Coronavirus (COVID-19)-induced re-imagination: 7 things we knew, but “could do nothing about”…until we could…and did

by Prof. Tolu Oni*

One thing is clear: we can’t avert a next pandemic with the same logic and systems that got us to this point. In addition to emergency responses to reduce transmission needed to end the pandemic, I have previously written about the need for emergency foresight in the midst of crises. This re-think of response as well as the re-imagination of a different future are important ingredients of action for societal reset.

The greatest threat to positive societal reset is not the challenges of the present but a stagnant mindset of impossibility; and our perceived limits of what is possible, a major stumbling block in attempting a societal reset, need to be confronted. To this end, I share some thoughts on 7 things we have long known to be important but for which efforts to rectify were considered unthinkable, unacceptable or impossible, until now.

  1. Health is political. The quote by Rudolf Virchow that Medicine is a social science and politics is nothing but medicine writ large has never been truer figuratively and literally. Politics plays a central role in how health is debated and enacted in a policy agenda; with politicking being largely partisan. And yet, the pandemic has seen a disruption in traditional party lines, with ideas akin to universal basic income (conventionally a left-leaning policy) proposed by a right-wing US government as part of an economic stimulus package COVID response. I can’t help but wonder what other health decisions can cross political party lines.
  • Public service and care work are the backbone of society: Globally, the care work and public service required to look after the most vulnerable and to keep society running is systematically undervalued. Teachers are paid little, pay and work conditions for carers abysmal, and supermarket cashiers not previously considered key by any home affairs guidelines. The pandemic has revealed what we inherently know, that these key workers are vital to the functioning of any society, but persistently ignored until now. A trend across the world has evolved with an evening applause for key workers across sectors on the frontline of the pandemic. Beyond applause, we would do well to better align the value we place on these keyworkers to better reflect their invaluable role in society and re-examine the definitions of core societal function and critical work(ers).
  • Global production systems undervalue the physical and mental wellbeing of participants: The physical and mental wellbeing of those working in systems of production – be that material goods or knowledge production- are insufficiently prioritised, sacrificed at the altar of productivity and efficiency in order to be globally competitive. But the enforced lockdown in these spaces imposed by the pandemic has forced a slowdown and (particularly for those privileged enough to work from home) space to reflect on the unsustainability of the pace we have set.  Long may that continue.
  • Sectors outside health play an important role in (supporting or deleting) health: The age-old public health mantra says: “ the majority of factors that influence health lie outside the health sector”. And yet, engaging and activating sectors that influence health but lie outside healthcare has often proven challenging despite the fact that equitable population health and universal health coverage could never be achieved without intersectoral partnership. The ongoing pandemic has made it clear that health is everybody’s business; and we have witnessed extraordinary contributions to managing the pandemic, from private and public sectors. A different world would emerge if all sectors started with the primary goal of health and wellbeing and recent experience has demonstrated this is possible.
  • Access to healthcare is highly unjust: The inequitable access to healthcare is a global shame on humanity and a stain on the societies we have constructed. While this is a well-known challenge in lower-resourced settings, the pandemic shed light to the darkness in high-income countries where the poor access to quality health care across that society and poor health system preparedness were laid bare. And yet again, addressing this seemingly insurmountable challenge is being attempted e.g. with the passing of an emergency bill to expand healthcare coverage to uninsured individuals. That said, the access to testing and protective equipment in the private sector across low, middle and high-income settings by any who can afford it in the context of shortages in the public sector highlights the degree to which a healthcare system overhaul is required.
  • Government role in supporting access to healthcare and social care is necessary but inadequate and/or diminishing: Government investment in healthcare has been deficient across the globe. In the African region, countries pledged in 2001 to set a target of at least 15% of their annual budget to the health sector. Yet as of 2017, only 3 countries had met this goal.  In the UK, government spending on the National Health Service as a proportion of GDP has systematically fallen for at least the last decade.Fast-forward to the COVID-19 pandemic, and we have witnessed an exceptional ramp up in government expenditure with the construction of new temporary hospitals to manage COVID-19 cases, mobilising of the workforce, and purchasing of necessary equipment. Some philanthropic organisations have been stepping in to fill the public spend gaps globally, but this is unmatched by the ability of governments to mobilise huge resource reserves. Investing in health systems is, as it turns out, a possible and important government role with several countries taking IMF loans to cover this expenditure. It will be important to consider loan conditions in different countries to avoid regressive longer term consequences in countries with lower credit ratings.
  • Leadership from government plays a critical role in shaping society. The varying public health measures implemented in response to the pandemic has demonstrated the key role that public leaders play in the setting of priorities that shape the broader societal response. This should come as no surprise; and yet the social infrastructure that drive inequities in society, neglected and abandoned through de-prioritisation of public expenditure, have had to be propped up by private and philanthropic organisations. While such efforts are laudable and, more often than not, necessary in partnership with the public sector, this leaves such societal good at the whim of organisations (often vested in particular approaches such as technological solutions) not accountable to the public. The government leadership in coordinating a coherent response to the pandemic, with cities and state governments stepping up where federal/national governments lagged, is a lesson to be remembered in peacetime.

