We need to “build back better”

Caroline Costongs, Director of EuroHealthNet and speaker at the European Health Forum Gastein 2020, explains in this interview why health inequalities in Europe have been magnified by the COVID-19 pandemic and why subsequent rebuilding must be healthier, more social, and more sustainable.

Interview: Dietmar Schobel

According to the statistics, people with a low income and a lower educational outcome suffer from illness more frequently and die earlier. How have these socio-economic inequalities in health changed in Europe as a result of the COVID-19 pandemic?

Caroline Costongs: There were huge socio-economic inequalities in health even before the pandemic. For instance, the WHO Health Equity Status Report from 2019 highlighted that men with the fewest years of formal education still die 15 years earlier than their peers with more years of education, and this is the case across the European Region.  There are also inequities in the health and quality of lives lived. Almost twice as many men and women in the poorest 20 per cent reported having a limiting illness compared to those in the richest 20 per cent.  Individuals with a relatively low level of education are around three times more prone to depression and roughly two times more prone to diabetes or overweight compared with those who have a relatively high educational outcome. It is almost certain that the COVID-19 pandemic has caused a further increase in these socio-economic inequalities in health.

What are the reasons for that?

Portrait of Caroline Costongs, Managing Director of EuroHealthNet
Caroline Costongs, Photo: Jo Hloch

Caroline Costongs: The coronavirus outbreak did not affect everyone equally. For example, people with lower incomes were at greater risk of infection because it was more difficult for them to keep their distance and avoid contact. They are more likely to live in small and overcrowded apartments and houses, and their jobs more frequently involve a higher level of exposure to the virus – in the care sector, retail outlets, and other services such as deliveries and refuse collection.

In addition to this, individuals who struggle financially are also more likely to have pre-existing medical conditions. This means that after becoming infected with the virus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), they have an increased risk of suffering more severely from the disease COVID-19. There is also a higher probability that socially disadvantaged people display a relatively low level of health literacy. As a result, they may be less able to take necessary precautionary measures, and in case of illness they potentially fail to receive the correct treatment on time.

Socially disadvantaged people are therefore affected by the disease more frequently and severely. Are there any social differences in the indirect effects of the COVID-19 pandemic?

Caroline Costongs: Yes, there are huge differences in the indirect effects as well. For instance, people already facing disadvantages are more likely to work in unstable jobs that are the first to go in an economic crisis. They are also more often unable to support their children when schools close. Home schooling is naturally more difficult for families with less money, for example if children don’t have sufficient access to a computer or an internet connection. Especially in the initial weeks and months of the COVID-19 pandemic, there was an enormous amount of recognition for the key workers in areas such as health, care, retail and education. But clapping from windows and on balconies alone just isn’t enough. Many of these workers also need more job stability and higher wages. In the future, we must generally try to better ascertain the needs of those population groups who feel left behind. Newly structured forms of dialogue will be necessary in order to achieve this.

People with a low income were at greater risk of infection.


What data and facts on social differences already exist for the COVID-19 pandemic?

Caroline Costongs: The social consequences of the COVID-19 pandemic have been and are currently being examined by many institutions. For example, the report “Disparities in the risk and outcomes of COVID-19” published in August by Public Health England shows that people living in more deprived areas are more likely to die after being diagnosed with COVID-19 compared with people in the least deprived areas. The risk of fatality from COVID-19 is also higher for black, Asian and minority ethnic groups than for white people. Black men are even four times more likely to die from COVID-19 than their white peers.

My team is collecting all data and reports on COVID-19 and health inequalities from each country as they become available. We circulate them in a monthly newsletter, and will soon launch an online information hub on health inequalities. I invite everyone to get in touch, subscribe, and to send us any results you would like to share.

How would you rate the reaction of the EU and its Member States to the COVID-19 pandemic?

Caroline Costongs: The European Union and also most of the Member States responded relatively quickly and appropriately, and they set up funds for emergencies and rebuilding. From the perspective of EuroHealthNet, it is especially important that some of these funds specifically benefit vulnerable groups and their health and social security. We must also ensure that the focus is not exclusively on economic recovery at any cost. Right now, measures such as the “Action Plan for Implementing the European Pillar of Social Rights” and the “EU Green Deal” are more important than ever before. We cannot continue in the same vein as previously; we have to make sure that Europe becomes more social, more sustainable, and healthier as well – we need to “build back better”. EuroHealthNet, as the European umbrella organisation for public health and health promotion, will contribute to this.

In England, black men are even four times more likely to die from COVID-19 than their white peers.


How has the situation changed for state organisations in the areas of health promotion and public health as a result of the COVID-19 pandemic?

Caroline Costongs: The COVID-19 pandemic – which we will hopefully gain control of in the coming months with the help of a vaccine and other medical treatments – naturally caused an extreme amount of work for the state organisations in the areas of health promotion and public health which we represent. One positive side effect of this is that people have a better understanding of the work of public health experts and their significance – when I describe what I do to other people, I no longer have to do as much explaining (laughs). – EuroHealthNet has lately drawn up an e-guide that clearly describes what support funds can be used at the present time in general for scientific and practical work in the areas of health promotion and public health, and what funds have been specifically set up to mitigate the direct and indirect impacts of the coronavirus crisis. Incidentally, one of the consequences observed early in the pandemic had been the relatively high level of trust among the population in the activity of the state institutions. This has been evidenced in current studies by our members RIVM – the National Institute for Public Health and the Environment in the Netherlands, and BZgA – the Federal Centre for Health Education in Germany.

Caroline Costongs (51) was born in the Netherlands and studied Public Health at Maastricht University. Since 2014 she has been Director of EuroHealthNet, the European umbrella organisation of public health institutes and health-promotion agencies. EuroHealthNet is a not-for-profit partnership of organisations, agencies and statutory bodies working on public health, disease prevention, promoting health, and reducing inequalities. It has 61 members, associate members and observers from 26 European countries, including from 23 EU Member States.