AREA 1: HEALTH INEQUALITIES

Racial bias exists within a number of public institutions in the UK and the health service is no exception. In our battle against Coronavirus, we must ensure we don’t overlook the impact this can have in our response. The disproportionate representation of BAME people among Coronavirus cases relative to their share of local populations is troubling and must be explored and addressed.

BAME GROUPS ARE OVER-REPRESENTED IN “AT RISK” COVID-19 GROUPS

BAME communities are facing barriers to health care access and are at greater risk of developing serious and long-term health conditions. BAME groups are, as a result, overrepresented across many of those identified as ‘vulnerable’ to COVID-19 by the Government. For example, South Asians have a higher prevalence of diabetes and Black Africans are disproportionately affected by HIV and hypertension, conditions which categorise them as vulnerable and increase their risk of developing a critical case of coronavirus. It is important to note those with disabilities are likely to fare worse outcomes. There are real concerns at the moment around people with disabilities not getting the treatment they need for COVID-19 due discrimination in the health system

When discussing comorbidities, however, it is crucial to recognise that this is a nuanced issue and we must be cautious not to engage in biological racism, for example the assumption that individuals from black and south asian groups are inherently more likely to have diabetes, despite limited evidence that links genetics to likelihood of diabetes and which instead points to social factors. Assertions made about BAME communities being inherently susceptible to illness erase the important intersection of poverty and race in generating health inequalities and the likelihood of disease, thus preventing an effective response in tackling the root causes of poor health.

Evidence points to the virus’ worse effects being the result of people being racialised into categories that are more vulnerable. Professor in cultural and social analysis Alana Lentin writes that “The pandemic shows us that race is not a biological fact, as the “race realists” believe, since there is no meaningful biological explanation for the BAME experience of COVID-19. Instead it is a technology of governance that shapes the life chances of many racialised people and maintains white supremacy”.

What is growing increasingly clear is the need for BAME-centred research. BAME patients are under-represented in health research and this must be rectified in order to understand why minority ethnic communities are experiencing this disease burden.

#CharitySoWhite has lifted the lid on the level of structural racism still in the charity sector – healthcare charities are no exception. As provisions become increasingly stretched, the importance of an approach rooted in lived experience and an intersectional understanding of needs is critical.

RACISM AND POVERTY ARE PUBLIC HEALTH ISSUES

Research in race and poverty has found that the UK poverty rate is twice as high for BAME communities than for white groups. Combined with the increased likelihood of employment in low-paid, precarious, and public-facing work, such as bus and taxi drivers, care workers, NHS workers and security guards as well as living in multigenerational households where social isolation may not be possible, we can see why there is a corresponding higher risk in contracting the virus amongst BAME communities.

Government figures confirm that overcrowded housing is far more likely to pose an issue for BAME communities. For example, 30% of the UK Bangladeshi population are considered to live in overcrowded housing compared with 2% of the white British population.

This heightened exposure is reflected in new data indicating that BAME groups could also be at greater risk of developing critical Coronavirus. The Intensive Care National Audit and Research Centre found that 35% of critically ill Coronavirus patients are from BAME backgrounds, nearly triple the 13% proportion in the UK population as a whole. A study by Imperial College London has found that a third of patients who are admitted to hospital in the UK with COVID-19 are dying. The team who carried out the study are also looking closely at why a disproportionate number of admissions and deaths are seen in Black People and those from south-east Asian backgrounds.

A mosque in central England has converted its car park into a morgue for those who have died from COVID-19. This volunteer-run mortuary has spaces for 150 bodies, and is evidence of the toll that the virus is having on British Muslims and the ethnic minority community.

Analysis done by the Institute of Fiscal Studies has found that the death rate of British Black Africans and British Pakistanis in English and Welsh hospitals is more than triple that of the white population. It was also found that the number of deaths of people from a Black Caribbean background were 1.7 times higher than for White British people. Disparities based on underlying conditions of BAME people and regional areas they live in cannot currently be accounted for by non-hospital deaths.

The latest statistics from the Office for National Statistics (ONS) have found that even when geography, age, health and wealth are recognised as factors, Black People are still 1.9 times more likely to die once contracting COVID-19 than white people. Marsha de Cordova has said that as we move through the crisis, we must use the data to “address the structural inequalities” in our society, and continue this conversation after the pandemic too.

