Dr. Edelweiss Aldasoro discusses health inequalities in light of Covid-19

I spy with my little eye… a black swan, the elephant in the room or a grey rhino?

In figurative speech a Black Swan is an unprecedented and unexpected event with a significant impact. After the occurrence it becomes inappropriately rationalised because we do not cope well with uncertainty(1). It seems that some people use this black swan metaphor to describe the COVID-19 pandemic and its consequences. I, along with others, am not convinced the term is correct for this pandemic(2). I am uncertain what colour the swan is, but it does not look black to me. There have been loats of references about the tragic and disastrous repercussions of the pandemic worldwide, even though it has affected some population groups more than others. However, pandemics are not unprecedented and the several outbreaks in the past few years showed us how the national borders were not enough to contain infections in a globalised world(3). Hence, I think the swan I see is more grey than black, as the chance of a pandemic of this magnitude, or even worse, has been repeatedly predicted in the past 20 years(4, 5, 6, 7, 8, 9, 10, 11, 12 ,13 , 14, 15, 16, 17, 18). What we can agree is that we were unprepared. What is more, in the event of another unexpected and unpreventable system shock, we know our systems and responses are ill-prepared. In the recently published paper , IFIC proposes that working towards integrating care can add value and help us have more resilient systems, better able to react to new challenges. The more we can act as one system and one team worldwide, the greater chance we have to survive with less damage next time. We have seen we are all connected, and the predicament of one person can have an effect and be amplified globally.

It is at this point we need to talk about the elephant in the room. Can we function as one system, identify with the shared values and vision, and believe that everybody can be a partner in the care of each other when many societies structurally impoverish, marginalise, deprive, neglect or abandon some of their communities? The pandemic has highlighted that some communities and groups are systematically neglected and unprotected.(19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32) It is not new and it was not unknown, but the pandemic has demonstrated the dead fish effect: instead of sinking and decomposing, the fish has surfaced for all of us to see. And, mirror, mirror, on the wall, who in this land is fairest of all? The image reflected in the mirror is not fair: is ugly and troubling. We can clearly see the real values and priorities of our societies, who and what we value, we protect and cherish, and who we decide to neglect. And this is where we meet our third animal metaphor, the grey rhino.(33) Is it really a surprise that communities that are structurally disregarded and underserved suffer the highest impact during a pandemic or any other crisis?(34,35) Evidence on inequalities and its impact is well known, additional challenges would be further detrimental and yet many communities were still ignored. Therefore, the main specimen of this ‘zoo’ is a big grey rhino, which represents highly visible, predictable, and yet, neglected threats. An example of this is how the pandemic has further highlighted the existing racial and ethnic disparities at many levels. Structurally marginalised communities due to race and ethnicity have been caught in a vicious circle: they are impoverished and deprived communities with higher risk of infection and COVID-19-related complications, with poorer health outcomes. The higher prevalence of chronic conditions amongst this group resulted in lower survival scoring, resource allocation and access to intensive care due to their poor survival prognosis.(36, 37, 38, 39) Other examples are older people and those with disabilities. This pandemic has shown how little our societies value them. There are many examples worldwide of the lack of capacity to protect people living in institutions such as residential and nursing homes who have been denied higher level of care based on utility scoring for resource allocation. Basically, people who are in most need, have received less.

Looking to the future, we need to decide on what kind of society we want to build because it will inform the new health and care systems we create. We need to define what values, principles, ethics and morals are going to lead the new structures and alliances. It is highly likely that in this rapidly changing world, new challenges, unprecedent events and unpredictable catastrophes will occur sooner or later. I believe we can build a stronger society and system, prepared to adapt and resilient, which will improve our ability to control the potential consequences. Unfortunately, this is unlikely unless we construct a fair and just society where every person is equally valued, and we protect one another. If some survive at the expense of others, it does not reflect well on our principles and values as human beings, and it will not work. Protecting everybody is the only way to protect each of us. Words such as diversity and inclusion have lost their meaning unless they are acted upon. It is time to open our eyes and ears; we need to listen to the communities who are demanding their rights and give a voice to those who cannot. It is time we invested effort in healing historical damage and inequalities to build a new society together. No longer should the principles imposed by privileged communities define everyone’s values. It is time to respect and value each other and build structures that demonstrate this using innovative approaches to create better societies. Stop talking, it is time to act. If the world needs to act as one system and one team, we need to recognise each other, with our differences, as equal partners in this global initiative. Working in a team is complex, as is recognising and prioritising others’ needs before yours. Reaching a consensus is challenging and letting go of power is a struggle. However, as difficult as it may be, these are the steps need to be followed to become stronger. But as Machado said, “wanderer, your footsteps are the road, and nothing more; wanderer, there is no road, the road is made by walking”(40). So, if I want to make the world a better place for my children, for my parents, for me and for all, I am starting with the woman in the mirror (41).

Dr. Edelweiss Aldasoro,  
Senior Researcher