COVID-19 pandemic: a unique opportunity to ‘build back fairer’ and reduce health inequities in the Eastern Mediterranean Region

PDF version

Editorial

Ahmed Al-Mandhari,¹ Michael Marmot,² Abdul Ghaffar,³ Rana Hajjeh,⁴ Jessica Allen,⁵ Wasiq Khan⁶ and Maha El-Adawy⁷

¹Regional Director, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 2Chair Eastern Mediterranean Region Commission on Social Determinants of Health & Director Institute of Health Equity, University College London, London, United Kingdom. 3Executive Director Alliance for Health Policy & Systems Research, World Health Organization, Geneva, Switzerland. 4Director Programme Management, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 5Deputy Director, Institute of Health Equity, University College London, London, United Kingdom. 6Advisor Health Promotion & Social Determinants of Health, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. 7Director Healthier Populations, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt. (Correspondence to: Wasiq Khan: This email address is being protected from spambots. You need JavaScript enabled to view it.).

Citation: Al-Mandhari A; Marmot M; Ghaffar A; Hajjeh R; Allen J; Khan W; et al. COVID-19 pandemic: a unique opportunity to ‘build back fairer’ and reduce health inequities in the Eastern Mediterranean Region. East Mediterr Health J. 2021;27(3):217-219 https://doi.org/10.26719/2021.27.3.217

Copyright © World Health Organization (WHO) 2021. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo)

Evidence has shown that some of the major causes of health inequities arise from the conditions in which people are born, grow, live, work and age, in addition to a wider set of forces and systems shaping individuals’ and societies’ health and well-being. ‎Such conditions are known as the ‘social determinants of health’ (1). However, efforts to address these determinants have remained challenging and unsatisfactory in many parts of the world, including in the Eastern Mediterranean Region. Policies to contain the ongoing COVID-19 pandemic have further exposed and amplified the existing and even created new dimensions in social and health inequities, as we elaborate further below. Meanwhile, the pandemic offers a unique opportunity to tackle inequities and build back fairer.

To address these issues, the World Health Organization Regional Director for the Eastern Mediterranean took the initiative to establish the Commission on Social Determinants of Health, which was convened in November 2019 and tasked to analyse health inequities and recommend strategic actions to effectively pursue social justice in health and well-being in the Region. The forthcoming Commission’s report reveals path-breaking insights into the state of health inequity, the daily life conditions and structural issues, which aggravate inequities and require actions by the stakeholders (2). The Report also discusses COVID-19 both as a challenge and an opportunity to build back fairer in the Region.

The notified number of deaths from COVID-19 is low in the Region compared to other WHO regions; however, as the Commission report highlights, the containment measures are having significant impact on health equity. Those living in poverty and crowded ‎conditions, with a lack of access to safe water, good nutrition and cooking fuel, are at higher risk of exposure to infection (3–7). Additionally, also those people are unable to effectively use preventive and protective measures against infection. It is likely that this will be more an issue among internally displaced persons (IDPs), refugees, and migrants (8,9). As the long-term impact of the pandemic unfolds, further evidence is needed to devise context specific strategies for such vulnerable populations. ‎

The pandemic has exposed underinvestment in health systems and the resulting inadequate access to health services in several countries in the Region (10), especially in conflict-affected settings. Essential health services have either been reduced or suspended; for example, several countries halted their regular ‎immunization programmes during lockdowns resulting in millions of children missing necessary routine vaccination, which could have potentially serious future implications on their health and well-being (11).

The economic and social disruptions caused by the pandemic have had a devastating impact worldwide (12). The enormously damaging economic impacts of the pandemic are expected to amplify already wide social and economic ‎inequities in the Eastern Mediterranean Region and increase health inequities, particularly in countries already facing economic sanctions. The World ‎Bank estimated that there would be an increase of between 2.8 and 3.4 million people living in extreme ‎poverty in this Region by the end of 2020 (12). Women, migrants, refugees and IDPs work in large numbers in informal employment in low- and ‎lower-middle income ‎countries and have been particularly affected by the containment measures in the Region.‎ Heavy job losses among refugees and IDPs mean they are more dependent on humanitarian aid.

