2021

             

Photo by: Clay Banks (Unsplash)

 

Global herd immunity remains out of reach because of inequitable vaccine distribution – 99% of people in poor countries are unvaccinated

 

In the race between infection and injection, injection has lost.

Public health experts estimate that approximately 70% of the world’s 7.9 billion people must be fully vaccinated to end the COVID-19 pandemic. As of June 21, 2021, 10.04% of the global population had been fully vaccinated, nearly all of them in rich countries.

Only 0.9% of people in low-income countries have received at least one dose.

I am a scholar of global health who specializes in health care inequities. Using a data set on vaccine distribution compiled by the Global Health Innovation Center’s Launch and Scale Speedometer at Duke University in the United States, I analyzed what the global vaccine access gap means for the world.

A global health crisis

Supply is not the main reason some countries are able to vaccinate their populations while others experience severe disease outbreaks – distribution is.

Many rich countries pursued a strategy of overbuying COVID-19 vaccine doses in advance. My analyses demonstrate that the U.S., for example, has procured 1.2 billion COVID-19 vaccine doses, or 3.7 doses per person. Canada has ordered 381 million doses; every Canadian could be vaccinated five times over with the two doses needed.

Overall, countries representing just one-seventh of the world’s population had reserved more than half of all vaccines available by June 2021. That has made it very difficult for the remaining countries to procure doses, either directly or through COVAX, the global initiative created to enable low- to middle-income countries equitable access to COVID-19 vaccines.

Benin, for example, has obtained about 203,000 doses of China’s Sinovac vaccine – enough to fully vaccinate 1% of its population. Honduras, relying mainly on AstraZeneca, has procured approximately 1.4 million doses. That will fully vaccinate 7% of its population. In these “vaccine deserts,” even front-line health workers aren’t yet inoculated.

Haiti has received about 461,500 COVID-19 vaccine doses by donations and is grappling with a serious outbreak.

Even COVAX’s goal – for lower-income countries to “receive enough doses to vaccinate up to 20% of their population” – would not get COVID-19 transmission under control in those places.

The cost of not cooperating

Last year, researchers at Northeastern University modeled two vaccine rollout strategies. Their numerical simulations found that 61% of deaths worldwide would have been averted if countries cooperated to implement an equitable global vaccine distribution plan, compared with only 33% if high-income countries got the vaccines first.

Put briefly, when countries cooperate, COVID-19 deaths drop by approximately in half.

Vaccine access is inequitable within countries, too – especially in countries where severe inequality already exists.

In Latin America, for example, a disproportionate number of the tiny minority of people who’ve been vaccinated are elites: political leaders, business tycoons and those with the means to travel abroad to get vaccinated. This entrenches wider health and social inequities.

The result, for now, is two separate and unequal societies in which only the wealthy are protected from a devastating disease that continues to ravage those who are not able to access the vaccine.

A repeat of AIDS missteps?

This is a familiar story from the HIV era.

In the 1990s, the development of effective antiretroviral drugs for HIV/AIDS saved millions of lives in high-income countries. However, about 90% of the global poor who were living with HIV had no access to these lifesaving drugs.

Concerned about undercutting their markets in high-income countries, the pharmaceutical companies that produced antiretrovirals, such as Burroughs Wellcome, adopted internationally consistent prices. Azidothymidine, the first drug to fight HIV, cost about US$8,000 a year – over $19,000 in today’s dollars.

That effectively placed effective HIV/AIDS drugs out of reach for people in poor nations – including countries in sub-Saharan Africa, the epidemic’s epicenter. By the year 2000, 22 million people in sub-Saharan Africa were living with HIV, and AIDS was the region’s leading cause of death.

The crisis over inequitable access to AIDS treatment began dominating international news headlines, and the rich world’s obligation to respond became too great to ignore.

“History will surely judge us harshly if we do not respond with all the energy and resources that we can bring to bear in the fight against HIV/AIDS,” said South African President Nelson Mandela in 2004.

Pharmaceutical companies began donating antiretrovirals to countries in need and allowing local businesses to manufacture generic versions, providing bulk, low-cost access for highly affected poor countries. New global institutions like the Global Fund to Fight AIDS, Tuberculosis, and Malaria were created to finance health programs in poor countries.

Pressured by grassroots activism, the United States and other high-income countries also spent billions of dollars to research, develop and distribute affordable HIV treatments worldwide.

A dose of global cooperation

It took over a decade after the development of antiretrovirals, and millions of unnecessary deaths, for rich countries to make those lifesaving medicines universally available.

Fifteen months into the current pandemic, wealthy, highly vaccinated countries are starting to assume some responsibility for boosting global vaccination rates.

Leaders of the United States, Canada, United Kingdom, European Union and Japan recently pledged to donate a total of 1 billion COVID-19 vaccine doses to poorer countries.

It is not yet clear how their plan to “vaccinate the world” by the end of 2022 will be implemented and whether recipient countries will receive enough doses to fully vaccinate enough people to control viral spread. And the late 2022 goal will not save people in the developing world who are dying of COVID-19 in record numbers now, from Brazil to India.

The HIV/AIDS epidemic shows that ending the coronavirus pandemic will require, first, prioritizing access to COVID-19 vaccines on the global political agenda. Then wealthy nations will need to work with other countries to build their vaccine manufacturing infrastructure, scaling up production worldwide.

Finally, poorer countries need more money to fund their public health systems and purchase vaccines. Wealthy countries and groups like the G-7 can provide that funding.

These actions benefit rich countries, too. As long as the world has unvaccinated populations, COVID-19 will continue to spread and mutate. Additional variants will emerge.

As a May 2021 UNICEF statement put it: “In our interdependent world no one is safe until everyone is safe.”

 

 

By               :          Maria De Jesus (Associate Professor and Research Fellow at the Center on Health,                                                                      Risk, and Society, American University School of International Service)

Date            :         June 22, 2021

Source        :          The Conversation

https://theconversation.com/global-herd-immunity-remains-out-of-reach-because-of-inequitable-vaccine-distribution-99-of-people-in-poor-countries-are-unvaccinated-162040

 

Inequalities Are Shaping How We’re Fighting the Pandemic — And How We’ll Remember It

 

Covid-19 infections in most countries have been hugely underestimated — not least because rich countries bought almost all the tests.

The first wave of the 1918-19 influenza pandemic did not have much impact in India; it was the second wave that was the most devastating.

It is now thought that 12 million people died in India during the flu pandemic, the equivalent of 4 percent of the population at that time. Most of these deaths were concentrated in a few short months from September to December 1918. This quote is from Punjab’s sanitary commissioner at the time:

“The hospitals were choked so it was impossible to remove the dead quickly enough to make room for the dying….; the burning ghats (cremation site) were literally swamped with corpses; the depleted medical service, was incapable of dealing with more than a minute fraction of the sickness requiring attention.”

Yet amazingly this incredible event was barely recorded. While photographic images are widely available for the 1918-19 flu pandemic in Europe, the United States, and the UK, there are virtually no such images for India.

A century later, another deadly pandemic is sweeping India, and watching our screens it feels like the only thing that has changed from a century ago is that the impact of coronavirus in India is not hidden; it is on 24-hour news across the world. The Covid-19 pandemic is many terrible things, but unlike the 1918 flu, it at least seems to be being clearly recorded and understood across the world.

Yet in fact I think this is far from the case. Instead, brutal historical and existing inequalities are not just shaping how we fight this pandemic but how we are recording it and how we will remember it too.

Twenty years before influenza hit India, there was an outbreak of bubonic plague. While it did not take nearly as many lives, it was still very serious. Unlike the influenza epidemic, there is a relatively strong photographic and written record of this outbreak. So why no pictures of the influenza pandemic?

One of the obvious differences was that, unlike the flu, other countries were not impacted by India’s bubonic plague. I think part of the reason events in India today are getting so much coverage in the Western press is probably because widespread vaccination in rich nations has meant Covid deaths at home have collapsed to very low levels.

