Part 2 of the PHE’s Understanding the impact of COVID-19 on BAME groups was finally published on 16 June 2020, a fortnight after Part 1. It makes for chilling reading.
The findings
In addition to setting out 7 recommendations for action, the PHE report summarises the results of a literature review on the relationship between Covid-19 outcomes and ethnicity, and the results of PHE’s engagement with “over 4,000 people with a broad range of interests in BAME issues”.These individuals included “participants from national, regional and local bodies including the Royal Colleges; the devolved nations; cross-government departments; local government leaders, chief executives of local government, directors of public health, faith groups, migrant health leaders, community and voluntary sector leaders and representatives, researchers and academics, pharmacist organisations, business leaders, political leaders and health and wellbeing board chairs”.
The literature review cites the only study to date of mortality in healthcare workers in the UK by ethnicity (Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from COVID19 analysed. Health Services Journal. 2020) which “used data gathered from social media, news reports, and other publicly available ‘In memoriam’ websites to gather outcome data, meaning it is high risk of bias”. This found that “Of the deaths in healthcare workers reported, 63% were in BAME groups: 36% were of Asian ethnicity (compared to 10% of NHS workforce) and 27% were of black ethnicity (compared to 6% of the NHS workforce).
The PHE report found that “those in minority ethnic groups have poorer health outcomes compared to the majority of the population. Differences in cultural factors may play a role in disease risk, but it is more likely that the decreases in life expectancy and health outcomes are due to social, economic, and structural determinants of health”.
Among the factors the report referred to were overcrowded (as well as inter-generational) households; occupational concentration in the health and social care workforce as well as cleaning, public transport and retail and, within the NHS, concentration in “lower paid roles [which] cannot be done remotely”; greater reliance on public transport. In addition: “Individuals that identify as being part of an BAME group may feel marginalised, have experienced racism, or have had previous experiences with a culturally insensitive health service that could create barriers to engagement. Research has shown that individuals from BAME backgrounds often have poorer access to healthcare services as well as poor past experiences of care and treatment. This may mean they are less likely to seek care when needed or as NHS staff less likely to speak up when they have concerns about PPE or testing”.
Concerns that there was a direct relationship between the disproportionate death rates among BAME workers and race discrimination and harassment at work were also voiced by those involved in the PHE’s community engagement who “pointed to racism and discrimination experienced by communities and more specifically by BAME key workers as a root cause affecting health, and exposure risk and disease progression risk”. Some referred to: “racism, bullying and harassment at work [which] meant that they were reluctant to speak up about issues (such as PPE shortages), which placed them at higher risk. Others believe that BAME front line workers were sometimes given substandard quality or inadequate PPE given the nature of their roles and the risk of exposure. Numerous examples were given of staff not able to access appropriate PPE to protect themselves adequately in line with national guidance and being afraid to speak up about this”.
PHE suggested that “BAME staff are concerned about raising issues because of past experiences and fear of consequences for speaking up. Others raised issues about fairness in the workplace. Staff want support and an environment for staff to express their concerns and have these met effectively”. Those engaged in the consultation suggested that “there have been a significant number of instances of direct and indirect discrimination based on ethnicity” since the start of the pandemic and that “A high number of our BAME members have felt concerned about raising issues because of either previous instances of poor treatment, or a fear that they will face adverse consequences if they speak up.”
Comment
The PHE report indicates that the disproportionate impact of Covid-19 on BAME communities results not only from structural factors, many of them the result of accumulated discriminatory decision-making and behaviour, but also from current discrimination which directly exposes BAME NHS workers to additional risk. To point this out is not to imply a hierarchy of wrongs. It is, however, to suggest that questions need to be asked about why, over 50 years since the Race Relations Act 1968 first prohibited race discrimination in employment, it appears to be the case that BAME workers, employed by the state, are not protected from even the most extreme manifestations of race discrimination. Answers which spring to mind include the individual approach taken by the EqA and its predecessor legislation which subjects those who would complain to the likelihood of victimisation, as well as to the uncertainties and risks of litigation. This approach also renders immune from challenge the accumulated past decisions and behaviours which create and reproduce the structural disadvantage experienced by those in BAME communities. The current pandemic emphasises that race discrimination is a systemic problem which requires a systemic solution.