Hello, I'm David Edmonds and this is the Pandemic Ethics Accelerator Podcast.
The UK Pandemic Ethics Accelerator was a project funded by the Arts and Humanities Research
Council in 2021 22 to examine the ethical challenges faced during the COVID pandemic,
it combined expertise from the University of Oxford, Bristol, Edinburgh University College, London and the Nuffield Council on Bioethics.
This six part podcast series covers some of the themes that emerged from the research.
The pandemic affected different groups and communities differently.
Lockdown wasn't so tough for people with gardens than it was on those living in apartments with no outside space.
There were also disproportionate impacts measured by ethnicity, gender and geography.
Beth Hammond, Opodo and John Coughlan are both legal scholars, both interested in inequality.
Beth among the POTO and John Coughlan, welcome. Hello.
Thank you. We're talking today about the pandemic and inequality.
There are inevitably going to be some groups more affected by the pandemic than others.
That's almost a matter of logic. Not every group will be affected in the same way.
The question then is what inequalities we should care about.
Now, some people had underlying medical conditions that made them more vulnerable.
But let's start with age inequality. The one thing everybody knows about the pandemic is that it effected old people more than young people.
That's not anybody's fault, is it? That's just a result. Not of discrimination.
It's just a medical fact. Yeah, you're right.
In mentioning that health crises such as pandemics will affect different people in different ways.
The issue that causes, such as myself or John would be interested in is the point at which these variations in outcome become inequities.
So not just inequality in terms of difference of outcome, but where it is unfair and unavoidable.
However, I think I would have in trouble just looking at age in isolation and recognising that age aligns with other systemic locations such as race,
gender. Even where you live is going to affect that.
I think the question directs itself to problems that exist innately to particular people,
rather than suggesting that the products of socially generated conditions.
So we say if you are older. It is a biological matter that you're more likely to be susceptible to harm from the virus.
And one thing I would urge is that we don't allow outright disentanglement of features such as age when we evaluate that.
So surely it's the case that older people were inherently more vulnerable to the more harmful aspects of the disease,
all things equal, including severe illness or death.
But the conditions in which people were living were subject to decisions that were made by political decision makers,
by professionals, by family members,
by carers, and of course, by individuals themselves in circumstances that aren't just reducible to greater or lesser biological susceptibility.
So if we approach these questions,
we need to do so in a social context that cannot just be abstracted from by reference to innate biological vulnerability and by social context.
Do you mean, for example, that obviously many elderly people were in care homes and these didn't necessarily have the equipment they needed?
There was a problem when lots of people were released from hospital and sent back into care home, spreading the disease very rapidly indeed.
So we didn't start from scratch at the beginning of the time of the virus's arrival.
And then there was a collection of individuals,
some of whom were more and some were less susceptible to it just by the process of the generation and spread of disease.
So people had questions around the vulnerability and so on,
determined as well by their environments, the decisions around their environments and so on.
For example, questions of supplies of PPE and so on in care homes are directly relevant to
the level of susceptibility that someone might face regardless of their age.
Yes. So vulnerability, as John is saying, is socially constructed.
So how badly then are impacted?
That's a socially constructed question that goes beyond your biology.
So, for example, there's no particular reason why if you're an older person living in a richer area,
you should have less worse outcomes than if you're an older person living in a deprived area.
But I think the other thing that we wanted to think about was to not make the pandemic special,
as though these problems began with the pandemic and would go away with the pandemic,
or as though these are simply problems of planning and administration, which would have been avoided had there been better planning.
So of course, questions of PPE are extremely important when decisions were made to take people back into care homes,
those are extremely positive questions.
But it's not as though the inequalities or the inequities would have ceased to exist simply by having better planning or better administration.
So I want to get onto that in a minute and also get onto the issue of how these various individual factors are connected.
But we've touched on age. Let's also talk about.
Nicety. One issue about ethnicity and the pandemic was whether ethnicity per say explains the inequality.
Was it really a biological issue?
Or, as seems more likely, might it be, the ethnic minorities are disproportionately poor and that it was the poverty,
not the ethnicity, that really drove a disparity between different ethnic and racial groups.
I hesitate to make those distinctions between race and class or race and income and which one matters more.
Because obviously then your race is more likely to then impact various life outcomes and job opportunities and education and schooling
and so many other things that then determine what sort of cushions and buffers you have to enable you to meet difficult situations.