Perhaps events in India are so terrible that they would have broken through even during the height of the coronavirus pandemic in the United States and Europe. Yet the pandemic has been as bad in Latin America from the beginning as it has been India, but this has barely registered. Queues for oxygen, overwhelmed graveyards, deaths on the street, privatized health systems leaving the poor to die — all have been pretty much a constant in Latin America for the last year.

This also says a lot about our colonial ties and historic connections. That news from Latin America barely registers time and again is partly because of a linguistic and cultural gap that itself is a product of colonialism.

The other main similarity with the influenza pandemic is something that is perhaps the ultimate inequality: lives and deaths that are not even recorded at all. The official numbers of those testing positive for Covid-19 in most countries have been hugely underestimated — not least because rich countries bought almost all the tests. In Kenya, the government is still testing about 3,000 people a day, and tests cost as much as $100. The UK is testing a million people a day.

The Economist magazine estimates that the true death toll from Covid-19 so far is more like 10 million people, not 3 million, and that two thirds of these deaths have not been in rich nations but in poor and middle-income countries. In Egypt, the level of excess deaths (the difference in the total number of deaths in a crisis compared to those expected under normal conditions) is 13 times the number of official deaths from Covid-19. Yet the story of the last year has been dominated by deaths in rich nations, and the history of the first year of this pandemic is likely to be so too.

This inequality in reporting and measuring, leading to the sense that this pandemic was not very serious in the developing world over the last year, has in turn had a major impact on the response. The drive to get vaccines to the developing world has been criminally inadequate and continues to be so.

The scenes in India, in contrast to a rich world now rapidly heading towards full vaccination, are only now finally making the issue of global vaccine apartheid and the suffering in developing countries bigger news.

Part of the reason the dramatic scenes in India are getting more coverage is in turn a result of inequality. It is because they are happening in Delhi, where global media outlets have their correspondents, and the middle classes are being impacted so tragically. The huge suffering of the poorest and of those in the countryside where there is literally no hope of any medical care of any substance is once again being barely recorded — just as it was in 1918. Independent epidemiologists believe India could be seeing not the official 4,000 deaths a day but in fact as many as 32,000.

Without hard facts, the void is filled by anecdotes and personal stories. It seems likely to me, for instance, that coronavirus is also raging across Kenya as we speak and is probably more serious now than at any point in the last year — not because the official numbers show this, but simply by the number of people I know who have lost loved ones or been sick themselves in recent weeks and months.

When my friend Doreen died suddenly and tragically from Covid-19 earlier this year, I found out by WhatsApp. I woke up one morning and sent a message to her husband Stuart to see how she was doing. Only the day before her oxygen levels had been stable and things were looking positive. Stuart’s reply was short and devastating: “Max she is no longer with us.”

I was reminded of this this week when I heard from colleagues and friends in India. They said every morning they dread switching on their phone for fear of seeing messages about friends who have died in the night. It made me reflect on the many thousands of heart-breaking messages being sent each day, each one bringing with it sadness, loss, rage, and disbelief. Beyond the selective headlines, maybe it is this most personal and intimate communication that is in some ways the more accurate record of this terrible moment in our history.

There is no doubt that Covid-19 is a huge global trauma, operating on a personal, family, community, national, and global scale all at once. Its ramifications and implications will be felt for decades to come. In her book on the 1918 influenza pandemic, Pale Rider, the author Laura Spinney asks how we can have forgotten the most lethal episode of the 20th century. I don’t think there is the same danger of humanity forgetting Covid-19.

But I do think that inequalities in the way we measure and record this pandemic have direct implications for how it is understood at the time, how it is responded to, and how it will be remembered.

And it is frightening to think that after all the world has been through in the last year, that unless something dramatic changes, most deaths from Covid-19 are yet to come. A year ago, the main barrier to beating this cruel disease was science. Today it is inequality.

 

Max Lawson is Head of Inequality Policy at Oxfam International.

 

By                   :                      Max Lawson 

Date               :                      June 7, 2021

Source           :                      Inequality.org 

https://inequality.org/research/inequality-pandemic-developing-countries/

 

There a lack of female home ownership in Latin America – here’s how can we change this

 

  • Female home ownership in the developing world is a critical issue, writes the International Finance Corporation VP Georgina Baker.
  • It affects both living conditions and women’s ability to build and grow their own businesses.
  • In Central America, less than 40% of women have access to a bank account, and only 6% have taken out a mortgage.
  • Baker explains why that's a problem and what needs to be done to change it.

For people in the developed world, a mortgage is a step toward owning a home. In developing countries, that dream is often elusive—especially for women.

Female home ownership in the developing world is a critical issue: it not only has ramifications on living conditions, but in women’s ability to build and grow their own businesses. Accessing formal credit relies heavily on collateral, namely large assets—a house or an apartment—that women often lack but which are essential to building their credit history. In many cases, women also use their homes as the base for their business.

Central America presents a clear example of this challenge. Less than 40% of women in this region have access to a bank account, and only 6% have taken out a mortgage . In comparison, 16% of women in Colombia and 13% of women in India used formal loans to purchase housing, according to a recent IFC study, Her Home—Housing Finance for Women.

These gender disparities limit women’s financial capacity and business growth opportunities. Women demonstrate greater educational performance and positive traits (such as lower default rates on their bank loans) as banking clients, but they remain woefully underserved by the financial sector. Women-owned businesses have less access to commercial loans because they tend to be part of the informal sector and therefore lack the proper documentation—for example, proof of income or real estate collateral—required to access financial services. Central America needs to break down this barrier to make its growth more inclusive and to continue reducing inequality.

With this in mind, IFC (the private sector arm of the World Bank Group), recently pioneered a new partnership with Global Bank in Panama to launch the first ever mortgage product targeted specifically toward women . The aim is to create opportunities that will tackle the two interconnected issues of housing finance for women and supporting women-owned businesses. The initiative will address the fact that women-owned businesses in Panama currently have less access to loans because they lack the real estate collateral that financial institutions require.

With one of the largest and most stable financial sectors in the region, this initiative in Panama will show the commercial viability of promoting financial products and services for women to become homeowners and use this as a gateway to receive loans to finance their businesses. This could potentially be a solution that developing economies in Latin America and other regions could replicate to expand access to capital for women entrepreneurs.

The financial sector could also stand to benefit as female homeownership is an untapped business opportunity. Despite the hurdles that women face, there is a large unmet demand for housing finance for women-headed households, particularly in developing countries . IFC’s latest study on women’s access to home ownership—covering Colombia, India, and Kenya— confirms that the women’s housing finance market is more than $70 billion in these three countries alone.

In the one of Panama’s neighboring countries, Colombia, the estimated market size for women’s housing loans is $23 billion, and 49% of women who participated in a survey planned to purchase a home or make home improvements in the next five years. While women make up half of the population, only a small fraction of them are property owners. In fact, only 8% of female-headed households in Colombia applied for a housing loan in the last five years.

Colombia is trying to address this challenge. The country started putting in place initiatives to offer subsidized interest rates for a lower income segment of the population, which includes female-headed households. In another example, India’s “Housing for All,” a Credit Link Subsidy program, provides a subsidy if a woman is on the registered title.

Latin America is also well positioned to start adopting innovative housing finance products and services geared toward women . This way, the banking sector can tap into a large underserved market and add value to their bottom line while contributing to the growth of the housing sector. The positive impacts could be widespread: for the banks, these initiatives help to attract and retain women as retail customers, while also supports women-owned businesses and thus promoting and inclusive economic growth. It’s time for women to own a home and turn their dream into a reality.

 

By                            :                        Georgina Baker (Vicepresidente, IFC para Latinoamérica)

Date                        :                         May 4, 2021

Source                    :                         World Economic Forum 

https://www.weforum.org/agenda/2021/05/women-latin-central-america-housing-houses-poverty-change-gender/

           

Photo by :  Steve Knutson (Unsplash)

 

What ancient Greek handwashing can teach us about socio-economic inequality

COVID-19 poses massive challenges nationally and globally when it comes to socio-economic inequality. It has hit the vaccine rollout especially hard, threatening new and potentially more lethal variants, while low-risk people are being vaccinated in rich countries well ahead of high-risk people in poorer countries.

