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Hello, I'm David Edmonds and this is the Pandemic Ethics Accelerator Podcast.

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The UK Pandemic Ethics Accelerator was a project funded by the Arts and Humanities Research

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Council in 2021 22 to examine the ethical challenges faced during the COVID pandemic,

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it combined expertise from the University of Oxford, Bristol, Edinburgh University College, London and the Nuffield Council on Bioethics.

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This six part podcast series covers some of the themes that emerged from the research.

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The pandemic affected different groups and communities differently.

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Lockdown wasn't so tough for people with gardens than it was on those living in apartments with no outside space.

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There were also disproportionate impacts measured by ethnicity, gender and geography.

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Beth Hammond, Opodo and John Coughlan are both legal scholars, both interested in inequality.

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Beth among the POTO and John Coughlan, welcome. Hello.

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Thank you. We're talking today about the pandemic and inequality.

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There are inevitably going to be some groups more affected by the pandemic than others.

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That's almost a matter of logic. Not every group will be affected in the same way.

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The question then is what inequalities we should care about.

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Now, some people had underlying medical conditions that made them more vulnerable.

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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.

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That's not anybody's fault, is it? That's just a result. Not of discrimination.

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It's just a medical fact. Yeah, you're right.

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In mentioning that health crises such as pandemics will affect different people in different ways.

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The issue that causes, such as myself or John would be interested in is the point at which these variations in outcome become inequities.

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So not just inequality in terms of difference of outcome, but where it is unfair and unavoidable.

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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,

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gender. Even where you live is going to affect that.

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I think the question directs itself to problems that exist innately to particular people,

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rather than suggesting that the products of socially generated conditions.

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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.

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And one thing I would urge is that we don't allow outright disentanglement of features such as age when we evaluate that.

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So surely it's the case that older people were inherently more vulnerable to the more harmful aspects of the disease,

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all things equal, including severe illness or death.

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But the conditions in which people were living were subject to decisions that were made by political decision makers,

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by professionals, by family members,

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by carers, and of course, by individuals themselves in circumstances that aren't just reducible to greater or lesser biological susceptibility.

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So if we approach these questions,

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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.

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Do you mean, for example, that obviously many elderly people were in care homes and these didn't necessarily have the equipment they needed?

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There was a problem when lots of people were released from hospital and sent back into care home, spreading the disease very rapidly indeed.

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So we didn't start from scratch at the beginning of the time of the virus's arrival.

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And then there was a collection of individuals,

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some of whom were more and some were less susceptible to it just by the process of the generation and spread of disease.

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So people had questions around the vulnerability and so on,

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determined as well by their environments, the decisions around their environments and so on.

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For example, questions of supplies of PPE and so on in care homes are directly relevant to

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the level of susceptibility that someone might face regardless of their age.

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Yes. So vulnerability, as John is saying, is socially constructed.

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So how badly then are impacted?

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That's a socially constructed question that goes beyond your biology.

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So, for example, there's no particular reason why if you're an older person living in a richer area,

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you should have less worse outcomes than if you're an older person living in a deprived area.

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But I think the other thing that we wanted to think about was to not make the pandemic special,

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as though these problems began with the pandemic and would go away with the pandemic,

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or as though these are simply problems of planning and administration, which would have been avoided had there been better planning.

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So of course, questions of PPE are extremely important when decisions were made to take people back into care homes,

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those are extremely positive questions.

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But it's not as though the inequalities or the inequities would have ceased to exist simply by having better planning or better administration.

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So I want to get onto that in a minute and also get onto the issue of how these various individual factors are connected.

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But we've touched on age. Let's also talk about.

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Nicety. One issue about ethnicity and the pandemic was whether ethnicity per say explains the inequality.

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Was it really a biological issue?

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Or, as seems more likely, might it be, the ethnic minorities are disproportionately poor and that it was the poverty,

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not the ethnicity, that really drove a disparity between different ethnic and racial groups.

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I hesitate to make those distinctions between race and class or race and income and which one matters more.

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Because obviously then your race is more likely to then impact various life outcomes and job opportunities and education and schooling

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and so many other things that then determine what sort of cushions and buffers you have to enable you to meet difficult situations.

