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Public health responses are quite blind to the realities of those who are most marginalised.

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And what happens is that then this results in a different kind of humanitarian crisis and then further increases and exacerbates injustices,

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structural injustices and structural inequalities. Hello, I'm Katrien Devolder.

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This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all.

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This is a special edition on ethical questions raised by the Corona pandemic.

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In this video, I talk to Dr Agomoni Ganguli-Mitra, about the social justice aspects of pandemics.

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Thanks very much for taking the time to do this interview,

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and so much of your work focuses on ethical issues arising from social injustices and inequalities.

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How are these issues relevant to outbreaks of epidemics or pandemics?

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Yes, thank you very much for having me.

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It has been shown that pandemics will, and epidemics, any kind of global health emergencies, will affect people differently.

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And these will exacerbate they will magnify existing social and health inequalities.

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Those who are already disadvantaged or marginalised would be hit more severely.

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And these crises will then create new inequalities and new vulnerabilities.

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And this will in turn, of course affect people's ability to access care.

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So they might be more adversely affected within the systems of triage or allocation if somewhere down the line,

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we haven't thought about who they are, where they are situated in society before they come to us in terms of health care, health care system.

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So can you make that a little bit more concrete? So how would they be affected in triage, for example? If we decide that, decide

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for example, that triage is based on first come, first serve serve basis.

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If you have somebody with a disability or issues with mobility, for example, this affects your ability to access health care in the first place.

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They'll never be the first one to access health care. And therefore, there will be a pattern of discrimination within the triage system.

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If we are not attuned to the fact that people with disability or mobility issues,

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for example, will have more obstacles to face in terms of accessing health care.

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Similarly, in our public health responses and policies, if these are not attuned to the social determinants of health,

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to existing structural inequalities and things like racial, gender, path based discrimination,

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they'll end up reinforcing those social and structural inequalities.

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So how would that work? How would they reinforce these inequalities?

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So I can give you some examples maybe from an area, that is, how pandemics or outbreaks are always gendered.

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So if we think about the 2014 2016 Ebola outbreak, women were far more susceptible for many reasons.

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They were more susceptible in their role as carers. They were closer to people with the illness.

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There was an increased vulnerability to sexual and other kinds of violence, especially in context of conflict.

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There was also a rise in, for example,

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in maternal deaths as resources were deviated and allocated to fighting Ebola rather than to the other broader health care issues

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existing there. There was a decrease in childhood vaccination rates, which meant that when these children got ill,

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mothers had to stay home to care, take care of them. There are also examples from the Zika outbreak.

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Early on in that outbreak, there was a policy response to tell women to access contraception, to avoid pregnancies.

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And this was done in a context where women have very little autonomy over their own productive and sexual health and choices.

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Some of the most disadvantaged women would not have had access to contraception, and will certainly not have had access to abortion.

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And yet the policy really responsibilised them to avoid passing on the infection to their potential children, to avoid congenital zika syndrome.

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And so there will be examples from the current COVID crisis as well as we fight against this virus.

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So, for example, early on, there are worries about the lockdown,

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women not being able to access contraception, not being able to access, importantly, abortions.

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There are also worries about women being subjected to increased violence within the home space in the UK, but also worldwide.

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And the lockdown, women being forced to live in constrained situations with their abusers and also the

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fact that the women's aid sector has been hit quite hard by austerity measures.

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He said there are fewer measures of support that we can provide women who will be in these situations.

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There will be also worries around the fact that women are in the frontlines of this fight against the virus, not only as nurses in hospitals,

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but also as staff in care homes where there is a considerable shortage of protective personal protective equipment.

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So these are some examples from the UK. There are also many examples worldwide.

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So if I can just take one example from India, the lockdown came on rather suddenly.

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So everything, shops, transport, etc were all closed down within hours of the announcement of the lockdown.

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This meant that given that a large percentage of the workforce in India are migrant labourers they were then left stranded without livelihood's,

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without hope. And within that, women who work in India are also a majority of them work as within the informal sector.

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Right. So they will work as day labourers. They'll work as cleaners and cooks in other people's homes.

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And of course, all these income sources would then be closed would then be closed for.

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And so there'll be much more heavily hit by measures such as lockdowns.

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And so what we see, unfortunately.

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is that there is the fact that public health responses are quite blind to the realities of those who are most marginalised.

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And what happens is that then this results in a different kind of humanitarian crisis and then further increases and exacerbates injustices,

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structural injustices and structural inequalities, gender being one of those examples.

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But of course, this will apply across race, class, disability and other minorities.

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Well. What could be the explanation for why there is so little attention being paid to this major problem?

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I think if we look at public health measures, we're quite used to look at looking at demonology as numbers or statistics without

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necessarily looking at the differentials between between people and how they're situated.

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We think about life saves, life saved,

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but we'd think less about which life is being saved and whether there's a pattern of discrimination, for example.

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There is not also potentially enough ethical and social justice discourse discussion within

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how policy is being made within different models of responses that are being discussed.

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We tend to think about ethics quite narrowly in terms of access to health care,

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end of life decisions, event access to ventilation and things like that.

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But perhaps we're less attuned to thinking about the broader social justice aspects of

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how we should think about policies and how we should think about ethics in this context.

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So do you have any sort of idea about what ought to be done to address these problems?

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What we need to do is to start thinking about this far earlier than we have so far.

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So when we start thinking about modelling pandemics, when we start thinking about various scenarios,

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whether when we start thinking about pandemic planning, that absolutely has to be a systematic consideration of these aspects,

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both in the ways in which the pandemic will affect various parts of the population,

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but also how our responses will then affect these individuals, these groups and populations.

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These are not just numbers. These are people who are situated differently in society with more or less privilege.

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And this has to be taken into account. Also, quite importantly, we need to hear these voices.

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There is not enough in terms of representation of marginalised people,

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of women or people of various ethnic backgrounds and disabilities and so on, other minorities as well.

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We have to do this early on and we have to do it systematically.

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So it's not to create further injustice and to exacerbate already existing social and structural disadvantage.

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