We know prevention is better than a cure, so it is common sense that the best strategy to combat Covid-19 has been keeping the virus from taking hold.

But even preventive action is not isolated from the social systems it exists within. The way in which the economic, social, and health consequences of the pandemic have followed known patterns of inequality is a vivid illustration of this.

We could have predicted these unequal consequences.

I began my first gig as a research assistant more than 20 years ago, coordinating a team involved in one of the earliest Ministry of Health efforts describing the extent of social inequalities in health in Aotearoa.

The report released in 2000 detailed the unequal and patterned nature of health outcomes caused by social determinants such as income, housing, and education—and how these are shaped by where you live, and ethnicity (via institutional racism).

The NZ Deprivation Index was also new, producing compelling maps showing compounding of socioeconomic disadvantage in parts of the country.

The extent of inequality in Aotearoa was—is—all a bit surprising to many Kiwis who don’t see it or feel it in their daily lives. Many believe instead our egalitarian ideals have buffered the powerful processes of globalisation and the worst of capitalism.

But it is crystal clear the greatest harms from the pandemic have been caused by our historical neglect of these wider determinants—and the communities that suffer them. Our neglect hasn’t been through not knowing what to do, but rather forgetting that simple actions aimed at shifting population trends are rarely effective for everyone—and fraught with uncertainty and unintended consequences.

We can’t seem but help revert to perceiving things with harmful but preventable consequences for health as simple and within an individual’s control—if only they could be enlightened. But the path to “enlightenment” is complex.

The experience from numerous public health crises—not only epidemics of diseases but harmful behaviours, environments, and belief systems—have shown us time and time again that, when something spreads widely throughout populations, it becomes anything but simple to resolve.

The end of our elimination strategy signals this truth—as social complexity increases, silver-bullet solutions are not possible.

It has been fascinating to see this play out in real time, the country organising to act and stamp out the spread of a minuscule virus. Covid-19 is one of many which have existed before us, co-evolved within us and around us, and that will still be here when we are long gone.

Now with the Delta strain and the vaccination rollout in Aotearoa, we are seeing again the tail end of inequality - the tail that repeatedly reminds us trust matters, and community-led, context-specific ways are needed to engage all people and communities.

Even well-intentioned public health action frequently spends too much of the wrong kind of energy at the “top”, faltering and stalling as it gets closer to marginalised communities. Anti-smoking efforts, whilst a hard-won success story for much of the population, are still wallowing in the challenges of inequality.

It seems a shift in mindset is needed to recognise that those at the tail of a population distribution where inequality exists are deeply connected to the rest of the distribution.

Things that spread through populations—disease, behaviours, money, or beliefs—are driven by our social systems. These systems derive purpose and create patterns from the fabric of relationships between individuals, organisations, and sections of society—an understanding well-known in health promotion and Māori health fields where effective action on health and wellbeing is framed as relational and multi-level.

All complex systems—including social systems—consistently behave in ways where, as time frames get longer and numbers of interactions increase, the ability to predict outcomes with certainty decreases. Initial “local” conditions also have disproportionate effects. For place-based communities, this means they hold disproportionate power to effect change.

We not only want to stop detrimental diseases and artefacts spreading. We also want ways to ensure the good stuff, the stuff beneficial to health and the planet, can spread.

For this to happen, policy leadership and political “will” are necessary, but not sufficient. Their changeability over time, capture by commercial interests and tendency to reinforce polarising ideological positions, makes them vulnerable, especially in the long term. Top-down action has consistently failed inequality.

We know the best health investment is in early prevention—early in people’s lives, and locally in their lived environments. This knowledge, and our historical undervaluing of community-led, power-sharing and adaptive approaches to change, makes us culpable for how the outcomes of the pandemic are playing out.

What we needed before the pandemic is what we need now—evidence-informed policy action to strengthen local systems.

Communities need to move beyond reacting to systemic crises and instead become system influencers. And policy relationships have to overcome their counterproductive need for certainty and control.

Dr Anna Matheson is a Senior Lecturer in Health Policy in the School of Health at Te Herenga Waka—Victoria University of Wellington.

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