Health Inequalities As Evidenced By COVID-19

Since the week ending March 20th, the UK has registered 61, 920 excess deaths1. With the second highest death rate worldwide at the time of writing, the effects of the UK COVID-19 outbreak have been profound. But far from a ‘great leveller’, this quake has left an uneven landscape in its wake. 

Early evidence warned of disproportionate effects amongst UK ethnic minorities; the Intensive Care National Audit and Research Centre reported that 34% of critically ill patients belong to Black, Asian or other ethnic minorities, over twice their proportion of the population2. An early Office for National Statistics (ONS) report3 found that after adjusting for age, Black men and women were 4.2-4.3  times more likely to die of COVID-19 than their white counterparts. Over-represented in high-risk ‘essential roles’, ethnic minorities belong to 41.1% of NHS medical staff yet comprise as much as 72% of NHS carer deaths4 and 94% of clinician deaths from COVID-195

Such figures prompted both Labour and Government inquiries. The recently-published government inquiry6 confirmed the findings of early reports: minorities are at greater risk from COVID-19-related ill-health. Death rates were highest in Black, Asian, and minority ethnic (BAME) groups, specifically for those of Bangladeshi ethnicity, who had twice the risk of death than people of White British ethnicity. Other ethnic minorities had between a 10% and 50% higher risk of death, and, notably, “this is the opposite of what is seen in previous years, when the mortality rates were lower in Asian and Black ethnic groups than White ethnic groups”. The report also found a high increase in all-cause mortality amongst those born outside the UK and Ireland compared to previous years. Taxi and minicab drivers, security guards, and those working in social care, nursing, and care homes all saw increases  in mortality.  In London, the epicentre of the UK crisis, BAME workers are even more over-represented, where death rates were over three times higher than in the South West. With low earners often designated as ‘essential workers’7,  mortality rates in the most deprived areas were twice than those of the least deprived. 

These findings corroborate those of the ONS report, which suggested that the increased odds of death for minorities were “partly a result of socio-economic disadvantage”. Adjusting for such variables substantially reduced the odds of COVID-19-related deaths for all ethnic minorities, relative to the odds of white deaths. This led many to suggest that inequalities are not merely socially distinguished, but socially determined. Worse still, the PHE report concluded that “the impact of COVID-19 has replicated existing health inequalities and, in some cases, has increased them”.

It would be improper to surmise causation from this observational data alone, and the report offers no comment on its findings nor recommendations. However,  this does not preclude speculative comment, and as a prism, the pandemic sheds light on a society riddled with health-determining and social inequalities. In a pandemic in which proximity is itself a risk factor, government figures state that 30% of the UK Bangladeshi population, at twice the risk of death from COVID-19, live in ‘overcrowded housing’, compared with 2% amongst the White British population”8 and wards of over 40% BAME people face up to 11 times less green space”.

Such statistics recall an important concept of health equity: ‘structural violence’. The term, first described by Johan Galtung10, describes how structural and institutional barriers hinder the attainment of basic needs. Readers of the RUMS Review will be familiar with the term ‘social determinants of health’, which describes the comparatively broader “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life”11. From Jon Snow’s theory of cholera transmission via the Broad Street pump, ‘social determinants’ have become a mainstay of public health policy, and are the focus of Black12, Marmot13 and Acheson14 reports. More than simply correlative, measures of wealth, education, occupation, housing, socioeconomic status, access to healthcare and legal status serve as an explanatory paradigm for factors that determine health outcomes – from morbidity, to mortality, to our very relationships with health15. Social determinants may help to explain the “gulf in living standards that still blights our communities” that Lady Doreen Lawrence, who leads the Labour inquiry, describes16. Indeed, Professor Nishi Chaturvedi, Professor of Clinical Epidemiology at UCL, believes that the  disproportionate COVID-19 death rates of BAME groups are “ultimately about health inequalities, about deprivation and affluence and how important socio-economic status is in determining health outcomes.” This isn’t just an ethnicity story, it affects all of us”17. The PHE inquiry found the greatest health inequalities in age; among those diagnosed with COVID-19, people aged 80 or older were seventy times more likely to die than those under 40, and the number of deaths in care homes was over twice that expected. That only 46.4% of these deaths were attributed to the disease may reflect widespread under-diagnosis or deaths indirectly caused. These avoidable deaths restate the importance of social determinants. 

