Beyond the pandemic: building forward better?

There comes a point in every disaster when the question arises as to what affected societies want to achieve from their recovery efforts. Do they return to the predisaster a priori situation? Alternatively, do they seek a different objective?

The pandemic has revealed and exacerbated the stark inequalities present within our societies. The poorest and most vulnerable members of our societies have been worst affected—those in low-paid insecure employment such as day labourers, those with disabilities, ethnic minorities, the homeless, migrants and refugees and many other inclusion health groups. Indeed, the risks of infection and disease burden are increased in these socio-economically disadvantaged groups. Some of this population vulnerability is explained by the prevalence of long-term health conditions and higher levels of overcrowded housing. In the UK, for example, areas with pre-existing higher levels of socio-economic deprivation have seen transmission of COVID-19 at higher rates than regions that are more affluent.

Many of these determinants of population susceptibility to infection predate the pandemic such as poorer access to health care, lower levels of literacy, lack of health insurance, poor housing including multiple occupancy housing, riskier work environments and practices and the consequences of structural racism. Restoring societies to their prepandemic state may simply mean recreating the conditions that allowed the pandemic to flourish in the first place.

It may seem intuitive that affected societies would want to ‘build back better’, but is that what affected societies really want? What are the alternatives? Moreover, what compromises are they willing to make to achieve this? Paradoxically, affected communities may be unprepared to change behaviours and may wish to return to the familiar ways of living. Here is where greater dialogue between policymakers, public health and the public is required to try to establish a vision as to where society could and should go.

Much of the current discourse on building back better has been on recovering from the effects of the pandemic and restoring society back to a less vulnerable state. However, there is scope to consider a more ambitious goal to ‘build forward better’ and tackle a much broader remit. The UN has described pandemic recovery as ‘an opportunity to address inequality, exclusion, gaps in social protection systems, the climate crisis and the many other fragilities and injustices that have been exposed’. Others have called for the strengthening of public institutions that promote the rule of law, protection of human rights and the environment, as well as the pursuit of a more inclusive, greener and resilient future through domestic and global partnerships focused on sustainable development. , Such aspiration will require greater efforts to eradicate the socio-economic inequalities and wider determinants of health that exist in our societies, beyond just addressing health equity issues.

However, change comes at a cost and it is uncertain if governments and the public are prepared for what is required to be more pandemic resilient. In libertarian societies such as the US, Australia and UK, for example, there has been resistance to some of the more stringent public health measures such as vaccine certification or face covering mandates. In the UK, the government has adopted a policy position of leaving it up to individual choice as to whether public health measures were followed. Unsurprisingly, adherence to the measures has plummeted in recent months which has coincided with a surge in case rates fuelled by the more infectious Delta variant.

Changing population behaviour and norms is not easy at the best of times, as public health practitioners well know from decades of trying to shift public attitudes towards smoking, alcohol, obesity and other public health illness. Nevertheless, change is possible. It has to be deliberate. It requires persistence and continued pressure. The case for change also has to be clearly articulated, covering both the benefits and costs of doing so. The ‘new normal’ needs to be defined, advocated for and supported with appropriate policy measures.

However, what does this ‘new normal’ look like? Is it a future where the use of face coverings and social distancing is ubiquitous? Does it entail significant changes in how education is delivered with greater use of digital home learning? Will work practices change to include more remote working and less emphasis on ‘presenteeism’ that are common in many settings? Will health controls at borders be made more stringent? Will COVID-19 vaccinations become mandatory requirements for certain occupations? Do building design regulations need to change to meet higher ventilation requirements?

Some of the positive changes in the way health care is delivered, such as the greater use of digital and telehealth modalities, are probably here to stay. The pandemic has also shown the value of civil society organisations for augmenting the response, supporting and engaging local communities and addressing service gaps and marginalized groups. More challenging to address are the wider societal issues such as housing, low-wage local economies and racism. There may also be some in society who remain disadvantaged by the ‘new normal’. For example, the elderly, those with learning disabilities, the poor and ethnic minorities may disproportionately be affected by digital exclusion.

At some point, the world will need to ‘live with the virus’. At that point in time, the virus will be endemic, probably like its cousins, the other human coronaviruses, and manifest itself through seasonal epidemics. Population immunity, from either past infection or vaccination, will hopefully keep the health consequences, including mortality, down. However, we are not there yet and the pandemic has at least another year to run. Recovery may take years. Until then, as societies transition towards this endpoint, there is a window of opportunity to determine the destination and for governments to steer towards. Urgent dialogue is needed now.

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