The unprotected many and the protected few: Working towards a health justice approach to future pandemic preparedness.

There are two diverging paths emerging out of the COVID-19 outbreak, in the UK and the world.

One is that of those who are vaccinated, who are able to access care, can work from home with secure employment and incomes that have allowed them to save for the economic storm that is brewing.

The other is of those who aren’t yet vaccinated, unable to access care, are employed in workplaces that you cannot socially distance in, with inadequate sick pay and income, living in homes that are overcrowded and insecure. The people and families who have lost lives and livelihoods are burdened with both the health and economic crisis.

COVID-19 is endemic in the most deprived neighbourhoods of the UK. This is where new variants have also taken hold that pose the risk of a fourth wave. Vaccines are being rolled out successfully in the UK – a testament to the public service effectiveness as compared to the privately run Test and Trace system – but the outbreak is still not controlled.

Now is an important time for us to reflect on the systems and practices that have led us to this point. Knowing what went wrong, what was not done and what could have been done, is essential to begin the processes of rectifying the harms still being caused by COVID-19 and preparing for the inevitable future pandemic.

Our current economic system is predicated on the extraction of natural resources that sees industries encroaching on natural habitats. This encroachment increases the risk of zoonotic diseases that sometimes reemerge, or are novel, as is the case with the virus that causes COVID-19 according to the most up to date evidence on the matter.

Over a 100 years of public health evidence points to the fact that ‘viruses don’t discriminate, societies do’. Social and economic factors increase the deadliness of such viruses as they spread along the paths laid out by systemic racism and pre-existing inequalities in access, income, housing, and wealth. Therefore a strategy that minimizes avoidable death and destitution, and prevents onset, would be the course that ensures everyone’s right to health is protected.

The current economic system also produces artificial scarcity of medicines and vaccines through profit-driven capture of the production and methods of distribution epitomised by the practice of large private pharmaceutical companies. Not withholding the fact that many advances in medicines and vaccines have occurred from public tax expenditure.

We need to not only limit the risk of diseases, such as those caused by viruses, but also address social conditions that create paths of unequal access, unequal risk and unequal impact that those viruses perpetuate during an outbreak.

The shortcomings of the UK pandemic response were grounded not in the lack of funds or state capacity, but the political choices. Choices that went against public health evidence. Choices that perpetuated the false dichotomy that there is a tradeoff between protecting public health versus protecting economic wealth. After 15 months, the deadliness of this political choice is clear: over 100,000 people who have lost their lives, countless more who have long-term illness, and 14.2 million who are financially insecure are tethering on the edge of destitution and possible homelessness.

This national impact reflects the global picture, with the additional burden of poor vaccine access for many countries and their people in the global south alongside the economic crisis, hitting hardest for women, migrants, precarious workers and renters.

So what must we do to address this issue and make sure it never happens again? How can we build towards real pandemic preparedness that prevents avoidable loss of life and protects the wellbeing of everyone?

Evidence points to an urgent need to address the deficits of current economic and welfare systems. This means ensuring that everyone has access to livable wages, secure employment and the right to refuse working in unsafe conditions, as well as access to sick pay and social insurance to mitigate the economic harm caused by sudden unemployment.

Welfare systems need to act as social safety nets for all, including migrants, with support that ensures livable incomes and access to health and care services free at the point of use for everyone, ensuring that there are plans to help people with access to food, to self-isolate safely in secure and quality housing or temporary accommodation.

We need to have a global compact to ensure the public provision of vaccines, medicines and technology required to fight outbreaks. Meanwhile, we must ensure the comprehensive funding of public health and healthcare infrastructure to meet the global standard of universal access to healthcare for everyone.

In the longer term, we need to address the harm caused by economic inequality and systemic racism. This means redressing and reforming the systems that perpetuate this harm by focusing on achieving real health equity and economic justice. This follows from the understanding that socioeconomic factors are a major determinant of health, and therefore the transformation of welfare and economic systems is one of the ways we can ensure more effective population health outcomes in the event of a future pandemic.

In order to fully recover, we need an approach grounded in redistributing the protective factors of livable wages, stable employment, secure housing and a social safety net that everyone, regardless of their immigration status, can access and be protected by. Income equality, fair housing and equitable access to health care for all must be part of the plan.

For these changes to happen, we need to challenge the political and economic conditions, institutions and actors that undermine public health for private economic gain. Only then can we truly ensure our social fabric is prepared for the next pandemic.