Karim Mitha, Kaveri Qureshi, Shelina Adatia, and Hiten Dodhia
As of December 21 2020, over 2.1 million individuals in the UK have tested positive for COVID-19, with approximately 76 000 deaths with the virus registered as a cause. The UK is in the midst of its second wave. Areas in England are now entering, and parts of Scotland are due to enter, the highest level of Tier 4 restrictions in response to a mutation of the COVID-19 virus increasing transmissibility. This is on the heels of what seemed a positive turn in the evolution of the pandemic with the approval and roll-out of the Pfizer vaccine in early December.
Yet, the effects of repeated lockdowns, and plans for the dissemination of vaccines, call in question issues of equity amongst those most marginalised. Indeed, as substantial commentary from the first wave noted, we are not really “all in this together” and many groups, including minority ethnic communities, have suffered disproportionately health, social, and economic impacts of COVID-19.
According to Fenton, Public Health England data from mid-September – when a second lockdown was first suggested by SAGE – showed that the highest rates of COVID-19 cases were in the Other Ethnic group (1737 per 100 000) and Pakistanis (1487 per 100 000). Those from White backgrounds have the second lowest rates (490 per 100 000 population). Data from ICNARC up to 22 October 2020 showed the substantial effect of deprivation with more than three times the number of critically ill cases in the North, North East, and Midlands coming from the most deprived backgrounds.
Mortality data from the first wave showed BAME individuals were of a younger age group (Oxford Covid-19 Data Service; ICNARC; Zakeri at al) and required greater critical care support (ICNARC; Pan et al). Even after accounting for comorbidities and deprivation, the disproportionate burden of disease remained amongst ethnic minorities, with Black groups at greater risk of hospitalisation and Asian groups of mortality (Zakeri at al). Data from Public Health Scotland were similar, showing individuals of Asian origin having twice the rate of admission to critical care and death (see, also, Chaudhry).
In the first wave, several hypotheses explaining racial/ethnic disproportionalities emerged, focusing on more proximal levels of causation. For instance, ACE-2 inhibitors may increase the risk of acquiring SARS COV-2 with an interaction effect in certain ethnic groups where risks of COVID-19 are higher despite the use of ACE-2 inhibitors (Hippisley-Cox et al). ICNARC showed a greater proportion of admitted cases from those who were obese (BMI > 30); yet, amongst minority ethnic individuals, a greater proportion were admitted to the ICU with a lower BMI than White British. Those with lower BMIs were more likely to die in critical care. Interestingly, the same report showed, there was some evidence to suggest that ethnic minorities in the least deprived areas were less likely to be admitted to ICU (0.4x) than White British.
Public Health England’s initial report into examining ethnic inequalities in COVID-19, highlighted the extent to which these were related to underlying socio-economic inequalities. The accompanying report recognised the relevance of ‘the social and structural determinants of health’ (p.20). Nevertheless, the narrow, biomedical focus of the second report’s headline messages, and its references to factors such as ‘diet’ or Vitamin D (p.8), detracted from a coherent focus on the social and structural determinants.
Reports published by the Race Disparities Unit of the Government and for the Opposition by Lady Lawrence in October both denied and attributed, respectively, structural racism as a contributing factor to COVID-19 mortality and morbidity amongst ethnic communities. Both reports agree that the disproportionality is connected to factors such as type of work, place of residence, and pre-existing health conditions. However, the Government’s report did not provide any explanation as to why ethnic groups should be disproportionately placed in higher risk environments, neglecting the ‘differential access to the goods, services and opportunities of society by race’ (p 1212). It appears the Government’s focus has been to attribute causality to more proximal ‘causes’ while negating the wider, macro-social environmental influences which, for Dahlgren and Whitehead, are the elementary principles of public health. Indeed, Williams and Mohammed and Nuru-Jeter and colleagues have explained racial/ethnic disparities in health connecting the distal and proximate causes.
As noted by Bambra and colleagues, and emphasised in the Lawrence Review individuals from ethnic communities are disproportionately overrepresented in lower-paid and lower-skilled jobs, leading to heightened exposure to the virus and greater loss of income as a result of COVID-19 control measures. Individuals from ethnic groups are less likely to be part of trade unions, limiting their ability to collectively change workplace environments.. Ethnic minority communities may also experience poorer quality of care – lack of culturally-appropriate communication, misrecognition in symptom presentation, and systemic discrimination.
The Government’s endorsed recommendations, including the need to provide culturally sensitive communications, are not incorrect, but they fail to address fundamental causes. While rectifying generations of structural racism may be an arduous ask, several short-term actions can buffer ethnic communities from these fundamental causes. For example, the Hostile Environment policy and limitations of ‘No Recourse to Public Funds’ mean that some migrants are ineligible for benefits or support services to support self-isolation. Both Independent SAGE and the Lawrence Review spoke of the necessity of workplaces to ensure risk assessment processes take into account comorbidities/underlying conditions amongst staff,. The Government must also take ownership regarding its engagement strategy, involving communities in decision-making about realistic protective measures. For instance, the Lawrence Review noted that ethnic minorities were seven times more likely to be fined for breaking lockdown restrictions than White individuals. Yet, the Government fails to adequately acknowledge why, choosing instead to outlaw the use and teaching of critical race theory. This closing down of debate and discussion is particularly problematic as, to ensure fair deliberative process, “process is the point” .
As Bambra and Horton have noted, COVID-19 must be considered a syndemic. As expressed by UN High Commissioner for Human Rights Michelle Bachelet, the COVID-19 pandemic has “fallen off a deep social and economic crisis fuelled by discrimination and inequalities that existed before the pandemic”. Efforts to reduce transmission must focus on risk minimisation amongst communities at higher risk, and address institutional and structural racism. This is particularly important given vaccine deployment – where high-risk groups are also the most reluctant to access mainstream services and get vaccinated. Phelan and Link remark “understanding racism as a fundamental cause of health inequalities is important because the fundamental cause must be addressed directly” (p.325). The Faculty of Public Health’s position statement endorsed on 21st December 2020 declaring “racism is a public health crisis” outlines strongly that public health has a role to play in addressing issues of racism as influencing health inequalities. By addressing racism, and its syndemicity with COVID-19, we can protect our most vulnerable and marginalised communities.
Karim Mitha is Speciality Registrar in Public Health Medicine at Imperial College NHS Healthcare Trust, an instructor at Edinburgh Medical School, and a PhD Candidate in Sociology at the University of Glasgow. Kaveri Qureshi is a lecturer in Global Health Equity at the University of Edinburgh. Shelina Adatia is a PhD Candidate in the Faculty of Education at the University of Ottawa. Hiten Dodhia is a Consultant in Public Health Medicine at Lambeth Council and an instructor in the School of Population Health and Environmental Sciences at King’s College London.