The reduction in income and rising unemployment due to the pandemic have had immediate impacts on food security and nutrition, which has mostly occurred in low- and middle-income countries and those ‎affected by conflict (13). The low levels of access to adequate water supply in many countries also ‎increase the risk of infection since it becomes impossible to wash frequently (14). Access to the internet in certain countries and for some groups, especially women, is very low in the Region, which poses a challenge to communicate up-to-date information about COVID-19 and lockdown measures (15,16). This digital divide has also exacerbated existing educational inequalities (5). Students, including girls, without easy access to ‎the internet, a mobile phone or a personal computer, will struggle with remote learning and could lead to an increase in school dropout rates and lower attainment (17,18).

It is anticipated that as a result of the COVID-19 containment measures, there could be rise in feminization of poverty, gender-based violence and child marriage. ‎However, despite the increasing evidence, only very few countries in the Region have included ‎violence against women and girls as essential services and as an integral ‎part of their COVID-19 response plans (19).

However, the COVID-19 pandemic, and despite its dramatic impact, offers an unparalleled opportunity to embed greater fairness, social justice, and equity in health in the Region. Urgent action is needed in all countries to build back fairer by supporting disadvantaged groups who are faced with increasing poverty, destitution, hunger and ill-health, because no one is safe until everyone is safe. Now with the increasing availability of COVID-19 vaccines, most countries in the Region are looking forward to COVID-19 Vaccines Global Access (‎COVAX) in order to implement vaccination programmes, in addition to various bilateral deals and donations. We must ensure that ‎access to vaccines must be afforded to low-income and middle-income countries and those experiencing humanitarian crises and conflict.

The COVID-19 pandemic has demonstrated that protecting health is the highest priority for the public and that health should become a high priority in government agendas. Economic growth has been the driving vision of many governments. However, the pandemic has shown that economic growth and health go hand-in-hand and that economic growth should be considered not as a goal in itself, but as one among other steps to achieve greater health for all. Therefore, the whole-of-government and whole-of-society approaches that have been necessary to contain the pandemic should continue into plans for recovery, and building back better and fairer in the Eastern Mediterranean Region.

