Covid-19 and BAME deaths: A call for action

Black, Asian and Minority Ethnic (BAME) deaths

Three of the four NHS workers reported to have died from Covid-19 in Oxfordshire to date were from a BAME background.^[1] The first ten doctors to die of Covid-19 infection were BAME, many of them born outside the UK. This situation among health workers^[2] reflects the pattern for deaths in the general population – the ONS has just found that Black people in the UK are four times more likely to die from Covid-19 than White people^[3] – as well as for deaths among people working in the NHS (including outsourced workers) and, probably, care workers.^[4]

Health and economic inequality sustained by structural racism, and exacerbated by austerity and privatisation of the welfare state, is the cause. The Covid-19 pandemic has highlighted the extreme racial and class inequalities in the UK.^[5]Michael Marmot’s recent Ten-Year Review of inequalities highlights straightened circumstances and poor life chances, and moves away from focusing on the behaviour of individuals. Marmot and the UN Special Rapporteur on Racism remind us of the austerity context within which the current pandemic is taking place, with the UN Rapporteur stating that ‘austerity measures in the United Kingdom are reinforcing racial subordination.’^[6]

NHS England and Public Health England and their leaders must be held to account.^[7] The current inquiry to be led by the very bodies being investigated is not adequate. We must hold the Government to account for running down the public sector and undermining the NHS and its capacity to deal with pandemic, for its response to the pandemic, and for exploiting the situation to further privatise the NHS.^[8]

An effective enquiry into Black, Asian and minority ethnic deaths must be based on serious analysis of the interlinked socioeconomic and structural factors that may be involved and an understanding that racism adversely affects health even when these factors are accounted for.

The socioeconomic effects of racism include:

Longstanding structural discrimination in employment:

Low paid, insecure work with an overrepresentation of BAME workers in health and social care and allocation to higher risk roles.^[9]
The effects of racism persist amongst medics – and, though less research has been done on this, presumably amongst all workers in the health and care sectors – with the evidence that BAME doctors are much less likely to make complaints around safety due to a fear of recrimination.^[10]
Frontline, ‘key worker’ roles which do not permit working from home, with relative poor access to limited PPE.
The gig economy, and in jobs in domestic work, cleaning, childcare, small retail and family businesses. The economic packages allow many in these groups to fall between the gaps and make shielding for high risk workers and their families impossible.
Poorly protected outsourced jobs often with low union membership: the true impact of the policy of privatisation of public services and utilities needs to be investigated. This investigation must cover employment and NHS trust practices, policies and guidelines around the health and safety of all workers on their sites, not just those in their direct employment.
The lack of clarity about what constitutes a ‘vulnerable’ worker who should be shielding further increases the risk of pressure on less favoured groups in the population.

Structural discrimination in housing and access to healthcare with:

Relative overcrowding in housing compared with White households.
A high proportion of BAME communities in densely populated urban areas of deprivation with (per person) under resourced health and social care facilities and higher levels of air pollution.

Factors relating to migration include:

Whether a person was born outside the UK: 53 of 64 BAME Covid-19 deaths among NHS staff in one study were of people born outside the UK.^[11]
Immigration status: some overseas workers fear losing their jobs and may feel driven to accepting additional risks.

Some continue to propose various biological explanations for the prevalence of BAME Covid-19 deaths. Such evidence must be robustly scrutinised and not allowed to distract the focus on the overwhelming socioeconomic causes and the urgent need to address structural racism.

Action

Urgent tasks

The most urgent task is to reduce all deaths from COVID-19 through adequate provision of personal protective equipment (PPE), workplace practices that minimise risk, and physical distancing. Workers have the right not to work in unsafe conditions and employers have the duty to ensure safe conditions. A working, effective system to trace infection routes must be part of any loosening of lockdown. Local public health teams must be restored to deliver this.^[12] All the evidence so far points to the fact that centralised privatised solutions have failed us.

