The injustices were always there, but a core part of the injustice was that we didn’t even hear of them—the early deaths, or those whose quality of life was ruined by illness. Devastating health inequalities predate the covid-19 pandemic, and have been intensified by this crisis. They will outlast the so-called “recovery” unless we take this moment to transform health outcomes for the most vulnerable.
As a medical student, I have spent much of the past year volunteering in the intensive care units and wards of London’s hospitals most affected by covid-19. I saw first hand how those admitted were disproportionately from ethnic minorities, poorer populations, and with pre-existing health problems. This fact is widely acknowledged, but what is less discussed is people’s continuing exposure to a broader, continuing crisis of inequality. As we look to the future, we cannot simply replicate what came before. We must rectify the flawed economic and health structures that meant that the most vulnerable were always disproportionately likely to contract covid-19, and to die from it.
This piece is intended to stimulate challenging conversations about accountability amongst those in power, and the many voices in healthcare that influence these decisions. In this important and transient moment of reflection and reckoning, I propose that we must measure ourselves against the standard of equal health outcomes going forward. It is not within the scope of this article to set out every policy detail to achieve this. Rather, it calls for these detailed discussions to begin now, to raise their ambitions, and to focus on three lessons of justice from the covid-19 era. First, we require preventative interventions to break cycles of ill health. Second, we should preserve and re-deploy our covid-19 infrastructure towards other diseases. Finally, we must project the patient stories that will hold us accountable.
We know that co-morbidities such as obesity and hypertension correlate with more severe covid-19 outcomes. Underlying conditions were seen as innate or outside of the sphere of governmental responsibility—rather the onus was put on individuals. Yet the sickest patients in intensive care were not there primarily due to their own behaviour, or to circumstances outside of anyone’s control. They were there because of inequalities we laid the foundations for.
Covid-19 showed our capacity to deliver preventative public health interventions when we don’t allow ourselves the luxury of resignation. By investing in effective disease prevention, supporting businesses with distancing measures, and funding rapid vaccine rollout, we turned a corner on the pandemic. Conversely, until now we have expected primary care physicians and their most vulnerable patients to fight an uphill battle against diabetes, liver disease, and heart failure—all conditions defined by modifiable risk factors. Now vaccine rollout continues at pace, it is tempting to breathe a sigh of relief and stand down. Instead we must refuse to rest until rates of these other, equally damaging, diseases begin to fall. Such ambitious targets would generate further interventions, such as pop-up clinics for blood pressure readings to increased investment in diabetes and cardiac specialist nurses.
As we track and trace covid-19, other diseases run rampant. In the third quarter of 2020, 1,007 tuberculosis cases were notified in England—a 15.5% decrease compared to 2019.  Far from reassuring, this suggests a diagnostic gap layered on top of prior challenges detecting tuberculosis in predominantly poor communities. If one opportunity arises from the pandemic, it is that the infrastructure developed to control covid-19 can be redeployed effectively. We now run hundreds of thousands of tests daily—this newfound capacity could expand TB screening, turning the tide back towards eradication. By creatively utilizing the capabilities developed in response to the pandemic, covid tools could help solve pre-covid problems.
The lasting message I take from the hospital wards is that we cannot forget the roots of injustice in patient stories. Amplifying patients’ voices would keep our feet to the fire so that we strive towards fairer outcomes than came before.
Over the coming months many will want to look towards the future, or at best acknowledge policy failings during covid-19. We cannot pretend that this is enough. Our responsibility began before this pandemic, we must reckon with these deep forces of injustice. We are a country that takes a unique pride in the collective project, and success, of our NHS. We can, and should, be proud, but measure ourselves against its founding ideals and extend the scope of health justice beyond its doors. Now is the time to recreate, rather than to return to differential outcomes we told ourselves were inevitable but were never truly just.
Anne Williamson is a medical student at Barts and the London School of Medicine and Dentistry and Princess Alexandra Hospital, Harlow, Essex, UK.
Competing interests: none declared.