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So I wouldn't want to say, well, it wasn't race, it was income,

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because even within poor people or within even working class communities that I know, it's not the same class and income.

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But even within that, there's still disparities of who was more likely to be on the front end of the scene.

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What you're doing now is one of the things that we were then critiquing in our work.

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Taking various axes in isolation. And so we've talked about age.

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Now we're talking about race. And we may talk about something else.

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It's impossible to really understand these issues without understanding them in how they

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commute the junction at which they come together in order to make proper sense of them.

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So I hesitate to discuss whether it was race or income.

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I would say it's the collision of both of those things. John, you want to come in?

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So historically within public health and I should say that I'm a humanities scholar who works in public health,

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so I don't engage directly in the epidemiological science on this.

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But historically, health inequalities have been examined in particular by reference to socioeconomic position.

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So we've looked at gradations of wealth and seeing correlations there between being a

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better position socioeconomically and enjoying better health opportunities and outcomes.

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What Beth and scholars such as Beth have brought within the ideas of critical public health is an examination along other lines as well.

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So the answer isn't that socioeconomic position is irrelevant or cannot explain disproportionately high burdens of ill health,

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including in the context of COVID 19.

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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.

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And their age was a good example.

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If you are older, all things equal, you are less likely to survive the disease or go through it with less severe impacts.

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But also, for example, along axes of gender, we've seen different impacts.

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Men were more susceptible to the virus itself,

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but also women have been shown to have suffered a greater burden as a consequence of the pandemic, regardless of socioeconomic position.

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But also, when you look at this empirically, because what you're saying is,

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is it the fact that people are poor that maybe explains the situation rather than questions of race?

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But you can look at people of colour, of higher income who then still faced disproportionate burdens, for example,

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medical doctors who were still then facing disproportionate burdens, for example, in the NHS or even beyond.

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And so the poverty element does explain something but wouldn't explain fully.

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Why is it then that consultants were dying at a higher rate than their white colleagues, for example?

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So what would explain that?

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Well, I mean, it comes to like worse problems that have existed within the system before the pandemic and after the pandemic.

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Even people's voice not being heard when they talk about problems that have existed in the past,

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people's expertise not being acknowledged or respected.

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So I'm thinking, for example, of consultants who themselves have recorded their own stories,

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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.

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And. Well, so I'm thinking of of one of the stories where this medical consultant comes in saying that she has particular symptoms.

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She says she's a doctor, take me seriously. And people say, well, you're a drug addict.

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And by the time they realise, oh, my goodness, yes, you actually are a medical doctor.

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What you're seeing is what is happening. It was way too late.

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This sort of issues impacts people of higher income as well as lower incomes.

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So we've touched on issues of ethnicity and sex and age.

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Let's throw geography into the mix. The difference, for example, between urban and rural or between the south of the country.

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In the north. Would you like to comment on that as another factor causing disparities in so far as geography tracks socioeconomic position?

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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,

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I'm thinking here of restrictions, regulations, including the outright lockdowns, is that they were blanket by their nature.

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What we needed to think about and worth thinking about from the start was not just the possible harms of the virus,

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but also the harms of the measures that could have been implemented and were implemented.

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And that sort of uniformity immediately can strike you as problematic if you imagine the difference between, for example,

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regulating somebody in central London or Birmingham or Liverpool and somebody in the rural Southwest, for example.

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The conditions differ radically. So you're going to necessarily find unequal impacts of those regulations in a close urban setting.

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The opportunity to come across other people is necessarily much higher.

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I live in central Bristol and I would go out. The regulations early on were quite open, textured in what they prescribed,

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but the understanding advanced by ministers was that you should have about one hour

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of recreation a day and I would do that in close proximity to lots of other people.

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Do you mean that lockdowns were a fairly crude, blunt instrument and they should have been more nuanced?

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They made more sense in more densely populated areas than they did in sparsely populated areas.

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I don't mean that.

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So having a uniform measure could be justified against uncertainty, the severity of the threat, the fact that the more nuance you provides,

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the harder it is both for people who need to follow the regulation and those who need to police it.

