Original Article International Journal of Health Services We Must Take Advantage of This Pandemic 0(0) 1–5 ! The Author(s) 2020 to Make a Radical Social Change: The Article reuse guidelines: Coronavirus as a Global Health, Inequality, sagepub.com/journals-permissions DOI: 10.1177/0020731420946594 and Eco-Social Problem journals.sagepub.com/home/joh Joan Benach1,2,3 Abstract COVID-19 not only constitutes a serious public health problem and a global major threat to the poorest and most vulnerable social groups and neighborhoods of the world, creating a potential pandemic of inequality, but also poses an enormous challenge from the perspective of public health, ethics, economy, environment, and politics. However, many of the deep and complex systemic interrelationships created and developed by this pandemic are largely hidden, unknown, or neglected, both by the hegemonic media and by a highly specialized and fragmented academic world. However, when all the available knowledge is critically integrated, the origins and effects underlying this pandemic are likely to be found in the development of neoliberal capitalism and its inherent logic of ceaseless accumulation, economic growth, large inequalities, and ecological devastation. This commentary reflects on these issues, drawing out some of the most important lessons to be learned and challenges to be faced in the COVID-19 pandemic and its aftermath, advocating for a radical social change to deal with these challenges. Keywords capitalism, COVID-19, eco-social crisis, health inequalities, policy change, public health So nature does indeed need protection from man; but the face of the crisis, calling health care workers man, too, needs protection from his own acts, for he “heroes” when just previously they had disparaged is part of the living world. His war against nature is those very same workers by deepening the lack of inevitably a war against himself. resources and increasing precariousness in those jobs. From a public health point of view, in addition to its – Rachel Carson1 direct impact on mortality (especially severe in nursing homes) and morbidity, the pandemic is causing delays in Is capitalism a disease? diagnostic tests and surgical operations for hundreds of thousands of chronically ill people and in interventions – Richard Levins2 for people with mental ill health, while also delaying or complicating treatment for serious or very serious health The Main and Immediate Public Health 1 Concerns Associated With the Pandemic Health Inequalities Research Group (GREDS-EMCONET), Department of Political and Social Sciences, Universitat Pompeu Fabra, Barcelona, Spain in Wealthy Countries 2 Johns-Hopkins-UPF Public Policy Center, Barcelona, Spain 3 GinTrans2, Madrid Autonomous University (UAM), Madrid, Spain In high-income countries, we are in a temporary situa- Corresponding Author: tion of “low-income-worldization” of public health care. Joan Benach, Universitat Pompeu Fabra, C/Ram on Trıas Fargas, 25–27, It is shameful and scandalous to hear many reactionary Barcelona 08005, Spain. and neoliberal politicians preach calm and confidence in Email: joan.benach@upf.edu 2 International Journal of Health Services 0(0) processes. From the ethical point of view, there are populations, face a public health disaster; in the West dilemmas about how, when, and on whom to act: Bank and Gaza (Occupied Palestinian Territories), Professionals must decide who can live or die, as hap- which have very serious problems in terms of having pens with great frequency in low-income countries. to face homicidal apartheid; and for the population From an emotional and psychological point of view, and poor neighborhoods of a country like the United the impacts of the pandemic – including heightened States, where President Donald Trump’s criminal poli- stress levels and emotional trauma – on professionals, cies could generate a social catastrophe with fatal con- patients, and families is undoubtedly enormous. sequences for an enormous number of impoverished Family members cannot say goodbye to or mourn communities. In Western European societies, the pan- their deceased loved ones who, in many cases, cannot demic will impact existing inequalities in a variety of even be buried or cremated. The most positive aspect ways, although we will have to wait until we have ade- of this experience is the commendable commitment, quate studies to understand this impact in detail. bravery, and immense effort of health and social profes- In relation to the health sector, the disproportionate sionals and many other workers of all kinds, who were risk faced by health and social services professionals who invisible before, and the huge outpouring of solidarity, often work with scarce or inadequate resources, and by community work, pride, and hope that has been trig- those who care for elderly women and men in nursing gered