Through the examples of COVID-19 responses outlined, I’ve sought to illustrate that seemingly impossible feats are surmountable.  Whilst these (non-exhaustive) examples are temporary responses to the COVID-19 global emergency and don’t (yet) constitute the norm, it would behove us all to pause for a moment to recognise what is possible. Indeed, there are several other examples that I could have cited of “intractable” societal challenges that are being addressed as part of the COVID-19 response, including improving water access in informal settlements in the world’s rapidly growing cities (to enable handwashing), addressing the scourge of homelessness in the richest countries (to shield the most vulnerable), confronting the injustice of internet access (with temporary free access to Wi-Fi hotspots), and addressing inequitable access to knowledge production and outputs (through access to software for virtual learning and open access to published evidence).

Emergency foresight seeks to identify points of leverage in an interconnected system, made more apparent during an emergency, to improve health in ways that may not exist yet or may not be immediately evident. Imagination is a necessary ingredient of such emergency foresight, taking a systems-approach to the resetting of building blocks for a future that is centred on planetary health without being trapped by the present.

And so, in that vein,

  • what if contribution to health became the primary performance indicator of urban infrastructure development?
  • what if incentives such as tax breaks were aligned with disease burden attributable to manufacturing, transport and trade?
  • what if a surge of impact investment deployed post-pandemic prioritised health goals over short term returns? 

These will require that we confront the contradictions of conflicting paradigms of economy, ecology and health; systems that are currently overly weighted in favour of the economic at the detriment of health and the environment, paralysing our imagined ability to effect system change, and keeping us stuck in recurring loops of celebratory rhetoric. However, as painful as this confrontation may be, requiring trillions of currency to acutely address a global fire like this pandemic, only to get back to lighting more fires is somewhat nonsensical.

Practical problem solving for today and imagination of tomorrow are often pitted as diametrically opposing forces. But imagination has to be a key part of rebuild, shaped by interests and values of the majority.

Against global trends, the (often younger) population in emerging economies in Africa and Asia such as Nigeria and India are more optimistic about the future, suggestive of an active social imagination in the face of adversity. The challenge is to harness this optimism, from a mere exercise in abstraction into reality. The Overton window discourse suggests that the political viability of any idea is not fixed but instead depends on where it falls on a spectrum from unthinkable to popular in order to become reality.

To this end, however temporary in intention, it is worth recognising the potential for the COVID pandemic, and the societal responses engendered, to accelerate our re-imagination of a different future, and to catalyse action to address health, social and planetary inequalities; shifting the needle on society’s view of these strategies from unthinkable and radical to acceptable and perhaps even popular.

*Prof. Tolu Oni is a public health physician and urban epidemiologist, Clinical Senior Research Associate at the University of Cambridge, Honorary Associate Professor at the University of Cape Town, a 2015 Next Einstein Forum Fellow and a 2019 WEF Young Global Leader.