In a recent clip widely shared on social media, Newsnight’s Emily Maitlis highlighted the inequalities at the heart of the current COVID-19 emergency, describing it as “a public health issue with huge ramifications for social welfare and a social welfare issue with huge ramifications for public health”. Here, Dr Bella Starling, Professor Arpana Verma and Nasima Begum outline how COVID-19 can disproportionately affect those who are already impacted by social, ethnic and gender inequalities. They find that existing inequalities map onto increased exposure to risk, both in their susceptibility to the disease, the severity of the illness, and in the response to treating them.

• COVID-19 is more likely to affect vulnerable groups, and is likely to be more severe in many of those cases.
• Inequalities of access (to treatment and to technology) will further heighten the disproportionate impact of COVID-19.
• We must learn from existing evidence and experience, both to identify those exposed to greater risk and to prioritise research and policy solutions to mitigate these effects.

Prevalence and risk

Emerging data show that nearly 35% of people who are critically ill with coronavirus are from Black and Asian backgrounds. This is higher than the 13% of the UK population who identify as from Black, Asian and ethnic communities in the last Census. While some factors might explain this higher proportion – for example, COVID-19 has primarily affected urban areas, including local authority wards with large, ethnically diverse populations – based on this current data, Black people are significantly more likely to be critically ill with COVID-19 when taking account of local demography.

Those with ‘underlying health conditions’ have been shown to be at risk of more severe cases of COVID-19. BBC News have reported that nine out of ten COVID-19 deaths recorded by the ONS so far have featured underlying health conditions. In this context, it is imperative to recall that ‘underlying health conditions’ are often associated with those that are already marginalised or living with protected characteristics. For example, diabetes is associated with higher risk of COVID-19. At the same time, people of South Asian origin are up to six times more likely to develop Type 2 diabetes than the general population in the UK. Such correlations may account for some of the greater numbers of hospitalisations being seen in ethnic communities, though further evidence and analyses are required.

There is also increasing evidence of a gendered aspect to COVID-19 risk. Men are more severely affected than women, according to mortality data. In this case, it is important that this disparity, occurring as it does along the lines of a protected characteristic, are taken into account when creating policy responses and the development of clinical practice.

Access to care and treatment

Evidence shows that in some conditions people present differently for care. LGBT communities, for example, are less likely to access healthcare. In cancer, Black, Asian and ethnic communities present later, at a more advanced stage of disease. Awareness and help seeking behaviour is low across all ethnic groups, with the lowest awareness in the Black African group. Access to screening, and the location of COVID-19 screening facilities, is therefore vital and needs to be inclusive of areas where different communities are located.

Great strides have been made in supporting the move to remote healthcare consultations and online interactions during the coronavirus outbreak. However, access to technology is unequal. Those in manual occupations and the unemployed have lower rates of smartphone use: 67% in lower (eg. DE) socioeconomic groups and 86% in higher (eg. AB) socioeconomic groups (in 2018). In addition, little is known about attitudes and acceptance of telehealth methods amongst diverse groups. Take diabetes again, for instance; low participation rates of ethnic diabetes patients have been reported in systematic reviews focusing on telehealth interventions, and the ethnic composition of studies is often unreported.

Workforce(s)

Those in public services and the service industry, who work with large numbers of the general public, are at greater risk of exposure to COVID-19. Their numbers include high rates of Black, Asian, and working class members. According to a recent report, BME individuals account for 21% of all NHS staff; 20% of nursing and support staff and 44% of medical staff. Tragically, as of 22^nd April, they also account for 63%, 64% and 95% of deaths in the same staff groups. In addition, 50% of health and social care workers who have died were born outside the UK, compared to a reported 18% of NHS staff.

The same report highlights that women are in higher numbers in this dataset (contrasting with the dominance of men infected or admitted to intensive care). Taken together, these data might suggest that the burden of, and risks associated with formal care during the outbreak (and perhaps also the burdens of informal care: community volunteering, homeworking and home-schooling) fall more to women, ethnic and migrant groups, reinforcing societal inequalities.

