Two million covid-19 deaths have brought the violence of unequal societies squarely into public discussion—“social murder” as Kamran Abbasi has argued in The BMJ.¹ What recourse do we have, he and others² have asked, when elected authorities are too incompetent, or too callous, to address public health failures? In many cases, these failures follow society’s existing fault lines, exacting the greatest toll from those least enfranchised, such as those marginalized by racism, classism, or discrimination based on religion, ethnicity, or other factors.^3-5 The strikingly unequal distribution of death from covid-19, concentrated among marginalized people, signals deep societal flaws and raises questions about how to advance societal performance in health.

The limitations of electoral politics for choosing competence and enforcing accountability are on full display in the countries performing the worst against covid-19, including the United States, the United Kingdom, and Brazil. Perversely, the overwhelming obviousness and vast extent of inequality are obstacles to political attention. In part, this is because inequality generates economic benefits for most political elites, but there are other reasons, as well. 

The largest societal problems are so difficult for individuals to reckon that ethicists have distinguished between statistical lives and identifiable lives in explaining why a few deaths register so much more forcefully in public consciousness than do a million deaths.⁶ This is one reason for inadequate action and absent accountability against covid-19 and other underpinnings of inequality. The often straightforward causality of smaller problems and the limited scale of their consequences contrast sharply with the circumstances of social murder, where cause bleeds into context and accountability succumbs to deniability. These dynamics demonstrate the hazard of relying on electoral politics to address systemic problems—it is normal that attention comes and goes, majorities often neglect minorities, and neither individuals nor groups show broad inclination to prepare until after disaster has struck.

But the apparent intractability of the largest problems is misleading. Progress is possible: in many ways the history of government itself is defined by periodic advances against the greatest societal threats, including infectious diseases. Pandemics have been an important source of motivation. Many capacities now standard in all modern nations were generated in response to epidemic infectious diseases in the 19th century, including municipal water filtration, sanitary sewerage, food and drug purity, housing codes, workplace safety standards, and disease surveillance.^6-8 Epidemics of cholera, typhoid, and other diseases spurred citizens and states to organize around public health capacities as well as broader societal advancements such as progressive taxation to support redistribution, universal education policies, social safety nets, and voting rights for women and minorities.

Certainly, democracies can solve problems, but they do not always choose to do so. The social murder of mismanaged covid-19 and persistent inequality painfully reveal that as the spectre of infectious diseases faded from public consciousness in the 20th century, so too did the commitment to collective action and popular engagement in public problems. Where citizens once insisted that their officials advance public health, consensus has given way to highly partisan politics and inaction on the defining challenges of the 21st century, whether climate change, non-communicable diseases, or covid-19. The inconsistent ability of normal electoral politics to solve complex societal problems is a long-recognized vulnerability of democracy. Frederick Soper, a former director of the Pan-American Health Organization and a towering figure in malaria and yellow fever, once remarked that democracy is incompatible with disease eradication.⁹

Both central banks and court systems show how to insulate essential government functions from the immediate influence of electoral politics. Monetary policy and justice are vulnerable to the same problems that now plague the health sector. The low and indirect incentives for preparedness, shifts in uninformed opinion, and technical complexity render these areas susceptible to corruption by weak elected leadership. All three areas can have conflicts between short- and long-term incentives that are difficult to weigh within the immediate pressures of election cycles. A long time ago citizens rejected justice that owed more to partisan convenience than fairness and grew tired of the economic destruction of politically motivated monetary policy. Improving societal performance meant building politically insulated institutions around technical expertise, using consensus processes to make long-term or lifetime leadership appointments, and empowering them with broad mandates.

As covid-19 rages on, it is clearer than ever that major national institutions in health remain unacceptably exposed to day-to-day political concerns. The variation in performance—so disastrous in some countries as to be called social murder—demonstrates the need for health institutions that can provide leadership in times of crisis and strategic stewardship of the nation’s health in normal times. Just as pandemics did in the past, the arrival of covid-19 has opened limitless windows of opportunity, although it guarantees nothing. Want better pandemic performance? It is time to bank on it.

Jesse B. Bump is Executive Director of the Takemi Program in International Health and Lecturer on Global Health Policy in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health, and a Member of the Bergen Center for Ethics and Priority Setting at the University of Bergen.

Competing interests: none declared

References:

1. Abbasi K. Covid-19: Social murder, they wrote—elected, unaccountable, and unrepentant. BMJ 2021;372:n314. doi: 10.1136/bmj.n314
2. Clift AK. Anatomising failure: there should be a statutory public inquiry into the UK Government’s handling of COVID-19. Journal of the Royal Society of Medicine 2020;113(6):230-31.
3. Aldridge RW, Lewer D, Katikireddi SV, et al. Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data. Wellcome open research 2020;5
4. Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. Journal of Public Health 2020;42(3):445-47.
5. Charlier P, Varison L. Is COVID-19 being used as a weapon against Indigenous Peoples in Brazil? The Lancet 2020;396(10257):1069-70. doi: 10.1016/S0140-6736(20)32068-7
6. Cohen IG, Daniels N, Eyal NM. Identified versus statistical lives: An interdisciplinary perspective: Oxford University Press, USA 2015.
7. Melosi MV. The sanitary city: Environmental services in urban America from colonial times to the present: University of Pittsburgh Pre 2008.
8. Porter D. The history of public health and the modern state: Rodopi 1994.
9. 9. Gladwell M. Fred Soper and the global malaria eradication programme. Journal of public health policy 2002;23(4):479-97.