Research from Oxford University shows that while previous assumptions were the BAME groups were at higher fatalities due to underlying health conditions, deprivation is a key factor “it is very concerning to see that the higher risks faced by people from BAME backgrounds are not attributable to identifiable underlying health conditions''. The investigations have analysed the data of 17,425,445 adults who were registered with a GP, linking it to the patient information of those hospitalised with COVID-19. The initial observations highlight that deprivation and being from a BAME background are major risk factors for COVID-19 fatalities. This also highlights the need for data to improve the patient care and mitigate those at highest risk.

THE HEALTH OF CHILDREN AND YOUNG PEOPLE

BAME children and young people experience the health consequences of these comparatively higher rates of poverty even more acutely in light of the crisis. For example, the rapid school closures will hit families who depend on free school meals for their children. Given the higher poverty rate for BAME communities, we know these children will be particularly affected. The increased rates of overcrowding in BAME households will invariably mean that children and young people have less space to play and exercise, this is compounded by a comparable lack of access to parks and green spaces.

The COVID-19 crisis has had a huge impact on the mental health of children and young people, with NSPCC delivering over 900 counselling sessions about the virus, and over 50 with children having suicidal thoughts in light of the crisis. Since the oubreak, Muslim Youth Helpline has experienced a 300% increase in calls, web chats and emails from distressed young people, including a spike on Eid weekend. With BAME children and young people often living on the sharper edges of inequality, they face considerable risk regarding their mental health.

BAME GROUPS ARE AT HIGHER RISK OF DEVELOPING MENTAL ILL HEALTH

BAME communities are at higher risk of developing serious mental ill health as they are disproportionately impacted by the social determinants associated with mental illness, such as poverty according to analysis by the Racial Equality Foundation. Findings from their research also shows that BAME individuals are 40% more likely to access mental health support via a criminal justice route rather than voluntarily seeking and accessing support. This can lead to their rights, liberties and autonomy being temporarily limited. We are concerned that the new measures introduced to loosen the safeguards around the use of the Mental Health Act may lead to an increase in this trend during the crisis. 

It is also well-documented that those exposed to racism may be more likely to experience mental health problems such as psychosis and depression; this can interlink with the current need to self-isolate as well as existing forms of oppression to detrimental consequences.

A recent Survey of Londoners showed that loneliness and social isolation is more common amongst those facing wider disadvantage, with Black Londoners indicating particularly high rates of social isolation. With closure of cultural spaces and places of worship, particularly as important religious festivals like Ramadan, Passover, Vaisakhi and Easter approach – we expect risk of isolation and loneliness to be further compounded. We have already heard of numerous anecdotal examples of elderly and disabled BAME people who live alone struggling to access support and basic amenities.

Spark have launched a resource hub with curating links to organisations and information designed to help those from BAME backgrounds. A new free text service has been created by a group of trans activists to support the non-binary and transgender community. The Validation Station has over 500 signups and sends out daily reminders reinforcing their identity and reminding them how great they are.

THERE IS NO EQUAL ACCESS TO HEALTHCARE AND SUPPORT

Quality of healthcare provision and access is a postcode lottery. BAME people are much more likely to live in densely populated and deprived areas where NHS services are already overstretched, and this comparative lack of access to healthcare services compounds the risks they face.

It is also critical to bear in mind that the top ten areas in England hit hardest by COVID-19 are all in London, where 40% of the population are from minority ethnic backgrounds. 60% of all British Jews live in or around London for example. 

The London borough of Brent has had 450 coronavirus cases for every 100,000 people, the highest proportion in the capital and one of the highest in the country. The borough is also one of the most densely populated in outer London and has the second highest percentage of populations from BAME backgrounds. During this crisis, anticipating a disproportionate number of BAME people needing healthcare support, their ability to access services will be even more challenging.

