As of April 21, the coronavirus outbreak has infected more than 2·3 million people and taken 162 956 lives—35 884 in the USA, 24 114 in Italy, 20 852 in Spain, 20 233 in France, 16 509 in the UK, 5209 in Iran, 4642 in China—all underestimates most probably. Beyond these numbers are people, families, communities, societies that have been affected in unprecedented ways. The coronavirus pandemic puts societies to the test: it is a test of political leadership, of national health systems, of social care services, of solidarity, of the social contract—a test of our very own fabric. In the face of this enormous challenge we risk deepening already stark health and social inequalities.
In this issue of The Lancet Public Health, a series of research Articles, Comments, and letters tackle some of the most pressing issues in the response to the coronavirus outbreak. The disease and its societal consequences pose enhanced risks to already vulnerable groups, such as the elderly and people living with disability, as Richard Armitage and Laura Nellums point out in their letters, the detained, as noted by Allen Keller and Benjamin Wagner, migrants and refugees, homeless people and children living in temporary accommodation, as Diana Rosenthal and colleagues note in their piece. Risk of infection and mortality is higher for individuals with underlying health conditions and comorbidities and might be so for socioeconomically disadvantaged people and ethnic and racial minority groups. For Faheem Ahmed and colleagues, inequality has aided the spread of COVID-19. In the USA, for example, African Americans are disproportionately affected by the outbreak. The response to COVID-19 cannot be a success without an equity lens to mitigate these health inequalities.
To contain the outbreak and prevent a health system overload, isolation, school closures, and lockdown measures have been imposed in many countries, with social and economic consequences and effects on mental and physical health, which are still to be fully evaluated. The consequences for vulnerable groups are a concern and for children in particular. For Wim Van Lancker and Zachary Parolin, school closures could affect poor children through food insecurity and worse educational outcomes in particular. They warn that “While learning might continue unimpeded for children from higher-income households, children from lower-income households are likely to struggle to complete homework and online courses because of their precarious housing situations”…“[T]he current health crisis could become a social crisis that will have long-lasting consequences for children in low-income families.” For UNICEF, without urgent action, this health crisis risks becoming a “child-rights crisis”. Child protection is at stake. With the disruption imposed on communities and families, children already at risk of violence and abuse will find themselves even more vulnerable. Domestic violence is also on the rise. In the first weeks of the lockdown, emergency numbers for domestic violence recorded an 18% increase in calls in Spain and a 30% increase in France. The public health response to COVID-19 must safeguard people in the community.
Looking to the future, low-income families could also face the hardship of the economic recession that is likely to follow the pandemic. “Previous recessions have exacerbated levels of child poverty with long-lasting consequences for children's health, wellbeing, and learning outcomes” note Van Lancker and Parolin in their Comment. The International Food Policy Research Institute suggests that for each percentage point reduction in the global economy, 10 million people could fall into poverty worldwide. Social security and welfare safety nets will be severely tested. Governments should avoid repeating the mistakes of the austerity policies that followed the 2008 financial crisis, which have affected the resilience of the health systems in Spain (according to Helena Legido-Quigley and colleagues' Comment) and Italy (as noted by Benedetta Armocida and colleagues).
The potential fallout of an economic downturn on physical and mental health are likely to be profound but they are not inevitable. By identifying and ensuring that the most at risk are protected, government measures will be crucial in mitigating widening inequalities and public health consequences. For Amartya Sen, writing in The Financial Times on April 15 about the policies enacted so far, “equity has not been a particularly noticeable priority”, still a better society can emerge from the lockdowns. The world has paused—there is an opportunity to invest in social protection, to prioritise policies to reduce inequalities, and to give equity a particularly noticeable priority.
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