The colour of coronavirus

Hina J Shahid is a GP in London and holds an MSc in Public Health. She is the Chair of the Muslim Doctors Association; a non-profi t organisation working to reduce health inequalities and improve inclusion in healthcare. She sits on the General Medical Council’s Black and Minority Ethnic Doctors forum and is co-founder of the NHS Religion Equality Advisory Group. She enjoys travelling, musicals and afternoon tea.

Racism, discrimination and inequities

The disproportionate impact of COVID-19 on BAME (Black, Asian and Minority Ethnic) groups is well documented.1-5 On the frontline over 95% of doctors6 and 76% of all NHS staff who have died were from a BAME background.7 These health disparities are not new, they amplify longstanding and intersecting inequalities and injustices. Racism and discrimination, although used interchangeably, are distinct terms. Racism is a system of oppression, based on racial hierarchies constructed to justify colonialism, that systematically privileges one group (dominant) over another (subordinate) through unequal distribution of power, resources and opportunities. Racial discrimination is the differential treatment of one group by another on the basis of race. This can include biases and stereotypes, prejudiced and exclusionary attitudes, and direct actions of discrimination and marginalisation. Racism and discrimination are important explanatory factors for the unequal impact of COVID-19 on BAME communities.8 Another key concept is intersectionality; understanding that BAME groups are heterogeneous with important in-group differences and who may simultaneously experience multiple axes of discrimination and oppression beyond racism. Muslims, for example, experienced the highest risk of deaths among all religious groups;9 here religionbased oppression intersects with racism and classism. These multi-dimensional experiences influence vulnerability and demand individualised and contextualised responses.

Why are BAME groups dying more from COVID-19?

Structural factors

The majority of health outcomes are structurally determined. BAME communities are more likely to live in socially deprived and densely populated areas in overcrowded and multigenerational houses10. This makes self-isolation, social distancing and shielding more difficult resulting in increased exposure, transmission and risk of severe complications. They are also more likely to work in key worker roles in the health, social care, transport and hospitality sectors and in low paid or insecure jobs2 with reduced opportunities to work from home and lack of income protection if ill. These increase household viral exposure and transmission11 as well as financial vulnerability, stress and risk of mental health disorders.12

Institutional factors

Divisive media and political narratives blaming BAME communities for transmission create alienation and structural stigma. Austerity policies disproportionately impact BAME communities,13 immigration policies create barriers to seeking healthcare due to finances or fear of being deported.14 Security policies, such as Prevent, create fear and mistrust of health authorities.15 These reduce trust and engagement with health authorities and public health messaging. At work, BAME people face barriers in accessing PPE, testing and risk assessments, and this includes doctors.12,16 This reinforces longstanding institutional discrimination; BAME doctors are more likely to fail postgraduate exams,17 face barriers in recruitment, progression and pay18,19 and are more likely to be referred for fitness to practice hearings and face harsher sanctions.20 This translates into individuals having less autonomy over their work, being more likely to be re-deployed to high risk areas without adequate protective equipment, and less likely to raise concerns.

Healthcare access

BAME patients are less likely to trust and be satisfied with healthcare services and engage with preventative, primary and secondary care services.21 Discrimination by healthcare providers and negative experiences of care form a barrier to accessing healthcare and affect quality of care received.22 BAME patients are more likely to present late to services and with atypical symptoms, which can contribute to misdiagnosis and adverse outcomes.23 These increase risk of adverse outcomes from COVID-19.

Biological and cultural factors

BAME groups are more likely to experience socially patterned and stress related chronic conditions such as diabetes, heart disease and obesity, as well as nutritional deficiencies such as vitamin D,24 which are linked to poorer outcomes from COVID-19. Cultural and religious misconceptions and communal practices such as funerals, burials and congregational prayers can increase risk of exposure and transmission. Fatalistic beliefs and language barriers can create preferences for alternative cultural or faithbased remedies, healers, and media channels, and may reduce engagement with mainstream public health messaging and delay access to health care. These highlight the need for community-led tailored responses.

What can be done to reduce health disparities among BAME groups?

The poorer outcomes among BAME groups are due to a combination of increased risk of exposure, transmission and serious disease, and reduced protection. The widespread and deeply embedded inequities can sometimes engender a sense of helplessness among doctors, as well as discomfort on addressing the issue of “race”. As healthcare professionals we should be at the forefront of reducing racially patterned health inequities in our patients, wider society, and our workplaces. The scope, priority and impact of work will depend on a number of individual and structural factors, but everyone can do something.

Addressing wider social determinants

Advocacy and campaigning: form networks or join existing organisations, write letters to the government and MPs, create petitions and movements challenging structural inequities.

Community partnerships: Trusts, Clinical Commissioning Groups (CCG) and Primary Care Networks can set up partnerships with voluntary organisations, schools, welfare and housing associations, food banks, faith-based organisations and commission social prescribers, link workers and/or care navigators to support their populations holistically.

Health promotion work: outreach work in under-served communities, creating multilingual culturally and faith sensitive resources. Education at undergraduate and postgraduate level: on structural determinants of health, decolonisation of the medical curriculum which incorporates a non-Eurocentric worldview of medicine and examines the impact of colonialism and slavery on medicine and health outcomes. Eliminate epistemic racism which delegitimises narrative and other qualitative-based approaches to knowledge.

