“Inequalities that are preventable by reasonable means are unfair,” says Michael Marmot
The Covid-19 crisis has clearly had a devastatingly unequal impact on different communities. Deaths in the most socioeconomically deprived areas have happened at a younger age and the odds of dying have been significantly higher for non-white ethnicities, particularly people classed as having Pakistani, Bangladeshi or Black ethnicity. Often the two issues – poverty and ethnicity – have intersected.
As the vaccination programme rolls out at breakneck speed and society reopens, the same groups who have suffered most in pandemic and who remain at higher risk of infection are also at greatest risk of not being vaccinated, as this sobering report and map from Bradford makes clear.
Directly standardised mortality rate per 100,000 population and proportion of total population receiving the Covid-19 vaccine with one dose in Bradford (to 11th February 2021)
Despite heroic efforts to promote vaccine uptake by local public health teams, higher levels of vaccine hesitancy among the less well off remains, particularly among people from non-white ethnic backgrounds. This hesitancy has its roots in mistrust of institutions and long standing discrimination. As the above map demonstrates, with age driving vaccine prioritisation, younger and sicker inner city populations will inevitably lag behind in terms of vaccine coverage as the programme is rolled out.
When reflecting on this subject, I immediately think of Omar *, the elderly Pakistani-British man I saw in the Covid vaccine clinic who did not believe that the tray of syringes full of vaccine that I had in front of me contained the AstraZeneca vaccine and that I was going to inject him with something ineffective or harmful. A lifetime of exposure to racism and poverty can lead to this level of skepticism. Fortunately, I was able to show him the vaccines being drawn up from the labelled vials and he agreed to go ahead.
Biology and premature aging are only one part of the risk equation. Social conditions are also critical, particularly in relation to spread of the virus. If you are poorer you are less likely to be able to work from home, more likely to work in an environment where social distancing is more difficult, less able to afford to self-isolate if unwell, less able to isolate within the home if sick (due to more cramped housing) and more likely to have to use public transport. All of these will increase your risk of catching and therefore dying from Covid-19. The official statistics on death and occupation are concerning.
Patients like David * are the people behind the statistics. I spoke to David a number of times in April 2020, at the height of the first wave of the pandemic. He was in his fifties, suffered from Chronic Kidney Disease, Coronary Artery Disease and COPD but did not initially make the shielding list, meaning he was having to turn up everyday to the busy, windowless and cramped warehouse where he worked. Here, there was little prospect of social distancing or good ventilation. He had to travel to work by bus because his chest and heart would not permit the 3 mile walk and he could not afford to own a car. His nervousness around the daily risk of catching covid meant he became very anxious, was not sleeping, started drinking alcohol to cope (from being a teetotaller) and, eventually, became depressed. I had no choice but to sign him off sick and we did everything we could to help him through a very difficult time financially. Clearly his risk of catching and dying of Covid was very high and the impact of the pandemic on him and his family has been significant.
I also think of Rachel *, a care worker on minimum wage at a local nursing home. I was called out to see a resident where she worked. Some masks, gloves, aprons, no face protection and some very watery alcohol gel were piled on the floor outside a Covid positive resident’s room. The landing was not ventilated and all the rooms were carpeted and full of furniture, making them impossible to disinfect. Proper hand washing facilities were only available on the floor below. It was not hard to see why carers going in and out of the room several times a day could easily be infected with Covid.
Most GPs, particularly those working in areas of socioeconomic deprivation, will have heard many similar stories of the working poor being exposed to excess covid risk solely due to social factors. There are tens of millions of Davids and Rachels in the UK. Rachel caught Covid-19 but only had mild symptoms. David managed to escape infection. Many of our patients in similar circumstances were not so lucky, caught Covid and ended up very sick or died.
The vaccine programme prioritisation categories do not include the flexibility that local areas ideally need to respond to local factors (i.e. housing conditions, infection rates, known rates of under-diagnosis of long term conditions etc). Q-Covid will help but not entirely resolve the problem and is only being introduced several months into the vaccine rollout.
It is entirely understandable that a national vaccine programme would use age to prioritise vaccination as this remains the most important driver of risk. However, what works in wealthy towns in South East England might not work so well in Bradford, Leicester and East Lancashire, parts of the country that have suffered the most, with their younger, sicker and more ethnically diverse populations.
These communities need to be able to flex their vaccine programmes according to local risk profiles and social conditions, be given the resources and scope to regulate and enforce Covid-safe work environments and support their poorer residents financially and logistically when they need to self isolate.
The number one priority must be to get as many people vaccinated as quickly as possible. Primary Care Networks have been incredibly successful in doing this so far and should remain front and centre of the vaccine programme. Vaccine hesitancy is far more likely to be overcome if vacccines continue to be delivered close to where people live, by trusted local healthcare professionals and, ideally, in a range of trusted community venues.
Omar was vaccinated at a clinic in run in his local mosque and I’m sure was mainly reassured by everyday surroundings and the presence of familiar faces when he was at his most anxious.
What does this mean for PCNs and those overseeing vaccination programmes? Ideally:
- Working with grass roots community organisations, community leaders and the voluntary and charitable sector to promote vaccination, address peoples’ concerns and hesitancy about vaccination and build trust
- Taking vaccination clinics out into trusted and familiar community venues, focussing on those communities where uptake and coverage is lowest
- Getting the message about vaccine effectiveness and safety out there using trusted multilingual messengers and formats that will be accessible to all
- Using mainstream media and social media to promote vaccination and make trusted healthcare professionals as accessible to the community as possible
- Thinking about how the most vulnerable will be reached: people with serious mental illness, people with learning disabilities, people who are homeless, refugees and asylum seekers
- Ensuring people with chronic disease and carers have up to date coding on their medical records that will ensure they are vaccinated as soon as they are eligible
- Using good data to track progress with vaccination, including by index of multiple deprivation and ethnicity
As we emerge from the pandemic, we should remember the sense of solidarity and togetherness of March and April 2020. Until everyone is safe, none of us are safe.
We have the vaccines and we have the means to distribute them equitably, achieving high uptake in every community. Failing to do so would be grossly unfair to those who have been hardest hit by Covid-19.
Primary care teams in West Yorkshire running a vaccine clinic at Keighley Central Mosque – February 2021
The RCGP Standing Group on Health Inequalities have produced an excellent resource on increase vaccine uptake here.
*patient names and other details have been altered to preserve anonymity.