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18 September 2020

Why Covid-19 is more than a public health crisis

Jeanelle de Gruchy, president of the Association of Directors of Public Health, on how tackling inequality is key to the pandemic response.

By Samir Jeraj

When Jeanelle de Gruchy began her career in medicine 30 years ago, the Aids pandemic had gripped her home country of South Africa. She worked as a clinician in a rural area of Eastern Cape as the country emerged from Apartheid. While there was political equality between black and white people, the social and economic legacy of more than 40 years of enforced segregation had left a visible and toxic legacy. “Poverty and its impact on some of the most vulnerable people in society is just devastating,” she told me recently via Zoom.

Now, de Gruchy is at the forefront of tackling Covid-19 in the UK as president of the Association of Directors of Public Health (ADPH). These are the public servants in local government in charge of everything from infection control to encouraging healthy eating and exercise. She combines this role with her job as director of public health at Tameside Council, which borders Manchester.

In 2016, the health and social care services previously divided between the NHS and local government were devolved to Greater Manchester in an effort to integrate them and provide a better service. The value of joining forces when it comes to care has never been clearer to de Gruchy than in the pandemic response. With “something like Covid-19 you need all parts of the system to be working really well,”, she explains.

When we spoke, Tameside was one of the boroughs with a local lockdown, with household mixing restricted, among other measures. De Gruchy stresses the importance of cooperation between local government and Public Health England. “The CMO [chief medical officer] right from the early days, contacted us, and myself as president, and said [he was] ‘really keen to have close dialogue with the directors of public health in local areas’.”

There were tensions, however, particularly over Westminster-led policy. “There was a lot of designing policy nationally without really appreciating or understanding that local knowledge and expertise that was already there,” she says. “If you design things nationally and in silos, somebody in a local place has to knit them together.”

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But there has been progress: data is being shared, there is greater flexibility in local testing, and public health teams are more integrated into the national test and trace programme.

Austerity has been a major challenge – both its direct impact on services, and on jobs, housing and welfare. The public health grant received by councils from central government has been cut by £850m since 2015, according to a 2019 study by The King’s Fund. “Our capacity has been cut,” she says, “I know that from my personal experience of good staff that aren’t there anymore.”

One of the less tangible effects of austerity has been the erosion of trust in government and public services. De Gruchy remembers how a cocktail of poverty, discrimination, stigma and conspiracy theories, including from those in positions of authority, weakened the fight against HIV. “The consequence of all of that… is a lot more people get infected, a lot more people die,” de Gruchy says.

Apartheid and its legacy are a key influence on de Gruchy’s approach to healthcare. “Inequality, racism or any forms of discrimination is really, really bad for your health. And it’s really bad for your society. And everyone suffers as a consequence,” she says.

When de Gruchy became ADPH president two years ago, one of her main objectives was to make discrimination and inequality visible, because, she says, “you need social justice for a healthy population”. In South Africa inequality and prejudice were obvious because they were the law under Apartheid, but in the UK she thinks it is harder for people to see how discrimination operates.

And that is often in the most innocuous of ways. De Gruchy recalls going to a presentation about pensions as an NHS employee in the late Nineties, where she was informed that straight, married couples could depend on the system to support them in the event of the death of their partner. When she asked about her status as an unmarried lesbian with a partner she was told not to expect anything. The situation has now thankfully changed. “It’s so banal and yet, that’s how it works. And it’s this massive, ridiculous difference.”

She calls this the “hidden hegemony of what’s normal”, and in order to change it de Gruchy believes we need to ask the “uncomfortable” questions that disrupt what many people consider the “everyday lovely English life”. But she also wants to affect attitudes to the wider determinants of health. If a government just puts money into hospitals, then it is missing opportunities to make sure people do not get sick in the first place. The NHS is “amazing”, she says, but there needs to be more focus on prevention and public health, particularly factors like better housing and jobs. She is hopeful this crisis will open people’s eyes.

But looking to the future and the likelihood that winter will bring a rising R-rate, de Gruchy believes that those living in poor housing and working lower-paid jobs will be worst hit. She calls for some “immediacy” in improving those conditions; she does not want a return to a normal where a blind eye is turned to inequalities. Insecure jobs, structural discrimination and underfunded social care all contributed to the UK’s poor response to the pandemic. “What’s the post-Covid vision?” she asks.

Days after we spoke the government announced that Public Health England (PHE) would be abolished and replaced, at least in part, by a National Institute of Health Protection. There is little information about where all of the work PHE did on the wider determinants of health, like housing and work, will go.

In the aftermath of the decision, de Gruchy stated that dismantling a national public health agency in the middle of a pandemic was “a bold move”, and that setting up a new one as a second wave approaches “presents a significant risk”.

This article originally appeared in a Spotlight supplement on healthcare. Click here to download the report.

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