Social epidemiologist Kate Pickett is best known for her work on inequality. In her 2009 book The Spirit Level, she, and her co-author and husband Richard Wilkinson, argued that a more equal society was better for the poor and the rich in terms of everything from health to crime. In the time since its publication, a decade of austerity, rising infant mortality and falling life expectancy meant the UK was in poor shape when Covid-19 began to sweep through the world. Pickett talked to Spotlight about what can be learned from the pandemic, and how the UK has failed to get to the roots of its problems with inequality.
As a social epidemiologist, what do you feel your role is in a pandemic?
We’ve definitely gone from a situation where nobody in the public knew what an epidemiologist was to having one on our TV screen every day. The pandemic has raised the profile of the importance of public health, the determinants of the health of the public, and epidemiological science. So those things have become more salient to everybody: government, public, the works.
The role of a social epidemiologist in it all has been quite interesting, because none of the things that seemed to surprise others have surprised us. The notion that we would see more infection, illness and more deaths among black, Asian and minority ethnic populations, that was no surprise to a social epidemiologist, and when it was first noticed, immediately some people started saying “genetics, there might be a genetic explanation”. We were like: “Well, no, you probably won’t [see that].” As soon as you start looking at social determinants of health, you’ll have your explanation for those increased risks. Same with the deprivation gradient in infection, worse morbidity, and more death; and a lot of the behavioural stuff around the pandemic is more understandable too: who could and could not comply with track and trace and recommendations to self-isolate. So, in a way, it’s been seeing all of the things we know become much more visible in a frantic and emergency setting.
Do you think government has been “following the science” in its response to the pandemic?
All through the year I was listening to politicians talk about “we’re just following the science”, and that mantra was always used to justify the things they did. To some extent they’ve done OK, following the science. They’ve been slow on things, they were pretty useless at first, but they’ve got better as time goes on.
If they’d been following my science, or lots of other people in public health and social epidemiology, for the past 40 years we would not have had the deaths we had. We would not have entered this this pandemic with such a lack of resilience and with such high levels of chronic disease. Nor would we have entered the pandemic with so many people in such low-paid precarious work, who then had to put themselves at further risk. We would not have entered a pandemic with our public services so decimated. There’s so much that has happened as a consequence of decisions made over decades, that were poor decisions, and that were done contrary to what the evidence suggests should be done.
Has the pandemic had an impact on your thinking around inequality?
I think it has highlighted how important governance and government is. It’s clear that women leaders have done better in coping with the pandemic. That’s not because they are female; it’s because having a woman leader is a signal of a whole lot of other progressive stuff. Women in government throughout the world have taken better policy decisions around coping with the epidemic than “strong men”, who’ve been noticeably bad at it and been associated with higher excess deaths. I think it has highlighted how important the government you get is to the health of the nation, and how policy decisions that are made at that level of government really do affect who lives and who dies in really stark terms.
I think the pandemic has also highlighted how important regional and local governments are, and regional and local knowledge. When it comes to coping with something like a pandemic, knowing your patch becomes crucially important: how your population will behave; knowing where the areas are where you might need to do more outreach or more education; knowing where the areas are where people are going to need more financial support and more medical support. The solution is to have really strong local and regional public health, and local and regional government, but all have been decimated over the past ten years of austerity.
What are the challenges for local government in having real, tangible impacts on inequality?
I work with Born in Bradford, a birth cohort study with a whole platform of loads of different studies. We worked on really strengthening partnership with the local council and that is now a very strong relationship. That means that particular local council now understands how to use research, how to use expertise, and I think it has a very sophisticated understanding of the social determinants of health.
Through the pandemic, the local Gold Command [for emergency services in times of major operations] in Bradford set up a Covid scientific advisory group to advise it. A whole group of us, who were working in the Bradford Institute for Health Research, Born in Bradford, and on other studies, formed this advisory group. We were directly doing research to inform the local response to the pandemic. We were doing modelling of infectious disease cases; we were researching vaccine hesitancy really early on; we were looking at the impact of the lockdown on people’s mental health and financial security and children’s well-being and all of that. I thought that was quite remarkable and I think it reflects this sort of decade of building up partnerships between researchers and local policymakers and politicians, that then really paid off. We were able to provide them with local intelligence really rapidly, we were able to analyse things really quickly, to help provide data that helped them make decisions about where they targeted support.