Research

A programme of research is urgent to clarify the main factors and provide the basis for new policy. Ethnicity must form part of data collected by health and care services.^[13]

Health and Safety Executive guidelines and definitions in analysing workplace deaths, and procedures for investigating workplace deaths, need to be strengthened to keep workers safe and protected. Currently NHS trusts are left to assess themselves – a clear conflict of interest.

Beyond immediate tasks

The government’s hypocrisy must be challenged. Boris Johnson’s government has promised to ‘level up’ areas where health has deteriorated. Oxfordshire County Council leader and chair of the Local Government Association’s community wellbeing board, Ian Hudspeth, called the Marmot report a wake-up call: ‘Councils want to work with government on closing this gap… . Sustainable, long-term investment in councils’ public health services is also needed.’^[14] Just one week later, on 4 March, a majority of MPs voted not to call on the Government to end austerity, invest in public health, and implement the recommendations of the Marmot review.^[15] Opposition parties must be unrelenting in denouncing this hypocrisy now.

The Runnymede Trust’s proposal^[16] to introduce the socioeconomic duty, making class an ‘equality ground’ should be supported. This would return to the situation before 2010 when Theresa May scrapped the legal requirement designed to make public bodies try to reduce inequalities caused by class disadvantage (the socioeconomic duty).^[17]^[18]

Migrant workers are the lifeblood of our NHS, our care system and our society. The hostile environment must end now. That means granting indefinite leave to remain to all NHS and care workers and their families, and abolishing a) ‘no recourse to public funds’ barriers to health and other services, b) charging migrants for NHS treatment, c) charging migrants a health surcharge on top of their income tax, and shutting detention centres.

Action is necessary to end health inequalities. The Marmot Review’s recommendations must be implemented with race as a ‘social determinant of health’ as put forward by the Runnymede Trust. Inadequate public health expenditure and ‘shrinking the state’ disproportionately affect poorer people including our BAME communities. More ‘austerity’ to ‘pay for’ the pandemic is not an option as austerity widens the health inequalities that lead to disproportionate BAME Covid-19 deaths.

This briefing gives rise to a number of issues to be taken forward in national and local investigations which we will be pressing Trusts and Local Authorities to undertake.

Oxfordshire Socialist Health Association Committee

May 2020

^[1] Oscar King and Elbert Rico, porters, and Philomina Cherian, nurse, at the John Radcliffe Hospital, Oxford, and Margaret Tapley at Witney Community Hospital.

^[2] https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article

^[3] https://www.theguardian.com/world/2020/may/07/black-people-four-times-more-likely-to-die-from-covid-19-ons-finds

^[4] ‘Death rate among black and Asian Brits is more than 2.5 TIMES higher than that of the white population, reveals stark analysis by Institute of Fiscal Studies’, Daily Mail, 1.5.20:

https://www.dailymail.co.uk/news/article-8276097/Clear-disparity-ethnic-groups-Covid-19-deaths-IFS-study.html;

Office of national Statistics: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19bylocalareasanddeprivation/deathsoccurringbetween1marchand17april

^[5] https://morningstaronline.co.uk/article/coronavirus-highlighting-extreme-racial-and-class-inequalities-–-let’s-vow-end-them

^[6] https://hjt-training.co.uk/un-special-rapporteur-criticises-hostile-environment-policy/

^[7] http://www.irr.org.uk/news/institutional-racism-in-the-nhs-intensifies-in-times-of-crisis/

^[8] https://www.theguardian.com/business/2020/may/04/uk-government-using-crisis-to-transfer-nhs-duties-to-private-sector

^[9] https://metro.co.uk/2020/04/21/nhs-puts-pressure-ethnic-minority-staff-work-coronavirus-wards-12589058/

^[10] https://www.theguardian.com/society/2020/apr/10/uk-coronavirus-deaths-bame-doctors-bma.

The February issue of the British Medical Journal was devoted to the subject of racism in medicine: https://www.bmj.com/racism-in-medicine

[11] https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article

^[12] https://www.theguardian.com/world/2020/apr/26/to-tackle-this-virus-local-public-health-teams-need-to-take-back-control

^[13] ‘Ethnicity and COVID-19: an urgent public health research priority’, Lancet: https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930922-3