So I wouldn't want to say, well, it wasn't race, it was income,
because even within poor people or within even working class communities that I know, it's not the same class and income.
But even within that, there's still disparities of who was more likely to be on the front end of the scene.
What you're doing now is one of the things that we were then critiquing in our work.
Taking various axes in isolation. And so we've talked about age.
Now we're talking about race. And we may talk about something else.
It's impossible to really understand these issues without understanding them in how they
commute the junction at which they come together in order to make proper sense of them.
So I hesitate to discuss whether it was race or income.
I would say it's the collision of both of those things. John, you want to come in?
So historically within public health and I should say that I'm a humanities scholar who works in public health,
so I don't engage directly in the epidemiological science on this.
But historically, health inequalities have been examined in particular by reference to socioeconomic position.
So we've looked at gradations of wealth and seeing correlations there between being a
better position socioeconomically and enjoying better health opportunities and outcomes.
What Beth and scholars such as Beth have brought within the ideas of critical public health is an examination along other lines as well.
So the answer isn't that socioeconomic position is irrelevant or cannot explain disproportionately high burdens of ill health,
including in the context of COVID 19.
But we also find other axes across which people have been found more likely to suffer ill health, either directly because of the virus itself.
And their age was a good example.
If you are older, all things equal, you are less likely to survive the disease or go through it with less severe impacts.
But also, for example, along axes of gender, we've seen different impacts.
Men were more susceptible to the virus itself,
but also women have been shown to have suffered a greater burden as a consequence of the pandemic, regardless of socioeconomic position.
But also, when you look at this empirically, because what you're saying is,
is it the fact that people are poor that maybe explains the situation rather than questions of race?
But you can look at people of colour, of higher income who then still faced disproportionate burdens, for example,
medical doctors who were still then facing disproportionate burdens, for example, in the NHS or even beyond.
And so the poverty element does explain something but wouldn't explain fully.
Why is it then that consultants were dying at a higher rate than their white colleagues, for example?
So what would explain that?
Well, I mean, it comes to like worse problems that have existed within the system before the pandemic and after the pandemic.
Even people's voice not being heard when they talk about problems that have existed in the past,
people's expertise not being acknowledged or respected.
So I'm thinking, for example, of consultants who themselves have recorded their own stories,
including one who is recording the story as it was happening and unfortunately later died, where people are not going to be leaving them the door.
And. Well, so I'm thinking of of one of the stories where this medical consultant comes in saying that she has particular symptoms.
She says she's a doctor, take me seriously. And people say, well, you're a drug addict.
And by the time they realise, oh, my goodness, yes, you actually are a medical doctor.
What you're seeing is what is happening. It was way too late.
This sort of issues impacts people of higher income as well as lower incomes.
So we've touched on issues of ethnicity and sex and age.
Let's throw geography into the mix. The difference, for example, between urban and rural or between the south of the country.
In the north. Would you like to comment on that as another factor causing disparities in so far as geography tracks socioeconomic position?
The answer is there reside in the same place. I think one of the issues with the Corona virus and especially the earlier responses to it,
I'm thinking here of restrictions, regulations, including the outright lockdowns, is that they were blanket by their nature.
What we needed to think about and worth thinking about from the start was not just the possible harms of the virus,
but also the harms of the measures that could have been implemented and were implemented.
And that sort of uniformity immediately can strike you as problematic if you imagine the difference between, for example,
regulating somebody in central London or Birmingham or Liverpool and somebody in the rural Southwest, for example.
The conditions differ radically. So you're going to necessarily find unequal impacts of those regulations in a close urban setting.
The opportunity to come across other people is necessarily much higher.
I live in central Bristol and I would go out. The regulations early on were quite open, textured in what they prescribed,
but the understanding advanced by ministers was that you should have about one hour
of recreation a day and I would do that in close proximity to lots of other people.
Do you mean that lockdowns were a fairly crude, blunt instrument and they should have been more nuanced?
They made more sense in more densely populated areas than they did in sparsely populated areas.
I don't mean that.
So having a uniform measure could be justified against uncertainty, the severity of the threat, the fact that the more nuance you provides,
the harder it is both for people who need to follow the regulation and those who need to police it.
The practical effects of blanket measures, especially draconian such as lockdowns,
will be felt differently and have different rationales if you pick into the particular,
for example, of the contrast between an urban and a rural environment.