in many people. homes, stands out. Regarding the work environment, the most vulnerable are those who are fired from their jobs and the laborers and precarious workers whose work The Main Problems to Consider in the cannot be done from the safety of their homes, forcing Medium and Long Term them to face the dilemma of losing their jobs or getting First, long-term confinement will have a negative impact sick. Telecommuting is a luxury not afforded to cleaners, on the mental and emotional health of the population, housekeepers, care workers, cashiers, and employees in with the highly likely emergence of outbreaks of violence many other largely precarious and feminized occupa- related to insecurity and social changes. One example is tions. Moreover, these occupations have worse social, the case of women who must confine themselves together environmental, and occupational determinants of with their abusers. Another issue is that the virus is likely health, all of which will further worsen individuals’ con- to remain with us, mutate, recur, or even become more finement conditions and, more than likely, mental virulent, and furthermore, more severe pandemics may health. At home, the crisis is manifested most profound- appear. Third, many countries do not have appropriate ly in the women who carry the greatest burden: taking public health and health care systems for dealing with care of the elderly, sick, or disabled; children who cannot this coronavirus or, of course, many day-to-day illnesses, go to school; other dependent family members, etc. nor is there an adequate global public health system that Thus, COVID-19 has all of the characteristics for us can deal with global systemic threats similar to that of to consider it not only a viral pandemic, but a “systemic the coronavirus. Finally, we do not know when we will pandemic of inequality” in health according to class, have an effective vaccine without side effects, but so far gender, age, ethnicity, migration status, and place of we do know that Big Pharma is focused on the great residence. benefits they can reap from profitable diseases and not on tropical infections or the flu. Because there could be How the Hegemonic Media Hide the Root a fight over the vaccine monopoly, the problem then would be whether the poorer nations could have Causes of the Pandemic access to it. One of the great omissions of the mainstream media regards the causes of the pandemic: The common narra- tive of the coronavirus is as though it were a “curse” The Coronavirus Pandemic as a Problem coming from abroad, which has turned into a “war” of Inequality that must be seen out, and once that has happened, The pandemic constitutes an enormous threat to the sooner or later, we will return to the “normality” of poorest and most vulnerable social groups and neighbor- everyday life. Many of the deep and complex systemic hoods in many countries, living with fragile and even interrelationships of the pandemic (ecological destruc- dire social determinants of health: poor housing; pover- tion, the economic crisis, the psychology and culture of ty; precariousness; lack of basic services, water, and fear, unemployment, precariousness, etc.) are largely food; environmental pollutants, etc. These conditions hidden in the official account of the hegemonic media are prevalent in sub-Saharan Africa, Iran, and India, outlets, which are dominated by immediate, minute-by- which, although relatively protected by having young minute reporting. It is logical that the media talk about Benach 3 the data, who is affected, and what needs to be done to inhabitants of rich countries, more directly, and that has get out of this crisis as soon as possible. But beyond paralyzed the global economy. Furthermore, public knowing what’s going on, it is crucial to understand health problems are abundant in the world – for exam- why things happen and try to change them. ple, the 140,000 deaths a year from measles, a prevent- able disease with a cheap and highly effective vaccine,4 or the more than 1.6 million annual deaths from diar- The Origin of the Pandemic rhea.5 The fact is that the greatest pandemic is social The underlying reason for the pandemic must be found inequality, which creates health inequalities. in capitalism. The most relevant factors have to do with Paradoxically, despite the negative effects of the corona- the global alteration of ecosystems, which is also associ- virus on health and the economy, the economic slow- ated with the eco-social and climatic crisis that we are down has certain beneficial effects for the climate and experiencing. Deforestation in Southeast Asia and mas- ecological crisis and other health-related phenomena. sive changes in land use; habitat fragmentation and This apparent contradiction is resolved by understand- excessive urbanization; the growth of a massive agro- ing the perverse logic of