Mehrunisha Suleman: Beyond “following the science”: value judgements and transparency in pandemic decision-making

The following is an edited version of Mehrunisha Suleman’s remarks at a UK Pandemic Ethics Accelerator event on 23rd May 2022, discussing the place of values in public policy during a pandemic

Dr Mehrunisha Suleman is Director of Medical Ethics and Law Education at the Ethox Centre at the University of Oxford. She recently led the Health Foundation’s COVID-19 Impact Inquiry. She is a medically-trained bioethicist and public health researcher, whose research experience spans healthcare systems analysis to empirical ethics evaluation.

To answer the question of what is the place of values in decision-making in a pandemic, we need to zoom out a bit and travel back in time; to spend a few minutes thinking about the social determinants of health.

As part of the Health Foundation’s COVID Impact Inquiry we reviewed and commissioned evidence to understand better the impact of the pandemic on health and health inequalities.  The report we published in July 2021 shows that the nature of the UK’s recovery from the 2008 financial crisis, the last major global shock we faced, has had a direct bearing on our experience of the pandemic. In addition, more than a decade of austerity impacted who fell through the safety net during the pandemic.

It’s crucially important that we learn from the lessons of the previous crisis and this current one, so that we can build a more resilient society. I’ll therefore look at the overall picture of the UK and what that has meant, and then drill down more into this question of inequalities.

Weaker before the pandemic

In terms of our overall experience in the UK, the evidence shows that although the pandemic challenged governments around the world, the UK was notable in entering the pandemic with life expectancy stalling for the first time in a century and falling for some. You may be wondering why this happens in a country as affluent as ours. What we learned from the data is that the greatest influence on our health and opportunities for good health are factors that shape the conditions in which we are born, grow, live, work and age and there are huge disparities in people’s access to opportunities for good health.

Political choices undermined our resilience

What we’ve seen is that the political choices – the decisions that have been made following the 2008 financial crisis – meant that public services had been frayed, and the underlying economy and social fabric was weakened. This meant that going into the pandemic the UK’s health, social and economic assets were poor and, as a country, we were less resilient to withstand another external shock and were weaker compared to other countries.

What we found, in addition to this overall picture of the UK, was that countries with the greatest improvements in healthy life expectancy over the previous decades, experienced lower excess mortality during the early phases of the pandemic. We also saw that countries with more equal improvements in healthy life expectancy also fared better. That means, healthier, and more equal societies are more resilient societies.

It’s crucially important that we think about how we value health and ensuring there are opportunities for good health in future.

Unequal experiences

The other key factor is the issue of inequalities. Behind these overall UK figures lies the unequal burden carried by different populations and different regions. There are many groups that have been disproportionately impacted, but the group that I want to focus on are families and communities that were financially worse off prior to the pandemic and are facing a worsening crisis, as we move forward.

We know that COVID mortality in England was more than twice as high in the most deprived areas compared to the least deprived areas. However, this was acutely problematic for working age people. Those younger than 65 in the most deprived areas were four times more likely to succumb to the virus than those in the least deprived areas. There are a whole host of reasons that underlie these inequalities.

Addressing gaps in the safety net

What I want to focus on is the safety net. What we see is that low rates and coverage of statutory sick pay and difficulties in accessing isolation payments had a huge impact on people’s ability to self-isolate and increased their exposure to the virus. In fact, UK statutory sick pay (SSP) covers only a quarter of the average worker’s earnings and two million of the lowest paid workers are ineligible. Financial incentives to keep working are very strong in the UK – with only 12% of average wages being covered by unemployment benefits compared to 50 to 60% in most other European countries. We have the lowest SSP, and some of the lowest unemployment benefits in Europe.  What this means is that our existing social security is designed towards incentivising work, rather than allowing a minimum standard of living for those outside of work. We need to think carefully about these sorts of choices, and how our welfare system is designed, and we need to address these weaknesses in the welfare state, in order to provide people with an adequate safety net to support them through both income and health shocks.