Society and communication

In the early stages of the outbreak, an Ipsos MORI poll showed that casual racism was becoming apparent: 14% of those surveyed would avoid people of Chinese appearance. Should any prejudice arise against those who have had COVID-19 (once testing is more firmly underway), how can we guard against such prejudice being experienced by people with protected characteristics, if COVID-19 incidence remains higher among these groups?

People with limited financial and social resources are more likely to have limited health literacy, and we know that people from different backgrounds and protected characteristics seek health information through a variety of different and culturally specific media. The majority of mainstream health reporting is dominated by White voices, which may be a ‘turn-off’ for some communities seeking information about coronavirus, and social media can often provide incorrect information.

More widely, outside of the regulated systems of NHS patient and professional interactions, the wider move to increased online communication during this pandemic needs to be conscious of accessibility and language, as well as historical and recent targeting of people with protected characteristics online.

Finally, the language around COVID-19 and ‘underlying health conditions’ can be damaging. Language, and all its nuances, has power that goes beyond the speaker. It can guide our thinking and behaviour, providing a backdrop to what might be considered ‘normal’ or acceptable. So, when, probably through no ill-intention, narratives emphasise the serious risk of dying from COVID-19 ‘mainly’ amongst those with ‘underlying health conditions’, these can lead to the consideration that there are members of society who are considered to be more disposable than others. A recent editorial commented how labelling causes stigmatisation and public health should focus on reducing the stigma associated with COVID-19 to “inform immediate and long-term strategies to build empathy and social justice in current and future pandemics”.

Keeping inequalities central to the COVID-19 response

So, in Emily’s words, how do we stop inequalities becoming even starker because of coronavirus? Nationally, research is massively mobilising, including in Greater Manchester.

It is clear that COVID-19 is exacerbated by social inequalities, with marginalised groups often at most risk of contacting the illness and their illness more likely to be severe. Research, policy and practice needs to quickly adapt to this fact, and put social, gender, racial and access inequalities front-and-centre in our response.

With that in mind, we propose the following steps to help in this effort to ensure that we leave no-one behind;

• Better understanding of the patient experience of COVID-19 in those with protected characteristics, and investigations into the biological, medical, or sociological factors. NIHR and UKRI have responded to the emerging data with a funding call to explore the association between ethnicity, COVID-19 incidence, and adverse health outcomes. This is to be applauded, demonstrating agility and flexibility in signalling the importance of this research as quickly as possible. Interdisciplinary research could further strengthen the evidence base.
• Coronavirus research (including research priorities, planning, design and implementation) must be inclusive of people and patients including those with protected characteristics. NIHR has demonstrated leadership through its commitment to working in partnership in research with patients, communities and the public (public involvement, engagement and participation) during the pandemic in line with the UK Public Involvement Standards.
• COVID-19 related research needs to capture as much data as possible so as to be able to carry out subset analyses. There is an important role for ethics committees in ensuring that this can be carried out.
• Engagement with COVID-19 and related research, whilst supporting vital public health messages, needs to be imaginative, creative and inclusive in its reach, with appropriate translations as a minimum. Learning from how science communicates and listens to less well heard communities might be helpful here, as is keeping online safeguarding high on the agenda.
• Learning from existing good practice that places health inequalities at the heart of translational research. For example,
  • The Health Inequalities Steering Group supports the Manchester Biomedical Research Centre and Clinical Research Facilities to be conscious of, and address, health inequalities through its research
  • Applying the Health Inequalities Assessment Toolkit to translational research
  • Research advisory groups that focus on those with protected characteristics – eg The Public Programmes Team’s: Black Asian Minority Ethnic and Refugee research advisory group, Voice Up (Young People’s Research Advisory Group), and Deaf Experts by Experience
  • Programmes of work focused on health inequalities including (but not limited to) the Manchester Urban Collaborative on Health, i3HS Hub, Division of Population Health, GM ARC, Health Innovation Manchester, GM Patient Safety Translational Research Centre, the Manchester Biomedical Research Centre and Manchester Clinical Research facility.

Finally, we look forward to the results of the Parliamentary inquiry into COVID-19 impacts on those with protected characteristics, to which we have submitted evidence, and hope that these lessons can be learned in time to mitigate the risks and ensure we leave no-one behind.

Take a look at our other blogs exploring issues relating to the coronavirus outbreak.

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