Building Back Worse? The Prognosis for Health Equity in the Post-pandemic World

Abstract

The concept of health equity—in a simplified view, socially patterned inequalities in health outcomes that are unfair or unjust and avoidable—originated in the work for the World Health Organization’s European regional office, and was foregrounded by the work of WHO’s Commission on Social Determinants of Health (2005–2008). Yet as political scientist Julia Lynch observed pre-pandemic, ‘systematic efforts to reduce inequalities in the “fundamental causes” of health have been vanishingly rare’. The pandemic brought into vivid focus both inequalities in economic security and vulnerability and inequalities in health outcomes, in the form of economically and racially patterned differences in infection, hospitalization, and mortality rates as well as gendered impacts on daily routines and economic futures.

It might be supposed that an overdue increase in policy attention to reducing those inequalities will characterize the post-pandemic world. More likely, however, is the opposite outcome: a decline in the political salience of health (in)equity and, in most countries, its eventual disappearance from the policy agenda. Adopting the conceptual lens of political economy and drawing primarily from the experience of the United Kingdom, but drawing from other (mainly European) jurisdictions as appropriate, I identify at least four reasons for this prognosis:

• 1. Increased concentration of wealth at the very top of the economic distribution, in a context where ultra-wealth was already becoming ungovernable and its overt and covert influence on politics outsized. Relatedly,

• 2. The tendency of the income support and fiscal stimulus programmes implemented in response to the economic contractions associated with lockdowns to inflate asset prices, and therefore the incomes and wealth of asset owners, as observed notably in property and share prices.

• 3. In a less conspicuous process, the upward redistribution of resources from the tax base as a whole (which is ultimately responsible for repayment of pandemic-era borrowing) to the buyers of government bonds—disproportionately, wealthy individuals and large individual investors such as pension funds. Only a strongly progressive tax system could avoid this impact, and they are few and far between.

• 4. A widespread decline in the ability of democratic institutions to provide the accountability that might ensure renewed interest in health (in)equity.

On the basis of currently available data, probably only the first of these patterns is universal; exceptions may be found to the others. However, it remains to be seen whether the exceptions will be sufficiently influential to ensure that health (in)equity remains on, or returns to, the policy agenda. I conclude with a sketch of the generic policies that would be needed to change the situation identified by Lynch in the post-pandemic world, and leave the reader to judge their (im)probability.