Covid-19 and Inequality

Abstract

The Chapter 1, entitled “Origin and Causes of Covid-19” of the book titled “Covid-19 and Capitalism - Success and Failure of the Legal Methods for Dealing with a Pandemic”, aims to probe, by way of introductory chapter, the causes of the Covid-19 pandemic and of its immense impact on the capitalist, Western world. To this end, this chapter aims to provide a synthesis of the findings of a number of prominent international organizations and academic authors whose views and factual information have been relied upon for working out said in this chapter. The author of the book “Covid-19 and Capitalism” is not himself a medical academic and hence not in a position to conduct first-hand research into the medical causes of a pandemic, for which it has been necessary to rely on other people’s research findings to which reference is made. In addition, this chapter also seeks to explore the characteristics of the prevailing socioeconomic order, in particular capitalism, which help to explain why the Covid-19 virus has been so successful in creating a pandemic. This search, which will be explored in greater depth in the subsequent chapters of the book, at the same time allowed the author to test the research findings of some of his previous work (referenced throughout the chapter) against this new research.

10.1 Introduction: Historical Precedents

In an article that appeared in 1931, Edgar Sydenstricker highlighted the inequalities between socio-economic classes during the 1918 Spanish flu epidemic in the United States. From Sydenstricker’s research, it appeared that there was a significantly higher incidence of the Spanish influenza disease among the members of the working classes than of the rest of society. Sydenstricker’s findings implied an important breakthrough, as it challenged the until then prevailing popular and scientific consensus that the Spanish influenza was a disease that struck the rich as well as the poor.¹

In 2020, shortly after the outbreak of Covid-19, there soon arose similar claims by both policymakers and the media about the Covid-19 disease. It was, e.g., argued that “we are all in this together” and that the “Covid-19 virus does not discriminate”.²

In one of the earliest research articles on the matter, Bambra et al. have made an attempt to dispel this myth of indicating the Covid-19 disease as a purportedly “socially neutral disease”. Said authors demonstrated how, during the Covid-19 pandemic, just as a century ago during the Spanish flu pandemic, socio-economic inequalities occurred in the numbers of Covid-19 contamination and mortality rates, that at the same time mirrored pre-existing inequalities about the socio-economic determinants of health and pre-existing chronic diseases.³ Similar research was undertaken by Nolan, who also found that the Covid-19 pandemic has confirmed inequalities originating from the prevailing capitalist socio-economic order.⁴

10.2 Covid-19 and Socio-Economic Inequalities in General

For various authors, already soon after the outbreak of the Covid-19 disease, it was clear that prevailing socio-economic inequalities had deep implications for the manner in which Covid-19 affected different groups of people.

Saad-Filho has phrased this as follows:⁵

The social implications of the pandemic emerged rapidly, for example, through the differential ability of each social group to protect itself. In brief, the uber-rich moved into their yachts, the merely rich fled to their second homes, the middle class struggled to work from home in the company of overexcited children and the poor, already having worse health, on average, than the privileged, either lost their earnings entirely or had to risk their lives daily to perform much-praised but (needless to say) low-paid ‘essential work’ as nurses, care workers, porters, bus drivers, shopkeepers, builders, sanitation officers, delivery workers and so on; meanwhile, their families remained locked up in cramped accommodation. Since they were, effectively, treated as being expendable, it is not surprising that poor and Black, Asian and minority ethnic (BAME) people are dramatically over-represented in the death statistics (…).

The class and racial impact of the pandemic overlaps with its gender implications, as women tend to crowd the lower and more precarious rungs of the labour market, cluster in the ‘caring’ professions, take primary responsibility for their households and the well-being of elderly parents and children and suffer more heavily from loneliness as well as the burdens of caring for others. They are also highly vulnerable to violence, abuse and neglect at home during the lockdown.

Robert Reich expressed the same idea as follows:⁶

The super-rich have always found means of escaping the perils of everyday life. During the plagues of the 17th century, European aristocrats decamped to their country estates. During the 2020 pandemic, wealthy Americans headed to the Hamptons, their ranches in Wyoming or their yachts.

The rich have also found ways to protect themselves from the rest of humanity – in fortified castles, on hillsides safely above smoke and sewage, in grand mansions far from the madding crowds. Some of today’s super rich have created doomsday bunkers in case of nuclear war or social strife.

Since they had been for decades already treated as de facto disposable, it was in the further opinion of Saad-Filho not surprising that, in many Western countries, the poor black, Asian and minority ethnic people (also referred to as “BAME”) were dramatically over-represented in the Covid-19 contamination and death statistics. According to the same author, the class and racial impact of the Covid-19 pandemic also had specific gender consequences. This was attributed to the fact that, at the outbreak of Covid-19, women, especially women belonging to the mentioned minority groups, were over-represented in the lower and more precarious segments of the labour market, such as lower healthcare professions.⁷

Also according to Ali, Asaria and Stranges, international data pointed to the fact that marginalised groups were much more likely to become contaminated with and/or die from Covid-19. According to these authors, three groups suffered disproportionately from this inequal health impact of the Covid-19 pandemic: (1) ethnic minorities; (2) the socio-economically disadvantaged; and (3) the elderly.⁸

According to Bambra et al., already as early as April 2020, evidence on the impact of socio-economic inequalities on the risks associated with Covid-19 emerged in many countries, such as Spain, the United States and the United Kingdom. These authors, e.g., refer to interim data that were published by the regional Catalan government in Spain, showing that the rate of Covid-19 contamination was between six and seven times higher in the most deprived areas of the region, compared to the least deprived parts. Similar evidence was found with regard to the Covid-19 cases in New York City, from which it appeared that there was a significantly increased risk of Covid-19 related death among people living in the most deprived counties.⁹

Again in terms of the ethnic inequalities of the risks of Covid-19, research with regard to England and The Netherlands demonstrated that black, Asian and minority ethnic (“BAME”) people accounted for 34.5% of the 4873 earliest patients that had been struck with severe Covid-19 illness (in the period ending 16 April 2020). This was, moreover, indicated as a much higher than the percentage of 11.5% that had occurred for viral pneumonia in the period between 2017 and 2019. Even more striking were the data on racial inequalities in Covid-19 contamination and death cases that, shortly upon the outbreak of Covid-19, were published by various US states and municipalities. E.g., in Chicago (in the period ending on 17 April 2020), 59.2% of the Covid-19 related death cases were among black residents. The Covid-19 mortality rate among black residents of the city of Chicago, more precisely, amounted to 34.8 per 100,000 population, compared to 8.2 per 100,000 population among white residents.¹⁰

10.3 Covid-19 and Health(Care) Inequalities

10.3.1 Postulates by Bambra, Riordan, Ford, and Matthews

10.3.1.1 General

According to the already referred to research of Bambra et al., the Covid-19 pandemic has occurred against a background of prevailing socio-economic inequalities regarding a variety of class determined, non-communicable diseases (NCDs), as well as inequalities in the socio-economic determinants of health.¹¹ This meant that both the occurrence and the severity of Covid-19 cases were amplified by pre-existing occurrences of chronic diseases, which are themselves socio-economically determined and associated with various socio-economic determinants of health.¹²

Research made possible by the UK Health Foundation and the UK Institute of Health Equity on the situation in the United Kingdom has confirmed the hypothesis that inequalities in the early Covid-19 death rates mirrored socio-economic gradients about all types of death, and that the causes of the inequal impact of Covid-19 were, therefore, similar to the prevailing socio-economic inequalities in matters of health in general. This research in particular pointed out that while health behaviours significantly contribute to the causes of a variety of non-communicable diseases (NCDs), they are also “the socio-economic determinants of health” that lie at the root of these health behaviours, making the socio-economic determinants of health the “causes of the causes”.¹³