Language barriers also provide a restriction to access. These issues will be compounded by the COVID-19 no visitor policy, individuals will be less able to communicate symptoms and needs. For example, the assessment of pain scales can be culture-dependent; the horizontal pain scales used in the UK may be confusing for those originally from China, as Chinese languages are traditionally written and read vertically. Powerful anecdotes have emerged from the front lines of the crisis documenting the scale of impact of this unmet need. 

The government must prioritise health funding for the most deprived regions in the aftermath of the coronavirus crisis, politicians and public health experts have demanded, after new data analysis revealed the devastating scale of the death toll in the poorest parts of England and Wales.

In findings one expert said highlighted the fact that COVID-19 “is not a leveller” as politicians have repeatedly claimed, the Office for National Statistics (ONS) said that those living in the poorest parts of England and Wales were dying at twice the rate of those in the richest areas.

The lack of equal access to the NHS and higher death rates of BAME people are an issue that has been highlighted by this crisis. The NHS must be rebuilt with these barriers in mind, to provide a healthcare system that is equitable and accessible.

In addition to affecting BAME communities disproportionately, the extra pressure is seeing GP visits rise as routine tests, smears, immunisations are cancelled by hospitals. The deprioritisation of these appointments can result in A&E admissions for issues which escalate beyond being manageable if treated early enough.

BAME COMMUNITIES HAVE POORER DIGITAL ACCESS AND LITERACY

Even in 2020 access to internet and digital skills is not universal, evidence shows that marginalised ethnic groups have worse internet access. This has wide ranging impacts in the current context including higher likelihood of isolation and being less able to access important public health guidance and key services such as online food ordering. 

People from BAME communities are more likely to face digital exclusion which further compounds social isolation and poor mental health as we increasingly rely on technology for social connection. ONS data from 2018 suggests 5.3 million UK adults (10% of the adult population) do not use the internet, 18% of adults did not have access to a smartphone (Newzoo’s Global Mobile Market Report 2018). 12% of those aged between 11 and 18 years (700,000 children) reported having no access to a computer or tablet at home (Lloyds Banking Group 2018) 22% of the adult population – 11.9 million people – lack some or all of the five basic digital skills. Six million people cannot turn on a device and 7.1 million people cannot open an app. (Lloyds Banking Group 2018).

For example, specific concerns were raised recently by Jewish Leaders that public health guidance was not being effectively disseminated to ultra-Orthodox communities. It is important for charities to consider this as they move services online.  

UNCONSCIOUS BIASES LEAD TO UNEQUAL CARE AND TREATMENT 

There are false, racialised perceptions surrounding pain tolerance and subsequent treatment. Many of these are rooted within racist beliefs that have been long embedded within various schools of medicine, some of which have been institutionalised within modern day practice. For example, BAME women tend to be taken less seriously and therefore see their choices limited, and their lives endangered, as a result of this when accessing maternal care; the most recent figures indicate that black women are 243% more likely to die of complications in pregnancy and childbirth. Research has demonstrated that black women are 22% more likely to die of heart disease than white women.

Between 1 March and 14 April, BAME women made up 55% of the pregnant patients admitted with COVID-19. Maternal health disparities have been long publicised, and this study suggests that being from a BAME background is a higher risk factor in pregnant women’s hospitalisation with COVID-19 than age and obesity. When researchers excluded London, the West Midlands and the North West from the research, the inequalities were still present in the data. The Royal College of Midwives (RCM) acknowledges that these increased risks require BAME patients to be offered extra care and support, and have developed new guidance for midwives and maternity support staff to be “particularly vigilant” to mitigate these risks. The RCM is targeting a campaign at BAME women to raise awareness of this risk, and reiterate that help is available. One in five babies born to mothers hospitalised with COVID-19 were born prematurely (less than 32 weeks), requiring admittance to neonatal care. One in 20 babies born to mothers admitted to hospital subsequently had a positive test for COVID-19, and five women who were admitted and tested positive for COVID-19 have died. The maternal deaths include BAME women Salina Shaw (37) and Nurse Mary Agyeiwaa Agyapong (28).

Studies show that these false beliefs about the perceived biological differences between black people and white people abound. For example, the false ideas that black skin is thicker than white, and that black people are inherently stronger than white people. The health gap has been described as 'Disparity by Design', and an example of eugenics, blaming Black people for being victims of systems they didn’t create.

