This essay examines the implications of the COVID-19 pandemic for health inequalities. It outlines historical and contemporary evidence of inequalities in pandemics—drawing on international research into the Spanish influenza pandemic of 1918, the H1N1 outbreak of 2009 and the emerging international estimates of socio-economic, ethnic and geographical inequalities in COVID-19 infection and mortality rates. It then examines how these inequalities in COVID-19 are related to existing inequalities in chronic diseases and the social determinants of health, arguing that this is a syndemic pandemic. The authors explore the potential consequences for health inequalities of the lockdown measures implemented internationally as a response to the COVID-19 pandemic, focusing on the likely unequal impacts of the economic crisis. The essay concludes by reflecting on the longer-term public health policy responses needed to ensure that the COVID-19 pandemic does not increase health inequalities for future generations.
Equity in Health
The May 2020 session of the World Health Assembly was held as a virtual 'de minimis' meeting by video conferencing, with consideration of most items deferred to written procedure or a resumed meeting later in the year. In opening the Assembly the WHO Director General Dr Tedros Ghebreyesus stated "COVID-19 is not just a global health emergency; it is a vivid demonstration of the fact that there is no health security without resilient health systems, or without addressing the social, economic, commercial and environmental determinants of health". The full speech is available at https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73_3-en.pdf. The virtual WHA discussed and endorsed a key resolution sponsored by multiple countries, including Zambia in the east and southern Africa region and the Africa group and its member states. The resolution is shown at the website provided. The chair of the Africa group noted in the deliberations the importance of making full use of the flexibilities contained in the TRIPS Agreement and the Doha Declaration on the TRIPS Agreement and Public Health and called for the transfer of technology and know-how for medicines for vaccines, diagnostics and other commodities to meet demand and ensure equity. He also called for debt relief to enable countries to meet the demands of responses and the economic impact of the pandemic. The statements by countries to the WHA73 are reported at https://apps.who.int/gb/statements/WHA73/
Inequalities in human development are a roadblock to achieving the 2030 Agenda for Sustainable Development. They are not just about disparities in income and wealth and cannot be accounted for simply by using summary measures of inequality that focus on a single dimension. This 2019 Report explores inequalities in human development by going beyond income, beyond averages and beyond today. It asks what forms of inequality matter and what drives them, recognizing that pernicious inequalities are generally better thought of as a symptom of broader problems in a society and economy. It also asks what policies can tackle those drivers—policies that can simultaneously help nations to grow their economies, improve human development and reduce inequality.
This paper presents evidence on the potential for social capital to be a protective health resource by mediating the relationship between socioeconomic status and wellbeing of Ghanaian adolescents. A cross-sectional survey involving a randomly selected 2068 adolescents from 15 schools in Ghana was conducted. Relationships were assessed using multivariate regression models. Three measures of familial social capital were found to protect adolescents’ life satisfaction and happiness against the effects of socioeconomic status. There were variations in how socioeconomic status and social capital related to the different dimensions of adolescents’ wellbeing. Social capital was reported to be a significant mechanism through which socioeconomic status impacts the wellbeing of adolescents. The authors suggest that it can be utilised by public health and that the findings show that the role of the family in promoting adolescents’ wellbeing is superior to that of the school.
This study assessed the outcomes of children diagnosed with hearing impairment 3 years earlier in terms of referral uptake, treatment received and satisfaction with this treatment and social participation. A population-based longitudinal analysis of children with a hearing impairment was conducted in two rural districts of Malawi. Key informants within the community identified the cohort in 2013. Informants clinically screened children at baseline and by questionnaires at baseline and follow-up in 2016. 752 children were diagnosed in 2013 as having a hearing impairment and 307 traced for follow-up in 2016. Referral uptake was low, more likely among older children and less likely for those with an illiterate caregiver. Few of the children who attended hospital received any treatment and 63.6% of caregivers reported satisfaction with treatment. Difficulty making friends and communicating needs was reported for 10.0% and 35.6% of the children, respectively. Lack of school enrolment was observed for 29.5% of children, and was more likely for older children, girls and those with an illiterate caregiver. The authors propose that more widespread and holistic services are required to improve the outcomes of children with a hearing impairment in Malawi.
