Covid-19, racism and the roots of health inequality

Key:

HM: Helen McKenna
NC: Natalie Creary
JN: James Nazroo

HM: Hello and welcome to The King’s Fund Podcast. I’m Helen McKenna, a Senior Fellow here at the Fund and I’m going to be your host for this episode. Today we’re going to be talking about the disproportionate impact of Covid-19 on Black and ethnic minority populations. We’ll be looking at what the data tells us about how these groups are affected and how this varies between different communities, as well as exploring some of the factors that might be driving these differences. We will also look ahead and discuss what needs to happen next in terms of service recovering mitigating the longer-term impact of Covid-19 and tackling some of the wider issues that lie at the heart of what we’ve seen to date.

I guess, just a note at the start about terminology, we know that the language we use to discuss these inequalities is important. We’ve chosen to use the term ethnic minority to refer to people belonging to ethnic groups that are in the minority in the context of the population of England, unless we are referring to data that has been collected using different terminology, but we also recognise that ethnic minority groups are not homogenous and that there are differences between them and how they have been affected by Covid-19 and we’re hoping to look at some of these differences in today’s episode.

To help us look at these questions, I’m joined today by two fantastic guests, Natalie Creary of Black Thrive and Professor James Nazroo of the University of Manchester. Before we get into our discussion, can I ask you each to introduce yourself to our listeners and tell them a bit about what you do? Natalie, let’s start with you?

NC:  Hi, so I’m obviously Natalie, the Programme Delivery Director for Black Thrive. We’re a partnership between local communities, the voluntary sector and statutory and private sector organisations that work together to look at how you reduce mental health inequality that’s experienced by Black people in Lambeth and our work looks at how you improve Black people’s access to services, their experience of them once they’re within the system but also thinking about the prevention piece in terms of what is it that we can do when we’re thinking about the wider determinants or the social determinants of health, how can we reduce inequality in those areas in order to minimise the impact that it has on the mental health outcomes of Black people.

HM: It’s great to have you with us Natalie and James?

JN: Thank you Natalie, great to be here, my name is James Nazroo, I’m a Professor of Sociology at the University of Manchester. My research and policy work focuses on inequality and particularly inequality in health and within that, particularly inequalities in relation to ethnicity. My approach really is to think about how the social and economic inequalities faced by ethnic minority people shape their health experiences and their encounter with health institutions and really trying to centre experiences of racism in this to show how racism shapes people’s experience of inequality and inequalities in health.

HM: Well thank you James and Natalie for joining us today. So, I want to start by looking at what the data shows in terms of the impact of Covid on different minority ethnic groups and obviously in particular recognising that these groups aren’t homogenous and should be treated as such. We’ve had data analysis from the office of national statistics and Public Health England and both of those have shown variation across a range of characteristics, including age and sex and deprivation amongst other things but what’s particularly stark is the disproportionate impact Covid-19 has had on Black, Asian and minority ethnic groups. James can you talk us through what the data shows?

JN: Well, maybe I’ll just step back from giving detail and just talk about the broad pattern. So, the data do show, as you’ve described, marked inequalities and outcomes in relation to Covid-19 both in terms of risk of infection, in terms of risk of complication and in terms of mortality. Not surprising findings, although they are very shocking, not surprising findings, so perhaps it is a little unexpected to find that the public health community was not ready for these findings and indeed didn’t even uncover them themselves but were confronted by those findings by public and media concern but nevertheless, not surprising, shocking findings. Of course, as you suggested Helen, there are variations in the risk across different ethnic groups with some groups having higher risks than other groups. What is crucial here is apart from one group, Chinese women, who bizarrely or surprisingly, unexpectedly don’t have a higher risk, all other groups do have a higher risk including white minority groups. What characterises this is that these are groups that have been negatively racialised in our society. So, we need to ask ourselves what it is about the consequences of this negative racialisation that results in inequalities that then shape experiences of Covid-19. But the crucial point to make here I think is that this is not unexpected, this maps on very well, mirrors other studies that have shown ethnic inequalities in health.