But even after adjustment for social determinants including region, deprivation, household composition, socio-economic position, education, health or disability in the ONS report, “a remaining part of the difference has not yet been explained”. The findings of the PHE report also remain unexplained. 

Where genetic differences also fail to explain disparities in deaths, the PHE inquiry turns to co-morbidities, finding that a higher proportion of COVID-19 death certificates mentioned diabetes, hypertension, CKD, COPD, and dementia. But with little regard for the bearing of social (environmental) determinants on these chronic diseases, the review essentialises ‘biological’ factors. In favouring a purist – and politically palatable – biological determinism, the report underestimates the significance of socially-charged biological factors and other social determinants. Though the comparable ONS report did account for self-reported health conditions, the increased risk of minority death remained unexplained. 

One concern is that discriminatory factors, disguised as ethinic differences, have been overlooked in the PHE report.  The NHS surcharge, the hostile environment policy, and the implicit bias of foreign ‘Chinese virus’ narratives provided a pretext for the racism that typified the early UK response to the pandemic. Notably, this rhetoric is reiterated in the PHE inquiry, which suggested that because BAME groups are more likely to have been born abroad, worse statistics may be explained by “additional barriers in accessing services that are created by, for example, cultural and language differences”6. Without providing any substantive evidence for this generalisation, this rhetoric only distracts from governmental failings and discriminatory policies. The effect is to absolve responsibility for social determinants and to attempt to justify the blaming of at-risk groups (already at greater risk and disproportionately staffing NHS front lines), further threatening their health and wellbeing. It is, according to MP Marsha de Cordova19, a “gross irony” that the release of the inquiry was postponed for a second time over  “current global events”, threatening a “bad combination” following global outrage in response to the death of George Floyd. Alarmingly, the Health Service Journal (HSJ) reports20 that the government redacted the entire review section of the inquiry. Consultations with over 1,000 professionals over PPE shortages, institutional racism, and suggestion “that discrimination and poorer life chances were playing a part in the increased risk of COVID-19” for BAME groups “did not survive contact with Matt Hancock’s office”. With the complicity of the government, “many of the white doctors are in management positions leaving more BAME on the coal face”5; social determinants reflect structural inequalities. The pernicious language of ‘heroism’ and mandated clapping rationalised the collapse of an anaemic workforce, circumscribed by these inequalities.

Structural inequalities are sure to outlast this pandemic. Whilst the report recognises “it will be difficult to control the spread of COVID-19 unless these inequalities can be addressed”6, as de Cordova implores19, “if the government is serious about tackling racial injustice, they should not be shying away from understanding why these injustices exist”. 

In the short term, tackling injustice requires scrutiny of the government response to the pandemic. As the Health Foundation21 finds, early data from China22 and Italy23 made plain the risks of pre-existing health inequalities, but despite forewarning, findings were replicated in the UK24. From cutting corners on PPE as early as 201725, three missed opportunities to join the EU PPE scheme26, missed targets27 and delays in implementing  the lockdown28, governmental failures have contributed to the human toll. 

Attention must focus on structural inequalities orchestrated by a Home Office branded institutionally racist in the recent ‘Windrush: Lessons Learned Review’29 twenty years after the same accusation was made of the Metropolitan Police in the Macpherson report30, following their handling of the murder of Lady Lawrence’s son, Stephen Lawrence. This is the same Metropolitan Police that is now twice as likely to issue fines to black people over lockdown breaches31. Whether this reflects “proactive policing” or “geographical distribution of ethnic groups”, structural inequalities anticipate fines, and create risk factors of circumstantial social factors. Medicine falls victim to, and in many cases perpetrates, these same inequalities; Black mothers are five times as likely to die in childbirth32 and Black people were four times as likely to be sectioned under the Mental Health Act33.