10.3.1.2 Covid-19 as a “Syndemic”

According to Bambra et al., the concept of “a syndemic” has originally been developed by Merrill Singer for helping to understand the relationship between a wide variety of diseases and behaviours, ranging from HIV/AIDS, drug use and violence, as these occurred in the United States in the 1990s. In this viewpoint, a “syndromic condition” exists when risk factors (or, in case of diseases, co-morbidities) are “intertwined, interactive and cumulative”, which may increase the burden of disease and enhance its possible negative effects. A syndemic has thus, generally speaking, been defined as a set of closely related and mutually reinforcing health problems that significantly affect the overall health status of a population, against the background of a perpetual pattern of deleterious socio-economic conditions.¹⁴

Based on these observations, Bambra et al., have argued that, for the most disadvantaged communities, Covid-19 has had all the characteristics of a syndemic disease, i.e., a synergistic and concomitant pandemic that interacts with and exacerbates existing NCDs and socio-economic conditions.¹⁵

E.g., people belonging to minority ethnic groups, people living in areas of high socio-economic deprivation, people generally living in poverty and people belonging to other marginalised categories (such as the homeless, (ex-)criminals and prostitutes) generally suffer from a greater number of co-existing NCDs. Among these population groups, NCDs are not only more general and severe than among other populations, but they also often already occur at a young age. This implies that people living in socio-economically deprived neighbourhoods and people belonging to minority ethnic groups, whereby these two categories often overlap, showed higher rates of almost all the known underlying clinical risk factors that may increase the severity and mortality of Covid-19. These clinical risk factors include diseases and medical conditions such as hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), heart disease, liver disease, kidney disease, cancer, cardiovascular disease, obesity and smoking. This, moreover, appeared to be the case for people belonging to ethnic minority groups in Europe, the United States and other high-income countries. In Europe, a particular vulnerable group of people were the Gypsy/Roma community. It concerns one of the most marginalized ethnic groups in Europe, characterized e.g., by a smoking rate that is two to three times higher than the European average and by higher rates of respiratory diseases (such as COPD), besides a variety of other Covid-19 risk factors.¹⁶

These findings were largely confirmed by the research of Ali, Asaria and Stranges. These authors indicated that people belonging to (often overlapping) ethnic minorities and/or materially disadvantaged groups, were much more likely to suffer from so-called “chronic multi-morbidities”, making them more vulnerable during an epidemic or pandemic.¹⁷

These findings have been, furthermore, confirmed by research in the United Kingdom, from which it appeared that there were “shockingly” high rates of Covid-19 mortality among people living in the United Kingdom who identify as black, Bangladeshi, Pakistani and Indian.¹⁸

According to the quoted research, all of these inequalities in chronic disease are, in essence, the result of inequalities with regard to the so-called “socio-economic determinants of health”. These socio-economic conditions of health concern factor such as the conditions in which people live, work, grow up and age, such as working conditions, being unemployed oneself or belonging to a family where one or both parents are (often) unemployed, access to essential life-necessities and services (e.g., water, sanitary facilities and even food), housing and access to healthcare.¹⁹ In the opinion of Ali, Asari and Stranges, the above outcomes are by no means accidental, but the result of persistent structural and socio-economic inequalities.²⁰

10.3.1.3 Impact of Some Socio-Economic Determinants of Health

10.3.1.3.1 Housing and Working Conditions

According to Marmot et al., much of the above comes down to living and/or working in deprived areas, often in overcrowded housing. This had during the Covid-19 pandemic itself led to a higher exposure to the Covid-19 virus, both at work as at home. Such poor housing and working conditions are themselves the result of long-standing socio-economic inequalities and, with regard to people belonging to minority ethnic groups, even to structural racism. Many people belonging to black, Asian and minority ethnic (i.e., “BAME”) groups were, phrased differently, not well protected at work and at home and were in general less protected than their white colleagues.²¹

From research it has e.g., appeared that there are considerable occupational inequalities that determine exposure to unhealthy labour conditions (e.g., ergonomic hazards, boring and repetitive work, long working hours, having to work in shifts, low wages, being employed in temporary jobs, job insecurity …), which are highly concentrated in low-skilled jobs. Such labour conditions are in their own turn associated with increased risks of a wide variety of diseases, such as respiratory diseases, certain cancers, musculoskeletal diseases, and mental diseases, such as hypertension, stress and anxiety. In addition to being exposed to such long-term factors that are detrimental for one’s general health, inequalities in labour conditions also had an impact on the unequal distribution of the burden of the Covid-19 disease among groups of working people. An obvious example concerns the fact that many low-paid laborers (where, again, people belonging to BAME groups were represented in a disproportionate manner)—particularly people employed in the service sector, such as food preparing and delivery, cleaning and general delivery services—were during the Covid-19 pandemic much more at risk of being designated as key laborers. As a result, they were to a far bigger extent required to keep traveling to and back from work, often relying on public transport to do so as, because of their low wages, many of them did not have their own car. People belonging to these groups were also at higher risk of being obliged to keep showing up on the physical working floors. All these factors added to a much higher degree of exposure to the Covid-19 virus.²²

Similarly, access to healthcare appeared to be generally lower for people belonging to such disadvantaged and marginalised communities, even in countries that have universal healthcare systems.²³ E.g., In England, the number of patients per GP—short for “general practitioner”—was on average 15% higher in the most deprived areas of the country than in the least deprived areas, implying that access to the services of such a GP was more difficult in the former areas than in the latter ones. Medical and healthcare appeared to be even more unevenly distributed in countries such as the United States, where an estimated 33 million people belonging to the most disadvantaged and marginalised populations were said to have little or no access to medical and healthcare. Such reduced access to healthcare—both before the outbreak of Covid-19 and during the Covid-19 pandemic itself—is also believed to have added to the prevailing inequalities because of pre-existing chronic diseases. This inequal access to medical and healthcare services thus led to poorer Covid-19 outcomes for people living in such deprived areas and/or belonging to such marginalised communities. Another factor that added to this problem of inequal medical and healthcare access concerned the fact that people with pre-existing chronic diseases, such as cancer or cardiovascular disease, were also less likely to have access to treatment and diagnosis for such diseases in these deprived areas, to the extent that healthcare service-providers were overwhelmed by the Covid-19 epidemic itself.²⁴

Housing conditions have been indicated as one of the most important examples of socio-economic inequalities that qualify as socio-economic determinants of health. Exposure to poor quality housing has thus—already in times pre-Covid-19—been associated with a wide variety of health conditions and problems. E.g., damp, or ill-ventilated housing may result into respiratory diseases, such as asthma. Overcrowding can result into higher rates of infection from contaminated diseases but may also generate an increased risk of injury from domestic accidents. (Cf. already in Sect. 7.11.1., on the poor housing conditions of laborers employed in the meat processing industries.) Housing may also have a wide impact on health in terms of equality, both materially because of costs (e.g., due to high rents) and psychosocially because of insecurity (e.g., short-term tenancies, poor renting agreements …). It is, hereby, a well-known fact that people belonging to the lowest socio-economic groups are less likely to be able to afford good quality housing. As a result, they are more likely to become victims of the socio-economic determinant of health associated with bad housing conditions. Research has pointed out that some of these inequalities in housing conditions have a significantly contributed to the inequalities in Covid-19 exposure. E.g., deprived neighbourhoods are more likely to contain houses that are occupied by more households and/or houses with a lack of outdoor space, such as a garden. Such deprived neighbourhoods are also more likely of having higher population densities (which especially appeared to be the case for deprived urban areas), alongside a much lower access to communal green spaces. Already from the outset of the Covid-19 pandemic, it was considered likely that such housing and living conditions would add to the transmission rates of Covid-19, as had some years before been the case for H1N1, when strong associations had been found between infection rates and degree of urbanization. Even in cases when people in marginalised communities had no underlying health problems, the socio-economic determinants of health associated with poor housing have contributed to making them more vulnerable to Covid-19 infection.²⁵