Even before the pandemic was officially declared on March 11, 2020, socio-economic inequality was flagged as one of the greatest threats to the global economy.

The pandemic has only accelerated socio-economic inequality, impacting women and racialized people especially hard.

But why is socio-economic inequality so threatening to human societies and how can archeology inform public policies for mitigating it?

As an archeologist who has spent the past 13 years excavating and studying material culture at the site of Eleon, an ancient town in central Greece, I study the effects of a socio-economic collapse that took place over 3,000 years ago. By excavating and interpreting the human past, I believe that we can avoid past mistakes and build a more inclusive future.

Inequality in Mycenaean Greece

Long before Athens and Sparta were major players, Greece was home to the Mycenaeans, a Late Bronze Age culture comprising small city-states each ruled by a wanax (king).

The wanakes (kings) established their authority at feasts, where the wanax and other elites performed sacrifices to the gods. These feasts manifested and reinforced social inequalities within Mycenaean society. Inequalities between participants were emphasized by the rooms they could access within the palaces, the clothes they wore, the food they ate and even what they drank from.

Palace-sponsored feasting required contributions from individuals and communities. This had an effect on agricultural strategies, which favoured short-term intensification in production over long-term resilience.

This increased the Mycenaean elites’ vulnerability to climate change, disease and warfare. Ultimately, the Mycenaean city-states collapsed around 1200 BCE. The palaces burned and the wanakes disappeared from Greece for good.

While we are unable to identify a singular cause for the collapse of the Mycenaean Greek palatial culture, it is clear that the one per cent paid the highest price when the system went bust. A growing number of archeological studies across the globe question the economic and social impact of collapse on the 99 per cent.

The degree to which collapse disproportionately impacted elites has even led to the hypothesis that class warfare played a role in the fall of the Mycenaean palaces.

Handwashing and the performance of inequality

In a recent paper fellow archeologist Bart?omiej Lis and I examined one element of palace-sponsored feasting: handwashing.

Our research identifies handwashing equipment archeologically for the first time through a detailed study of abrasion patterns on clay vessels. We trace the origins of this equipment to Egypt, where similar metal handwashing vessels appear during the third millennium BCE.

Mycenaean elites maintained a monopoly over the earliest bronze handwashing equipment. Vessels were used for a form of purification that required both metal vessels and ritual knowledge to properly perform, preventing the custom from spreading outside the palatial elite.

Other forms of daily handwashing likely took place that did not require this equipment. Local elites performed handwashing with metal vessels to highlight their own privileged socio-economic status. Think of this showboating like gathering a few of your close friends and flying them to a tropical island for your birthday in the middle of a pandemic.

Our research found that post-collapse, Greek handwashing equipment became widely available, now manufactured in cheap clay versions. This demonstrates that some elites with knowledge of this handwashing custom survived the collapse. It also shows that the custom was no longer restricted to a specific social class. This shows how collapse functions not only to redistribute wealth and political authority, but also technology and information monopolized by elites.

While these may seem like positives, we should not forget the economic devastation brought by the collapse. Most Mycenaean infrastructure fell into disuse, settlements were abandoned and population levels plummeted. These impacts were felt for centuries.

Back to the future

The Mycenaean collapse serves as a warning: unchecked growth of socio-economic inequality increases the vulnerability of complex societies to collapse. However, the same data argues that reducing inequality can make economies more resilient to future climate challenges.

Geoffrey Kron, an expert in Greek and Roman economics, has shown how both in ancient Greece and the United States increasing economic inequality can be linked with authoritarian governments and the erosion of democracy. Governments should heed the growing socio-economic inequalities laid bare by COVID-19. Those that fail to address growing inequalities do so at their own peril.

It is easy to think that handwashing is accessible to all today, but COVID-19 calls attention to communities both within Canada and around the globe where clean water is not a given. In these communities, even the most basic defence against the novel coronavirus is a daily challenge.

While there are positive signs that socio-economic inequality is being recognized nationally in Canada and the U.S., more can be done by all governments to mitigate socio-economic inequality starting with investing in remote and traditionally disadvantaged communities.

In doing so, we can truly build back better.

 

By                  :                      Trevor Van Damme  (Postdoctoral Fellow in Greek and Roman Studies, University of Victoria)

Date              :                      April 20, 2021

Source          :                      The Conversation 

https://theconversation.com/what-ancient-greek-handwashing-can-teach-us-about-socio-economic-inequality-158405

 

Bridging the health inequality gap: an examination of South Africa’s social innovation in health landscape

 

Abstract

Background

Despite the end of apartheid in the early 1990s, South Africa remains racially and economically segregated. The country is beset by persistent social inequality, poverty, unemployment, a heavy burden of disease and the inequitable quality of healthcare service provision. The South African health system is currently engaged in the complex project of establishing universal health coverage that ensures the system’s ability to deliver comprehensive care that is accessible, affordable and acceptable to patients and families, while acknowledging the significant pressures to which the system is subject. Within this framework, the Bertha Centre for Social Innovation & Entrepreneurship works to pursue social impact towards social justice in Africa with a systems lens on social innovation within innovative finance, health, education and youth development. The aim of this study is to demonstrate the capacity for social innovation in health with respect for South Africa, and to highlight some current innovations that respond to issues of health equity such as accessibility, affordability, and acceptability.

Methods

Different data types were collected to gain a rich understanding of the current context of social innovation in health within South Africa, supported by mini-case studies and examples from across the African continent, including: primary interviews, literature reviews, and organisational documentation reviews. Key stakeholders were identified, to provide the authors with an understanding of the context in which the innovations have been developed and implemented as well as the enablers and constraints. Stakeholders includes senior level managers, frontline health workers, Ministry of Health officials, and beneficiaries. A descriptive analysis strategy was adopted.

Results

South Africa’s health care system may be viewed, to a large extent, as a reflection of the issues facing other Southern African countries with a similar disease burden, lack of systemic infrastructure and cohesiveness, and societal inequalities. The evolving health landscape in South Africa and the reforms being undertaken to prepare for a National Healthcare Insurance presents the opportunity to understand effective models of care provision as developed in other African contexts, and to translate these models as appropriate to the South African environment.

Conclusions

After examining the cases of heath innovation, it is clear that no one actor, no matter how innovative, can change the system alone. The interaction and collaboration between the government and non-state actors is critical for an integrated and effective delivery system for both health and social care.

 

By                  :                     Katusha de Villiers 

Published      :                      01 March 2021

Source          :                       Infectious Diseases of Poverty

                                             https://doi.org/10.1186/s40249-021-00804-9

                                             https://idpjournal.biomedcentral.com/articles/10.1186/s40249-021-00804-9#citeas

de Villiers, K. Bridging the health inequality gap: an examination of South Africa’s social innovation in health landscape. Infect Dis Poverty 10, 19 (2021).

 

Socioeconomic status determines COVID-19 incidence and related mortality in Santiago, Chile

Abstract

The COVID-19 pandemic has affected cities particularly hard. Here, we provide an in-depth characterization of disease incidence and mortality and their dependence on demographic and socioeconomic strata in Santiago, a highly segregated city and the capital of Chile. Our analyses show a strong association between socioeconomic status and both COVID-19 outcomes and public health capacity. People living in municipalities with low socioeconomic status did not reduce their mobility during lockdowns as much as those in more affluent municipalities. Testing volumes may have been insufficient early in the pandemic in those places, and both test positivity rates and testing delays were much higher. We find a strong association between socioeconomic status and mortality, measured by either COVID-19–attributed deaths or excess deaths. Finally, we show that infection fatality rates in young people are higher in low-income municipalities. Together, these results highlight the critical consequences of socioeconomic inequalities on health outcomes.