The Health and Aging Study in Africa: A Longitudinal Study of an INDEPTH Community in South Africa (HAALSI) is led by an interdisciplinary team of collaborators from Harvard School of Public Health, University of Witwatersrand, Johannesburg, and the INDEPTH Network, a global network of health and demographic surveillance systems based in Ghana. By integrating the HAALSI data with cause of death data from the INDEPTH Health and Demographic Surveillance System (HDSS) data at the MRC/Wits Agincourt research site, the authors explored the interrelationships between physical and cognitive functioning, lifestyle risk factors, household income and expenditure, depression and mental health, social networks and family composition, HIV infection and cardio-metabolic disease. In South Africa, the research found that people who were participating in the national HIV treatment programme were more likely to receive care for high blood pressure and achieve control of both blood pressure and blood sugar. This finding suggests that strong primary care systems are an important part of the answer to the disease trends of older adults and that South Africa’s national HIV treatment programme may offer a great platform for expanding primary care for all South Africans. Good health habits formed in childhood and in young adulthood – including avoiding smoking and alcohol overuse, engaging in physical activity and eating a nutritious diet are identified as being crucial to healthy ageing of the society of a whole.
This paper seeks to examine data from national surveys in 13 countries in sub-Saharan Africa with major conflicts during 1990–2016, to assess the levels and trends in reproductive, maternal, newborn and child health intervention coverage, nutritional status and mortality in children under 5 years in relation to the trends. The surveys provide substantive evidence of a negative association between these indicators at national level and armed conflict, with some exceptions. Major improvements in these indicators took place post-conflict, except for stunting. The short-term conflict in Congo and the Ethiopian–Eritrea war had limited effects on national trends, even though direct local associations with increased child stunting were
found in Eritrea. The authors findings suggest that armed conflict can have negative consequences on reproductive, maternal, newborn and child health. They argue that surveys are a critical data source which, in combination with further analysis of the distinct features of each conflict as well as programme data collected to measure conflict impact, can provide a better assessment of the national impact of armed conflicts on health.
This paper seeks to determine the prevalence of chronic respiratory diseases in urban and rural Uganda and to identify risk factors for these diseases. The population-based, cross-sectional study included adults aged 35 years or older. All participants were evaluated by spirometry according to standard guidelines and completed questionnaires on respiratory symptoms, functional status and demographic characteristics. The presence of four chronic respiratory conditions was monitored: chronic obstructive pulmonary disease, asthma, chronic bronchitis and a restrictive spirometry pattern. The age-adjusted prevalence of any chronic respiratory condition was 20.2%; the age-adjusted prevalence of chronic obstructive pulmonary disease was significantly greater in rural than urban participants, whereas asthma was significantly more prevalent in urban participants: 9.7% versus 4.4% in rural participants. The age-adjusted prevalence of chronic bronchitis was similar in rural and urban participants, as was that of a restrictive spirometry pattern. For chronic obstructive pulmonary disease, the population attributable risk was 51.5% for rural residence, 19.5% for tobacco smoking, 16.0% for a body mass index over 18.5 kg and 13.0% for a history of treatment for pulmonary tuberculosis. The prevalence of chronic respiratory disease was high in both rural and urban Uganda.
Tuberculosis can be treated, prevented, and cured. Rapid, sustained declines in tuberculosis deaths in many countries during the past 50 years provide compelling evidence that ending the pandemic is feasible. Yet this disease—which has plagued humanity since before recorded history and has killed hundreds of millions of people over the past two centuries—remains a relentless scourge. In 2017, 1.6 million people died from tuberculosis, including 300 000 people with HIV, representing more deaths than any other infectious disease. Moreover, in many parts of the world, drug-resistant forms of tuberculosis threaten struggling control efforts. The world can no longer ignore the enormous pall cast by the tuberculosis epidemic. Going forward, the global tuberculosis response must be an inclusive, comprehensive response within the broader sustainable development agenda. No one-size-fits-all approach can succeed.
WHO Director-General Dr Tedros Adhanom Ghebreyesus and WHO Regional Director for Africa, Dr Matshidiso Moeti, visited Butembo, in the Democratic Republic of the Congo. It was in Butembo on 19 April that WHO epidemiologist Dr Richard Mouzoko was killed by armed men while he and colleagues were working on the Ebola response. Dr Tedros and Dr Moeti traveled to Butembo to express their gratitude and show support to WHO and partner organization staff, while also assessing the next steps needed to strengthen both security and the Ebola response effort. They also met with local political, business and religious leaders, and called on them to accelerate their efforts to stabilize the surrounding environment. They urged the international community to step up support to contain the Ebola outbreak, including filling the funding gap that threatens to stymie the Ebola response. Most Ebola response activities, including community engagement, vaccination, and case investigation, have been re-launched following a slowdown in the wake of the attack that left Dr. Mouzoko dead and two people injured. However, they expressed deep concern that a rise in reported cases in recent weeks is straining resources even further. Only half of the currently requested funds have been received, which could lead to WHO and partners rolling back some activities precisely when they are most needed.