HM: That’s really helpful, thanks James and so clearly it’s not quite the great leveller that some people were describing it as in the early days of this pandemic. Natalie, before we get onto the factors that are driving these differences, that James alluded to some of those just now, obviously your work at Black Thrive centres on Black communities living in Lambeth. Does this data align with what you’re seeing at a local level?

NC: Yes, so I think I’d probably echo what James said in terms of actually communities were raising the alarm in terms of the impact that Covid was having on them before they decided to look at the data and I think that that in itself is always quite interesting, that we have to wait for the stats to come through before we actually listen to communities. I think one of the challenges that we are having locally is the generally poor collection of equalities data which is making it quite difficult for us to really understand what’s happening in a timely fashion. So a lot of the questions that we have, we’re having to go back, or the system is having to go back retrospectively to collect that data in order to be able to answer some of the questions that we have, which is really quite disappointing and I think one of the lessons from this really needs to be that there is no excuse not to collect equalities data in a robust way.

HM: And in fact, I was going to come onto this in a bit but one of the recommendations from the second Public Health England review was around collecting better data but it’s clearly an important gap, how bad are we at the moment in terms of the data that we collect?

NC: With our work at Black Thrive, poor data quality has been a challenge for us in some areas around being able to even assess the experiences and the outcomes for Black people in some services but through our work, because we have started asking that question, it has encouraged services to be better at doing that but I think Covid-19 has highlighted that there is still quite a long way to go and I think for us, it’s not just about collecting the data, it’s about what do you do with it afterwards? I think that ensuring that you have fast paced mechanisms to actually respond to that data is also the critical point, because I think a lot of communities are now a bit tired of us describing the problem and telling us how awful things are for us because we know, because we live it. So, collect it so that you know how to invest and focus your resource but please make sure that you actually do something about it.

JN: I think Natalie is making some really, very, very important points here. One is about the quality of data that we get, we collect. There are two other really important points, one is that the data need to be accessible and at the moment, much of the data that are being used by public health officials to describe the extent of ethnic inequalities in relation to Covid-19 or other health conditions are not available for broader public scrutiny and other forms of data are just not collected. Then the really crucial point, we need to go beyond collecting data and to describe differences, to describe inequalities and begin to use these data to monitor our progress in addressing inequalities.

NC: It’s also how we describe them and also it’s the context that we provide for this data because just providing information that, for example, in the context of Black communities that Black people’s outcomes are poor, without providing the context of structural racism and how that shapes our outcomes, I think is a real issue because you leave the person reading the article or the report to come to their own conclusions and assumptions about why that issue arises. So even when we’re thinking about, people from lower socio-economic groups, immediately people tend to locate the issue with the individual, with their community, they’re not well educated, they don’t have good jobs and so when you’re thinking about it in terms of from a policy or the perspective of trying to develop an intervention, you try to fix the person rather than trying to fix the system, that shapes their choice, that shapes their agency and so these are the things that we really need to make sure that when we are reporting them, that we provide that context.

HM: Thank you, I think James when you were unpacking the data a bit in a high level, it was clear that there are at least two very distinct things that were being highlighted, first that the risk of testing positive for Covid-19 is higher in people from minority ethnicities than white people and second that after contracting Covid-19, people from minority ethnic groups are much more likely to get severely ill and die compared to the majority white population. I know there is a lot that’s still unknown about this illness but Natalie and James, what do we know so far about what’s driving the higher risk for people from minority ethnic groups to test positive for Covid-19? Is it that these groups are more exposed to the virus and if so, why?

JN: There is the clear possibility that ethnic minority people are more likely to be exposed to the virus. There’s a question about testing programmes and how they operate, how representative they are and so on but regardless of that I think there is a clear chance that ethnic minority people are more likely to be exposed to the virus, to contract the virus because of where they’re employed. They’re employed in sectors that increase their exposure to Covid-19 like transport and delivery, security, cleaning, healthcare, social care and so on, the key services.

HM: And that’s where you’re in a greater risk of contracting the virus?