INTRODUCTION

The COVID-19 crisis has exposed major inequalities between communities. Understanding the societal risk factors that make some groups particularly vulnerable is essential to ensure more effective interventions for this and future pandemics. Here, we focus on socioeconomic status as a risk factor. Although it is broadly understood that social and economic inequality has a negative impact on health outcomes, the mechanisms by which socioeconomic status affects disease outcomes remain unclear. These mechanisms can be mediated by a range of systemic structural factors, such as access to health care and economic safety nets. We address this gap by providing an in-depth characterization of disease incidence and mortality and their dependence on demographic and socioeconomic strata in Santiago, a highly segregated city and the capital of Chile.

RATIONALE

Combining publicly available data sources, we conducted a comprehensive analysis of case incidence and mortality during the first wave of the pandemic. We correlated COVID-19 outcomes with behavioral and health care system factors while studying their interaction with age and socioeconomic status. To overcome the intrinsic biases of incomplete case count data, we used detailed mortality data. We developed a parsimonious Gaussian process model to study excess deaths and their uncertainty and reconstructed true incidence from the time series of deaths with a new regularized maximum likelihood deconvolution method. To estimate infection fatality rates by age and socioeconomic status, we implemented a hierarchical Bayesian model that adjusts for reporting biases while accounting for incompleteness in case information.

RESULTS

We find robust associations between COVID-19 outcomes and socioeconomic status, based on health and behavioral indicators. Specifically, we show in lower–socioeconomic status municipalities that testing was almost absent early in the pandemic and that human mobility was not reduced by lockdowns as much as it was in more affluent locations. Test positivity and testing delays were much higher in these locations, indicating an impaired capacity of the health care system to contain the spread of the epidemic. We also find that 73% more deaths than in a normal year were observed between May and July 2020, and municipalities at the lower end of the socioeconomic spectrum were hit the hardest, both in relation to COVID-19–attributed deaths and excess deaths. Finally, the socioeconomic gradient of the infection fatality rate appeared particularly steep for younger age groups, reflecting worse baseline health status and limited access to health care in municipalities with low socioeconomic status.

CONCLUSION

Together, these findings highlight the substantial consequences of socioeconomic and health care disparities in a highly segregated city and provide practical methodological approaches useful for characterizing the COVID-19 burden and mortality in other urban centers based on public data, even if reports are incomplete and biased.

 

By                :                        Gonzalo E. Mena, Pamela P. Martinez, Ayesha S. Mahmud, Pablo A. Marquet,

                                             Caroline O. Buckee, Mauricio Santillana

 

Date            :                         May 28, 2021

Source        :                         Science

                                             Science  28 May 2021:
                                             Vol. 372, Issue 6545, eabg5298
                                             DOI: 10.1126/science.abg5298

                                             https://science.sciencemag.org/content/372/6545/eabg5298.full

 

Book Review: Unsustainable Inequalities: Social Justice and the Environment by Lucas Chancel

In Unsustainable Inequalities: Social Justice and the EnvironmentLucas Chancel demonstrates the role that economic inequality plays in maintaining social injustice and environmental unsustainability, exploring ways to better balance the reduction of socio-economic inequality and the strengthening of environmental protections. This is an accessible, relevant and thought-provoking analysis that uses well-presented facts and figure to unpack the intricate relationship between social injustice and environmental harm, finds Gayathri D. Naik

 

Unsustainable Inequalities: Social Justice and the Environment. Lucas Chancel. Harvard University Press. 2020.

‘Inequality’, ‘social justice’ and ‘the environment’ are embedded in our discussions of climate change. These three terms are always interlinked, each reverberating with the others, and this interlinkage forms the premise of the new book by Lucas Chancel, Unsustainable Inequalities. Offering an economist’s perspective, this book will surpass the expectations of all non-economics readers through its accessible analysis and inclusion of a detailed examination of social injustice and environmental unsustainability.

Chancel argues that social injustice and environmental unsustainability are connected by one common element – economic inequality. Economic inequality remains the root cause of all other inequalities across the globe. From societal interactions to international diplomacy, the possession or lack of income and wealth brings either attention or discrimination. The terminology ‘developed and developing’ itself points to economic inequalities between nations. While developed countries try to sustain their income, developing countries focus on economic development to combat poverty and inequality. Often choices of development have resulted in unsustainable environmental policies.

Spanning seven chapters, the book demarcates Chancel’s arguments in three parts. Part One discusses the sources of unsustainable development; Part Two deals with the interactions of environmental and social inequities; and Part Three outlines the implications of political, social and economic policy for reducing inequality and raising environmental protections. The trajectory of the book’s analysis is essentially twofold. Firstly, it unfolds the basic cause of all inequalities as economic inequality, which is the result of less prudent public policy choices: a fact that is now attracting more attention from international agencies than ever before. Secondly, Chancel examines the link between this inequality and environmental inequities. The book focuses attention on the principles of the 2030 Agenda for Sustainable Development and its seventeen Sustainable Development Goals (SDGs) where equality meets sustainability. The SDGs are a United Nations-led collaborative approach uniting all countries in ensuring economic development, socially equitable public policy and actions against climate change.

Throughout Unsustainable Inequalities, Chancel discusses the need and ways to balance the reduction of socio-economic inequality against environmental protection. Unless economic inequalities are addressed, the SDGs would remain incomplete. Chancel highlights the fact that environmental harm is caused by, and itself a cause of, social inequalities among present generations as well as between generations. Thus, both inter-generational and intra-generational equity are threatened.

The book underscores Chancel’s argument that while reducing economic inequality leads to improvements in the environment and ecosystems, this is not an automatic guarantee. But why can’t inequality be addressed? What are its causes that have such a devastating impact on social equality and the ecosystem? Chancel presents his findings here. Inequalities vary among nations and they have increased within nations in the twentieth century. According to him, the decrease in public wealth and the exponential increase in private wealth are key factors in the widening of wealth inequality, leading to the confinement of wealth with a few, while others live in poverty or below poverty lines without any welfare measures from the state. Additionally, technological innovation, trade and financial globalisation as well as the adoption of neoliberal trade policies have contributed to the slow death of the social state.

Sharing the benefits and burdens in natural resources has always been inequitable – be it in access to natural resources, exposure to hazards, burden-sharing in responsibility and unequal participation in policymaking as well as inequalities in enjoying the benefits of environmental policies. A parallel could be drawn here to the unequal distribution of wealth among a small number of individuals who are also highly influential in politics. The super-rich influence not only tax policies, but also policies on natural resources. A contradiction arises here as countries argue for cleaner energies to address climate change, but vehemently support the rich and powerful in the perpetuation of environmental harm.

Chancel stresses the role of natural resources energy in inequality to substantiate this point. Energy is crucial in the economic and social development of a nation, improving its economy, strengthening its health, employment facilities and improving socialisation. Access to and use of energy are unequal across the globe with developed countries like the United States leading the world’s energy consumption; in many developing countries, electricity is a dream for millions. This is true in the case of other resources like clean drinking water, healthy food and territorial resources.

Income inequality also causes unequal exposure to risk. Poor people are vulnerable to both natural hazards and human-caused environmental accidents, risking their health, life and property. Chancel highlights this through the example of discrepancies in the health impacts caused by air pollution in cities like New Delhi. These cities are not only the victims of hazards but also of unequal and untargeted policies. A vicious cycle formed by economic, environmental and political inequalities is thus highlighted by Chancel.

The book argues for the need to reduce economic inequality without compromising environmental needs. For this, substantial amounts of public investment are required in energy, water, health and transport. This needs to be supplemented by efforts to change social choices regarding energy and transport. Chancel suggests that progressive ecological taxation can be introduced where every polluter is held responsible for paying based on the legal principle of ‘the polluter pays’. The benefits of such taxation should be spent to ensure inclusiveness among the poor to enable them to switch to greener choices. For all these efforts, a coherent and collaborative approach in policymaking is required, with the participation of all stakeholders at local, regional, national and international levels.