10.3.1.3.2 Mental Conditions

According to Bambra et al., decades of research on the socio-economic determinants of health associated with psycho-social factors has indicated that chronic stress due to material or psychological deprivation can suppress the immune-system, causing various related diseases. E.g., psycho-social emotions of subordination or inferiority resulting from one’s position in the social hierarchy can stimulate physiological stress responses (such as elevated cortisol levels). Prolonged exposure to such stresses is believed to have long-term negative consequences on both physical and mental health.²⁶

By way of illustration, studies have indicated that there are consistent associations between, on one side, low occupational status (e.g., low control in the working environment, combined with high demands) and stress-related morbidity, besides a wide variety of chronic diseases, including coronary and/or heart disease, hypertension, obesity, musculoskeletal disorders and psychological ill health. There is also growing evidence that living in a deprived neighbourhood can attribute to a general sense of powerlessness and collective threat among residents. All these elements may, furthermore, result in what has been referred to as “chronic stressors” that can ultimately damage health. Research has also pointed to the fact that such adverse psychosocial circumstances may have increased susceptibility—influencing the onset, course and outcome—of infectious diseases, such as Covid-19 itself.²⁷

10.3.1.4 Other Health Consequences of Covid-19

The association between Covid-19 and socio-economically determined health inequalities did not only manifest in terms of susceptibility of Covid-19 contamination and mortality itself, but also in terms of the health effects of certain policy responses to the pandemic. Certain countries, e.g., resorted to immediate health surveillance measures that have traditionally proven successful in combatting infectious diseases, such as contact tracing. Such measures were successfully applied especially by Asian countries, e.g., Taiwan and South Korea (cf. Sects. 2.4.2.4.1 and 2.4.2.4), to fight off the Covid-19 outbreak at early stages of the pandemic. To the extent that these measures successfully limited the breakthrough of Covid-19 on their territory, these countries also succeeded in avoiding the more detrimental effects on public health arising from, on one side, Covid-19 itself and, on the other side, harsher containment measures. However, most Western countries did not respond in such a manner. As a result, (neoliberal) governments around the world were eventually forced to implement far more severe mass quarantine and isolation measures, even in the form of lockdowns, of varying levels as the Covid-19 pandemic progressed. This inconsistent approach led to a variety of containment measures that, to a lesser or greater extent, put people in social isolation and confinement at home and/or in the immediate neighbourhood of their home setting.

These emergency lockdowns had many unequal health impacts amongst various groups of people. A first example concerned unequal experiences of lockdowns arising from a variety of (external) socio-economic factors, such as job and income loss, living in overcrowded accommodations, urbanization, (lack of) access to green space, being a keyworker… A second example related to how the lockdowns themselves attributed to the creation of new socioeconomic determinants of health, e.g., in cases when Covid-19 had led to an overall reduced access to healthcare services for non-Covid-19 diseases, due to the fact that the healthcare system was overwhelmed by the pandemic (having to provide hospitalizations for Covid-19 contaminated people, increased testing, etc.). A third example concerned inequalities related to the immediate health impacts of the lockdown measures themselves, e.g., in mental health and gender-based violence; or a lack of physical exercise and fresh air…²⁸

Arguably, the most impactful long-term consequences of the Covid-19 lockdown measures on health inequalities will be of a political and economic nature. Specifically, the global economy has been severely affected by Covid-19, with e.g., record stock market drops on an almost daily basis, collapsing oil prices and record levels of unemployment. These economic consequences, moreover, appeared despite interventionist measures resorted to by a wide variety of national governments and central banks on a global scale (cf. Chaps. 3 and 4).²⁹ Economists have thus expressed their concern that the economic impact of the Covid-19 crisis will be far deeper than that of the financial crisis of 2007/2008, and perhaps even deeper than the Great Depression of the 1930s. Like the influenza pandemic of 1918 (which had a severe impact on economic performance and had led to increased poverty rates), the Covid-19 crisis is, therefore, believed to have a huge impact on the economy and, through this, on public health. As has been the case with previous economic crises, it is hereby likely that these consequences will impact the population in an inequal manner, thus further exacerbating health inequalities themselves.³⁰

10.3.2 Differences Between Countries

10.3.2.1 Inequalities Between Countries in the Treatment of Covid-19

In the assessment of Stiglitz, Covid-19 has been far from an “equal opportunity virus”. In this renowned author’s further opinion, the Covid-19 virus has on the contrary affected people in poor health and, among those, especially people whose daily lives expose them to more social and/or physical contact, to a much bigger extent than others. This basically comes down to the fact that Covid-19 has disproportionately attacked the poor, not only in poor countries, but also for poorer social groups living in advanced economies with no or no sufficient universal healthcare system, such as the United States.³¹

In the further opinion of Stiglitz, one of the main reasons why, in particular throughout 2020, the United States has been affected by such extreme numbers of Covid-19 contamination cases and Covid-19 related deaths (cf. Sect. 2.5), is that the United States has one of the lowest average levels of medical and healthcare access among the major developed economies.³²

Health(care) inequality was in the United States already extremely bad before the Covid-19 pandemic and has been worsening in capitalist economies the world over. (Cf. Chaps. 5 and 6) The Covid-19 crisis has revealed many more inequalities prevailing within capitalist societies, showing their huge impact on the life and health of communities on a global scale. The post Covid-19 pandemic world could, unfortunately, witness even greater effects of socio-economic inequality on health(care), unless governments finally start to do something about it. Furthermore, the fear of another pandemic, which may result in a repetition of all what has happened, keeps persisting.³³

These aspects will be examined below in relation to two of the countries where problems of inequality have been widely reported in the past³⁴ and where, moreover, a great deal of information is available on the subject, namely the United Kingdom and the United States.

10.3.2.2 Covid-19 and Inequality in the United Kingdom: Summary of the Findings of the 2020 Covid-19 Marmot Review

Research about the United Kingdom conducted by Marmot et al., has largely confirmed many of the assessments and assumptions made by Bambra, Riordan, Ford and Matthews, as referred to above. From this research undertaken by Marmot et al., it has, more in particular, appeared that, as far as the United Kingdom is concerned, many of the people who throughout 2020 and 2021 got contaminated with the Covid-19 virus, and/or died from severe Covid-19 illness, suffered from pre-existing health conditions determined by socio-economic inequalities, such as dementia, Alzheimer’s disease, diabetes, cardiovascular diseases and other chronic diseases, such as chronic obstructive pulmonary disease and kidney disease.³⁵

According to Marmot et al., some of these pre-existing diseases, such as dementia, reflected the age groups amongst which Covid-19 deaths have mostly occurred. Other pre-existing diseases, such as diabetes, have in contrast been indicated as risk factors for adverse effects of Covid-19 infection among all age groups. The research by Marmot et al., also pointed to the fact that the underlying health risk factors associated with a more severe impact of Covid-19 were in most cases the result of poor health conditions determined by socio-economic inequalities.³⁶ Indeed, in England, as in most other countries throughout the world, Covid-19 related mortality rates appeared to have been higher in the more deprived areas, especially those where in the run-up to the Covid-19 pandemic itself, deprivation-related health inequalities were high and/or increasing. This implied that, within the United Kingdom, Covid-19 related death cases have followed a trajectory that is similar to mortality inequalities from other causes. Marmot et al. have summarized these findings by indicating that the more deprived an area of residence was or is, the higher Covid-19 mortality in that area has been.³⁷

