Since COVID-19 was first declared a pandemic in March of this year, numerous policies around the world have implemented some degree of lockdown, slashing social events and gatherings, shuttering once-bustling businesses and changing the face of the global economy. While the lockdowns in place were likely necessary to reduce the infection rate and resulting morbidity and mortality associated with the coronavirus, there are potentially undesirable consequences of these policies that affect measures of equity. In a new publication, Glover and colleagues present a framework for considering these effects and weighing them against the benefits of slowing the spread.
The work builds off of a novel combination of two existing frameworks. First, the Lorenc and Oliver framework lays out five potential harms of public health interventions which require mitigation: direct health harms, psychological harms, equity harms, group and social harms, and opportunity costs. Second, the PROGRESS-Plus health equity framework provides a list of 11 general categories that can affect measures of equity: Place of residence, Race, Occupation, Gender/sex, Religion, Education, Socioeconomic status, Social Capital, sexual orientation, age, and disability. Each of the two frameworks' individual components are used as a lens to examine the other. The resulting matrix of 55 potential sources of inequity related to the COVID-19 pandemic and its resulting public health policies provides an exemplary approach to considering all aspects of any large-scale public health intervention and the impact its implementation may have on inequity.
Key to the authors' resulting framework is the concept that both the policy responses to the pandemic and the nature of the pandemic itself are potential sources of inequity. For instance, individuals in lower-income occupations are also typically considered essential workers, and are less likely to have a safety net that would allow them to choose not to work or a job that is compatible with working remotely. Thus, the existing systemic inequities are exacerbated by the fact that they are now more likely to be exposed to the virus by continuing to go to work outside the home. However, policymakers can help reduce the impact of their policies on these sources of inequity - as well as ones caused by lockdown policies more directly - by considering mitigation strategies when implementing these policies (for example, by mandating improved sanitation, personal protective equipment, and social distancing for workers in vulnerable occupations). The figure below from the publication provides an overview of the relationship between the pandemic, policy responses and their resulting inequities, and potential points of intervention.
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The framework also allows for a more nuanced consideration of context in efforts to reduce the spread of coronavirus. Policies that are highly effective and viable in higher-income countries or areas with greater population density, for instance, may not be as beneficial in low- and middle-income countries and may even result in greater inequity. As with any intervention of any scale, the potential harms must be weighed against the desirable effects, and the context of the given intervention is key. This framework allows for consideration of a wider range of impacts when attempting to reduce illness and mortality in the age of a pandemic.
Glover, R.E., van Schalkwyk, M.C.I., Akl, E.A., Kristjannson, E., Lofti, T., Petkovic, J., ... & Welch, V. (2020). A framework for identifying and mitigating the equity harms of COVID-19 policy interventions. J Clin Epidemiol 128:35-48.
Manuscript available from the publisher's website here.