Many point out that the poor are simultaneously significant polluters at the local (although not the global) level due to their inability to switch to unaffordable greener choices and the victims of that same pollution. Chancel shows this to be true. But why? Unsustainable Inequalities provides an answer – economic inequality. Through a simple and well-organised presentation of facts and figures, this book has unpacked the intricate relationship between social injustice and environmental harm and argues for delinking the complex nexus they form with economic inequality. This book is a highly relevant and thought-provoking read during the COVID-19 pandemic when millions are affected socially and economically by lockdowns and restrictions. Our changed circumstances have nonetheless raised hopes for a better, eco-friendly future if we have the determination to regulate our consumption and emissions.


Gayathri D Naik is a Doctoral Candidate at the School of Law, SOAS, University of London. She holds BAL.LLB (Government Law College, Ernakulam), MPA (Indira Gandhi Open University, New Delhi) and LLM (South Asian University, New Delhi). She is a Commonwealth Scholar from India. Her doctoral research looks into equity and groundwater issues in India.

 

Note: This article gives the views of the authors, and not the position of USAPP– American Politics and Policy, nor of the London School of Economics. 

 

By                     :                       Gayathri D Naik

Date                  :                       April 25, 2021

Source              :                       LSE Blogs Phelan US Centre

https://blogs.lse.ac.uk/usappblog/2021/04/25/book-review-unsustainable-inequalities-social-justice-and-the-environment-by-lucas-chancel/

 

 

 

 

Photo by :  Karthikeyan K (Unsplash)

 

Inequality and the Care Economy

 

Care work has long been considered the work that makes all other work possible.

The term “care work” encompasses both paid and unpaid work. The International Labor Organization includes two overlapping activities in their definition of care work: direct, personal and relational activities, like caring for children or nursing someone who is ill, as well as indirect care, like cooking and cleaning.

Most of the care work done around the world is unpaid and done by women and girls, often from marginalized groups. The amount of time women spend doing unpaid caregiving in comparison to men has profound impacts on economic inequality across gender.

The undervalued nature of care work also has ramifications for paid care workers. Care work has already been one of the fastest-growing sectors of the American economy, the Institute for Women’s Policy Research finds. The number of these jobs, which tend to pay less than the median annual wage across all sectors, is expected to expand further as the elderly population in the United States grows.

Domestic workers are one particular category of care workers. Domestic workers, whether they are hired by an individual or through an agency, do a wide range of work, from cleaning to personal care. The common denominator is that they work in private homes. Like all care work, the demographics of domestic workers is very gendered, analysis from the Economic Policy Institute shows.

Domestic work is also heavily racialized. Domestic workers are more likely than all other workers to be immigrants, and undocumented workers in the sector face additional vulnerabilities.

In the United States, domestic work is deeply entwined with the legacy of slavery. This legacy is why domestic workers, along with agricultural workers, were left out of the labor protections granted in the 1930s, including the collective bargaining protections of the National Labor Relations Act. This exclusion continued in various subsequent labor protections.

Domestic work is also borne out of the history of settler colonialism in the United States. Indigenous people worked during the colonial period as domestic servants, both as enslaved or waged laborers. Policies created by the Bureau of Indian Affairs institutionalized the practice. This was a part of the U.S. policy of assimilation – Indigenous girls were placed in boarding schools to learn about maintaining a household, and then placed in the homes of white settler colonial families as domestic workers.

The current realities of domestic workers reflect these racist histories. Domestic workers continue to be excluded from a variety of labor protections to this day. Working in private residences leaves domestic workers particularly vulnerable. Surveys done by the Institute for Policy Studies and National Domestic Workers Alliance have highlighted the lack of worker protections and potential for sexual harassment and abuse. This lack of protection goes hand in hand with the devaluation of domestic work. As the Economic Policy Institute shows, domestic workers face high poverty rates.

Groups like the National Domestic Worker Alliance have long organized and advocated to enshrine rights and benefits tailored to the unique challenges domestic workers face. Several cities and states have passed domestic worker bills of rights, and Rep. Pramila Jayapal and Sen. Kamala Harris have introduced a National Domestic Worker Bill of Rights in Congress.

Implementing worker protections and benefits is one crucial aspect of reducing inequalities in the care economy. So too is investment in care. A first of its kind study from the UCLA Labor Center sheds light on the California households that employ domestic workers, which total as many as 2 million,  44 percent of which are low-income.

Poor pay is also prevalent in California, UCLA found.  Four in ten employees are paid a low wage, defined as less than two-thirds the full-time median wage, which at the time of the study was $13.83 an hour. Seventeen percent were paid below the minimum wage. One in five moderate and high-income households paid a low wage despite being able to pay more, while a third of low-income households paid higher wages.

Some states have implemented programs to begin to offset the costs of providing care. In Hawaii, the Kupuna Caregivers Program provides financial assistance to employed caregivers to offset the cost of care so they can remain in the workforce. Washington has created a social insurance program to help cover the costs of elder care. The National Academy of Social Insurance has laid out a menu of options for states building towards universal family care. Modeling from the International Trade Union Confederation also shows that investments in the care economy is a more gender equitable way to stimulate employment and economic growth.

Care work is critical to the functioning of our society at any time. During the Covid-19 pandemic, this workforce, which is overwhelmingly female and disproportionately people of color, has become even more essential. The term “care work” encompasses both paid and unpaid work and encompasses both direct activities, like caring for children or nursing someone who is ill, as well as indirect care, like cooking and cleaning.

Domestic workers are one particular category of care workers. Whether hired by an individual or through an agency, this workforce performs a wide range of tasks, from cleaning to personal care, in private homes. Already a vulnerable category of workers, domestic workers are under immense stress as they serve on the frontlines of the Covid-19 pandemic. According to an April 2020 survey by the National Domestic Workers Alliance, 84 percent of domestic workers reported experiencing food insecurity, 77 percent were the primary breadwinners for their families, 72 percent reported having lost their livelihoods, and half reported lacking access to medical care during the pandemic.

As a joint survey from the Institute for Policy Studies and the National Domestic Workers Alliance shows, Black immigrant domestic workers are even more vulnerable during this crisis. More than 800 respondents in three communities — New York, Boston, and Miami-Dade County in Florida — show the scale of this crisis. As of June 2020, 65 percent reported being at risk of eviction or utility shut off in the next three months, 49 percent were fearful of seeking out government aid due to their immigration status, 45 percent had lost their jobs, and a quarter reported having their hours reduced.

 

Source                :         Inequality.org

https://inequality.org/facts/inequality-care-economy/

 

Economic inequality can help predict COVID-19 deaths in the US

 

COVID-19 has not affected everywhere in the US equally, there are significant disparities in Covid-related illnesses between the states. In new research which analyses the relationship between COVID-19 and economic, social and demographic factors, Harold Clarke and Paul Whiteley find that those states with greater income inequality are more likely to see coronavirus cases and related deaths.  

The United States has more reported cases of COVID-19 and more deaths from the virus than any other country in the world. So far, over one million Americans have contracted the disease and nearly 70,000 have died.  The incidence of Covid-related illness varies widely across the states with the number of people infected ranging from over 100,000 in New York to less than 400 in Alaska.  Differences in economic inequality are important for explaining these highly divergent health outcomes.

In 2014 the French economist Thomas Piketty published a widely cited book, Capital, which showed that economic inequality has increased markedly since the early 1970s in the US and many other countries.  Reacting to Piketty’s findings researchers have shown that inequality has many undesirable effects including significant negative impacts on public health, and the COVID-19 crisis is a case in point.

We gathered data on the number of Covid cases and fatalities in each state and developed a statistical model of the impact of economic inequality and other possibly influential factors on the pandemic.  We assess economic inequality with the Gini Index, a standard measure which varies from 0 (total inequality) to 1 (total equality).  Although economic inequality is considerably greater in the US than in other major Western democracies such as Great Britain, France and Germany, the extent of inequality also differs significantly across states within the US. For example, in 2018 the Gini varied from a low of .43 in Alaska and Utah to a high of .52 in the District of Columbia and New York.