Figure 10.1³⁸ shows that Covid-19 related death rates in England between March 2020 and July 2020 have been twice as high in the most deprived areas than in the least deprived areas. From this figure, it moreover appears that there has been a clear gradient in deprivation-related Covid-19 death rates.³⁹

Fig. 10.1

Age-standardized mortality rates from all causes, Covid-19 and other causes (per 100,000), by sex, deprivation deciles in England, between March 2020 and July 2020

As predicted in the study by Bambra et al., there occurred in the United Kingdom significant regional differences in Covid-19 mortality rates. These were, e.g., related to poverty levels, occupational structure, ethnicity, age and housing conditions. From the research by Marmot et al., it e.g., appeared that during the first wave of the Covid-19 pandemic, London experienced the highest Covid-19 related mortality rate, while during the second wave of said pandemic, the Covid-19 mortality rate for the Northern regions were higher than the average for the whole of England. In contrast, the Southeast and Southwest regions of the country faced lower than average Covid-19 related mortality rates during both waves of the Covid-19 pandemic. With regard to the latter two regions, it however also appeared that their overall Covid-19 mortality rates in November 2020 were slightly higher than had been predicted in light of the low levels observed in the period from August until October 2020.⁴⁰

From the research of Marmot et al., it moreover appeared that overcrowded housing conditions and poor-quality housing were both associated with higher risks of mortality from Covid-19. Such dwellings were, in addition, more likely to prevail in generally deprived areas and in areas inhabited by people with low average incomes. The research by Marmot et al., also indicated that housing conditions had for many people significantly deteriorated over the decade starting in 2010, with overcrowding increasingly appearing in areas with a lot of rented houses. The research of said authors also pointed to a strong link between such situations of overcrowding and Covid-19 related mortality rates among children and young people under the age of 19.⁴¹

The research with regard to the relation between housing and the inequal impact of Covid-19 undertaken by Marmot et al., also confirmed that physical housing conditions had both a direct and an indirect impact on health. From this research, it, e.g., appeared that poor housing conditions, in general, increase the risk of contracting a wide variety of chronic diseases and infections, besides a wide variety of mental illnesses. However, overcrowding was not only associated with poor mental and physical health at a general level, but also appeared to be a high-risk factor for Covid-19 contraction and mortality. From the research undertaken by Marmot et al., it, moreover, appeared that housing costs are, generally speaking, also a key determinant of health. This was attributed to the fact that huge rental costs may push households living on low wages into poverty, which causes a poorer living quality and adds to both stress and a variety of mental health problems. From the research undertaken by said authors, it also appeared that due to the Covid-19 pandemic, housing became an even more important socio-economic determinant of health and general well-being than in normal circumstances. This was, e.g., due to the fact that during the lockdown periods, people had to spend much of their time in their homes, which for some exposed them to unsanitary and overcrowded living conditions, adding even more to the already existing stress of poor housing quality. Additionally, while all types of households—except for the very rich—experienced a general decline in welfare during lockdown periods, private renters appeared to have experienced the largest in such declines.⁴²

There also appeared significant regional differences regarding the quality of housing which had a meaningful impact on differences in experiences during the lockdown periods.⁴³

The lockdown measures appeared to have further exacerbated the abovementioned health inequalities associated with inequal housing conditions. E.g., it appeared that, during the lockdown periods, people living in houses with gardens—who, in addition, tended to be more affluent, and also “white” rather than “BAME”—were less likely to have missed out on the significant positive effects of spending time outdoors on health and general wellbeing. It thereby appeared that during the Covid-19 pandemic, inequalities in access to outdoor space were even more exacerbated than in normal circumstances.⁴⁴

With rising unemployment and falling wages resulting from the closure of the economy and/or specific business, housing costs, moreover, became an even greater burden than in normal times.⁴⁵

In general, throughout 2020, housing costs remained high throughout England. This was because real-estate prices had risen due to stamp duty. In order to be able to pay the high or even rising rent costs, almost 20% of both private and social tenants had to cut back on other essential spending. In addition, 16% of private tenants and 12% of social tenants, started to use their savings in order to pay their rent. Other people even had to start borrowing money in order to be able to pay their rent. Even people with existing mortgages had in some cases to reduce their expenditure and/or use their savings for paying rents, but to a lesser extent.⁴⁶

The economic impact of Covid-19 in general and the difficulties connected with paying rent also led to increased homelessness. Already between 2010 and 2017, the number of homeless people in England had risen by 165%. During the early Covid-19 period, albeit for a brief time only, the UK government resorted to unprecedented action for fighting homelessness. As a result of this policy approach, in March 2020, the UK government both ordered and funded local authorities across the country to accommodate homeless people during the Covid-19 panic. 15,000 homeless people in England were thus, albeit for a brief time only, accommodated in safe emergency housing, such as empty hotel rooms. In addition, homeless people were also given access to social benefits and medical treatment. Regretfully, this policy approach was soon abandoned, implying that homeless people were soon left on their own again. In part due to the loss of jobs and homes during the lockdowns, there has since been an increase in the number of homeless people, including people who resorted to temporary accommodation, such as friends’ or relatives’ sofas. A factor adding to this problem was that many support services had to cease face-to-face work and/or move online, which reduced their access and usefulness for providing shelter to homeless people.⁴⁷

As it appears from Fig. 10.2,⁴⁸ some occupations had significantly higher Covid-19 mortality rates. These professions included: (1) jobs that could not be performed from at home, (2) jobs that required physical proximity to other people, (3) lower-level jobs, (4) jobs with a higher-than-average percentage of older laborers, and (5) jobs that were more likely than others to be occupied by BAME people.⁴⁹

Fig. 10.2

Age-standardised mortality rates at ages 20 to 64, by sex, and major occupational group, deaths involving Covid-19 registered in England and Wales, between 9 March 2020 and 25 May 2020

From the research of Ali, Asaria and Stranges, quoted earlier, it similarly appeared that people belonging to marginalised groups were in the United Kingdom disproportionately represented in jobs for which home-based work was impossible. People performing such jobs were, hence, more than average exposed during the Covid-19 pandemic. Said authors thereby refer to a poll in which 2108 adults residing in the United Kingdom were surveyed in March 2020. From this survey, it appeared that people belonging to the lowest income households had been six times more likely not to be able to work from home during the Covid-19 pandemic. It, moreover, appeared that people belonging to these low-income households had been three times less likely of being capable of isolating themselves in their homes, which has in part been attributed to the prevalence of crowded housing conditions, whereby people from different generations had to live together. Many of the people belonging to such low-income households were, moreover, employed as low-skilled staff and without permanent contracts, which made them in times of Covid-19 even more vulnerable. The labour conditions to which these people were subjected raised serious questions. One of the main matters of concern was the uncompensated inequality of risk exposure to which these people were systematically subjected. These issues were however very rarely, if ever, dealt with in the policy measures resorted to for fighting the Covid-19 pandemic.⁵⁰ (Compare Sect. 7.11.1, dealing with the working and housing conditions of meat processing workers.)

Figure 10.2 gives an overview of the age-standardised mortality rates at ages 20 to 64, by sex, and major occupational group (involving Covid-19 registered in England and Wales, between 9 March 2020 and 25 May 2020).