Reform is needed such that social determinants are no longer determinants. A Lancet report34 on COVID-19 and the impact of social determinants of health suggests “mitigating social determinants—such as improved housing, reduced overcrowding, and improved nutrition—reduces the effect of infectious diseases” and resolution of health needs, financial hardship, education and social mobility has been called for elsewhere21. The Lancet report urges that “as the lessons of COVID-19 are considered, social determinants of health must be included as part of pandemic research priorities, public health goals, and policy implementation”. As the tragic death of Belly Mujinga and countless others makes clear, the recognition of structural inequalities as determinants is imperative. 

Lord Woolley, chair of the government race disparity unit’s advisory group that co-authored the inquiry, is optimistic. He perceives “a unique opportunity to tackle those deep-seated inequalities, which existed even before Covid-19, that could get very much worse, without dramatic action, without radical action”20. The need for radical action is pressing. Mass protests threaten the very same BAME groups so affected by the structural inequalities that gave rise to this public health crisis. This threatens to widen the ‘gulf’. As forecasters warn of a likely recession, an impending socioeconomic fallout will compound existing inequalities. The IFS reports that lower earners are seven times as likely to have worked in a sector that is now shut down, with women further affected”35. Though at lesser risk of death from COVID-19, evidence suggests women are experiencing greater rates of period poverty36 and domestic violence37 as a result of COVID-19. Black people are twice as likely as white people to be unemployed and BAME people are 48% more likely to be on zero-hour contracts and the pandemic could well see “high levels of unemployment, which for young black kids could go to 50, 60, 70%”38.  Following growing unemployment and rising costs, there has been a  threefold rise in food bank usage39. Additionally,  the need for education and free school meals has seen many resume schooling, ushered forth by an inevitable economic downturn that has forced many back into work prematurely, threatening health. 

Questions must demand not merely “who is at greater risk of infection and death?”, nor “what can be done to mitigate risks?” Instead, “why are government measures ‘exacting a heavier social and economic price on those already experiencing inequality”’21and “how is the obstacle to equitable health and wellbeing constructed, and how may its determinants be dismantled and overcome?”. 

For meaningful reform, health equity must be valued in itself. Secondly, we must  recognise social equity as its standard. We must abandon the false dichotomy of ‘public health versus economy’ that suffocates nuanced debate and demands that healthcare needs be estranged from social concern.40 Thirdly, action must refigure rather than remediate, for when structural inequality is left untreated, healthcare is not only palliative, but exacting. As we await return to normal life, we must seize this “unique opportunity to tackle those deep-seated inequalities” and redefine ‘normal’, for a vaccine will offer no immunity to a crisis of structural inequality. 

By Benjamin Choudhury

References

1.  Giles, C. There have been 61,920 excess deaths in the UK since week ending 20 March.  A rate of 929 per million. This is again the highest among countries with comparable data (overtaking Spain again) https://www.ft.com/content/6b4c784e-c259-4ca4-9a82-648ffde71bf0. Twitter. June 2020 [Accessed June 3rd 2020] Available from:  https://twitter.com/ChrisGiles_/status/1267756563923709952?s=20

2.  Croxford, R. Coronavirus: Ethnic minorities are ‘a third’ of patients [online] BBC April 2020 [Accessed June 3rd 2020] Available from: https://www.bbc.co.uk/news/uk-52255863 

3.  Office for National Statistics. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020 [Accessed June 3rd 2020] Available from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020

4.  Rashid,  I. Coronavirus: BAME people make up 72% of all NHS and carer deaths with COVID-19 [online] Sky News April 2020 [Accessed June 3 2020] Available from: https://news.sky.com/story/coronavirus-bame-people-make-up-72-off-all-nhs-and-carer-deaths-with-covid-19-11977263 

5.  ITV REPORT. ‘Discrimination’ on frontline of coronavirus outbreak may be factor in disproportionate BAME deaths among NHS staff [online] ITV May 2020 [Accessed 3 June 2020] Available at: https://www.itv.com/news/2020-05-13/discrimination-frontline-coronavirus-covid19-black-minority-ethnic-bame-deaths-nhs-racism/ see also BMA Council Chair’s message to members [online] May 2020 [Accessed June 4th 2020] Available at: https://www.bma.org.uk/advice-and-support/covid-19/what-the-bma-is-doing/bma-council-chair-message 

6.  UK. Public Health England. Disparities in the risk and outcomes of COVID-19 [online] June 2020 [Accessed 3 June 2020] Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/889195/disparities_review.pdf