It doesn't follow from that that they're not justified.
And we also saw as restrictions eased, that the Government moved to a situation of allowing localised lockdowns,
so being more responsive to more local geographical situations and that presented both benefits,
it allowed for a wider opening up of freedoms and also challenges because people would say,
well, how come my neighbour is allowed freedoms that I can't enjoy?
There was a football stadium, the occupied space, both in England and in Wales,
and so we saw a jurisdictional boundary that clearly doesn't make sense.
If you just look at the local.
What I would invite when we reflect on these is for us to consider not doesn't that therefore mean the regulations are stupid,
but rather we think about the challenges of particular differences where general requirements need to
be imposed and the rationale isn't necessarily embarrassed by apparently silly or absurd situations.
But if we have a blanket measure across, for example, the whole of the United Kingdom,
we will find problems and challenges from a regulatory perspective and challenges that individuals could say this doesn't make sense,
but from a population approach and from an approach that is attentive to workable governance may well be the least bad option.
You touched on this earlier, but what's the point of intersection analysis?
Intersectional is a buzz word that is used a lot nowadays, and it means the bringing together of lots of separate factors,
not just ethnicity or class or geography, but thinking about issues of inequality in the ground.
Best intersectionality. Why does that matter when we're talking about inequality?
In regard to the pandemic, the concept has been there for a long period of time.
Black feminists. Well, first of all, the term was coined by black feminist Kimberlé Crenshaw,
and they're the ones who have really done a lot to help us understand the ways in which various axes of power and oppression
collude in order to create these systems of domination and intersectionality when it began was actually quite a radical idea,
an idea that's helped to then show, for example, within the context of feminism,
that while all women were subjugated, the inequalities did not fall in the same way.
So using examples within African American women and the ways in which those differences between white women and women of colour in general,
but in terms of what is its usefulness and gender and I have this table that we quite enjoy that was
created by the Townsend Centre for International Poverty Research at the University of Bristol,
which sort of critiques the ways in which inequalities are dealt with.
Just give me one example. Yes, the table responded to the then chief medical officers in 1999.
The chief medical officer issued ten tips for better health. And they.
Call it very individually focussed advice around behaviours. So don't smoke or if you can stop if you can't cut down.
Follow a balanced diet with plenty of fruit and vegetable. Keep physically active and so on.
And the alternative tips were advanced really to satirise,
but also really explain how we have to incorporate systemic thinking into our understandings here.
So it offers advice such as Don't be poor. If you are poor, try not to be poor for too long.
Don't live in a deprived area if you do move. And it's trying to articulate exactly what Beth is saying,
these questions of power dynamics and the structures around you that the saying just choose health if you want.
Health is not either helpful advice or even meaningfully actionable advice.
Yeah. And when it comes to place, for example, there seemed to be a lot of if you live in an overcrowded flat,
just move to a place where you have a green garden,
that sort of narrative that first of all, individual faces and kind of puts responsibility just on the person.
It doesn't go far enough.
Whereas intersectionality would then enable us to then think about what was the impact, for example, on austerity in creating where people live.
How has decades of austerity colluded with racism, with patriarchy?
Which then means that certain people are more likely to live in overcrowded, mouldy, disgusting housing and so on.
When we reflect on inequality, we tend to think in terms of the pandemic stats themselves who's died from the pandemic, who's living with long COVID,
etc. But of course, pandemic decisions such as lockdown had effects elsewhere in the system, on the economy, on other areas of health.
Can you comment on how inequalities cropped up in these other areas of life as a result of the pandemic?
I think that's such an important point.
And again, throughout we've been very interested not just to look at the effects and the probable future effects of the virus.
And there you might look at unequal susceptibility as we were discussing right at the start.
And for example, when you're thinking about your vaccine rollout,
you might prioritise by reference to susceptibility to harm and capacity to benefit against the virus itself.
But because of the nature of the interventions that have been implemented,
it's been really important as well to consider the harms caused by policies caused by decisions themselves.
Of course we hear lots of framing of health versus the economy or the economic harms of lockdowns and so on.
This isn't to discount that discussion, but even more subtly, but no less importantly, we have health trade-offs within the pandemic decision making.
So in order to provide protections against the harms of coronavirus, there are other costs.
And we've seen this play out in relation, for example, to NHS waiting lists.
We saw redeployment of staff within the NHS, which meant the other harmful, including lethal health conditions were being deprioritized.