Medical professionals are using a scoring system called NEWS2 to check suspected COVID-19 patients. Ultimately, medical professionals are human, and as such, are not immune to their own racial bias, especially in times of heightened pressure and stress. We are concerned that some of these beliefs and practices will be magnified during the crisis, meaning many BAME people with Coronavirus will not receive access to timely support. This has been highlighted in the recent tragic passing of Kayla Williams who died from a suspected case of COVID-19 and the family of Anand who recounted the trauma of having to plead with paramedics to admit him to hospital.

We must acknowledge that the prejudice BAME individuals face from healthcare professionals who are simply not listening or not willing to believe what they are hearing due to racialized perceptions can have fatal consequences.

FUNERAL CEREMONIES

Guidance about funeral ceremonies was published on March 23rd, restricting the numbers of people who can attend funeral ceremonies. Some councils have gone as far as to ban all funeral ceremonies. Many people are not able to attend the funerals of their loved ones. Furthermore, there are delays and backlogs burials, meaning that Muslim and Jewish burials may not be able to take place in timings that are in accordance with their religious beliefs. The Inter Faith Network has provided some guidance from faith communities and organisations on funeral rites and practices in light of the Coronavirus pandemic.

BAME COMMUNITIES MISS OUT ON ADEQUATE PALLIATIVE CARE SERVICES

There is evidence that when it comes to making decisions between saving a life or preserving quality of life, BAME communities are more likely to opt for life saving measures. Existing evidence indicates that minority ethnic groups may have more unmet palliative care needs than people from white backgrounds and experience a number of barriers to accessing high quality end of life care.

The Care Quality Commission has documented that BAME groups, who may have specific end of life care needs, are often less considered in published care strategies. This lack of consideration will invariably be magnified in the midst of this crisis, where healthcare professionals are having to make difficult decisions at an increased rate.

The lack of culturally sensitive approaches and translated resources is likely to impact the quality of palliative treatment that people receive and support their bereaved families and loved ones will be offered.

BAME HEALTH AND SOCIAL CARE WORKERS FACE HEIGHTENED RISK IN THE COVID-19 RESPONSE

Health and social care staff, who are particularly exposed to the virus, are disproportionately drawn from minority ethnic communities.

As previously stated, 1 in 5 NHS employees come from BAME backgrounds. This number rises acutely in London, the virus’ UK epicentre, where BAME staff represent 44% of the entire NHS workforce. Over 75% of BAME doctors fear they will contract COVID-19, and almost two-thirds are concerned about passing the virus on to people they live with.

This has tragically translated into the disproportionately high number of deaths of BAME health and care staff. The first 10 doctors and 70% of the nurses in the UK named as having died with the virus all coming from BAME backgrounds, numbers so troubling that the British Medical Association has called on the government to investigate BAME groups’ vulnerability to the Coronavirus. By 23 April, official figures showed that 111 health and social care workers had died from the virus, and an analysis by Sky News found that 72% of these were from BAME communities. The latest figures show that 27 of the 29 doctors who have died from COVID-19 are BAME.

BAME Nurses comprise 20% of the workforce, but only make up 7% of senior management. Saharia Musa says “Nursing, especially for black, Asian and ethnic minorities has become a job of two extremes: extreme low pay and extreme risk to life and limb”. She calls for an inquiry into the effects on BAME healthcare staff and action taken to fix the racial inequality in nursing, and society.

4,000 BAME medics responded to a call from ITV for anonymous accounts of COVID-19, with key themes emerging that BAME staff feel discriminated against and under pressure when complaints are met with warnings of investigation. For migrant BAME NHS workers, the fears of losing their jobs are also tied to fears of deportation, especially when visas are tied to their employment.

Carol Cooper, Head of equality, diversity and human rights at Birmingham Community Healthcare NHS Trust, spoke to the Nursing Times about how BAME staff feel they are being put to work on COVID-19 wards more so than their white colleagues. She spoke about how some staff were taken from the wards they usually worked in and placed in COVID-19 wards, and how staff felt there was a bias – “the same bias that existed before”.