an economy based in endless industry; the transmission of diseases between many spe- growth that, as it grows, destroys the material bases that cies in close contact with each other, which are then sustain life, and as it decreases, improves biogeophysical passed to humans as in this zoonotic virus, the SARS- indicators and various indicators of collective health. CoV-2 coronavirus; the traditional diet that includes A third lesson to be drawn is the need for a different wild animals in countries such as China; the destruction kind of knowledge that allows us to comprehend com- of biodiversity; the massive growth of tourism and air plex historical processes. Today we have an abundance travel; and the weakness and commodification of public of genomic and virological knowledge, diagnostic tests, health systems and social services are without doubt the vaccine creation, epidemiology, ecology, and extensive most important. If we integrate and interpret all of this, psychological, sociological, and political knowledge, we see that what lies behind is neoliberal capitalism and but unfortunately little integrated systemic, historical, its inherent logic of accumulation, economic growth, and political knowledge. At the same time, today’s civ- profit, and inequality, which crashes against planetary ilization has created an enormous variety of destructive biophysical limits in a “full” world. processes that must be understood and modified. We live in a “full world” (i.e., one in ecological overshooting in which we are consuming 1.7 planets a year),6 with a huge What This Pandemic Teaches Us in population – almost 8,000 million human beings – living Relation to the Capitalist System in a dynamically complex existence with constant global Which We Live movement. During the 14th-century plague, the pan- demic moved from China to England in perhaps a The first aspect to highlight concerns assessing what to decade. Now, the “tourism pandemic” entails large num- do in emergencies. In the short term of an emergency bers of people moving from one side of the planet to the situation, it is evident that all resources and efforts must other in a matter of a few hours. The generation of new be directed toward the reduction of mortality and suf- global epidemics must be prevented by understanding fering. Above all, the objectives should be saving lives, the conditions that facilitate the transmission of new protecting families and workers, and safeguarding com- viruses that may endanger all of humanity. This means panies in an economy that is practically at a standstill. avoiding the ecological destruction and social inequality Unlike private services that are based on short-term profit that we are rapidly producing under capitalism. and therefore can only organize limited emergency plans, The fourth lesson is that of humility. How can it be public services can prepare and organize social emergency that a tiny infectious agent can generate such a global plans in “normal” times, making societies resilient to disaster, with a social and economic crisis of this mag- events such as fires, earthquakes, or pandemics. nitude? Already in the 19th century, Friedrich Engels A second lesson is to carefully assess the severity of said: “Let us not, however, flatter ourselves overmuch the pandemic. There is no doubt that we are facing a on account of our human conquest over nature. For very serious pandemic. However, if the current pandemic each such conquest takes its revenge on us . . . Thus at had a level of lethality equivalent to the poorly named every step we are reminded that we by no means rule “Spanish flu” of 1918, worldwide perhaps between 200 over nature like a conqueror over a foreign people.”7 We and 400 million would die. This pandemic also reflects are not invulnerable, but human beings, fragile, intra- our ignorance and capacity for amnesia: In 2009, the dependent, interdependent, and eco-dependent. We are H1N1 influenza pandemic (H1N1pdm09 virus) killed intrinsically dependent on our own psychobiology, phys- between 150,000 and 575,000 people worldwide.3 The iological needs, and cultural environment; we are depen- difference is that now, the pandemic is affecting us, the dent on others from before birth until the moment of 4 International Journal of Health Services 0(0) death; and we are dependent on nature, of which we are program, organization, and management. A final chal- part and without which we cannot survive. lenge is to understand the enemy and the adversary; to One last lesson to consider is of a practical and polit- be strategic; to understand that we are in a process of ical nature. We have to change, and we have to change brutal class struggle. radically. We live in a context of fossil capitalism, with In the long term, I only see 2 main pathways: either a exponential growth in production and consumption, transformation toward