Investigating the impact of inequality on the incidence of Covid in various states needs to take into account other potentially influential factors.  Most obvious is population size – other things equal, large states can be expected to report more cases and fatalities than small states.  Population density matters as well since inter-personal transmission of the virus will be higher in densely populated areas.  Also, older people, especially those over 65, are more vulnerable to the disease.

The size of minority populations (African-American, Hispanic) is relevant too.  People in these groups frequently are employed in blue-collar and service occupations that involve close contact with others which increases their exposure to the virus.  In addition, ethnic minorities are more likely to suffer from co-morbidities such as asthma, diabetes, obesity and cardiovascular disease that make the impact of the disease particularly debilitating and possibly fatal.

The overall health and well-being of a state’s population also is important.  We measure this using the Human Development Index (HDI) which combines information on educational attainment, annual income and longevity.  The quality of a state’s health care system is relevant as well and so we control for that.

Our analyses show that several factors affect the number of Covid cases and also deaths.  Although the percentages of African Americans and Hispanics and the over 65s do not have significant direct effects, states with larger and more dense populations have more Covid cases. Figure 1 shows that this is true for deaths as well where the coefficients measure the size of the impact of different variables on fatalities. In contrast, states with superior health care systems and higher levels of human development have experienced fewer cases and fatalities.

All these factors aside, states with greater income inequality are more likely to report more COVID-19 cases and fatalities. The effect of inequality is large – it is tied with the Human Development Index as the second strongest predictor of Covid deaths in various states.    Figure 2 shows that the predicted number of cases in a state grows nearly seven-fold, from 2368 to 14,618, if the level of economic inequality increases from its lowest to its highest observed level.  Similarly, the number of deaths climbs from 65 to fully 723 as economic inequality increases.

These large predicted effects of inequality are statistically robust. Including other possible predictors such as whether a state has a Democratic or Republican governor does not change effects.  In addition, the results remain strong if we exclude states like New York or New Jersey that have experienced very high levels of cases and fatalities.

The fact that minority populations do not directly affect the number of cases or fatalities can be understood by noting that African American and Hispanic populations tend to be concentrated in states with higher levels of economic inequality.  Members of these groups are more likely to experience negative health effects associated with greater inequality and these effects drive the incidence and seriousness of the illness.

Minorities are not alone – economic inequality works to increase the incidence and impact of COVID-19 among all segments of the US public.  Although the future course of the Covid crisis is uncertain, state-level differences in inequality are working to define how the pandemic will unfold across America in the months ahead.

 

Harold Clarke – University of Texas at Dallas

Harold D. Clarke, Ph.D. Duke University is Ashbel Smith Professor, School of Economic, Political and Policy Sciences, University of Texas at Dallas, and Adjunct Professor, Department of Government, University of Essex.

 

Paul Whiteley – University of Essex

Paul Whiteley is a Professor in the Department of Government at the University of Essex. His research interests are in electoral behaviour, public opinion, political economy and political methodology.

 

Date            :            May 6, 2020

Source        :            LSE USCentre

https://blogs.lse.ac.uk/usappblog/2020/05/06/economic-inequality-can-help-predict-covid-19-deaths-in-the-us/

 

Challenging disability stigma across sub-Saharan Africa

 

The IPC and Loughborough University have collaborated on a project – Para Sport against Stigma – to develop the reach and impact of Paralympic sport across sub-Saharan Africa.

The Paralympic Games have been a powerful vehicle in stimulating progressive social change toward greater inclusion of disabled people within sport and wider cultural life. The Paralympic movement has established itself as a forerunner in the pursuit of a more inclusive world. Its impact has raised awareness of disability rights, advocated for equal opportunity, promoted the use of assistive technologies (AT) and challenged ableist assumptions that have contributed to the cultural stigma around disability.

However, Paralympic sport has yet to reach many low to middle income countries across the Global South, where stigma associated with disability continues to reinforce social exclusion, marginalisation, and a lack of investment in infrastructure for disability sport. Indeed, there is somewhat of a global divide when it comes to equal access of Para sport.

Despite over 160 countries competing in the Paralympic Games, only around 60 countries have Paralympic sport embedded in their sports systems. This global disparity in equality and access has been recognised by intergovernmental organisations, disability rights groups, and scholars and practitioners working within the field. It also presents the single biggest challenge for the International Paralympic Committee (IPC), who aim to bring the Paralympic Games – starting with Tokyo 2020 - to Sub-Saharan Africa.

It is this challenge that has led to a partnership between Loughborough University, IPC and the University of Malawi, Chancellor College on a project entitled, ‘Para Sport against Stigma’. The project aims to develop the reach and impact of Paralympic sport across sub-Saharan Africa by harnessing the communicative and socially transformative power of Paralympic sport as a vehicle for challenging disability stigma.

It is part of  AT2030, a programme funded by UK Aid and led by the Global Disability Innovation Hub (GDIH) that aims to test ‘what works’ to improve access to Assistive Technology. Over the next four years (2020-24), the project will coordinate interdisciplinary action research within Gambia, Malawi and Zambia, working closely with local community groups, stakeholders, Universities, media organisations and National Paralympic Committees (NPC). It is a research approach that has collaboration with local communities and organisations at its core, to enable better understanding and perspective on how Paralympic sport can be localised and have effective, relevant and sustainable impact.

The research is built upon 3 pillars of activity that connect Paralympic broadcasting and media with community engagement and the development of Paralympic sport pathways. Some key activities include, for example: working with national broadcasters and the IPC to localise and adapt highlights of the Tokyo Paralympic Games to suit community radio –  an important, accessible and trusted media source that spans social class and urban/rural divides – and the inclusion of Paralympic stories from national athletes. Community education and theatre, as important sites of knowledge reproduction, will bring these stories to life and help challenge dominant disability narratives. In addition, the IPC will work to support NPC’s with development toolkits, designed to establish and maintain effective pathways towards international competition for grassroots athletes and coaches.

The project is an important platform for the growth of para sport in parts of the Global South. It is, however, not without its challenges. Disability concerns differences in ability, and we must recognise the varying perspectives and reservations held by those that live with these differences as we work to combat the stigma that has been identified.

The provision and quality of AT fluctuates across the urban and rural landscape and this must be addressed effectively through the adaption of Paralympic media content. In particular, stigma at the intersection of gender and disability requires consideration, and this project offers an important opportunity to better understand the complex socio-economic inequalities and relations that underpin the lives of many disabled women in Sub-Saharan Africa. Using the power of para sport, this project hopes to establish yet more foundations, upon which we can build a fairer and more prosperous world for those with a disability.

 

 

Dr Emma Pullen is a lecturer in the School of Sport, Exercise and Health Sciences at Loughborough University. Her main research interests include disability, gender, culture, and media.

Sam Ruddock is a two-time Paralympian that debuted for Great Britain in track and field athletics at the London 2012 Paralympic Games. After Rio 2016, he is now focusing on track cycling for Tokyo 2020. Alongside his preparations for Japan, he is a physical education and school sport coordinator in primary/elementary education.

Jennie Wong is a sport practitioner with expertise designing and managing inclusive sport programmes on a global scale.  She is currently the project manager for Para Sport Against Stigma at Loughborough University London.

 

Date                     :                   November 27, 2020

Source                 :                   Sportanddev.org

https://www.sportanddev.org/en/article/news/challenging-disability-stigma-across-sub-saharan-africa

 

 

Tackling Social Determinants Of Health Around The Globe

 

A global health equity movement relies on research showing how social factors affect health.

Social determinants of health—factors such as housing, education, neighborhood, and income—have increasingly entered health policy conversations as a growing body of research reveals the direct relationship between these so-called social determinants and health outcomes. Professor Sir Michael Marmot was an early proponent of shifting from the traditional model that focused on how health affects economic status to a new view that economic status affects health.

A renowned thinker, leader, author, and researcher on health equity in England and across the world, Marmot has led research groups on health inequalities for more than forty years. His work at the World Health Organization as chair of the Commission on Social Determinants of Health and on the report Closing the Gap in a Generation (2008) led health officials in England to ask him to apply these findings to their own country. The result was Fair Society, Healthy Lives (2010), also known as the Marmot Review.