Then there is the impact that the COVID-19 pandemic is having on the Filipino community in the UK. At least 23 Filipino people have died in the UK since the beginning of the pandemic, many of them healthcare workers. 18,000 Filipinos work in the NHS, the community providing the backbone of the NHS. An anonymous Filipino nurse said that many Flilipino and Indian nurses are placed in situations they’re not prepared or trained for, but fear saying no. The Philippines' ambassador to the UK has called for key workers to be ‘properly protected’.

Given the heightened risk they face daily, health and social care professionals deserve recognition and protection. A recurring complaint among healthcare workers has been inadequate personal protective equipment (PPE). With BAME staff twice as likely not to raise concerns over fears of recrimination and as they face higher levels of bullying and harassment, this could be having fatal consequences. This need for protection is all the more urgent in light of Dr Abdul Mabud Chowdhury’s appeal for appropriate PPE just five days before being admitted to hospital, before ultimately dying with the virus.

As well as a lack of availability, feedback from BAME NHS staff highlighted that some forms of PPE are not suitable for some minorities. Some health and care workers wear hijabs or have beards for religious and cultural reasons, this impacts the fit of PPE. A Sikh doctor at Wolverhampton hospital was told to shave his beard to fit PPE, and was relegated to ‘background work’ for refusing, despite PPE being adaptable to beards. This highlights further how the medical system is designed for and by colonial powers, with BAME forced to assimilate and sacrifice further as they already risk their lives to work.

NHS improvement’s chief operating officer, Amanda Pritchard, sent a letter on 30th April 2020 to hospital trusts, providers of mental health care, ambulance services and organisations providing community-based healthcare. It stated that NHS staff from BAME backgrounds will be “risk-assessed” and could be given different roles away from the frontline. We will continue to assess how this is incorporated into specific NHS trusts. Somerset NHS foundation trust has begun asking BAME staff if they feel safe at work, giving them priority for testing and ensuring that they undergo a “fit-test” in order to wear an FFP3 ventilator mask.

The British International Doctors Association is urging NHS Trusts to take action and support their BAME staff. In a letter, they outlined steps NHS Trusts could take in support. These steps include: Ensuring all BAME staff wear well-fitted FFP3 masks in hospitals; making accommodations or redeploying to relieve anxieties; prioritising testing for them and their families; and ensuring any sickness absence as a result does not impact their finances or career progression.

Lord Adebowale, the chairman of the NHS Confederation, has warned that a lack of diversity in decision making rooms could be leading to mistakes. He believes a “listening culture” needs to be fostered, where ethnic minority staff feel free to express concerns and have their religious needs catered to as well.

The ninth male GP to die from COVID-19, 84-year-old Dr Karamat Ullah Mirza, is also the fourth Essex GP to die from the virus. British Asian GP Zara Aziz also calls for robust measures to protect BAME staff, with more “more effort and care than platitudes and a tickbox tool”. Durham GP Dr Poornima Nair is also believed to be the first female GP to die from COVID-19 too.

Milton Keynes Hospital, where COVID-19 has ‘peaked’ and is declining, have acknowledged the disproportionate BAME NHS deaths. Hospital chiefs have also been speaking to 100 BAME staff about their concerns and setting up a network to address these.

NATIONAL RESPONSE TO HEALTH INEQUALITIES FOR BAME COMMUNITIES

The disproportionate number of BAME people with critical cases of coronavirus has been so troubling that the British Medical Association has called upon the Government to investigate BAME groups’ vulnerability to the Coronavirus. There has also been a call for research investigating the emerging evidence of the association between ethnicity and COVID-19 incidence and adverse health outcomes from National Institute of Health Research and UK Research and Innovation, who are seeking to fund this research.

The government appointed Trevor Phillips and Richard Webber to review the impact of coronavirus on BAME communities. Phillips’s appointment has sparked a great deal of criticism from BAME communities, with many calling the choice ‘alarming’ and ‘shameful’ in light of his suspension from the Labour party for Islamophobia and other racist comments. The Muslim council of Britain has described the move as ‘wholly inappropriate’ given that so many doctors who have died during this pandemic are Muslim. The reactions are unsurprising in light of Phillips' comparison of Grenfell Tower (another disaster disproportionality affecting working class BAME people) to a ‘Tower of Babel’. Public Health England (PHE) have since backtracked on this, stating that rather than leading the review, his research company, Webber Phillips, “is one of a number of stakeholders who have offered assistance for contributing to further research on the relationship between Covid-19 and BAME communities”.

