When the COVID-19 pandemic first hit Europe in February 2020, government responses primarily aimed to ‘flatten the curve’ of infection rates to prevent illness and death and the overburdening of the health system. However, they failed to consider the impact that these harsh mitigation responses would have on those in precarious employment, poverty, crowded housing, and other vulnerable circumstances. Consequently, existing health and social inequalities worsened. How was it that, during the largest public health crisis in a century, psychosocial insights were not taken into consideration?
Lack of capacity in public health
Public health authorities were at the forefront of their countries’ responses during the first months of the pandemic. Most public health authorities had to take on additional tasks, providing guidance to the public and serving as advisors to policy and decision-makers. They produced research and knowledge on the outbreak, while simultaneously managing the tracking and tracing of infections.
To meet the most urgent demands in response to the pandemic, public health agencies were forced to shift their capacities to meet this pressing need. This left authorities with insufficient time and resources to properly assess the health equity impact of decisions. As a result, a response based on the principles of public health, health promotion, disease prevention, and "Health in All Policies" was often not considered, and there was hardly any collaboration with either mental health, social services, or civil society bodies also responding to the pandemic on the ground.
Challenges to establishing the evidence on psychosocial impact
While it is relatively straightforward to collect data on infections, hospital admission, and mortality, it is much more difficult to quantify the impact of loneliness, domestic violence, and drug abuse, or other challenges to mental health and educational development.
Looking at just one mitigation measure - the closure of schools - we can understand the dramatic and unequal impacts it had on children, with long-term consequences for their education and wellbeing. During these closures, many children, in particular those with learning disabilities, fell so far behind that they will never be able to catch up on this vital education. These lost learning opportunities will echo across their life-course, with negative health and socioeconomic consequences. Education, with its effect on income, employment, and health behaviour, is an important determinant of the health and wellbeing and it will be years until we are able to gauge the full impact of COVID-19-related school closures.
Failing to consider the social gradient
Vulnerable groups, such as families living in poverty, migrants, homeless people, or disabled people, are among the groups that were hit hardest by the pandemic, often with dramatic consequences. However, this is only the tip of the iceberg. There is also a much wider group of people, higher on the social gradient, but still living on small incomes or in small homes, who perhaps do not consider themselves vulnerable but who have also been affected tremendously by the pandemic. Parts of this group might also be more critical towards vaccination or might see less value in the science around COVID-19. Rather than dismissing people's individual views, we should better listen to their concerns, find more effective ways to communicate, and propose solutions that respond to their needs, in order to improve trust in our societies and public health systems.
There is no one voice in public health
In the realm of public health, there are many different voices and perspectives, reflecting the various disciplines within public health. We need to consider all those voices and realise that there are always trade-offs to be made when responding to public health threats. Responses to public health threat should be carefully balanced to address both the biomedical as well as psychosocial impacts the threat may pose, in addition to the short-term and long-term impacts. We know that there is no ideal solution to a pandemic, unfortunately, and some groups always risk being more negatively impacted than others. Yet, we can act conscientiously to mitigate these negative impacts. As public health actors, we should also be empowered to determine which trade-offs to implement, not leaving this decision to others.
How can we do better?
There are several ways in which we could better integrate psychosocial and health promotion considerations into our public health strategies - both to respond to and recover from the current ‘multi-crisis’ we face, as well as in future pandemics:
- Psychosocial measures must be integral to public health response packages. To be fully effective, this must include fiscal and financial policies to mitigate the socioeconomic effects of the pandemic (for instance, to support people while they self-isolate)
- Decision-making should be equity-driven, based on evidence from health equity audits and health inequalities impact assessments of response measures.
- Increase the use of behavioural and cultural insights to inform public health policies and subsequently improve trust in and facilitate adherence to chosen public health measures. This includes working with focus groups and using qualitative methodologies for gathering evidence on psychosocial wellbeing.
- Improve collaboration and coordination between key sectors, including education, social protection, employment, and housing sectors. These sectors can play supportive and integrative roles in the delivery of health and social care in modern public policy systems.
- Increase investments in health promotion and disease prevention, primary care, early childhood education and care, long-term care and mental health services to strengthen and better integrate these services in pandemic response measures.
- Build systematic links with civil societies and organisations on the ground to further facilitate the delivery of care.
- Ensure ensure effective health communication strategies (e.g., from health authorities and political leaders) and address disinformation and fake news, on social media.
Caroline Costongs is Director of EuroHealthNet and expert in public health and health promotion. Caroline leads a multi-disciplinary team working on European and (sub)national policy, advocacy, research and capacity building addressing health inequalities. Caroline is active in various EU and WHO fora, Advisory Boards and various EU projects, and is a member of the ICC – International Council for the European Public Health Conference.