We don't need another review of evidence, covid-19 has showed we need concrete action to tackle racial health inequality, argues Mona Kamal
We know that we live in a fundamentally unequal society. This is not news, but what the Covid-19 pandemic has done is highlight the pervasive nature of these social and racial inequalities and how they manifest in very tangible ways in our physical wellbeing and health outcomes. Health inequalities are why those with black or brown skin who live in the US or UK are likely to have poorer health on average than their white counterparts and this exists across many different health outcomes: mental health, obstetric complications, infant mortality rates, cardio-vascular disease and diabetes.
What we are now seeing is that the likelihood of contracting the Covid-19 virus, the likelihood of becoming more critically unwell from it and your risk of mortality are all undeniably worse if you are from a BAME background. Right now a third of all patients lying in intensive care units on life support are of black and ethnic minority background (despite the fact they only make up 14% of the population) and the death rate among Black British and British Pakistani groups from coronavirus in England is 2.5 times that of white counterparts. This disparity also exists within the population of NHS workers: all of the first ten doctors to be named as having died from coronavirus in the UK were from ethnic minority backgrounds and of the total number of NHS workers who’ve died from it, almost three out of four are BAME.
There have been lazy attempts to attribute this to genetic differences but there is no evidence of this. Ethnicity is a complex socio-cultural construct which has no known genetic basis. If we want to understand the mechanisms by which this has happened it has to be based on our knowledge of how health inequalities work as well as what we know about this virus. When it comes to inequalities in health outcomes the most important factors are not genetic, but socioeconomic.
Mechanism of Health Inequalities and the Social Determinants of Health
It is well established that Black, Asian and other ethnic minority communities are more likely to work in lower-paid jobs, live in more densely populated areas and more crowded housing. It is also a fact that they face greater delays in accessing healthcare and struggle to access public health information. When it comes to Covid-19, understanding the impact of working conditions is particularly important to understand why it is BAME NHS staff have been so disproportionately impacted. There are clear unequal divisions of labour across society and this is no different in the NHS. So my colleagues who are in the lower paid riskier jobs are more likely to be of BAME backgrounds. The more junior healthcare assistants, the cleaning and domestic staff, the porters and junior care work assistants on casualised contracts, all are much more likely to be of BAME origin than not. Essentially we have a situation where BAME individuals in the NHS are concentrated in the roles that are more physically unsafe, more likely to be in the frontline patient facing jobs (rather than the more senior managerial roles where distancing or working from home is an option) and so they are more likely to be exposed to risk and occupational hazards.
We also know that a significant proportion of these key workers have, during a decade of austerity been hit the hardest. In London NHS trusts, staff members can be earning below the London living wage and there is no question that the anxiety of not being able to provide for their families on such punishingly low income or on the wholly inadequate statutory sick pay of just £94.25 a week, will impact physical wellbeing. Crucially, it is again BAME staff that are much more likely to be the domestic staff, porters and security guards who are enduring such conditions.
Even among clinical staff, it is BAME individuals who are most likely to be in the junior lowest paid roles. In fact there are more BAME nurses in the very lowest pay band (known as a band 5) than in any of the higher pay bands combined. And because they are more likely to be in the more junior more precarious positions, we know they are less likely to raise concerns about their working conditions.
Furthermore, BAME staff are disproportionately more likely to be in jobs that are precarious where they are at the mercy of insecure labour conditions. It is important to note this is the result of outsourcing, so security guards and cleaning staff (who are almost entirely of black African background in my trust) are not employed under NHS terms and conditions but under Sodexo who, according one of the domestic staff I spoke to, immediately reduced sick pay to the statutory minimums and cut the annual leave entitlements of the cleaning staff after being awarded the contract.
What we know from the work of epidemiologists most notably Michael Marmot, the combination of work that is both extremely physically demanding and where the individual feels powerless to exercise power or control over that work, these are the optimal condition for development of illnesses such as high blood pressure, heart disease and diabetes – all those chronic illnesses that we know increase your risk of developing more severe forms of Covid-19 infection and increase your risk of dying from it.
We know already that the most at risk groups are not only the elderly but those with chronic underlying illnesses such as cardiovascular disease and diabetes in particular and these are precisely the conditions from which you are more likely to suffer from the more socially and economically disadvantaged you are. So the social inequalities experienced by BAME individuals in particular can directly cause physical illness and then these vulnerabilities are further compounded by income inequalities which result in poorer nutritional states and poorer quality housing which all increases your risk of contracting and then becoming more severely unwell from this virus. What we have therefore is a wholly predictable perfect storm of health and social inequalities which are being evidenced very clearly in the significantly higher mortality rate among BAME individuals.
What is crucial to remember is that none of this is new, we have known about the health inequalities and social determinants of health since the 1950s and despite that we as a society continue to enact economic policies which widen and further entrench these inequalities further.
It cannot be overstated that our NHS is held up by the work of migrants and BAME staff. More than half of all the NHS staff who have died from Covid-19 were born abroad. These are individuals who have come to this country and faced all the hardship and disadvantage that comes with migration and scapegoating by this government, all the while providing genuine service to their communities through the essential work that they do, and then they and their families are made to pay to access NHS care when they need it and furthermore are not guaranteed leave to remain in the country.
A very achievable key demand that we need to be making now is an end to the NHS surcharge which is the £624 that migrants must pay annually to receive treatment in the NHS. A measure that was brought in by the Conservative/Lib Dem coalition government, it has caused unnecessary hardship for thousands of families who are falling into debt because of the charges or are refusing to present to health services altogether when they need to as they cannot afford it.
The government has announced plans to give the families of NHS workers who have died whilst at work indefinite leave to remain and of course we should welcome this but we should be demanding that this be extended to all NHS staff and their families. It is shameful that a family of immigrants must wait to lose a loved one in service to be allowed to remain in the country.
We also must demand an end to the appalling punitive practice of NHS trusts being required to forward the details of patients who are migrants to the home office, information which the home office then uses for the purposes of immigration enforcement or to enable chasing down patients to pay their healthcare debts. Patient information must never be used in this manner and what it creates is fear and unwillingness among patients of immigrant backgrounds to present to health services and ask for the treatment they need. This is unacceptable at all times but during a pandemic of an infectious disease it is potentially catastrophic.
Matt Hancock has not promised an enquiry into the disproportionate impact that the Covid-19 pandemic has had on BAME communities, all that is being suggested is a ‘review of evidence’. But it is not more reviews and investigations that we need, what we need is to be acting on the evidence we already have and begin addressing the widening inequalities that exist which are quite literally cutting short the lives of the poorest and most disadvantaged in our communities. We have known about the mechanisms by which socio-economic inequalities including race, impact health from as far back as 1950s and despite that we as a society are moving in a direction which is widening those inequalities through programs of punishing economic austerity and what we must demand now is a new social contract to address these inequalities and their pernicious effects once and for all.
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