the common good, or a road to based on spending huge and cheap amounts of fossil barbarism and extermination. Currently, we have only fuels and finite natural materials that are running out. had a small taste of the reactions that are likely to come This means that we are facing not only the climatic from the establishment to preserve their status quo – for emergency but also a major ecological crisis, which can example, that of Dominic Cummings, senior strategist of only be understood by also understanding the energy Boris Johnson’s government in the United Kingdom, crisis. Paraphrasing Naomi Klein when talking about when, semi-concealed by a technical formula, he justified the climate crisis,8 we can say that this pandemic changes the U.K. policy of protecting business at the cost of everything, and that it is essential that we take advantage many people dying.9 In the United States, we have wit- of it to create radical social change. This includes chang- nessed Donald Trump’s statements in which he ing our individual and daily lives to move toward a more expressed his intention to buy the rights to a potential humane and truly sustainable world, by creating a vaccine for the exclusive use of Americans.10 In Brazil, homeostatic economy that uses much less primary Jair Bolsonaro has said that COVID-19 is a “little cold,” energy and adapts its eco-social metabolism to the bio- that children and young people are not in danger, that physical limits of the Earth. schools should not close, and that the economy should continue as is.11 After the initial shock of the crisis will come the post- The Great Medium- and Long-Term pandemic economic shock, and the political decisions to Challenges Posed by the Coronavirus be made will be the “social laboratory” in which the Pandemic future of humanity will be at stake. It will be a time of growing fear and insecurity, a perfect breeding The economics and cultural logic of capitalism must be ground for demagogues and neofascists. In his impor- dismantled as soon as possible. Perhaps we will be able tant book Auschwitz, Does the 21st Century Begin? to cope – better or worse – with this pandemic, or with Hitler as a Precursor,12 the German writer Carl the overall conditions of the coming social and economic Amery wrote that the struggle for scarce resources on crisis. Perhaps we can improve equity levels, the environ- a finite earth was the key theme of this century, warn- ment, housing, or the social factors that create inequality ing of a world in which a superior neofascist group and insecurity. Doing all this is very important, needless would want to impose their way of life on an inferior to say, but if we continue with the current model of group that would be enslaved. Therefore, one possible exploitative capitalism, we will continue to further pro- path is the authoritarian path of total population con- mote the great ecological, nuclear, biological, and polit- trol: a militarized society that would be characterized ical threats that will end civilization (and perhaps, in the by social control, repression, and racism. An authori- worst case, the human species). That means there are tarian techno-digital society that would bring us closer many challenges that we must reflect on and work on. to the surveillance and control implemented in China One of them is the value of the commons. This pandemic and other Asian countries. The other general direction places us in a “war economy” where the value of the that we must imagine, promote, and fight for is a much public and the commons, of the community, are a more democratic society that takes care of all forms of hope for change. Another key challenge is to generate life. COVID-19 teaches us the importance of public a culture of hope, joy, and life. We must develop – from health and equity, and how fundamental it is to all possible angles – an understanding of how to live create an economy that is organized around human well: how we can live better with much less and be well-being, care of all life, and ecological stability, more together, with more emotional empathy, solidarity, rather than the incessant accumulation of capital. The and fraternity. To promote this is to promote an anti- most powerful groups and elites of the world will not capitalist, ecofeminist, and anti-colonial culture. relinquish their power or their privileges; they have Another essential challenge has to do with how to under- never done so nor will they do so. It is truly moving stand and transform the global and the local simulta- to see the many cooperative and social initiatives being neously. Social and critical movements generally deal formed today. But when the acute pandemic passes, it with concrete issues at the local level. This is fundamen- will be essential to have built an organized and con- tal, but also insufficient in today’s world. We need to scious