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The practical effects of blanket measures, especially draconian such as lockdowns,

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will be felt differently and have different rationales if you pick into the particular,

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for example, of the contrast between an urban and a rural environment.

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It doesn't follow from that that they're not justified.

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And we also saw as restrictions eased, that the Government moved to a situation of allowing localised lockdowns,

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so being more responsive to more local geographical situations and that presented both benefits,

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it allowed for a wider opening up of freedoms and also challenges because people would say,

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well, how come my neighbour is allowed freedoms that I can't enjoy?

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There was a football stadium, the occupied space, both in England and in Wales,

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and so we saw a jurisdictional boundary that clearly doesn't make sense.

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If you just look at the local.

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What I would invite when we reflect on these is for us to consider not doesn't that therefore mean the regulations are stupid,

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but rather we think about the challenges of particular differences where general requirements need to

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be imposed and the rationale isn't necessarily embarrassed by apparently silly or absurd situations.

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But if we have a blanket measure across, for example, the whole of the United Kingdom,

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we will find problems and challenges from a regulatory perspective and challenges that individuals could say this doesn't make sense,

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but from a population approach and from an approach that is attentive to workable governance may well be the least bad option.

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You touched on this earlier, but what's the point of intersection analysis?

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Intersectional is a buzz word that is used a lot nowadays, and it means the bringing together of lots of separate factors,

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not just ethnicity or class or geography, but thinking about issues of inequality in the ground.

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Best intersectionality. Why does that matter when we're talking about inequality?

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In regard to the pandemic, the concept has been there for a long period of time.

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Black feminists. Well, first of all, the term was coined by black feminist Kimberlé Crenshaw,

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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

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collude in order to create these systems of domination and intersectionality when it began was actually quite a radical idea,

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an idea that's helped to then show, for example, within the context of feminism,

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that while all women were subjugated, the inequalities did not fall in the same way.

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So using examples within African American women and the ways in which those differences between white women and women of colour in general,

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but in terms of what is its usefulness and gender and I have this table that we quite enjoy that was

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created by the Townsend Centre for International Poverty Research at the University of Bristol,

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which sort of critiques the ways in which inequalities are dealt with.

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Just give me one example. Yes, the table responded to the then chief medical officers in 1999.

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The chief medical officer issued ten tips for better health. And they.

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Call it very individually focussed advice around behaviours. So don't smoke or if you can stop if you can't cut down.

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Follow a balanced diet with plenty of fruit and vegetable. Keep physically active and so on.

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And the alternative tips were advanced really to satirise,

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but also really explain how we have to incorporate systemic thinking into our understandings here.

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So it offers advice such as Don't be poor. If you are poor, try not to be poor for too long.

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Don't live in a deprived area if you do move. And it's trying to articulate exactly what Beth is saying,

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these questions of power dynamics and the structures around you that the saying just choose health if you want.

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Health is not either helpful advice or even meaningfully actionable advice.

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Yeah. And when it comes to place, for example, there seemed to be a lot of if you live in an overcrowded flat,

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just move to a place where you have a green garden,

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that sort of narrative that first of all, individual faces and kind of puts responsibility just on the person.

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It doesn't go far enough.

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Whereas intersectionality would then enable us to then think about what was the impact, for example, on austerity in creating where people live.

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How has decades of austerity colluded with racism, with patriarchy?

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Which then means that certain people are more likely to live in overcrowded, mouldy, disgusting housing and so on.

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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,

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etc. But of course, pandemic decisions such as lockdown had effects elsewhere in the system, on the economy, on other areas of health.

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Can you comment on how inequalities cropped up in these other areas of life as a result of the pandemic?

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I think that's such an important point.

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And again, throughout we've been very interested not just to look at the effects and the probable future effects of the virus.

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And there you might look at unequal susceptibility as we were discussing right at the start.

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And for example, when you're thinking about your vaccine rollout,

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you might prioritise by reference to susceptibility to harm and capacity to benefit against the virus itself.

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But because of the nature of the interventions that have been implemented,

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it's been really important as well to consider the harms caused by policies caused by decisions themselves.

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Of course we hear lots of framing of health versus the economy or the economic harms of lockdowns and so on.

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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.