Addressing organisational factors

Make health disparities a high priority organisational problem: this should be at the core of organisations’ healthcare delivery strategy. Collect and publish data on ethnicity-based health outcomes to monitor for disparities: at primary and secondary care levels as well as for public health programmes. Create diverse, inclusive and compassionate organisational cultures: enable leadership development and career progression, psychologically safe routes for raising concerns and rigorous implementation of zero tolerance policies against discrimination, bullying and harassment. Set up Equality, Diversity and Inclusion (EDI) or BAME networks: monitor inequalities in outcomes and experiences of BAME healthcare staff, hold Trust/Clinical commissioning Group (CCG) boards to account and offer formal support, mentoring and skills development. Training: unconscious bias training is widely used but there is little evidence that it makes impact. Fund EDI work: to avoid cultural taxation on BAME staff expected to deliver work for free. Ensure policies, programmes and interventions undergo an ethnic impact assessment: e.g. the use of technology and risk of digital exclusion of BAME patients, dress code policies for staff.

Inner work

Become aware: of your own biases and prejudices through educating yourself on race and ethnicity issues. Authentic allyship: it can be exhausting for BAME people to explain their experiences all the time, avoid assumptions and strive for compassion and mindful communication and connections focusing on practical action. Self-care and support: dealing with racial injustice either as an activist and/or a victim can create physical and psychological trauma and/or burnout. If you have been affected by this it is okay to take time out for yourself and seek support through friends, family or peer support networks, or formally through coaching, therapy or medical support.

Conclusions

The disproportionate impact of COVID-19 on BAME communities and frontline staff is multi-factorial but structural and institutional factors are major drivers. Sustainable anti-racism work is demanding and requires dedicated effort, authentic allyship and adequate support and resources. Denial and de-legitimisation of experiences and knowledge is common, painful and costs lives, as we have seen with COVID-19. Doctors have a unique and important role in eliminating race-based health inequities and there is a moral, ethical, legal and professional obligation on all to create healthier and more equal societies and workplaces.

References 1 ICNARC report on COVID-19 in critical care: 05 June 2020. London:

Intensive Care National Audit and Research Centre; 2020. 2 Platt, L. and Warwick R. Are some ethnic groups more vulnerable to COVID-19 than others. Institute for Fiscal Studies, Nuffield Foundation; 2020. 3 Williamson, E., et al. Open SAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients. medRxiv: 2020.2005.2006.20092999. 4 Coronavirus (COVID-19) related deaths by ethnic group, England and

Wales London: Office for National Statistics; 2020. Available from: https://bit.ly/3jMg2dH 5 Public Health England. Disparities in the Risk and Outcomes of COVID-19, London; 2020. Available from: https://bit.ly/326NiGz 6 Cook T, Kursumovic, E., Lennane, S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Service Journal. 2020. 7 Levene LS, Coles B, Davies MJ, Hanif W, Zaccardi F, Khunti K. COVID-19 cumulative mortality rates for frontline healthcare staff in England. British Journal of General

Practice. 2020; 70:32 8 Public Health England. Beyond the Data: Understanding the Impact of

COVID-19 on BAME Groups, London; 2020. Available from: https://bit.ly/2HX5ETt 9 Coronavirus (COVID-19) related deaths by religious group, England and Wales: 2 March to 15 May 2020. Available from: https://bit.ly/2THl94t 10 Khan O. A Sense of Place: Retirement Decisions among Older Black and Minority

Ethnic People. Runnymede Trust, London; 2012. 11 Li W, Zhang B, Lu J, Liu S, Chang Z, Cao P, Liu X, Zhang P, Ling Y, Tao K, Chen J.

The characteristics of household transmission of COVID-19. Clinical Infectious

Diseases; 2020. 12 Runneymede Trust. Over-exposed and under-protected: the devastating impact of COVID-19 on Black and Minority Ethnic Communities in Great Britain, London, 2020. Available from:https://bit.ly/35T1qUY 13 Runneymede Trust. Intersecting inequalities: the impact of austerity on

Black and Minority Ethnic women in the UK. London, 2020. Available from: https://bit.ly/3oQ7OVC 14 Medact. Patients not passports, published by Medact, London; 2020.

Available from: https://bit.ly/35QiPO8 15 Aked H, False positives: the Prevent counter-extremism policy in healthcare, published by Medact, London; 2020. 16 BMA. Analysing the impact of coronavirus on doctors, London 2020.

Available from: https://bit.ly/3jPNHU3 17 Rimmer A. Ethnic minority and non-UK doctors are more likely to fail exams,

GMC data show. 2016. 18 Linton S. Taking the difference out of attainment. BMJ. 2020;368. 19 Appleby J. Ethnic pay gap among NHS doctors. BMJ. 2018;362: k3586. 20 GMC. Fair to refer; 2019. Available from: https://bit.ly/3mPRKlb 21 Hunt KA, Gaba A, Lavizzo-Mourey R. Racial and ethnic disparities and perceptions of health care: does health plan type matter?. Health Services Research. 2005;(2):551-76. 22 Laird LD, Amer MM, Barnett ED, Barnes LL. Muslim patients and health disparities in the UK and the US. Archives of disease in childhood. 2007;92:922-6. 23 Szczepura A. Access to health care for ethnic minority populations. Postgraduate

Medical Journal. 2005;81:141-7. 24 Khunti K, Singh AK, Pareek M, Hanif W. Is ethnicity linked to incidence or outcomes of covid-19?. BMJ 2020;369:m1548.