civil society to deal with the ubiquitous, systemic implement systemic policies, which requires analysis, a crisis that will follow: the “chronic pandemic.” The Benach 5 collective struggle must be unitary, persistent, intelli- 7. Frederick Engels. Dialectics of Nature. https://www.marx gent, and extremely determined. ists.org/archive/marx/works/1883/don/index.htm. Published 1925. Accessed May 20, 2020. Acknowledgments 8. Klein N. This Changes Everything. Capitalism vs The Climate. New York, NY: Simon & Schuster; 2014. This article is based on a long interview published in 9. Ahmed N. Covid-19 special investigation. Part Two. Byline Spanish in the magazine “Sin Permiso” on March 28, 2020 Times. March 23, 2020. https://bylinetimes.com/2020/03/ (https://www.sinpermiso.info/textos/hay-que-aprovechar-esta- 23/covid-19-special-investigation-part-two-government- pandemia-para-hacer-un-cambio-social-radical-entrevista-a- documents-reveal-concern-for-economic-and-business- joan-benach). I’m grateful to Aeve Ribbons for the English impacts-prevented-early-action/. Accessed June 19, 2020; translation of the text. Bland A, Weaver M. From evasion to evisceration: how the Cummings lockdown story unfolded. The Guardian. Declaration of Conflicting Interests May 29, 2020. https://www.theguardian.com/world/2020/ The author declared no potential conflicts of interest with may/29/from-evasion-to-evisceration-how-the-dominic- respect to the research, authorship, and/or publication of this cummings-lockdown-story-unfolded-durham. Accessed article. June 19, 2020. 10. Oltermann P. Trump ‘offers large sums’ for exclusive US access to coronavirus vaccine. The Guardian. March 15, Funding 2020. https://www.theguardian.com/us-news/2020/mar/ The author received no financial support for the research, 15/trump-offers-large-sums-for-exclusive-access-to-corona authorship, and/or publication of this article. virus-vaccine. Accessed June 19, 2020. 11. McCoy T. Brazil’s Bolsonaro, channeling Trump, dis- ORCID iD misses coronavirus measures – it’s just ‘a little cold’. The Washington Post. March 25, 2020. https://www.wash Joan Benach https://orcid.org/0000-0003-2285-742X ingtonpost.com/world/the_americas/brazils-bolsonaro-ch anneling-trump-dismisses-coronavirus-measures–its-just-a- References little-cold/2020/03/25/65bc90d6-6e99-11ea-a156- 1. Rachel Carson’s Speech “Of Man and the Stream of Time” 0048b62cdb51_story.html. Accessed at June 19, 2020. at Scripps College, Claremont, California, June 12, 1962. 12. Amery C. Hitler als Vorl€ aufer: Auschwitz – der Beginn des In: Rachel Carson: Silent Spring & Other Writings on the 21. Jahrhunderts? München, Germany: Luchterhand Environment. New York, NY: Library of America; Verlag; 1998. 2018:425. https://docs.google.com/viewerng/viewer?url=h ttp://www.loa.org/images/pdf/Carson_Stream_Time.pdf. Author Biography Accessed July 20, 2020. Joan Benach, MD, MPH, PhD, is the Director of the 2. Levins R. Is capitalism a disease? The crisis in U.S. public Health Inequalities Research Group – Employment health. Mon Rev. 2000;52(4):8–33. 3. Dawood FS, Iuliano AD, Reed C, et al. Estimated global Conditions Network (GREDS-EMCONET), the codir- mortality associated with the first 12 months of 2009 pan- ector of the Johns Hopkins – UPF Public Policy Center, demic influenza a H1N1 virus circulation: a modelling and a professor of sociology in the Department of study. Lancet Infect Dis. 2012;12(9):687–695. Political and Social Sciences at the Pompeu Fabra 4. World Health Organization. More than 140,000 die from University in Barcelona. His research interests include measles as cases surge worldwide. https://www.who.int/ social determinants of health inequities; precarious news-room/detail/05-12-2019-more-than-140-000-die- employment and employment relations; the intersections from-measles-as-cases-surge-worldwide. Published between class, gender, migration, and geography; health December 5, 2019. Accessed April 15, 2020. policy analysis; and complex political and environmental 5. Troeger C; the GBD 2016 Diarrhoeal Disease problems of health equity. He has shown his leadership Collaborators. Estimates of the global, regional, and in many international research projects, serving as co- national morbidity, mortality, and aetiologies of diarrhoea in 195 countries: a systematic analysis for the Global chair of the Employment Conditions Knowledge Burden of Disease Study 2016. Lancet Infect Dis. Network of the World Health Organization’s 2018;18:1211–1228. Commission on Social Determinants of Health; giving 6. Lin D, Hanscom L, Murthy A, et al. Ecological footprint presentations, conferences, and workshops; and collab- accounting for countries: updates and results of the nation- orating with social movements, unions, and govern- al footprint accounts, 2012–2018. Resources. 2018;7(3):58. ments around the world on the aforementioned subjects.