According to Marmot et al., the UK Office for National Statistics (ONS) identified 17 professions as extremely risk-prone during the Covid-19 pandemic. Among the professions with the highest Covid-19 mortality rates were security guards and related professions, healthcare and home care workers, and taxi drivers and chauffeurs. Most of these professions were subjected to a high Covid-19 mortality risk, with mortality rates that were on average twice as high as during the previous 4 years. These high mortality rates have been attributed to the fact that all these occupations required much physical proximity to strangers. Again, it appeared that many of these occupations with higher-than-average Covid-19 mortality rates were largely represented among BAME people.⁵¹

People belonging to BAME groups were also more likely to be subjected to discriminatory practices regarding workplace safety during the Covid-19 pandemic. Specifically, people identifying as either Black African, Bangladeshi or Pakistani, had been less likely of being provided with effective PPE than their white colleagues. In addition, there was a higher number of people identifying as Pakistani (20%) or Indian (20%) and working in key professions who indicated that their safety complaints had been remained largely unaddressed during the first UK lockdown period. However, such workplace abuses were not only referred to as a major problem during the Covid-19 lockdowns, but moreover indicated as a long-standing problem prior to Covid-19. Many BAME people who responded to surveys on these matters indicated that they were reluctant to raise these issues because of bad past experiences and out of fear of negative consequences, such as job loss, when speaking out.⁵²

Research funded by the Medical Research Council and published in The Lancet confirmed these findings on the peculiar situation of BAME people in times of Covid-19. From this research, it appeared that people belonging to BAME groups in the United Kingdom had been at excess risk of Covid-19 contamination, besides more adverse Covid-19 disease outcomes, compared to white people.⁵³

Another professional group that had in the period between 9 March 2020 and 25 May 2020 been at higher-than-average risk of contracting and/or dying from Covid-19 in the United Kingdom, were social and healthcare workers. For both men and women occupying these professions, Covid-19 related death rates had, moreover, been higher for social workers than for healthcare workers.⁵⁴

While the research from Marmot et al., indicated that Covid-19 related mortality rates varied significantly across professions, it appeared from the same research that there were additional differences within the same occupational groups in accordance with factors such as age, health status and place of residence. It, e.g., appeared that people performing low-risk occupations, such as managers and people in free professions, were within their professional group still exposed to a higher than average risk of Covid-19 related mortality when living in a deprived area, whereas people belonging to a professional group at higher risk, such as frontline workers, where subjected to a much lower than average risk of Covid-19 related mortality when living in a wealthier area. This added to the importance of the level of deprivation of the place of residence for assessing the mortality risk related to Covid-19.⁵⁵

Regardless of occupation, it was found that people belonging to BAME groups throughout the United Kingdom were generally exposed to higher risks of mortality from Covid-19 than people belonging to the white population. This has in part been attributed to the fact that people belonging to these groups were more likely to (1) be employed in high-risk occupations, (2) live in deprived areas, and/or (3) suffer from underlying health conditions that increase the risks related to Covid-19 risk, such as diabetes and asthma. All of these conditions have, moreover, been indicated as being the result of socio-economic inequalities and long-standing structural racism. However, according to Marmot et al., even this large degree of inequal treatment in various domains of socio-economic life does not fully account for the higher mortality rates of people belonging to BAME groups. Figure 10.3⁵⁶ indicates that even after controlling for age, geography, socio-economic factors and health, mortality rates still remained the highest for men and women of black African origin, while all the other BAME groups identified had higher Covid-19 mortality rates than white people.⁵⁷

Fig. 10.3

Death rates at ages 9 and over involving Covid-19 by ethnic group and sex relative to the White population, taking account of demographic, socioeconomic and health-related factors, England, from 2 March 2020 to 28 July 2020

The already-above cited research that was funded by the Medical Research Council, in addition, suggests that while some BAME groups were less likely to test positive for Covid-19 than others, all non-white groups were more likely to test positive for Covid-19, even when only taking people that have ever been effectively tested into consideration. According to these researchers, such a finding could suggest that people belonging to the white population were tested more frequently, e.g., also when only suffering from mild symptoms or when being completely asymptomatic, and/or that people belonging to minority ethnic groups were themselves only tested when showing more severe symptoms or at more severe stages of the Covid-19 disease. This could imply that, in general, people belonging to BAME groups were less frequently tested and that, in cases that they were tested due to severe symptoms, they were more likely of testing positive. It has, furthermore, been observed that disparities in testing may have been related to a wide variety of factors, such as lack of access to testing sites, lower health literacy, lack of appropriate and accessible—i.e., in a language that people from BAME groups could understand—health communications, and/or differences in testing behaviour. Further evidence also suggests that people belonging to BAME groups may have avoided testing out of fear of losing income or employment when testing positive for Covid-19. Given that people belonging to BAME groups were also more likely to be employed in precarious jobs characterized by poor working conditions, as well as in critical or key positions (e.g., healthcare labour) associated with a higher risk of Covid-19 mortality, it has also been suggested that people belonging to BAME groups generally faced higher socio-economic barriers against testing. From the same research, it furthermore appeared that people belonging to BAME groups were exposed to a higher risk of hospitalization, ICU admission and/or death from Covid-19, even after controlling for clinical comorbidities.⁵⁸

Figure 10.3 gives an overview of the death rates in England, at ages 9 and over, involving Covid-19 by ethnic group and sex relative to the white population, taking account of demographic, socioeconomic and health-related factors, from 2 March 2020 until 28 July 2020.

According to Marmot et al., one of the most immediate impacts in the United Kingdom of the containment measures the UK government resorted to during the early stages of the Covid-19 pandemic, has been unemployment. This, moreover, appeared to be the case even despite the “Coronavirus Job Retention Scheme” that aimed to protect as many jobs as possible. Another effect of Covid-19 on employment concerned regional inequalities in unemployment. Such regional differences with regard to unemployment levels were already high before the Covid-19 pandemic, but Covid-19 made them increase even further up to September 2020. It was, moreover, expected that these regional differences would continue to increase after March 2021. The same applies to regional health inequalities which were also expected to increase in the long term.⁵⁹

Until September 2020, it was more likely for part-time laborers and the self-employed to lose their jobs. It was also more likely for low-paid laborers than for high-paid laborers to become technically unemployed, in which case the already low income of the former group was reduced even more by an average of 20%. It was feared that many of the people belonging to the low-income groups would fall into poverty, given the fact that many of these people did not have sufficient savings or other means to withstand an economic shock.⁶⁰ In terms of ethnicity and age, it, furthermore, appeared that older workers identifying as Pakistani, or Bangladeshi were more likely to be working in the informal economy and to be, hence, particularly affected by wage cuts. For other ethnic groups, it was mainly the younger workers who were most affected by wage reductions.⁶¹

Furlough schemes and temporary measures of increased social benefits helped to alleviate the loss of earnings for many people, but they were, however, considered insufficient. Wages in the United Kingdom had already been low before the Covid-19 pandemic, as a result of which “in-work poverty” had risen significantly during the previous decade. By 2010, 221,000 people in England were earning less than the national minimum wage. By 2019, just before the Covid-19 outbreak, this figure amounted to 354,000 people who earned less than the “National Minimum Wage” (for those under 25) or the “National Living Wage” (for those aged 25 and over). However, by April 2020, the total number of people earning an income below these minimum wage and living rates had risen to an incredible 1.7 million. Of these, 649,000 had not been put on furlough due to Covid-19, and just over one million had been furloughed.⁶²