JN: Yes, because you remain active throughout a lockdown period and you remain as part of your working contact with other people and therefore are more likely to be infected. Then there’s also things like living in more densely populated areas and so on, that also increase risk of exposure. Important to say that none of these things are accidental. So, they’re shaped by the processes that Natalie has been talking about, they’re shaped by the ways in which ethnic minority people’s lives are influenced by a whole set of inequalities.

HM: And Natalie, anything you want to add on that?

NC: Yes I would agree that we’re increased exposure but I think even when we start to unpick what that means and how that plays out in people’s lives, we were hearing reports from people who were in these frontline roles who knew that they were being put at risk because they weren’t provided with the correct PPE or their employers hadn’t taken onboard the increased risks because they might have a long term condition or be living in a household with somebody who does have a long term condition. Certainly from the survey that we did, people who completed our survey were more likely to live with somebody who had a long term condition but what we found was that even though that was quite well known, the employers were not responding in a way to ensure that they minimised their risk. So people were feeling bullied and pressured into going into work and so I think that it’s also important that we surface those stories because actually it’s not just about people necessarily making that choice to go to work and people not seeing that not wanting to self-isolate and protect themselves but not having that choice.

HM: And when it comes to the factors behind why people from minority ethnic groups are more likely as the data suggests, to get severely ill and die from Covid-19, obviously I think some of this is going to be shaped by some of the ways you’ve both spoken about, the context. Are there particular factors that we should be interested in, including potentially pre-existing health conditions and how do they play into this?

JN: I think this relates very strongly to your earlier point Helen, that this condition is not a great leveller by any means, just like any other health condition, it’s not a great leveller, it’s patterned by inequality and of course in this case, patterned by the social and economic inequalities that are faced by ethnic minority people. Poorly paid employment, insecure employment, overcrowded, poor quality housing, living in deprived neighbourhoods, living in areas with high concentrated poverty and so on and so on. Those kinds of things increase your risk of having complications and of course they also increase your risk of having the conditions that aggravate an infection with Covid-19. So, diabetes and so on, those health conditions are not just arbitrarily at increased risk for ethnic minority people, they are also shaped by the social and economic inequalities that ethnic minority people face. So, we do have to think about this as being shaped by social and economic inequalities which are then shaped by processes relating to racism.

HM: Yes, Natalie?

NC: Yes to stop at explanations that are just limited to people having long term conditions or living in poverty is too narrow without understanding it within the context of structural racism and how that has, not only a negative psychological impact, but also that physiological side that we will miss a trick, essentially so we really do need to understand these inequalities in the context of structural racism.

HM: Yes, we’ve previously interviewed Professor David R Williams of Harvard University who has talked about the impact of discrimination and racism on health outcomes specifically. The question I’m about to ask, raises even more questions than it potentially answers but for the benefit of our listeners, I think it’s still worth asking. Is there any evidence that biological and genetic factors play a role in terms of explaining some of the differences we see between different ethnic groups?

JN: So, most of my research, I don’t want to overstate this, but I’ve been working in the field for 30 odd years, most of my research has pointed to the lack of any genetic or biological influence on ethnic inequalities in health. So, if you take that line of explanation, then you say illness, biological change, biological change driven by genetics. So, although we can find biological differences with people with different risk of illness, this is not driven by genetic risk, this is driven by social and economic inequality. The crass example, and I’m sorry to use the word crass in this case because there may be some evidence behind it, is the Vitamin D. I call it a crass example because the assumption that Vitamin D relates to genetics is immediately made and of course we know that Vitamin D is a disease of economic inequality. In the seventies it was addressed by giving Vitamin D supplements to white people’s diets so that white working-class people did not have rickets anymore. We need to think of Vitamin D in this way, not in terms of something to do with skin colour or genetics.

HM: And Natalie, I was reading something from a submission from Black Thrive this morning and in it you mention the scientific racism. Is that something that comes into play here?

NC: Yes, absolutely, every time I see or hear somebody talking about Vitamin D, it really just makes me want to weep. I think it plays into these racist narratives that Black and Brown bodies are genetically inferior and again it’s a bit of a distraction from actually focusing on the issue at hand which is structural racism because if you can locate the problem with the person, within the Black body, it therefore means you don’t have to do anything about it, or acknowledge your role in sustaining those inequalities. So I think that it’s really important that even if there is some kind of arbitrary link with Vitamin D that that is shared within the context of structural racism because I’m sure there are people from Black backgrounds dying in a context where they had plenty of sun and access to Vitamin D, so there has to be something more at play than just having enough Vitamin D supplements and a bit of sunshine, like come on please.

