Silver Linings Handbook: Tips for the Covid Cohort 7 - Covid Inequalities
Before the pandemic really struck, a spotlight was
already being shone on the stark inequities of the social determinants of
health in England. Marmot’s Health Equity in England Report, published the same month as the first confirmed cases of Covid-19 in the UK, made for bleak reading. Since 2010, life expectancy has stalled nationally (for the first time since 1900) and has even declined for the most deprived groups in society. Boys and girls born into the poorest ten percent of the population are expected to live 19 fewer years in good health than if they were born in the richest 10%. Covid-19 is already widening these stark inequalities, dispelling the myth espoused by the government, of the virus as a “great leveller.”
The Health Foundation describes trying to
understand the impacts of Covid-19 on social inequalities as like looking through a Kaleidoscope - a plethora of interconnecting and constantly changing factors related to wealth, ethnicity, employment, gender and more. To examine these further, we have tried to separate out the most striking examples of the "Covid-19 inequalities."
Black, Asian and Minority Ethnic (BAME)
I think these statistics prove that housing and
employment policies are health policies and also represent part of the
structural racism that has allowed for such a shocking disparity in deaths
between white people and people of colour. It is undeniable that these figures
stem from a political system which is structurally racist. To understand this,
we, as doctors, have a duty to study social science (which has never been
easier with the plethora of amazing resources being shared around the Black
Lives Matter movement.) We have a duty to challenge our own conscious and unconscious
biases and privileges that affect the way we think and work.
The United Nations has warned that Covid-19 is
sowing the “seeds of a major mental health crisis” and over the last few months, I (Silas) have been seeing higher numbers of people in mental health crises or following self-harm attempts attend the emergency department where I work. The isolation, fear and uncertainty that the disease and the subsequent lockdown has created is likely to have a lasting impact on the nation’s mental wellbeing.
One in four of us is said to suffer from a mental health disorder. Those with existing mental health problems will have faced considerable challenges due to the abrupt closure and interruption to mental health services whilst the country went into lockdown and the NHS channelled its resources into emergency and intensive care settings. Mental health charities have expressed great concern for individuals who were already struggling to gain access to services or who had a poor interaction with them prior to lockdown. Their worry is that these groups will be particularly vulnerable to mental health challenges in the long-term if cuts occur after the pandemic, making their participation in interventions and therapies even more precarious.
As well as affecting those with existing mental
health conditions, there is also likely to be a spike in new diagnoses. Studies have found that those living in isolation or incarceration (or an imposed government lockdown) are more likely to present with psychotic disorders, while those suffering from financial and employment insecurities (as happens in a newly
announced recession) are at risk of mood disorders.
According to the Centre for Mental Health’s most recent briefing paper, certain societal groups appear at high risk of the long-term mental health consequences of Covid-19, and therefore will require the most urgent attention. These are members of the BAME communities, adults and children experiencing domestic violence or abuse and older adults.
BAME Mental Health:
In the UK, people who belong to Black British,
Black African, Bangladeshi or Pakistani backgrounds are known to have the worst access to mental health services. Many individuals from BAME backgrounds were already finding it hard to access culturally appropriate mental health services prior to the pandemic. Young people from Black communities are more likely to have negative interactions with NHS mental health services and typically feel like these services are not safe or are unable to meet their needs. Instead, they fare better in small, informal settings which are more holistic. These types of service tend to be run by third sector providers or grassroots organisations and find themselves at the highest risk of closure during an economically volatile situation like the current one.
Domestic Violence Victims:
Almost one in three women will experience physical
or sexual violence in their lifetime. Refuge, a domestic abuse charity, has
reported a tenfold increase in the number of visits to their website
during the lockdown. It is a grim fact that people who suffer from mental illness are at greater risk of experiencing domestic abuse, which only further degrades mental wellbeing. Access to health and social services, as well as the shelters and charity helplines that provide support and protection for victims of abuse, were severely disrupted during the pandemic.
Experiences of abuse can lead to PTSD, depression,
alcohol and substance abuse, and risk of suicide. If mental health services do
not become more accessible, the vast majority of those living with domestic
violence will continue to suffer in silence.
The elderly population has been severely impacted
by both Covid-19 and the UK lockdown measures. PHE released data which showed
that those over the age of 80 are 70 times more likely to die from Covid-19 than people under the age of 40. The Office for National Statistics (ONS) reported that the majority of older adults are living with worries and anxiety as a result of this. Social distancing is also a major cause of loneliness, particularly in nursing and care homes, and is an independent risk factor for depression, anxiety disorders and suicide. Mental health care needs to be age-appropriate and take into account the uniquely challenging situation that the oldest and most vulnerable members of society find themselves in.
As doctors, who have spent years learning
physiology and pharmacology, we often try to find biological explanations for
differences in mortality and morbidity, because they are easier for us to
compute and also to try and resolve through medications and surgery. But it is
undeniable that these stem from a sociopolitical system which perpetuates deep
unfairness across society. The negative health effects of these inequalities
often far outweigh the good we can do when a patient reaches us at the hospital
Covid-19 is already widening the gap between those
privileged enough to access quality education, housing, employment and
healthcare - and those who do not. As advocates for our patients, we need to
take action. We need to use our platform as doctors to speak out against
hospital and national policies which discriminate against the most vulnerable
sectors of society, people whose voices are so often unheard.
Status Syndrome: How Social Standing Affects Our Health and Longevity,
Health Gap: The Challenge of an Unequal World, Michael Marmot
Spirit Level: Why Greater Equality Makes Societies Stronger by Richard
Wilkinson and Kate Pickett
Immortal Life of Henrietta Lacks, Sloot, R.
inequalities / BAME experience -
Race and Class in the Ruins of Empire, Akala
On Race, Identity and Belonging by Afua Hirsch
Good Immigrant by Nikesh Shukla
Apartheid: The Dark History of Medical Experimentation on Black Americans
from Colonial Times to the Present. Washington, H.
By Silas Webb
(@silas_webb) and Jessica Gjeloshi