The other work I’ve been doing recently is chairing the Independent Inequalities Commission for Greater Manchester, which [Mayor] Andy Burnham set up in autumn last year. The timing of that was obviously designed to mean that we would report just before he had to publish a manifesto for [the recent] local elections. So that was quite interesting because we could see clear train tracks between what we might recommend and then how it might actually get implemented, which is quite nice and quite rare in politics. I felt like they genuinely did want to do something about inequalities. You really need action to address inequalities at all levels, and so you need policy change at the right levels to pull the right levers, and some things only national government can do, and there’s some things only local authorities can do. It’s just figuring out what the right things are.
Do you think that addressing inequality will be a significant factor in how we “build back better”?
The noises are all correct. There’s a lot of talk going on, globally, about building back better. It’s exactly the same kind of conversations and language that we heard after the global financial crisis, which then never materialised into significant change. But because that happened the voices are a bit more strident this time saying “well, we wasted that chance”. I feel a more powerful impetus to do things differently.
I’m involved in three different commissions still: the Greater Manchester one, one at EU level that’s centred on the Vatican and led by [US economist] Jeffrey Sachs, and one that’s led by The Club of Rome [a 100-member club that addresses the crises facing humanity], which are all commissions that are about transformational economics, about building back better about doing things differently.
What will be the long-term impacts of Covid-19 on inequality?
Covid will cast a really long shadow. Part of that shadow is from the virus itself: we’re going to have significant numbers of people with long Covid and we don’t know how that’s going to resolve or stagnate or worsen. But most of the consequences for health inequalities are much more indirect. In our studies in Bradford, we were able to look at longitudinal change from before the pandemic to within it and we saw a doubling of depression and a doubling of anxiety among parents of school-aged children. I don’t think we know yet how deep, how profound, how widespread and how long-lasting all the economic impacts are going to be. But they will kill more people than Covid.
What’s the policy response to that? How do you turn that around or begin to repair that damage?
I think it’s no different from what we would have said before the pandemic: you need to be addressing poverty, you need to be addressing inequality. If you tackle those things, then health inequalities will reduce, average health will improve, and children will do better in school. It’s important that we crack on with it faster, and there’s maybe a lower base from which we need to be building than there was before, but the advice is no different.
Thinking of this as a health problem is wrong; thinking of this as something that a health service can address is wrong; thinking that this is something that schools can address is only very partially true. It’s what [epidemiologist] Michael Marmot calls “the causes of the causes of the causes”. We’ve known it for so long. If you look, the first report on health inequalities in the world was British – the Black Report in 1980. We had the Aitcheson Report in 1992, the Marmot Report in 2010 and the Marmot Review 10 Years On. They all say exactly the same thing. They all make the same recommendations.
Why has so little progress been made?
It’s driven by ideology. Through those 13 years of New Labour, health inequalities did reduce a bit – not a lot – child poverty came right down, and disability poverty came down. Things were better because there was attention paid to child poverty with child tax credits and various policies, and there were health inequality targets for local areas around life expectancy and infant mortality, reducing the gap between local measures and of those in the English average.
But since then what we’re experiencing are the consequences of an ideology that says “the state should be dismantled, public services are not important, and the private sector can do all of that better”. That has been wrong, but also the ideology says that individuals are responsible for their own health, and individuals need to step up to the mark and exercise more and eat their “five a day” and stop smoking. We call it “lifestyle drift” in public health, a drift from looking at structural issues to looking at the individual risk factors. That is a neoliberal ideology. So, if you’ve got the dismantling of the state alongside that belief in individual freedom, responsibility and accountability, then as a government you don’t consider yourself to be accountable for the public’s health. It’s their job; it’s not yours.
If you acted properly on the social determinants of health, poverty and inequality, and in a preventive way, with an eye to the medium and sort of long term, you really could transform the health and well-being of a large proportion of the British populace. We just continue to sort of turn our face to the idea that those things don’t matter. It’s fairly simple, and all that Covid has done is shine a tragic, brighter light.