JN: These types of explanations are also insidious, they’re present in media coverage, they’re present in political commentary as well as academic research. It’s not just a problem of scientific racism it’s a broader problem. This has never featured prominently in any inquiry into inequalities into health, we’ve seen a series of those, ethnicity has not appeared and the consequence of that is there has been no serious thinking about what drives ethnic inequalities which then allows us to move into these common sense assumptions about what ethnicity is and what causes differences across different ethnic groups. So, the public health community do not have the tools to understand the ways in which racism shapes the lives of ethnic minority people and the health consequences that brings.

NC: I think that’s also because these conversations, this research happens without us, it’s done on us, it’s done to us, we are very seldom the authors of this work, neither are we involved, if we’re not the authors, we’re not involved in sense making of the data that is produced. So, when we think about the public health literature, I think there was a recent systematic review and it basically said that the public health literature has been silent on the term systematic racism.

HM: And so actually on that, you’ve both clearly placed this within the context of structural and systematic racism and actually the follow up report from Public Health England refers to that, not the first report but the second one that looked specifically at the impact of Covid-19 on minority ethnic groups. I just wondered how important is it that the report acknowledges that and also if you could just say a little bit more about how that plays out in relation to health?

JN: I think it’s crucially important to acknowledge the role of racism in shaping the lives of ethnic minority people and therefore shaping their experiences of health, I think that is crucially important. I think the problem with reports like even the second Public Health England report is that they do not actually properly grasp what racism is and how it shapes people’s lives. So, they don’t properly grasp that and that relates to my earlier comment, that the public health community really does not have the tools to understand what drives ethnic inequalities in health. I talk about three dimensions of racism in my work, I talk about structural racism, which basically shapes people’s access to resources. I talk about interpersonal racism, the everyday slights, the insults, the violence that people face or people like you face, that then undermine your identity in very fundamental ways, threaten your security in the world in very fundamental ways and produce disadvantages in themselves and institutional racism which we haven’t perhaps talked about enough yet, the ways in which institutional racism then shapes your encounters with key institutions which then influence the outcomes of your life, and not just health, education, policing, employment and so on. That distinction between these three types of racism is really a heuristic device but it shows how deeply penetrating racism is in our society and then the consequences of that for the people who are racialised.

HM: I don’t think a report gets into the levels that you’re talking about James, from looking at it, Natalie?

NC: Yes, I think with that report, I was part of one of the consultation groups and my reflections were that the people who were attending made it very clear, their feelings around the links between structural racism and the impact that COVID was having on Black, Asian and other ethnic communities in the UK and what was quite disappointing was that although it mentioned that, the recommendations at the end were more or less your same old, same old, let’s reduce inequalities in the social determinants of health. I’m thinking to myself, isn’t this what we’ve all been working towards for however many decades and for me what would have been, radical within a statutory system was to actually say, “Hey one of the recommendations is let’s see racism as a public health issue in its own right.” But again I think part of the reason why people don’t talk about this and why it’s not important is because largely the people writing these reports, doing this research, do not share our experience and so if you don’t experience it yourself or you’re not touched by it, you don’t see any traction. I think this is one of the things that I think has been quite interesting with the death of George Floyd in the states that actually that incident did something in terms of moved people. So, people who didn’t necessarily share it, could see that injustice and that’s I think why, to some extent, we are starting to see some noise moving in the right direction. What I’m waiting to see is whether that noise actually moves towards action and that we actually start seeing better outcomes for communities who are most marginalised.

HM: So, you brought us on, Natalie, to the recommendations that Public Health England made in their second report and I think they were aimed at developing a greater understanding of the impact of the pandemic and rebuilding communities. But I wanted to get your sense on whether these are… I know they don’t go far enough in relation to kind of acknowledging and really trying to tackle the issue of structural racism, but in terms of what recommendations are there, are they right in terms of the sphere they’re trying to tackle?