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So in order to provide protections against the harms of coronavirus, there are other costs.

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And we've seen this play out in relation, for example, to NHS waiting lists.

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We saw redeployment of staff within the NHS, which meant the other harmful, including lethal health conditions were being deprioritized.

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And then more widely, as you've said, we've got health, for example, against economic goals.

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We've seen education compromised all sorts of wider impacts.

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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,

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it's important to think about real experience inequality as opposed just a sort of formal equality of opportunity against it.

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So it's no good saying everyone was free to go out and create, as Beth has indicated,

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that freedom wasn't universally shared, it permitted of different degrees.

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So in our evaluation in the round, I think it's extremely important that we don't just commit to a formal equality.

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I think this is where the idea that while we face the same storm, we were not in the same boat.

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You remember the beginning of the pandemic, especially the first lockdown.

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There was this constant refrain, as do we're all in it together when actually we weren't.

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And that became more and more clear as time went on.

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We know, for example, one of the harms that came out of the measures was an increase in domestic violence in the first pandemic.

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Food poverty, which was already bad enough before we went into the lockdowns, became even worse, and so on and so forth.

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And just the inequalities of that in terms of how work is shed in the home or how caring responsibilities are understood,

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have become even less to be generous to the people who are making decisions,

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especially at the beginning there was a lot that was unknown and I hate to use the word unprecedented,

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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.

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The point I keep coming back to that myself and John have been making in our work is that it's really important

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to realise that these questions existed before the pandemic and still exist even now when we've gone back.

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To normal, whatever that means.

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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,

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to measure, to talk about, to quantify multiple inequalities and nobody saying it's easy.

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It's not supposed to be easy. That's the whole point. It's supposed to move away from a simplistic approach,

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but that's where the culpability comes in as to what was happening before the pandemic and what's happening now since then,

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as we think about perhaps another pandemic, well, let's finish on that point.

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We've been discussing disparities, differences between different groups.

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Let me ask this. So what question? What follows from this analysis?

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What are the policy implications? Are there lessons for how governments and public bodies should respond to future pandemics?

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I actually think that governments need to think about their responses even prior to future pandemics.

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What the pandemic showed was the value that needs to be placed on health and public health systems.

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What it also showed, as Beth has indicated,

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is that we had systematised health harms built into the fabric of decision making and policy making and policy processes.

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So we need to learn from the pandemic and be better prepared for next time what might occur.

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But the different susceptibilities and so on that we have seen are not just going to sit latent in the meantime,

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harmlessly taking over until such time as another outbreak occurs or a new variant comes along of the coronavirus.

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We need to ask ourselves what it is about health we value and why.

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How control is held over health because we don't want to rob individual agency or deny the idea that people do,

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can and should have decision making power in relation to their own lives.

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But we also need to recognise the junctions at which the decision making of others, the actions of institutions also influence people's health,

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their opportunities for health, but also their health outcomes in ways that they cannot touch.

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Yes, that means learning lessons in relation to infectious disease,

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but it also applies to the way our environment's impacts our mental health and wellbeing.

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It applies to questions of what we consume, how and why and so on.

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Public health policy ought not to be too disentangled from emergency situations and the rest because they're all part of each other.

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Beth. Yeah, I think one of the key lessons that needs to be learnt is the need for more robust deliberations.

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So if health harms and health inequalities are baked into the system, then surely now is the time to have those discussions and deliberations.

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That points out in what way are these harms baked into the system and what is it that can be done about this?

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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.

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And also part of our work was to create frameworks that had questions that

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enable people to be able to have more robust conversations around these things.

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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?

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You know, they'll always be difficult decisions to make,

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difficult privatisations to be made within the context of a pandemic before, during and after.

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But it then enables us to think about is it the same sort of people who are always asked to put their own health

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care or mental health or other forms of care lost who's always falling through the cracks was always being told,

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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.

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I hope we don't have one, but the science says that will probably will.

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Bethke among Opodo and John Cogan, thank you very much. Thank you.

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Thank you. Thanks for listening to the Pandemic Ethics Accelerator podcast.

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You can hear more in this six part series on University of Oxford Podcasts.

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Well, that's Pandemic Ethics dot UK.