The negative impacts of low pay on health have been clear for a long time already. The large increases of low-paid jobs of the past decade have also been found to have widened health inequalities even more. But at the same time, the highest paid people saw their hourly pay increase faster in 2020 than it already had in 2019, further widening pay and health inequalities in England.⁶³

According to Marmot et al., the self-employed have been particularly affected by the measures for mitigating Covid-19, many of whom had to stop working while being ineligible for benefits under the furlough scheme.⁶⁴

In addition to the fact that the social care sector has been one of the sectors with the highest death rates from Covid-19 disease, the Covid-19 crisis also highlighted the difficult labour conditions and low wages that already characterised the sector before the Covid-19 outbreak.⁶⁵

The Covid-19 containment measures that the UK government resorted to for fighting the pandemic had in general a significant negative impact on the economy, as well as for a large proportion of the UK population. Still, the level of this negative impact varied considerably between households, depending on a variety of factors, such as prior socio-economic position, region of residence, profession, age, ethnicity and disability. It was expected that these inequal impacts would result into a further widening of income and wealth inequality in the United Kingdom.⁶⁶ One of the most immediate impacts of the mitigation measures resorted to for fighting Covid-19, including school closures, has been a rapid increase in food poverty and hunger. Already prior to the outbreak of Covid-19, food insecurity had been a major concern in the United Kingdom,⁶⁷ with the Trussell Trust having indicated that around 8-10% of households were moderately or severely food insecure between 2016 and 2018. These levels increased significantly during the Covid-19 pandemic, which has been attributed to a variety of factors, such as loss of jobs and income, as well as school closures (during which children were no longer served school meals) and the additional costs for households due to having to take care of their children at home.⁶⁸ (Cf., furthermore, Sect. 7.2.2).

The findings from Marmot et al., were largely confirmed in an NAO report of 13 May 2021, which found that the Covid-19 pandemic had a disproportionate impact on certain groups of people. The report, e.g., stated that:⁶⁹

• (1) The Covid-19 virus had been disproportionately lethal to BAME groups, the elderly, men (compared to women), and groups of people suffering from certain pre-existing medical conditions.

• (2) The school closures had especially been affecting children from a disadvantaged background, while the measures for resorting to distant schooling did not provide a sufficient solution for these groups.

10.3.2.3 Covid-19 and Inequality in the United States

In the United States, a study that appeared in The Lancet on 20 April 2021, in a similar manner, largely confirmed many of the earlier referred to postulates of Bambra, Riordan, Ford and Matthews. Said study, moreover, aims to draw public policy conclusions from these observations (cf. Sect. 10.3.1), especially referring to the fact that under the Biden-Harris administration, a renewed attention is to be paid to the intrinsic qualities of the United States that exacerbate vulnerability to the Covid-19 pandemic and that manifest themselves in a wide variety of racial and class disparities with regard to Covid-19 related morbidity, mortality and vaccination.⁷⁰ To the extent that the Biden-Harris administration indicated that public health would be at the centre of national priorities,⁷¹ the time was deemed ripe for adapting the US social and healthcare systems by abandoning all racial and other inequalities.⁷²

According to researchers Reinhart, Dawes and Maybank, American physicians and scientists already know for a long time that working conditions and economic security rank among the most important socio-economic determinants of health. Unfortunately, according to these researchers, most healthcare systems around the world, particularly the ones of the United States, have been designed around reductive and monetary notions of value. To the extent that the latter notions of value have mainly been determined by the doctrine of economic neoliberalism, they, moreover, appear to be completely at odds with the aim of achieving prevention (with regard to matters related to health), intrinsic fairness, anti-racism, and a focus on equitable care. The maintenance of what said researchers refer to as “reductive biomedical and economic emphases” has in the United States, furthermore, resulted into extremely narrow views on healthcare and even to a political disempowerment of physicians on all relevant health-related issues, such as disease prevention and patient protection.⁷³

Said authors also argue that the Covid-19 pandemic made clear that in the United States, healthcare as well as the socio-economic determinants of health have to a large extent become a matter of politics and individual choice, rather than as a collective good. For said authors, maintaining such an approach cannot be a viable option. Instead, among the most important policy domains in which the opinions of physicians and scientists should be listened to more, are those related to matters such as labour protection, employment, health insurance and housing. These are all matters revealed to have been of great relevance to the manner in which Covid-19 has affected the American society. E.g., policy decisions that determine laborers’ rights, labour conditions, income security and/or healthcare insurance, are all likely to influence national infection control, but even global biosecurity. In the long run, this will prove to be vital for protecting a sound national and global economy. As the Covid-19 pandemic has indicated, continuing to neglect this fundamental reality could even have more serious implications for the more than 2 billion people living in poverty around the world than Covid-19 itself already had.⁷⁴

For these researchers, in the United States, despite abundant wealth, public policy has basically failed to provide for an adequate system of socio-economic protection and health care for the general population, and especially for those belonging to deprived groups. Said researchers thereby point to the irony that, during the Covid-19 pandemic itself, essential laborers such as healthcare workers were publicly praised, but that, to the extent that practically no consideration was given to their health protection or social status, they were simultaneously treated as disposable. Of particular relevance in this regard has been the fact that women from BAME groups were over-represented both among those who had to continue to show up at the physical working floors in high-risk environments, such as hospitals and nursing homes, as well as among those who were most likely of losing their jobs and experiencing the highest levels of unemployment.⁷⁵ In addition, it similarly appeared from the research of Reinhart, Dawes and Maybank, that almost all US states had overlooked the most at-risk essential laborers—which, according to the data gathered by said researchers are people working in the sectors of food distribution, agriculture, transportation and manufacturing—in the early distribution schemes for the Covid-19 vaccines, while, in contrast, high-level professions such as physicians had not been left out.⁷⁶

Reinhart, Dawes and Maybank in addition argue that the Covid-19 virus has in the United States largely benefited from long-standing synergies, generated by public policy (or, in other words, by a public policy largely based on the dictates of economic neo-liberalism), between structural misogyny, racism, inadequate welfare and social benefits, and epidemiology.⁷⁷ This explains why, in the United States, millions of people, especially people belonging to the working classes, have been infected with Covid-19 and thousands have died from Covid-19. Said factors also explain why a disproportionate number of those being contaminated with or dying from Covid-19, were people belonging to BAME groups, particularly those employed in the healthcare sector, such as nursing assistants and health care aides of low occupational status. Of these, a disproportionate number were women, mirroring the fact that the minority female labour force, often stemming from immigrant populations, forms the basis of healthcare provision, not only in the United States, but also in the United Kingdom, besides many other countries.⁷⁸

10.4 Global Inequality Regarding Access to the Covid-19 Vaccines

In addition to the many inequalities that characterised the uneven impact of Covid-19 between groups of society within several countries around the world, there was perhaps an even greater problem of inequalities between countries. The latter category of inequalities proved to be the most acute in terms of access to the Covid-19 vaccines.⁷⁹ (Cf. already before, in Sect. 9.6.2.)