NC: I think they don’t go deep enough. I think that’s the problem. I think we should really stop having conversations about inequalities unless we’re prepared to engage with conversations around structural racism. We feel it’s really important that if we want to understand what that picture is, we need to have the communities who experience this at the forefront and so one of the mechanisms that we are using is working with community researchers to be able to undertake that research so that they are telling us about their experiences and that they then, have ownership of those research outputs. Actually, if we want to think about it from a structural perspective we should expect people to look like the people they’re talking about essentially. I think that is one of the big gaps I think in research, in terms of statutory organisations, as I said, I’m working on a programme that’s looking at how you address inequalities among Black people, I’m often the only Black person in the room. There is fundamentally something really wrong about that.

HM: James so the recommendations largely centre on the role of health services and to a lesser extent, local government, what about the role of national government?

JN: The role of central government is absolutely crucial. Public health inequalities should not be devolved to systems that do not have the power to make substantial change and so when we have government leaders including ethnic minority government leaders standing up in front of us and saying, “Things aren’t as bad as they were when I was young.” It does show a lack of grasp of what’s going on. So, one ethnic minority minister saying, “When I was young the National Front walked down my street.” Not recognising what’s going on, on the streets at the moment with far-right white supremacist groups marching, defending symbols of slavery and so on in response to the Black Lives movement. So, we do need government leaders to stand up and say, “Actually this is unacceptable.” To name racism, to talk about racism and then to set in place the processes that do set about enquiring into how we address these problems.

HM: So, there’s a real need for leadership?

JN: There is a real need for leadership and if we think about the entrenched social and economic inequalities and how they’re driven, this can’t be fixed at a local level or it can’t be fixed by Public Health England, it has to be fixed by government policy.

HM: So just looking ahead, as services start to focus on recovery and coming out of Covid, what are the things they need to be mindful of, Natalie I’m thinking particularly of your work because you’ve recently surveyed the communities you work with in Lambeth on a range of issues including this one?

NC: So, we’ve basically developed mechanisms where the voices of communities can be directly fed into decisions about the recovery plans around Covid. So, our community researchers are capturing people’s experiences and that is influencing decisions at a local level as well as at national level. So I think if others can find mechanisms to do that, I think that’s really important but more so that actually community members are in those spaces because I think even though I’m advocating on behalf of Black people in Lambeth it would be far better to have people from Lambeth in those spaces.

HM: Also, I think one particular legacy of Covid-19 is that we’re expecting to see a surge in demand for mental health support, again Natalie is that something that you’re already seeing in Lambeth or is it something you’re expecting to see?

NC: So, I think the pattern has been quite interesting. I think lockdown was very, very difficult for people and obviously had a negative impact for many but I think one of the things that we often forget is about the resilience of Black communities and one of the things that we’ve seen is that people are making use of online platforms, locally a peer support group run by a local Black man has grown, I think they have like 40 or 50 Black men joining every week to talk about mental health and their experiences of Covid. Obviously there are still people who are concerned and have a lack of trust in terms of accessing services, but we are currently fundraising to develop an offer that brings together Black therapists with Black communities to offer a range of therapeutic services. So, I think again, even that whole notion of Black people don’t want to access therapy or healing spaces, I think sometimes it’s about the type of healing space that you’re offering. We need to start thinking about different models of care and that kind of culturally appropriate peer support and advocacies but also making sure that with everything, we are involving communities as part of that process and then there’s likely to be a fallout I guess in relation to the broader impact of Covid in terms of unemployment.

HM: Yes, I was about to ask about that and the economy, yes.

NC: Yes, so all of those things, we saw that during lockdown that people were placed in some really desperate situations so that inevitably is going to have an impact. But I think when we’re working with our commissioners we need to look at, where are there the opportunities to create employment, to create business opportunities for people who experience the race disadvantage so they can maximise on those opportunities to improve their material circumstances. Also, there are people who’ve been furloughed who have skills, how do we mobilise them and provide the infrastructure to enable them to do stuff I guess in their communities? I think the key is about it being led by the communities who are most impacted.

