Part two: tackling population health challenges

In part two Gerry McCartney and colleagues suggest ways to build back after the pandemic

CREDIT: This is an edited version of an article that originally appeared on The BMJ 

The complex, and inter-related, health challenges, discussed in Part 1, require a strategic, long term and radical response which tackles the wider challenges of economic inequality and climate change.

Health policy responses to the pandemic have often been reactive, driven by the need to reduce viral transmission, with less consideration of interactions with social and economic factors and the longer-term consequences of measures taken. This has widened inequalities attributable to both direct and indirect effects of the pandemic – yet continued threats to health are not inevitable. 

Politicians have choices. It is reasonable to call on them to ensure that these choices pay particular attention to those with low incomes, insecure employment and cramped housing conditions who have been disproportionately affected during the pandemic. Countries that have prepared for future threats, and acted rapidly and decisively when they arise, have fared better, safeguarding the health of their people, and of their economies and core roles of government, while those that fail to do so will be judged adversely by history – and, probably, their electorates. 

We argue that three linked approaches are needed to protect health in the aftermath of the pandemic.

1. Prioritise equity

Recovery planning must prioritise investment in the wellbeing of populations – especially low-income families, caregivers and people with disabilities – that have been most severely affected by the pandemic; financial, practical and educational support for children and families will be required to reverse widening inequalities. In doing so, it is important to learn from policies that have gone before such as Sure Start centres, which have been shown to reduce hospital admissions, child tax credit expansion in the US, which has reduced food insecurity and learning from the 2000s when child and pensioner poverty fell in Britain, ‘overwhelmingly driven by tax and benefit policies and large increases in welfare entitlements’. 

Policies introduced during the pandemic like the ‘Everyone In’ policy, which offered shelter to all rough sleepers in the first lockdown, and the increase in universal credit, while reducing conditionality to lower poverty rates show what is possible to protect vulnerable populations. Like the state pension and the NHS, these policies and approaches should become routine in the British welfare state.

In addressing the backlog of unmet healthcare need, more of the additional investment in health needs to go to primary and social care; such investment has long been recognised as necessary to enhance prevention and reduce demand and inequalities in access to services. This is even more important for a health service that is experiencing the combined effects of an ageing population, the continued growth of unmet need throughout the pandemic, disruption due to Brexit and, in England, a major service reorganisation.

• Adopt a ‘health in all policies’ approach

As we move towards the recovery phase it will be essential to ensure that all policies – housing, employment, energy, social security, transport, justice, etc – not just healthcare, help promote health and reduce health inequalities. This is called a ‘health in all policies’ approach and involves public health professionals working closely with policy-makers and others in public, private and third sector institutions, at different geographical levels, to influence policy and tackle the wider social determinants of health. Well-established processes like health impact assessments provide a practical way to do this. 

Public Health Scotland took this approach in its social and system recovery programme, set up to respond to the wider effects of the pandemic. An example is work with transport policy-makers and planners which recommended policies to the Scottish government, local government and other transport providers to improve health and sustainability during lockdown and beyond, including policies to maintain the provision of public transport and improve infrastructure for walking and cycling. 

Similar analyses seeking to reduce the adverse economic impacts of the pandemic identified a series of policies that could be implemented to reduce poverty, increase employment inclusivity and redesign the economy to reduce inequalities. These recognise the key role of the economy in modifying the effect of the pandemic on health – for example, by reducing inequalities in exposure and susceptibility to the direct and indirect pandemic impacts – and the consequences thereof, and its importance for long term health trends. 

• Create a new economic model

The third element is more fundamental, and requires radical change. Addressing the fractures in our society illuminated by the pandemic requires a different economic model from the one that created many of the health problems discussed above. It requires economic institutions, and governance mechanisms, designed explicitly to provide equitable distribution of benefits and resources, within planetary boundaries. 

Some governments and other institutions are already collaborating on ways to create ‘wellbeing economies’ that prioritise human and ecological wellbeing above economic growth. Economies redesigned in this way would have low inequality and poverty, would rapidly reduce greenhouse gas emissions and excessive consumption and would create space, time and work that is fulfilling, and contributes to social outcomes.

Global inequalities in COVID-19 vaccination have shown the need for global co-operation to shift towards a wellbeing economy; for example, vaccine supplies have not been produced or distributed globally according to need, costs and a lack of healthcare infrastructure have been substantial barriers and lack of trust in institutions has damaged confidence in vaccine safety. 

Furthermore, by reducing the demands on healthcare and other services by reducing poverty, environmental damage and all of the negative ‘side-effects’ of the current economic model, a new model can go a long way to addressing the long-term financial challenges facing governments. We need to identify, investigate and evaluate alternative economic models, and ensure that the risks, benefits and uncertainties of all future scenarios are well-understood by both policy-makers and the public. 

An appropriate policy response to today’s challenges needs to radically reduce economic and social inequality, protect incomes and reduce poverty, provide sufficient resources for the health and social care system – and do all of this within planetary boundaries. 

This level of change may have seemed unthinkable two years ago, but the pandemic has taught us that governments can act quickly, and radically, when required. The pandemic has highlighted the cost of prioritising the short-term interests of better-off adults over the long-term health and wellbeing of the population as a whole. Rebalancing requires a fundamental shift in the purpose and design of the economy. 

Given the scale of the challenges facing us, a new framework of holistic, equitable and sustainable public health is urgently needed.