7.  Butcher, B., Massey, J. Why are people from BAME backgrounds dying from coronavirus? [online] BBC May 2020 [Accessed June 4th 2020] Available at https://www.bbc.co.uk/news/uk-52219070

8.  UK. Ministry of Housing, Communities and Local Government. Overcrowded households [online [Accessed 3 June 2020]  Available at: https://www.ethnicity-facts-figures.service.gov.uk/housing/housing-conditions/overcrowded-households/latest#by-ethnicity 

9.  Commission for Architecture and the Built Environment. Community Green: using local spaces to tackle inequality and improve health [Accessed 3 June 2020] Available at: https://www.designcouncil.org.uk/sites/default/files/asset/document/community-green-full-report.pdf 

10. Galtung, J. “Violence, Peace, and Peace Research” Journal of Peace Research, Vol. 6, No. 3 (1969), pp. 167–191

11. WHO. Social determinants of health. [Accessed 3 June 2020] Available at: https://www.who.int/social_determinants/sdh_definition/en/

12. Black, D. Inequalities in health: Black report. Pelican Series, Michigan: Penguin Books, 1982. 

13. Marmot, M. Fair Society, Healthy Lives: The Marmot Review. [online] February 2010 [Accessed June 3rd 2020] Available at:http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-full-report-pdf.pdf

14. Acheson, D. Independent inquiry into inequalities in health [online] 1998 [Accessed June 3rd 2020] Available at: https://www.gov.uk/government/publications/independent-inquiry-into-inequalities-in-health-report

15. Williams, E., Buck, D, and Babalola, G. What are health inequalities? [online] The Kings Fund February 2020 [Accessed June 3rd 2020] Available from: https://www.kingsfund.org.uk/publications/what-are-health-inequalities#life

16. BBC. Coronavirus: Doreen Lawrence to head Labour probe on minorities. [online] April 2020 [Accessed June 3rd 2020] Available at: https://www.bbc.co.uk/news/uk-politics-52405243

17. Devlin, H. Why are people from BAME groups dying disproportionately of COVID-19? [online] Guardian April 2020 [Accessed June 3rd 2020] Available at: https://www.theguardian.com/world/2020/apr/22/why-are-people-from-BAME-groups-dying-disproportionately-of-covid-19 

18. Khan, O. If my search function is working properly, the ‘review of disparaties in risk and outcomes’ does not include the terms social determinant (or ‘determinant’) race racism One reference to ‘discrimination’ (not in the context of race or ethnicity) (see below) Twitter. June 2020. Available at:  https://twitter.com/omaromalleykhan/status/1267800538315448320?s=20

19. Rashid, I.  Coronavirus: Review into impact of COVID-19 delayed again. [online] June 2020 [Accessed June 3rd 2020] Available from: https://news.sky.com/story/coronavirus-BAME-review-delayed-again-due-to-proximity-to-us-race-riots-over-george-floyds-death-11998897

20. Moore, A. Government censored COVID-risl review [online] HSJ June 2020 [Accessed June 2020] Available at:  https://www.hsj.co.uk/coronavirus/exclusive-government-censored-bame-covid-risk-review/7027761.article

21. Bibby, J., Everest, G., Abbs, I. Will COVID-19 be a watershed moment for health inequalities? [online] The Health Foundation May 2020. [Accessed June 3rd 2020] Available from:https://www.health.org.uk/publications/long-reads/will-covid-19-be-a-watershed-moment-for-health-inequalities

22. Chen, N., Zhou. M., Dong, X., Qu. J., Gong, F., Han, Y. et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet. 2020: 395; 10223 P507-513

23. COVID-19 Surveillance Group. Characteristics of COVID-19 patients dying in Italy: Report based on available data on March 26th, 2020. Italian National Institute of Health; 2020 

24. Office for National Statistics. Deaths involving COVID-19, England and Wales: deaths occurring in March 2020. UK government; 2020 