HM: It sounds like Black Thrive are doing quite a lot with local services to try to shape the kind of right offering as we’re coming out of this crisis that’s tailored to the needs of local communities. James, I did want to get your take on the point around the impact on unemployment and the economy, so obviously this is likely to impact on health. When it comes to thinking of the specific potential impact on the health of minority ethnic groups are there things we need to be particularly mindful of here?

JN: Yes, so I think I would argue two things really need to be considered, that the first that we all know and I’m sure policy makers expected the Covid-19 response to have an impact on the economy and it’s having a very fundamental impact on the economy. Judged to be worth it because of the benefits in terms of our health, but judged to be worth it on the basis of an on average impact and of course some people are in much more precarious situations than others and that is not the on average and so we need to think about how to mitigate the disadvantages that are faced by those in much more precarious situations, whether that’s difficult housing conditions, precarious zero hours employment, self-employment or whatever that might be, government needs to think about that as well in terms of the ways it’s establishes economic support, housing support and so on. The other area that’s really crucial to think about it what’s happening to health services. So, I think it was pretty much unanticipated how the withdrawal of health services would impact on the health of the population. But when you can no longer get a GP service, no longer get your routine treatment for your diabetes or your hypertension or whatever chronic condition you may have, then that is much harder to keep on top of that condition and then complications begin to happen. So I think that’s something that we really need to pay attention to because of these broader inequalities, ethnic minority people are more at risk of experiencing chronic illnesses but have also experienced at the same time a withdrawal of investment in support to care for those conditions, instead money has gone into acute services and all other services have in effect disappeared.

HM: So, there’s a lot of talk at the moment about the need to do some kind of rapid learning ahead of a potential second wave or further outbreaks. For each of you, what’s the one big thing that you hope policy makers and others involved in managing this crisis to date have learnt from the experiences of the communities you’ve been looking at and working with?

NC: I think for me, it’s that actually that plans are in place to protect communities who are at most risk, and that people act quickly because I think we spend too much time waiting for the data to come through, let’s take action and I think also ensuring that people from those communities are part of that process. I suppose some of our reflections is even in terms of trying to get some of that messaging out, that would help inform people’s decisions about whether they chose to self-isolate versus going into work. Even that information that was provided, wasn’t clear, it was conflicted. I’m on the shielded list, one minute I’m told I can open a window and get some fresh air and then the next day it’s like, actually you can step outside your door and go in your garden, make up your mind. So, I think there is something about ensuring that we’re part of this process.

HM: Yes, and James?

JN: So, I hope that people who are driving policy in response to a potential second wave of Covid-19 are aware that this is not equally distributed across the population. That’s absolutely crucial and it’s not just the risk of infection, the risk of complication, the risk of mortality but the consequences of measures designed to control the pandemic. Those negative consequences are not equally distributed across the population which then means in terms of ethnic inequalities, thinking very carefully about how those policies can be modified in order to protect those people who are particularly vulnerable, both of illness and of the economic and social harms. So, I’m sitting here in my office at home, looking out at my garden and my neighbour’s nice house, just me and my partner living here, no children, we’ve got lots of room and so on. It’s not quite the same as being on the seventh or tenth or thirteenth floor of a two bedroomed house with three or four children and no access to outside space. Why am I allowed the same use of external spaces as someone who’s in those terrible, in relative terms, conditions?

HM: I think that gets to the heart of some of the things we’ve been talking about today, hopefully people listening, policy makers and others will hear those final thoughts and think about how they can be incorporated as we move forwards. Thank you both so much for joining me. That’s it from us, you can find the show notes for this episode and all our previous episodes at www.kingsfund.org.uk/kfpodcast and please, we’d love you to subscribe, rate and review us on Apple Podcasts or wherever you get your podcasts as it helps others to find us and it also helps us to improve the show. You can also get in touch with us to let us know what you think via Twitter, either at The King’s Fund account or my account at @helenamacarena and thanks as always to you for listening but also to our podcast team, producer Ian Ford and special thanks to Veena Raleigh and Jonathon Holmes for their help with researching this topic. We hope you can join us next time.