Silver Linings Handbook: Tips for the Covid Cohort 7 - Covid Inequalities

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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) Populations:

From my (Silas’) experience of a particular day in intensive care, it was no coincidence that 12 of the 16 patients intubated and ventilated with the virus were from Black and South Asian communities. Analysis of excess deaths in England found that when compared to the general population, you were between 2 and 3 times more likely to die if you were Bangladeshi or Pakistani and over 4 times higher if a Black African.

It’s an established fact that studies of the human genome consistently find more variation within racial groups than between them. Therefore these differences are much more likely explained through inequitable social determinants of health and the deeply entrenched structural racism that perpetuate them, than inherent differences in physiology. In employment terms, ethnic minority groups in Britain are already more likely to work in insecure, low-paid work, and more likely to be unemployed. Within NHS hospitals BAME populations are more likely to work as porters and cleaning staff, who are predominantly employed by outsourced private companies. Their meagre statutory sick pay (less than £100 per week) is not a sustainable income for those living with a family in London. This meant that many working in these roles had to come into work despite the risk of infection, often without the same access to PPE or infection control training, to put food on the table. It is a tragic injustice that three members of the cleaning staff in my hospital, all from ethnic minority groups, died from Covid-19.

In terms of housing, BAME populations live in more than half of all overcrowded households in the country but make up less than 15% of the population. They have 11 times less access to green spaces and also are more likely to live in multi-generational homes. So it is not hard to see how there was increased exposure to the virus in these groups.

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.

Mental Health:

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.

Older Adults:

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.

Conclusion:

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 doors.

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.

Further Reading:

Health inequalities:

The Status Syndrome: How Social Standing Affects Our Health and Longevity, Marmot, Michael
The Health Gap: The Challenge of an Unequal World, Michael Marmot
The Spirit Level: Why Greater Equality Makes Societies Stronger by Richard Wilkinson and Kate Pickett
The Immortal Life of Henrietta Lacks, Sloot, R.

Societal inequalities / BAME experience -

Natives: Race and Class in the Ruins of Empire, Akala
Brit(ish): On Race, Identity and Belonging by Afua Hirsch
The Good Immigrant by Nikesh Shukla
Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Washington, H.