According to Duke University’s Global Health Innovation Center, by the end of April 2021, high-income countries had purchased more than half of the Covid-19 vaccine stockpile, and low-income countries only 9%. This explains why, by the beginning of May 2021, a country like the United States was on the verge of having vaccinated half its population with a single dose of a Covid-19 vaccine, while the rate in a country like Guinea was less than 1% (and not moving at all).⁸⁰ Figure 10.4 gives an overview of the number of people vaccinated against Covid-19 by 7 May 2021 in some countries. By comparison, Fig. 10.5⁸¹ gives an overview of the number of Covid-19 doses administered per 100 people, on 7 May 2021

Fig. 10.4

Number of people vaccinated against Covid-19 by 7 May 2021. [Source: https://ourworldindata.org/covid-vaccinations. Accessed on 8 May 2021]. Source: Official data collated by Our World in Data

Fig. 10.5

Number of Covid-19 doses administered per 100 people, 7 May 2021. [Source: https://ourworldindata.org/covid-vaccinations. Accessed on 8 May 2021]

At the beginning of May 2021, it was estimated that if the prevailing gross inequalities with regard to accessing the Covid-19 vaccines were to continue, it would take the large group of poor countries unable to pay the high prices for the Covid-19 vaccines at least 2 more years to vaccinate the majority of their population. This implied that at the beginning of May 2021, not accounting for possible, more resistant variants of the Covid-19 virus, the world was on the road to a long period during which people in high-income countries would enjoy the benefits and safety of a full vaccination against Covid-19, while the population of low-income countries would continue to suffer for some more years to come.⁸²

While such a situation is, obviously, intrinsically unjust and unacceptable, it is also against the interests of the high-income countries and their populations themselves: as long the Covid-19 virus continues to circulate, there is a risk that new variants will emerge, some of which could prove to be resilient against the existing Covid-19 vaccines. This insight led to an increasing awareness that the continuation of the Covid-19 pandemic in poor countries would continue to pose a threat to the entire world, including the countries that already had established a sufficient Covid-19 vaccination threshold.⁸³

From a socio-economic perspective, it has not been a coincidence that many of the world’s first approved Covid-19 vaccines—notably the BioNTech-Pfizer, Oxford-AstraZeneca and Moderna Covid-19 vaccines—had been developed, produced and first implemented in the most prosperous high-income countries. When the Covid-19 pandemic first took hold as of January 2020, it was mainly the wealthier nations, like the United States, the United Kingdom and the EU bloc, where the pharmaceutical industry had their head offices, their research and development departments and their main production plants. The richer countries had, moreover, paved the way for the development of the Covid-19 vaccines, in part indirectly through supporting universities where high-level viral and vaccine research was taking place for decades already, but also directly through funding and other forms of support for developing the Covid-19 vaccines in particular. This explains why, already as of March 2020, some of the world’s richest countries started making deals with the pharmaceutical enterprises for the development of Covid-19 vaccines. However, some of said rich countries had also been purchasing Covid-19 vaccine candidates, although these were not yet completely ready. (Cf. Sect. 9.3) Moreover, most of these agreements were negotiated on a bilateral basis, i.e., between a single country (or, in the case of the EU, a group of countries) and a single pharmaceutical enterprise (or, in the case of, e.g., BioNTech and Pfizer, two cooperating pharmaceutical enterprises). In accordance with some of these agreements, the governments of some rich countries were basically giving the pharmaceutical enterprises billions of dollars to accelerate research and development, in some cases in exchange for priority access to the Covid-19 vaccines (in case these would prove to be effective). However, these bilateral agreements also pushed the poorest countries further down the Covid-19 vaccine access line. They had little choice, as they lacked the financial resources to subsidize the pharmaceutical industry and purchase millions of doses of the Covid-19 vaccines in advance at the risk that these would eventually prove to be ineffective or not get the necessary approval(s).⁸⁴

Through these early agreements, rich countries overflowed with a glut of vaccines, with some countries’ stocks exceeding their population several times. E.g., by March 2021, Canada had purchased enough of the Covid-19 vaccine doses for inoculating five times its population, while the United States had purchased at least two times the amount of Covid-19 vaccine doses it actually needed. There, moreover, appeared to be huge differences between high- and low-income countries in terms of effective administration of the Covid-19 vaccine doses as well. While high-income countries were at the time home to 16% of the world’s population, by the end of April 2021, they accounted for 46% of the one billion by then administered doses of Covid-19 vaccines. The poorest countries, at the time home to 10% of the world’s population, had only been administering 0.4% of these doses. The lower-middle-income countries, at the time accounting for 40% of the world’s population, represented 19% of all doses of the Covid-19 vaccines administered.⁸⁵

In addition, many of the Covid-19 vaccine producing countries had resorted to export controls, or similar trade-obstructing measures, to relentlessly stockpile Covid-19 vaccines. In March 2021, the (de facto) US and UK export bans with regard to the Covid-19 vaccines even became a source of severe diplomatic tensions between both countries and the EU, which then started resorting to export restrictions of its own to address domestic supply shortages.⁸⁶ (Cf. Sect. 9.4.3.10.)

Curiously, this shameless hoarding of Covid-19 vaccines in rich countries to the detriment of poor countries, occurred in parallel with a large-scale and unprecedented multilateral effort to support the development and equitable distribution of 2 billion doses of the Covid-19 vaccines to the world’s poorest countries by the end of 2021, called “COVAX”. The COVAX initiative, an initiative of the WHO and the EU, (initially) had two main components: (1) establishing a buying group at the level of high-income countries, and (2) a fundraising effort to the benefit of the poorest countries. The idea was that by pledging to buy a certain number of Covid-19 vaccine doses from the vaccine manufacturers, participating countries would gain access to all of the Covid-19 vaccines approved in the COVAX portfolio. The further aim of this imitative was the creation of a global market for vaccines and to lower prices. But, in reality, the bilateral agreements mentioned above (even between the EU and most of the Covid-19 vaccine producing enterprises) took a lot of bargaining power away from COVAX, with some rich countries even wanting to have it both ways: becoming a member of COVAX so they could proclaim that they were good global citizens, while depriving COVAX of its lifeblood, namely Covid-19 vaccine doses that said countries (including the EU) first bought for themselves.⁸⁷

As of early May 2021, it was increasingly suggested that the Covid-19 vaccine manufacturers should have their patents lifted, which would allow other medicine manufacturers to enter the field of Covid-19 vaccine production.⁸⁸

For more considerations on the underlying policy questions, we additionally refer to the conclusions of Chap. 9. (Cf Sect. 9.6.)

10.5 Conclusions

10.5.1 General Assessment

According to Bambra et al., pandemics—besides a variety of other health-related problems—have historically always been experienced unevenly. There have always been higher rates of contamination and mortality among the most disadvantaged communities, even more so as socio-economic inequalities deepen. Recent evidence from a range of countries shows that this has also been the case with the Covid-19 pandemic.⁸⁹

Then as now, these inequalities show the so-called “syndemic nature of communicable diseases”, such as Covid-19. This term means that a contagious disease interacts with and further exacerbates existing socio-economic inequalities, amongst which the so-called “socio-economic determinants of health”. In this way, Covid-19 has exposed long-standing socio-economic and political inequalities in Western capitalist societies.⁹⁰

It has similarly been feared that there will be a global socio-economic collapse after Covid-19. This could worsen the health equity situation in the West even more, especially to the extent that health-damaging austerity policies will again be resorted to after Covid-19 (as has been the case in the aftermath of the financial crisis of 2008; cf. Chap. 5). It is, according to Bambra et al., therefore vital that, this time, the right public policy responses are made to deal with the post-Covid-19 world. These responses should at the very least include expanding social protection and public services, as well as pursuing green growth strategies, with as specific aim to ensure that the Covid-19 pandemic will not increase health and other inequalities for future generations.⁹¹ Given the inequalities in mortality risks that have appeared from Covid-19, it is essential that all efforts to rebuild societies should focus on the overall goal of greater equity and equality.⁹² This implies an approach of “proportionate universalism”, which calls for policy measures aimed at making communities all over the world safer, starting where it is needed most. Special attention should be given to high-risk areas, such as urban areas characterized by overcrowded and multiple-occupancy accommodation. Without these proportionate responses, with each new or additional health or similar crisis, high-risk groups and areas will continue to experience high mortality rates.⁹³