The Marmot Review concluded with six policy objectives where action was needed to achieve health equity. Cities and regions around the world have followed this blueprint, with some, such as Manchester, England, adopting the moniker of a Marmot City. Marmot recently completed a retrospective review of progress in England toward the Marmot Review’s policy objectives. That report, Health Equity in England: The Marmot Review 10 Years On (2020), reveals areas of progress but shows that much work remains.

In 2019 Marmot brought his framework to the Americas in the report Just Societies: Health Equity and Dignified Lives—Report of the Commission of the Pan American Health Organization on Equity and Health Inequalities in the Americas. This more recent effort includes perspectives on indigenous populations, gender and sexual identity, and migrant populations while also exploring emerging environmental threats such as climate change.

Spanning the globe while also reaching into cities and neighborhoods, Marmot’s contributions to the field of health equity have changed lives, policies, and the outlook for people around the world. Alan Weil, Health Affairs Editor-In-Chief, sat down with Marmot on April 28, 2020, to discuss his work and recent events. What follows is an edited transcript. The full interview can be heard at http://www.healthaffairs.org/podcasts.

 

Alan Weil:

Let me start by having you take us back to 2010, to the original Marmot Review [Fair Society, Healthy Lives]. Your charge was to focus on health inequality in England. You took on social inequality more broadly as the dominant determinant of health. That was a bold choice. I wonder if you could say a little about what led you to take a social determinants approach when your charge was to focus on health inequality?

Sir Michael Marmot:

Well, I had chaired the WHO [World Health Organization] Commission on Social Determinants of Health. And so you might say that the bold decision was there, going to the WHO, and suggesting to the director general that he should set up a commission on social determinants of health.

At the time, and in some quarters still, the discussion about economics and health was that the direction went from health to economics. In other words, it was your health that determined your income or the health of nations that determined the economic performance of nations. I was convinced from my own research that there was an important pathway that went the other way, and we should say that. I went to J. W. Lee, who was the newly elected director general of the WHO, and suggested we set up a Commission on Social Determinants of Health to say that there is a causal pathway from social and economic conditions to health.

My view was that health was a better goal than economic performance: Even though the pathway may go in both directions, which was the more important goal? Well, I had no doubt at all! I’m a doctor. I didn’t study medicine so that I could help contribute to a bigger economy. I studied medicine because I wanted to help people be healthy, and I went into public health because I wanted to help populations be healthy. So that was, in my view, a far more important goal.

Then the British government said, “You produced this global report; how could we apply the conclusions and recommendations of your global commission to one country, England? Could you do a commission for us?” I accepted that challenge, and we set up a high-level panel of commissioners. We set up nine task groups to review the evidence tailored to a rich country, and a specific rich country: England.

The charge was to look at, as we called it in the UK, health inequalities. That meant much more than inequalities in the health care system, it meant the conditions that made people sick, which means the social determinants of health. How could we use the evidence to make the case for what needed to happen on the social determinants of health in order to improve health and reduce inequalities?

We had six domains of recommendations: early child development; education and lifelong learning; employment and working conditions; having enough money to live on, to lead a healthy life; healthy and sustainable places in which to live and work; and taking a social determinants approach to prevention—so-called lifestyle.

None of the six domains had to do with the health care system—not because I thought that the health care system was unimportant, but because everybody was looking at the health care system. That’s what people do when you say health: everyone immediately jumps to the health care system.

 

SOCIAL GRADIENT

Weil:

One element of the original Marmot Review is this notion of a gradient. Equity isn’t just about lifting up the poorest or the bottom, but it’s the entire spectrum of disadvantage. Could you talk a little more about the evidence base for that and what the implications are?

 

Marmot:

Well, there aren’t many people who could say this, but the British Civil Service changed my life. Civil servants exclude the poorest people in society, and they exclude the richest. But they certainly know about hierarchies, and [in the Whitehall Study of the British Civil Service] we saw this amazing hierarchy in health and in mortality rates by grade of employment. By definition, everyone was employed; they were largely white, we had very few immigrants, and no women. It excluded a lot of the kind of normal variations, and yet we had this remarkable social gradient.

Of course, this phenomenon was not confined to civil servants. When we were then able to look at national figures, there it was, this remarkable gradient for the country for local areas and neighborhoods, classified by the index of multiple deprivation. Life expectancy runs in a graded way all the way from top to bottom, and there’s an even steeper gradient for disability-free life expectancy.

In my 2010 Marmot Review, I coined the rather unfortunate term “proportionate universalism,” a classic British compromise. The default position of social policy in Britain, as in the United States, is to target, to means-test. You don’t get certain benefits unless you’re below some threshold. Well, the problem with that is it misses the gradient. It seems to me that we want universalist policies that apply to everybody. Rather than say: “We’ll have this service for problem families,” say: “We’ll have this service for everybody, but with effort proportionate to need.” That was the idea of proportionate universalism. It was trying to combine the commonsense benefits of targeting with the universalist approach that would deal with the gradient.

 

AUSTERITY AND INEQUALITY

Weil:

So, here you have a vision, proportionate universalism, that’s designed to be progressive. But one of the findings in the 2020 Marmot Review ten years later [Health Equity in England: The Marmot Review 10 Years On] is that Britain went through a period of retrenchment, and government investments actually became more regressive.

 

Marmot:

If you classify local authorities into quintiles by deprivation, policies over the past ten years were neatly regressive. The more deprived the area in which the local authority is located, the steeper the reduction in spending by local government. In the poorest 20 percent, there was a 32 percent reduction in per capita spending, and in the richest, the least deprived 20 percent, it was 16 percent.

Two characteristics of austerity were implemented in 2010: one, rolling back of the state, and two, having regressive social and economic policies. You can’t get away with it and think you’re not causing damage. You may have had the aim of reducing the national debt and the annual deficit. But you can’t do it and think there are no ill effects.

My 10 Years On review showed a very clear change in the curve of improvement of life expectancy. The rate of increase of life expectancy slowed dramatically and, in fact, just about ground to a halt. The inequalities in life expectancy increased by deprivation and by region. And life expectancy of the poorest women, particularly outside London, went down. So, we have at least three phenomena: stalling life expectancy, increasing inequalities, and actually a decline in life expectancy for the poorest women outside London.

I’ve shown that most social and economic policies became more constrained and more regressive over the ten years, and health inequalities got worse. I can’t say the one caused the other. It is not an experiment. But it’s highly likely that austerity and erosion of these social and economic conditions contributed to the health picture that we see.

 

ROLE OF GEOGRAPHY

Weil:

In your work you focus on the role of geography and the geographic unit. Could you expand on the role of geography and community and neighborhood and how your thinking about that role has evolved?

 

Marmot:

It’s a very interesting question. I think about geography in different ways. One is, it’s a proxy for individual characteristics. We can get data on deprivation by area much more quickly than we can by characteristics of individuals. So, on one level I think of geography as a proxy for the individual.

Then there is the second way to think about it. My colleague, Peter Goldblatt, when he was at the Office of National Statistics, showed years ago in the UK—and Raj Chetty a few years later published similar data for the US—this very interesting interaction. If you look at people of the highest socioeconomic level, there’s no regional difference within the UK in life expectancy or mortality. If you’re at the top level, it doesn’t matter where you live. You can live in depressed Newcastle-upon-Tyne or you can live in opulent London, and it doesn’t make any difference. The lower you are in the social hierarchy, the more the region matters. And that’s really interesting.

Now you could say region is a proxy for the individual, but it’s capturing something that the national socioeconomic classification based on occupation is not capturing. So, being a shop worker or a deliveryman and living in the North East, life is harder than being a shop worker or deliveryman and living in the South East of the country. And you could translate it into individual characteristics.