25. Davies, H. Advice on Protective Gear for NHS Staff was rejected owing to cost [online] Guardian March 2020 [Accessed 3rd June 2020] Available at: https://www.theguardian.com/world/2020/mar/27/advice-on-protective-gear-for-nhs-staff-was-rejected-owing-to-cost?fbclid=IwAR21D_y5vpa_XuyBwVoZ2eN44T0e6nCZzu5NuG31dyxqDTzK2n4l7RipeCc 

26. Boffey, D. and Booth, R. UK missed three chances to join EU scheme to bulk-buy PPE [online]  April 2020 [Accessed June 3rd 2020] Available at: https://www.theguardian.com/world/2020/apr/13/uk-missed-three-chances-to-join-eu-scheme-to-bulk-buy-ppe

27. Mason, R. and Campbell, D. Pressure on Johnson as UK’s daily coronavirus testing target missed agin [online] Guardian May 2020 [Accessed June 4th 2020] Available at: https://www.theguardian.com/world/2020/may/06/boris-johnson-misses-coronavirus-testing-target-for-fourth-day-in-a-row

28. Calvert, J., Arbuthnott, G., Leake, J. Coronavirus: 38 days when Britain sleepwalked into disaster [online] The Times April 2020 [Accessed 4th June 2020] Available at: https://www.thetimes.co.uk/article/coronavirus-38-days-when-britain-sleepwalked-into-disaster-hq3b9tlgh

29. Windrush lessons learned review by Wendy Williams. Official Documents Archive. July 2018 [Accessed June 4th 2020] Available at: https://www.gov.uk/government/publications/windrush-lessons-learned-review

30. Sir William Macpherson’s Inquiry Into The Matters Arising From the Death of Stephen Lawrence. Official Documents Archive. February 1999. [Accessed June 4th 2020] Available at: https://www.gov.uk/government/publications/the-stephen-lawrence-inquiry

31. Dodd, W. Met police twice as likely to fine black people over lockdown breaches [online] Guardian June 2020 [Accessed 4th June 2020] Available at:https://www.theguardian.com/uk-news/2020/jun/03/met-police-twice-as-likely-to-fine-black-people-over-lockdown-breaches-research

32. MBRRACE-UK. Saving Lives, Improving Mothers’ Care 2018: Lay Summary [online] September 2019 [Accessed June 4th 2020] Available at: https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202018%20-%20Lay%20Summary%20v1.0.pdf

33. UK. NHS Digital. Detentions under the Mental Health Act May 2020 [Accessed 4th June 2020] Available at: https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest

34. Abrams, E.M. Szefler S.J. COVID-19 and the impact of social determinants of health The Lancet 2020 2600(20) pp.30234-4 doi: https://doi.org/10.1016/S2213-2600(20)30234-4

35. Joyce, R., Xu, X. Sector shut-downs during the coronavirus crisis affect the youngest and lowest paid workers, and women, the most IFS [online] April 2020 [Accessed June 3rd 2020] Available from: https://www.ifs.org.uk/publications/14797

36. ITV REPORT. Anguish as women unable to afford sanitary products during coronavirus outbreak [online] ITV June 2020 [Accessed June 4th 2020] Available at: https://www.itv.com/news/2020-06-03/period-poverty-coronavirus-outbreak/

37. Townsend, M. Revealed: surge in domestic violence during COVID-19 crisis [online] Guardian April 2020 [Accessed June 4th 2020] Available from: https://www.theguardian.com/society/2020/apr/12/domestic-violence-surges-seven-hundred-per-cent-uk-coronavirus

38. Siddique, H. BAME campaigners urge UK government to tackle race inequalities after high death toll [online] Guardian May 2020 [Accessed June 2020] Available from: https://www.theguardian.com/world/2020/may/27/call-for-coronavirus-uk-race-equality-strategy

39. Lawrence, F. UK hunger crisis: 1.5m people go whole day without food [online] Guardian April 2020 [Accessed June 3rd 2020] Available at https://www.theguardian.com/society/2020/apr/11/uk-hunger-crisis-15m-people-go-whole-day-without-food?CMP=Share_iOSApp_Other 

40. Williams, Z. The choices we make about coronavirus are way more complex than ‘lives v. the economy’ [online] Guardian April 2020 [Accessed June 2020] Available at: https://www.theguardian.com/commentisfree/2020/apr/14/coronavirus-lives-economy-lockdown-left-right