analysis suggests that it is more likely to kill those over 70 years old, those with heart disease/ circulatory conditions or who are being treated for cancer. These form overlapping groups, as the older you are the more conditions you are likely to have manifested. The figures for these premature deaths are being logged daily, often read out in sonorous tones by newscasters.
I am not in a position to comment on the specifics of handling this pandemic: the relative importance given to testing; the device of not insisting that pubs, restaurants and theatres close while telling people not to go out to public gatherings; the ‘choice’ about self-isolating for the over 70s; the lack of differentiation in measures across England despite apparently different degrees of incidence. There have been many changes to the guidance and no doubt will be more. This is a new virus which we have yet to fully understand.
I do not want to die prematurely, or to see that happen to any of my kith and kin. this is not impossible, given we are largely close to or over 70. However, myself and my social circle are probably protected, more than most, by our income, class and lifestyle.
This brings me back to the question of inequalities in life expectancy. Sir Michael Marmot has,for decades, been pursuing his chosen mission to provide evidence about the nature of inequalities in life expectancy across the social gradient. In February 2020 he produced a report about the UK ‘The Marmot Review, 10 years on’, which tracked progress since his 2010 recommendations relating to life expectancy, healthy life expectancy and the social determinants of health that impact on it. Four key points selected from the executive summary are:
“Life expectancy follows the social gradient – the more deprived the area the shorter the life expectancy. This gradient has become steeper; inequalities in life expectancy have increased. Among women in the most deprived 10 percent of areas, life expectancy fell between 2010-12 and 2016-18.
There are marked regional differences in life expectancy, particularly among people living in more deprived areas. Differences both within and between regions have tended to increase. For both men and women, the largest decreases in life expectancy were seen in the most deprived 10 percent of neighbourhoods in the North East and the largest increases in the least deprived 10 percent of neighbourhoods in London.
There has been no sign of a decrease in mortality for people under 50. In fact, mortality rates have increased for people aged 45-49. It is likely that social and economic conditions have undermined health at these ages.
The gradient in healthy life expectancy is steeper than that of life expectancy. It means that people in more deprived areas spend more of their shorter lives in ill-health than those in less deprived areas.”
A widely reported research study found that around 120,000 excess deaths occurred between 2010 and 2017 which were associated with reduced public expenditure on health and social care. In 2019 another study estimated that 130,000 preventable deaths occurred between 2012 and 2017 although they did not attribute these directly to reduced funding for public services. These premature deaths, and the years lived with the burden of poor health, have been unremarked, in contrast with the daily toll announced from Covid-19.
The analysis of figures for Covid-19 in the UK do not yet reveal differences in mortality according to gender or class, but it would be surprising if they do not follow the expected pattern of greater impact on those who are poor, and therefore more likely to suffer ‘underlying health conditions’.
So far, the debate about Statutory Sick Pay has been aired as part of a plan to stop ill people going to work. From first principles in a supposed welfare state one might have thought it was never a good idea to have sick people going to work, even if they were not potentially infected by a brand-new virus. The pandemic word seems to have focussed minds and helped the government find money in pockets no one knew existed. However, the question of adequate income to meet basic daily needs requires a lot more attention. The gig economy depends on zero hours contracts: meanwhile universal credit has a built-in delay between being eligible and receiving relief. The economic consequences go far beyond the current welfare system. The implosion of arts, culture, sport and entertainment industries may add many more people into the group requiring support.
On the plus side air quality may improve, with less congested roads. Public Health England estimated that 28,969 deaths a year are associated with Particulate Air Pollution associated with burning fossil fuels (2014). Reductions in travel by air and on and cruise ships will make a significant contribution to the reduction of emissions of carbon dioxide.
In terms of social change, there are signs that spontaneous community responses to the emergency are developing across the UK, you can see what is going on locally on this website . Might this sort of ground-up activism help us to re-discover the sort of politics we have forgotten in the recent years of discord and segmentation. And, at in international level, despite the trend to nationalism, in relation to some issues such as finding a vaccine there is co-operation.
If I believed in a benign overseeing life force, I might consider that Covid-19 was the kindest sort of shock that it could deliver to wake up a world where humanity has overstepped its rightful place in the scheme of things. If the shock was not serious enough to be frightening, we would shrug it off. As it is, we may be over-reacting to a virus that is unlikely to harm most of the population. However, if, in the process we have re-discovered that we created our economic and social systems to serve us, and that we can change them, fast, if we decide to, then that is a big step forward.
Ironically Climate Change has not yet made us feel under threat in this way. The slow nature of Climate Change means we can sleep-walk into situations potentially more catastrophic than that posed by Covid-19, simply by swimming faster like the proverbial frog being heated up in a pan of water.
Perhaps as we live through weeks and possibly months of ‘social distancing’ undistracted by the usual run of entertainment and activity, we can think about how we can act as better custodians to nurture the only planet we have. Imagination will be required to help us think of ways to maintain the most important benefits that capitalism has brought, while at the same time giving up the crazy idea of infinite growth. We are not here to make money. Money was invented to enable trade, and to enrich our lives. The impact of the virus has been rapid over the last six weeks and many apparently entrenched patterns have already altered. So, let’s use the time we have, to think about how to re-build our social and economic life in a way that respects the natural world, recognises the reality of finite resources, and values the diversity and creativity of every member of the human race.
Alyson Learmonth started to work for the NHS in 1978, after completing her PhD.at Bradford University. She retired in 2012 after nine years’ experience as a Director of Public Health the North East of England. She was an Honorary Fellow at Durham University until 2018. Her interests include reducing inequalities in health, mental health and wellbeing, and evidence-based practice.