According to Stiglitz, a first and probably effortless way out may involve the acceleration of labour-market skills, through upgrading and training. However, Stiglitz himself is the first to acknowledge that there are good reasons to believe that such a policy will not suffice.⁹⁴ It may, hence, become necessary to also resort to a more comprehensive policy approach aimed at reducing wealth and income inequality.⁹⁵

These findings are completely in line with the conclusions of some of our own previous work.⁹⁶

In the further opinion of Stiglitz, a complete rewriting of the rules of economics is therefore necessary. Stiglitz mentions as examples: (1) a need for monetary policies that focus on ensuring full employment of all population groups, rather than on (just) containing inflation, (2) better balanced bankruptcy laws that look after the interests of all those involved with the whereabouts of any given enterprise, rather than solely on the interest of creditors and (predatory) bankers, and (3) an approach to company law that acknowledges the importance of all stakeholders, not just shareholders. Similarly, the rules dealing with internationalization and globalization must go beyond serving the interests of the big corporate sectors: the interest of laborers and the environment should be ensured on at least an equal footing. E.g., labour and social law should provide better protection to all workers and should provide much more scope for collective action.⁹⁷ Again, the findings of our own previous work are entirely in line with these considerations.⁹⁸

However, while these measures are all vitally important, they will not suffice to create a more just and equal socio-economic system in and of themselves. Our own previous work has underlined the necessity of new systems for redistributing the overall wealth created through the economy. Paradoxically, in accordance with the dictates of economic neoliberalism, countries characterized by the highest degree of income inequality in the world, amongst which the United States, have at the same time regressive tax systems in which high earners suffer from taxation to a much smaller extent than low earners, thus enhancing income and wealth inequality even more.⁹⁹

It has, moreover, precisely been this neoliberal policy approach of favouring the rich (and their enterprises) to the detriment of everyone else that has determined many aspects of Western countries’ policy responses for fighting the Covid-19 pandemic. Because of this, policy responses in the Western world were deeply myopic and entrenched inequality, obstructing any effective management of the pandemic. (Cf. especially Chap. 3) As has been made clear throughout the previous chapters of this book, neoliberal countries were in such a manner insufficiently prepared for the outbreak of a pandemic, with, e.g., their economies largely relying on extremely vulnerable global supply chains. When Covid-19 struck, both American and European economies alike could not even supply enough of the simplest PPE materials, such as face masks and gloves, let alone more complex equipment that was needed for fighting Covid-19, such as viral test equipment and respiratory ventilators.¹⁰⁰ All of this attributed to the catastrophic events that occurred in hospitals and long-term nursing homes throughout the (neoliberalized) Western world upon the outbreak of the Covid-19 pandemic. (Cf. Chaps. 5 and 6). Furthermore, because of the inequalities between countries that have been created under the yoke of capitalism during the past three centuries, less developed economies suffered from general poorer sanitary conditions. The healthcare systems of this group of countries were, in addition, less developed for dealing with the Covid-19 pandemic. Some of these countries had, moreover, a large and poor population, with many people living in conditions that made them more vulnerable to contagion. Such less-developed countries, finally, lacked the financial and other resources available to advanced economies to deal with both the health crisis caused by Covid-19 itself, as well as with its long-term economic consequences.¹⁰¹

Covid-19 has thus, briefly put, exposed and exacerbated inequalities both between and within countries.¹⁰²

Although it was announced that the G20 countries would use all available instruments for dealing with the Covid-19 pandemic, this has not yet happened, or at least only to a very small extent. In particular, according to Stiglitz, a powerful instrument that has lain dormant within the IMF for decades already has not even been considered—let alone resorted to. It concerns the possibility for the IMF to immediately issue USD 500 billion in Special Drawing Rights (SDR).¹⁰³

In the meantime, the Covid-19 pandemic might very well lead to a series of debt crises (cf. already in Chaps. 3 and 4). This is in particular due to the fact that the Covid-19 crisis has left several countries, as well as their enterprises, with more debt than they will ever be able to repay.¹⁰⁴ We shall readdress the question how the world could deal with this in Sect. 10.5.2 and, furthermore, in Chap. 11.

10.5.2 Re-addressing the Plea for a New Care State Model

As has already been indicated above, most of the concerns which have been raised by Stiglitz, as quoted throughout Sect. 10.5.1., have been addressed in our own previous work as well. Moreover, we have not limited ourselves to merely identifying said various problems, but we have also put forward a ground-breaking model to solve them.¹⁰⁵

As already explained before (cf. Sects. 5.5.2 and 6.3), under the new international monetary order that has been proposed in Chaps. 4 and 5 of our 2017 book “Towards a New International Monetary Order”,¹⁰⁶ it would become feasible to finance a care state model which would allow to install a much more fair and just socio-economic order than ever has been possible under the rule of unbridled capitalism—or even under the classical welfare state model.¹⁰⁷

More precisely, under this newly to be established monetary order, state financing could occur in a totally different manner than is presently the case, namely out of the periodical allocations from a New Monetary World Institute (NMWI) would attribute to the countries participating to this new international monetary order.¹⁰⁸

Such a system could, to some extent, already be organized within the prevailing international monetary order. However, as also pointed out by Stiglitz (cf. Sect. 10.5.1), this would require the IMF to start using its power to attribute SDR’s to its member states in a far more systematic manner than is presently the case.¹⁰⁹ However, the proposal that is formulated in Chaps. 5 and 6 of our previous book “Towards a New International Monetary Order” would be much more far-reaching and imply the instalment of a system in which all the member states participating to this new international monetary order, would obtain the entirety of their financial means out of such (periodical) allocations.¹¹⁰

In the treaties establishing this proposed new international monetary order, the contours of a new welfare/care state model could then be worked out in more detail, amongst others, by providing lists of the public services and social security systems that should be made universally attainable based on the financial means each state will obtain out of said allocations.¹¹¹

In one of our other, previous books “The tools of law that shape capitalism. And how altering their use could give form a more just society”, we have already explored in more detail how the outlook of such a “care state” model could be. The lists of public services and social care systems that together could form the care state model referred to in said book, could, amongst others, contain the following elements:¹¹²

• (1) General access to food, housing and adjunct necessities.

• (2) A universal public education system (at all levels of education).

• (3) Universal health (and medical) care.¹¹³

• (4) Universal elderly care.

• (5) Universal child and youth care (amongst others providing means for taking care of orphans; for leisure and group activities of children and youth…).

• (6) Universal public transport (ensuring all levels of transport in an economic attainable manner; this allocation post should, obviously, also take infrastructure works into consideration).

• (7) Guaranteeing universal access to culture.

• (8) Financing a universal basic income for all human beings.

• (9) A further budget post for general state functioning (including the functioning of the national, central banks of the participating countries).

• (10) …

Needless to say that these are but some (evident) examples of what issues could be dealt with, on a global level, in order to establish a more fair and just socio-economic (world) order.¹¹⁴

To effectively reduce the gap between rich and poor, besides removing all other inequalities established under public policies based on the doctrine(s) of economic neoliberalism, the mentioned public and social care services will, moreover, need to be “universal”, “free”, “public”, “accountable” and to “work for both men and women”—besides people who consider themselves neither as men or women.¹¹⁵ With regard to the further outlook of such a new care state model, further reference is here made to our previous book “The tools of law that shape capitalism. And how altering their use could give form a more just society”.¹¹⁶

We shall readdress these policy proposals in some more detail in the next and final Chap. 11 of this book.