Or you could ask, What is it about the North East that’s different from the South East? It may relate to economic opportunities. It may relate to social conditions. It could be historical geography. I mean, it could relate to the decline of manufacturing in the North, whereas there was decline in manufacturing in the South East, but there was also the rise of the service sector, the very vibrant City of London and financial sector, in a race with New York to be the financial capital of the world, with all of the trickle-down in industry and employment that there is. So, one could think about geography as telling us something more about the lives of individuals, but also telling us something about place.

And then the third way I think about place is it’s a locus for action. We’ve talked about the fact that things went pretty poorly in terms of national action between 2010 and 2019. The only locus where there was encouragement was at the city level. So, the city of Coventry became a Marmot City. We’re working with Greater Manchester. They declared themselves a Marmot Region. We’re working with Gateshead, which is the city just across the river from Newcastle, on the Chester-le-Street side, so they’ve taken a Marmot approach to doing things at the city level.

If I ask myself, Which is more important, the national or the city level, the answer is, They’re both important. The national level sets fiscal policy, for example. Child poverty is very much affected by national policy. But there’s good reason for applauding action at the city level, not just because, well, if we can’t get national action, let’s get city action. But that is where people live and work. It is an appropriate locus of action.

 

CROSS-NATIONAL PERSPECTIVE

Weil:

You recently completed the Pan American Health Organization (PAHO) commission report [Just Societies: Health Equity and Dignified Lives]. Could you reflect on the additional challenges associated with analyzing these issues from a cross-national perspective?

 

Marmot:

Unlike the answer I gave you at the beginning of our conversation, we included health systems in the PAHO commission report because it’s important. In the UK, we have the National Health Service, which lots of people study. We have a high degree of equity of access. That’s not true when you go to the countries of the Americas. They have huge inequalities between countries and within countries. So, they are twin challenges.

In some of the South American, Latin American countries, there’s a strong tradition of social medicine that was active in the fight against military dictatorship. We needed to try and learn from that strong tradition in Argentina and Brazil and other countries, such as Chile, where they’ve been very active. They’d fought and died for their beliefs. There was a very good tradition on which we could draw, and also huge inequalities.

And there were also some particular challenges that we focused on. The health of indigenous versus nonindigenous peoples throughout the Americas united our commissioners from Canada, the United States, and the rest of the region.

Related to that, for people of African descent throughout the Americas—again, a huge issue of disadvantage. We talked about structural racism quite overtly. And we also were more explicit about gender. We certainly talked about sexual orientation and people with and without disability. So, we drew attention to several of these issues.

One thing that we did more explicitly than I’d done in my previous three reports (the global commission, the English one, and the European Review), we were much more explicit about human rights both as a value and as a mechanism—the value of respecting human rights, but also a mechanism for taking action.

We also wanted evidence from the region of what you could do, because it might be that you could adapt what was going on in the Italian city of Trieste to La Paz or Guayaquil or Rio de Janeiro. But it might be that you couldn’t very well. What’s going on in Trieste is very impressive, but it’s got this Austro-Hungarian tradition mixed with Italian. We wanted examples of what you could do in the [American] region.

 

COVID-19

Weil:

I do want to reserve a few minutes to talk about the current COVID-19 pandemic. I’m curious how your reaction to the pandemic is shaped by your work. And I’m also curious about how the pandemic shapes your views of your own work.

 

Marmot:

My view is that the COVID-19 pandemic and the societal response to the pandemic expose and amplify preexisting problems. I know the figures from Britain better, but I’m reading pieces in the New York Times that are more or less saying word for word what I’ve been saying about Britain.

Look at working from home: If you look at deciles of income, the lower your income, the less likely you are to be employed in an occupation where working from home is a possibility. So, professors can work from home, but workers in the hospitality industry can’t. Hotels have closed, restaurants and cafes and pubs and bars have closed. Those workers are either unemployed or, if they’re furloughed with 80 percent of their salary [as is the case in the UK], their income has dropped.

Something like a third of household income is spent on entertainment, dining out, and things of that nature. Well, of course, the richer the household, the more likely they are to dine out and go to restaurants and opera and even football. I mean, football tickets are so expensive, and it’s become something for the rich to enjoy. The poor people who worked in those industries are either unemployed or had a drop in income, and the people who are spending money in those industries are spending less, so they actually have more money.

Look at shelter. The same people who can work from home, probably, if they have an aging grandparent, can say, “Well, you use a separate bathroom.” I was talking to a journalist, and we were talking about a nurse living in a one-bedroom flat with two children and a husband. She comes home from a day in the wards and she’s trying somehow to get her clothes off and have a shower before she hugs her children so she can be clean. But that’s hard to do when you’re in a one-bedroom flat with a tiny bathroom.

So child poverty, education, work, income, and living conditions will all be made worse by the pandemic and the societal response to the pandemic.

Then the question is, What happens next? In 2009, the year after the global financial crisis, the global economy shrank by 0.1 percent, according to the International Monetary Fund. Now the IMF estimates that the effect of COVID-19 on the global economy is thirty times bigger than the global financial crisis of 2008. And I think they’ve underestimated.

Do you remember the Grenfell Tower fire, the high-rise housing block in London that went up in flames three years ago, and seventy-two people died? It was terrible, huge, terrible. You could think about that fire in two ways: One is it exposed the underlying problems in society, and the second is it told us that we need to do things differently. The underlying problem that it exposed was that if you look at the electoral ward adjacent to Grenfell Tower and the rich bit of the borough where Harrods is, the life expectancy gap for men is twenty-two years. Yes, the Grenfell Tower fire was a terrible tragedy, but what about the slow-burning injustice of that twenty-two-year gap in life expectancy between the poor area and the rich area within the same London borough?

Faced with the catastrophe, the conflagration, everybody—politicians of all stripes—said, “Oh, gosh, we’ve got to do something.” But what did they do about the underlying inequalities? They imposed austerity, made them worse, and fanned the flames of injustice.

So, coming back to COVID-19. We’ve got this pandemic, that’s a conflagration. What did the government do in Britain? They said, “We’ll spend whatever it takes.” The same political party that in 2010 presented debt reduction as a moral imperative, something where there was no alternative, now they’re saying, “Debt, forget it, whatever it takes.” Well, if they can do that for the conflagration, they should do that for the slow-burning injustice of persisting health inequalities. And the message of my 10 Years On report is: Whatever you do, don’t come out of this pandemic saying, “Ah, now we’ve got to impose austerity.” We have to do things differently as we emerge from the pandemic.

 

EVIDENCE OF PROGRESS

Weil:

I was hoping we could end with some positives. What do you see that encourages you?

 

Marmot:

If I showed you my diary (before COVID-19 hit), you would see that these ideas are taking off—people are concerned about it. We set up an Institute of Health Equity in Hong Kong. I was planning to go to Hong Kong, Japan, and South Korea to work on a network that we want to develop on social determinants and health equity. We were planning a meeting in Canada to promote uptake of the PAHO commission report. I was planning to go to Argentina and Brazil, and I’ve been invited to Colombia. I’m chairing a commission on the social determinants of health for the Eastern Mediterranean region of the WHO, the largely Muslim countries of that part of the world. And we’ve got lots of European activity. I can’t get to Australia as often as they invite me.

These ideas are taking off. And I’m delighted by that. There’s progress. We said at the beginning of the WHO Commission on Social Determinants of Health we wanted to create a social movement for health equity and social determinants. And I think we’ve been doing that. That’s what my diary is telling us, in every region of the world.

What’s behind it is two things. One is an increase in knowledge. We know a lot more than we did. And that comes from people working hard all over the world to produce the evidence. The second is a commitment to social justice and health. It’s both of those—it’s the evidence that people are compiling that we can make a difference and the wanting to make a difference because it’s the right thing to do, that is hugely encouraging.

We have to recapture that as we emerge from the pandemic.

Weil:

It’s been a wonderful conversation. I am grateful to you for taking the time to talk to me.

 

By                   :                 Alan R. Weil

Date               :                 July 2020

Source           :                  Health Affairs

HEALTH AFFAIRSVOL. 39, NO. 7: FOOD, INCOME, WORK & MORE   https://doi.org/10.1377/hlthaff.2020.00691

https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.00691