And then more widely, as you've said, we've got health, for example, against economic goals.
We've seen education compromised all sorts of wider impacts.
Now when we are assessing either the question of coronavirus itself or the unequal impacts of measures that might be instituted in response to it,
it's important to think about real experience inequality as opposed just a sort of formal equality of opportunity against it.
So it's no good saying everyone was free to go out and create, as Beth has indicated,
that freedom wasn't universally shared, it permitted of different degrees.
So in our evaluation in the round, I think it's extremely important that we don't just commit to a formal equality.
I think this is where the idea that while we face the same storm, we were not in the same boat.
You remember the beginning of the pandemic, especially the first lockdown.
There was this constant refrain, as do we're all in it together when actually we weren't.
And that became more and more clear as time went on.
We know, for example, one of the harms that came out of the measures was an increase in domestic violence in the first pandemic.
Food poverty, which was already bad enough before we went into the lockdowns, became even worse, and so on and so forth.
And just the inequalities of that in terms of how work is shed in the home or how caring responsibilities are understood,
have become even less to be generous to the people who are making decisions,
especially at the beginning there was a lot that was unknown and I hate to use the word unprecedented,
but then there was a lot that actually could have been foreseen, and there was a lot that they should have paid greater attention to.
The point I keep coming back to that myself and John have been making in our work is that it's really important
to realise that these questions existed before the pandemic and still exist even now when we've gone back.
To normal, whatever that means.
And so it's also about thinking about what was it that you were doing prior to the pandemic to create those spaces and opportunities to think about,
to measure, to talk about, to quantify multiple inequalities and nobody saying it's easy.
It's not supposed to be easy. That's the whole point. It's supposed to move away from a simplistic approach,
but that's where the culpability comes in as to what was happening before the pandemic and what's happening now since then,
as we think about perhaps another pandemic, well, let's finish on that point.
We've been discussing disparities, differences between different groups.
Let me ask this. So what question? What follows from this analysis?
What are the policy implications? Are there lessons for how governments and public bodies should respond to future pandemics?
I actually think that governments need to think about their responses even prior to future pandemics.
What the pandemic showed was the value that needs to be placed on health and public health systems.
What it also showed, as Beth has indicated,
is that we had systematised health harms built into the fabric of decision making and policy making and policy processes.
So we need to learn from the pandemic and be better prepared for next time what might occur.
But the different susceptibilities and so on that we have seen are not just going to sit latent in the meantime,
harmlessly taking over until such time as another outbreak occurs or a new variant comes along of the coronavirus.
We need to ask ourselves what it is about health we value and why.
How control is held over health because we don't want to rob individual agency or deny the idea that people do,
can and should have decision making power in relation to their own lives.
But we also need to recognise the junctions at which the decision making of others, the actions of institutions also influence people's health,
their opportunities for health, but also their health outcomes in ways that they cannot touch.
Yes, that means learning lessons in relation to infectious disease,
but it also applies to the way our environment's impacts our mental health and wellbeing.
It applies to questions of what we consume, how and why and so on.
Public health policy ought not to be too disentangled from emergency situations and the rest because they're all part of each other.
Beth. Yeah, I think one of the key lessons that needs to be learnt is the need for more robust deliberations.
So if health harms and health inequalities are baked into the system, then surely now is the time to have those discussions and deliberations.
That points out in what way are these harms baked into the system and what is it that can be done about this?
So as colleagues, one of the things that we have supported were the calls for the COVID public inquiry, and we look forward to seeing how that goes.
And also part of our work was to create frameworks that had questions that
enable people to be able to have more robust conversations around these things.
So for example, one of the questions that we offered to policymakers is whose care is seen as the type of care that can be left waiting?
You know, they'll always be difficult decisions to make,
difficult privatisations to be made within the context of a pandemic before, during and after.
But it then enables us to think about is it the same sort of people who are always asked to put their own health
care or mental health or other forms of care lost who's always falling through the cracks was always being told,
it's not your turn. And so these sorts of questions would really lead to just a more robust thinking in preparation for the next pandemic.
I hope we don't have one, but the science says that will probably will.
Bethke among Opodo and John Cogan, thank you very much. Thank you.
Thank you. Thanks for listening to the Pandemic Ethics Accelerator podcast.
You can hear more in this six part series on University of Oxford Podcasts.
Well, that's Pandemic Ethics dot UK.