Labour leader, Keir Starmer, has appointed Baroness Doreen Lawrence, campaigner and mother of Stephen Lawrence who was murdered in a racist hate crime in 1993, as the party’s race relations adviser. She will lead a review into the impact of coronavirus on the BAME community. The launch of the review was attended by Lawrence, Marsha de Cordova, Muslim Council of Britain, Operation Black Vote, Royal College of Nursing and the Sikh Network - key organisations that work with communities of colour.

The Mayor of London and a coalition of Bishops have both called for an inquiry into the disproportionate deaths of BAME people from COVID-19. Tower Hamlets Mayor John Biggs and Poplar & Limehouse MP Apsana Begum believe urgent government action needs to be taken to support BAME communities, and additional resources must be allocated. In addition to the health consequences, there are serious concerns of the secondary impacts that include poor mental health and loss of employment and earnings.

The Coalition for Race Equality and Rights is also calling for the Scottish Government to publish the numbers of BAME hospital admissions and deaths from COVID-19, alongside the data on health and social care staff affected. No data aggregated for ethnicity has been released for Scotland as yet. Scotland records ethnicity on death certificates, but England and Wales do not. Collecting data is vital to addressing health inequalities immediately and in the aftershocks of the pandemic and recovery. The collection, or lack of collection, of data is inherently political as it shines a light on which parts of society are of most concern.

There are concerns that the government’s recently launched contact tracing programme is unfit for purpose. As lockdown restrictions are eased and businesses start to reopen, we fear for what this will mean for the communities already at grave risk from contracting the virus. The Ubele Initiative will be hosting a conversation on 17th June to explore whether this programme will meet the needs of BAME communities across the UK.

PUBLIC HEALTH ENGLAND’S REVIEW LACKS TRANSPARENCY AND ACCOUNTABILITY

On May 4th, PHE announced their review will be taking place with results expected at the end of May. The aims of this review were to identify and present disparities in infection, hospitalisation, and mortality; describe the impact of age and sex on cases and outcome; quantify disparities in excess mortality; assess the underlying health conditions’ impact; analyse the link between occupation and infection; recommend further action to reduce disparities. The Chief Medical Officer for England, Professor Chris Whitty, asked for a targeted focus on the disparities for BAME people, but PHE have insisted they look broadly at all disparities. However, we know from history that if disproportionate relief is not given to those disproportionately affected, the problem will not be addressed. Having concrete data that highlights the disparities would be the first step to understanding and mitigating the disproportionate rates. It is also of note that the objectives of the review do not make reference to the difference in treatment and care given to BAME patients.

The government released the review without press alert after an initial delay, which they cited was due to fears that its findings on BAME communities would further stoke racial tensions in the wake of recent Black Lives Matters demonstrations. This rightly drew significant criticism, as did the review itself, for producing information that is already known to BAME communities and experts on the disproportionate impact of the virus, with no recommendations or action plan to address these whilst the risks to people’s lives are ongoing. Ahead of its publication, we had concerns that structural racism and socioeconomic inequalities that disproportionately affect BAME communities would be left out of the report, which they were. Our full response and thoughts on what the charity sector should take away from the review can be read here. 

Since then, it has emerged that additional elements to the report have been withheld, including evidence from 4,000 parties containing first-hand experience and the recommendations resulting from this engagement, such as calls for culturally competent occupational risk assessment tools for key workers, and that recovery strategies actively seek to reduce racial inequalities. Rehana Azam, GMB union’s National Secretary for Public Services, has described the handling of the review as “going beyond mismanagement of the crisis and has stepped into institutionalised racism”. Public Health England have said that this information will be belatedly published the week commencing 15th June.

The We Need Answers campaign is calling for an independent public inquiry, which would cast a wider net than the PHE review to consider the longstanding structural injustices that continue to negatively impact BAME groups in the UK and which have contributed to their increased likelihood of contracting and dying from the virus.

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