A fair distribution of health and wellbeing have to be at the heart of building back fairer, say Michael Marmot and colleagues

“Build Back Better” has become the mantra for what we should aim for post covid. Important, no doubt, but we also need to Build Back Fairer. The levels of social, environmental, and economic inequality in society are damaging our health and wellbeing. That was the main message in Health Equity in England: the Marmot Review 10 Years On, the report we, at UCL Institute of Health Equity, published in February 2020. We reported on the stagnation of health improvement in England that was the second worst in Europe, widening social and regional health inequalities, and deterioration in health for the most deprived people. We proposed that health is a marker of how well society is meeting the needs of its members. Society in England did badly over the decade from 2010 until 2020. There is now an urgent need to do things differently. We must build a society based on the principles of social justice; reduce inequalities of income and wealth; and build a wellbeing economy that puts achievement of health and wellbeing, rather than narrow economic goals, at the heart of government strategy. We must build a society that responds to the climate crisis at the same time as achieving greater health equity.

Our new report, Build Back Fairer: The COVID-19 Marmot Review revisits our 10 Years On report. We felt a need to revisit this now, for three reasons. Firstly, the pandemic and associated societal response amplified social and economic inequalities in all the domains that we analysed in 10 Years On—early childhood, education, employment, having enough money to live on, housing and communities. It also showed even steeper social gradients in mortality rates and strikingly high mortality rates among people from Black, Asian and minority ethnic groups. Much of this excess can be attributed to deprivation.

The second reason for revisiting 10 Years On was that during the pandemic England had the highest excess mortality rate in Europe. Observers of the US situation agree that the US handling of the pandemic has been a disaster. But what has not been commented on as much is that  certainly, at least until the second wave, excess mortality in England was higher. We make a link between the poor state of health that developed in England after 2010 and the high excess mortality during the pandemic. This could work in four ways. The quality of governance and political culture—failing to give priority to health and wellbeing, erosion of trust in government, privileging private sector solutions over the public good; the magnitude of social and economic inequalities; the cutback to social and health services that meant the country was ill-prepared for coping with a pandemic; and high levels of ill-health that would increase the severity of covid-19.

The third reason is that as we emerge from the pandemic it would be tragic to return to the status quo of early 2020. Each of the four reasons just elaborated for our poor state of health must be addressed. Quality of governance and political culture are necessary and set the context. A lesson from the pandemic is the primacy of the health of the population. It should not be health or the economy. Over many years we have been engaged in debates with economists as to whether good health leads to a stronger economy or whether better social and economic conditions lead to better health. They are intertwined. A clear lesson comes from international comparisons. Countries that managed the pandemic well had less of a hit to their economies. The UK with its high excess mortality had among the biggest drops in GDP in Europe, not because the disease itself is damaging the economy, but because failing to take the decisive action needed, means that the UK staggers from lockdown to partial restrictions to lockdown with immense damage to people’s livelihoods and their lives, and amplification of inequalities.

Related to this lesson, health and wellbeing should be at the centre of building back fairer. The central dogma of governments from 2010 was putting the public finances in order—austerity by another name. The state was rolled back in a regressive way. To the extent that health was seen as important, there was partial protection for NHS funding and some action on obesity. The social determinants of health did not feature in government priorities. It took the pandemic and Marcus Rashford, a young footballer, to get the government to see that there was something wrong with poor children going to bed hungry, or rough sleepers being left to die young on the streets. A fair distribution of health and wellbeing have to be at the heart of building back fairer.

A further clear message from the pandemic that should set the tone for the future is that when faced with a major threat to the nation’s health and to the economy, the government stopped acting as if austerity was a moral imperative and said, whatever it takes. Money to control the pandemic, and money to keep people away from economic disaster was seen as essential.

As we emerge from the pandemic finding the money, respecting the science, recognising the role of government and public services, and committing to social justice will all be needed if health, and health equity, are once again to flourish. That is what we mean by build back fairer.

Build Back Fairer: the COVID-19 Marmot Review
The Pandemic, Socioeconomic and Health Inequalities in England
Published by Institute of Health Equity, UCL

Michael Marmot, Jessica Allen, Peter Goldblatt , Joana Morrison

Institute of Health Equity, Department of Epidemiology and Public Health, UCL

Competing interests: None declared