References

1. Marmot M. Social determinants of health inequalities. Lancet. 365(9464):1099–1104, Mar. 2005, doi: 10.1016/S0140-6736(05)71146-6.
2. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Build back fairer: achieving health equity in the Eastern Mediterranean Region. Cairo: WHO/EMRO; 2021 [forthcoming].
3. Marmot M, Allen J, Goldblatt P, Herd E, Morrison J. Build back fairer: the COVID-19 Marmot review. ‎The pandemic, socioeconomic and health inequalities in England. London: University College London; 2020. (http://www.instituteofhealthequity.org/resources-reports/build-back-fairer-the-covid-19-marmot-review/build-back-fairer-the-covid-19-marmot-review-full-report.pdf).
4. Burstrom B, Tao W. Social determinants of health and inequalities in COVID-19. Eur. J. Public Health. Aug 2020;30(4):617–618 doi: 10.1093/eurpub/ckaa095
5. Hawkins RB, Charles EJ, Mehaffey JH. Socio-economic status and COVID-19–related cases and fatalities. Public Health. Dec 2020;189:129–134 doi: 10.1016/j.puhe.2020.09.016.
6. Wachtler B, Michalski N, Nowossadeck E, Diercke M, Wahrendorf M, Santos-Hövener C, et al. Socioeconomic inequalities and COVID-19 - A review of the current international literature.” J. Heal. Monit. 2020;5(S7) doi: ‎10.25646/7059‎.
7. Alkire S, Dirksen J, Nogales R, Oldiges C. Multidimensional poverty and COVID-19 risk factors: a rapid overview of interlinked deprivations across 5.7 billion people. Oxford: Oxford Poverty and Human Development Initiative; 2020. (https://ophi.org.uk/b53/, accessed 9 March, 2021).
8. Senghore M, Savi MK, Gnangnon B, Hanage WP, Okeke IN. Leveraging Africa’s preparedness towards the next phase of the COVID-19 pandemic. Lancet Glob Health. Jul 2020; 8(7):e884–e885 doi: 10.1016/S2214-109X(20)30234-5.
9. International Organization for Migration (IOM)‎. Somalia responds: together we can fight COVID-19 in Somalia. [online] (https://www.iom.int/donate/campaigns/somalia-responds, accessed 9 March 2021).
10. Al-Mandhari A. Coming together in the Region to tackle COVID-19. East Mediterr Health J. 2020;26(9):992-993 https://doi.org/10.26719/2020.26.9.992
11. World Health Organization. At least 80 million children under one at risk of diseases such as diphtheria, measles and polio as COVID-19 disrupts routine vaccination efforts, warn Gavi, WHO and UNICEF. Geneva: World Health Organization; 2020 (https://www.who.int/news/item/22-05-2020-at-least-80-million-children-under-one-at-risk-of-diseases-such-as-diphtheria-measles-and-polio-as-covid-19-disrupts-routine-vaccination-efforts-warn-gavi-who-and-unicef, accessed 9 March, 2021).
12. The World Bank. Poverty and shared prosperity 2020: reversals of fortune. Washington DC: The World Bank; 2020 (https://www.worldbank.org/en/publication/poverty-and-shared-prosperity).
13. World Health Organization Regional Office for the Eastern Mediterranean (WHO/EMRO). Food crisis likely to worsen in the Middle East and North Africa as COVID-19 continues. Cairo: WHO/EMRO; 2021 (http://www.emro.who.int/media/news/food-crisis-likely-to-worsen-in-the-middle-east-and-north-africa-as-covid-19-continues.html, accessed 9 March, 2021).
14. Howard G, Bartram J, Brocklehurst C, Colford JM, Costa F, Cunliffe D, et al. COVID-19: urgent actions, critical reflections and future relevance of ‘WaSH’: Lessons for the current and future pandemics. J. Water Health. Oct 2020;18(5):613–630 doi: 10.2166/wh.2020.162.
15. The World Bank. Individuals using the Internet (% of population). Washington DC: The World Bank; 2020 (https://data.worldbank.org/indicator/IT.NET.USER.ZS, accessed 9 March 2021).
16. United Nations Economic and Social Commission for Western Asia (UNESCWA), United Nations Women. The impact of COVID-19 gender equality in the Arab Region. Beirut: UNESCWA/UN Women; 2020 (https://www2.unwomen.org/-/media/field office arab states/attachments/publications/2020/04/impact of covid on gender equality - policy brief.pdf?la=en&vs=4414, accessed 9 March 2021).
17. Vegas E. School closures, government responses, and learning inequality around the world during COVID-19. Washington DC: Brookings Intitution; 2020. (https://www.brookings.edu/research/school-closures-government-responses-and-learning-inequality-around-the-world-during-covid-19/, accessed 9 March, 2021).
18. Organisation for Economic Co-operation and Development (OECD). Response, recovery and prevention in the coronavirus ( COVID-19 ) pandemic in developing countries : Women and girls on the frontlines. Paris: OECD; 2020 (https://read.oecd-ilibrary.org/view/?ref=136_136621-wc776cqdgx&title=Response-recovery-and-prevention-in-the-coronavirus-%28COVID-19%29-pandemic-in-developing-countries-Women-and-girls-on-the-frontlines, accessed 9 March, 2021).
19. United Nations Development Programme (UNDP). COVID-19 global gender response tracker fact sheets:Sub-Sahara Africa. New York: UNDP; 2020 (https://www.undp.org/content/undp/en/home/librarypage/womens-empowerment/COVID-19-Global-Gender-Response-Tracker.html, accessed 9 March, 2021)