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.
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.
A personal reflection on racism and steps for meaningful action byDr Mariya Aziz, GP, Keighley, West Yorkshire with input from Dr Tom Ratcliffe, Fair Health
Events over the last few weeks, from the brutal killing of George Floyd to the devastating effects of COVID 19 on the BAME community, have highlighted the racial inequalities that lie deep within our institutions and the appalling impact it has on so many.
For those from a BAME background, myself included, it has churned up memories and feelings that we try and suppress and brought them to the forefront.
I cannot pretend that my experiences of racism as a British born Pakistani are the equivalent to those of my Black counterparts. However, the impact is indelible and has shaped me into the individual I am today.
The Health Services Journal reports that 44% of NHS doctors currently self-identify as BAME. At the height of the epidemic, of the number of doctors who sadly lost their lives to Covid-19, a staggering 95% were from BAME backgrounds. The same pattern is seen in other clinical staff groups (see resources).
Data from the Office of National Statistics (see resources) showed that people from Black, Bangadeshi / Pakistani and Indian ethnic groups were all at a substantially increased risk of death from Covid-19 compared with white ethnic groups, even once multiple other factors, such as age, gender and socioeconomic deprivation, were controlled for. The data standardised for age alone is even starker. This showed that Black men and women were over 4 times more likely to die from Covid-19 than their white counterparts: a shocking disparity that reveals the stark intersection of race and poverty in health inequality.
Risk of COVID-19-related death by ethnic group and sex, England and Wales, 2 March to 10 April 2020 (Age adjusted model)
Odds ratio of Death compared to White ethnicity
Source: Office for National Statistics, UK
How do we respond? What can we do better? And what we must avoid doing from now on?
First, we must all recognise and challenge the overt and more subtle forms of racism that still exist in healthcare.
Second, we must stop assuming that “not seeing colour,” means racism will go away and adopt a stance of active “anti-racism”.
Third, we must take extra steps to be more inclusive, recognising that people from BAME backgrounds will often have past experiences that can trigger difficult memories and feelings that can impact on their ability to engage with colleagues, organisations and leadership opportunities. There may also be cultural barriers, which we are not sensitive to, that could also impact their progression to senior positions.
Recognising the challenge of racism
Overtly racist comments and use of unacceptable racial terminology is becoming less common but is certainly not unheard of. I do still hear people ask questions or use language that is unacceptable and have challenged it. Sadly, I have not always felt supported in doing so. I like to think that this not because people condone what others are saying (in the majority of cases) but because people are not always clear about the forms racism can take and feel uneasy about calling it out.
I do not feel this is acceptable. Inaction and failing to challenge racism is to be complicit in racial abuse.
Most difficult to address are comments and actions that are borne from ignorance and form “micro-aggressions”. Insidious in effect, these can create self-doubt and a pervasive worry about the way in which one is perceived. This can be more harmful than the overt racism that most people would easily recognise.
Examples in healthcare include:
Patients refusing to see a BAME clinician due to their race;
Ill thought out comments such as “your/her English is surprisingly good” in clinical feedback;
Unnecessarily prefacing references to colleagues with a racial identifier that would not be used when referring to white colleague (i.e. “the Asian doctor”, “that Asian family”)
Asking questions about another person’s cultural or social life out of curiosity but posing these in a way that uses stereotypes disrespectfully (i.e. “are people in your culture allowed to have more than one wife?”)
Being actively anti-racist
Some people conclude that the answer to these issues is to remove race as an issue entirely. Co-workers have reached out to me with comments such as “I don’t see your colour”. Whilst well intentioned, I have never felt such an approach provides comfort or reassurance. For me, it minimises who I am. My race and culture are part of me, not something that can be simply ignored.
In her book, White Fragility, Robin Di Angelo, illustrates this point when reflecting on an interaction between a White woman and African-American man:
“His race meant that he had a very different experience in life than she did. If she were ever going to understand or challenge racism, she would need to acknowledge this difference. Pretending that she did not notice that he was black was not helpful to him in any way, as it denied his reality and kept hers insular and unchallenged. This pretence that she did not notice his race assumed that he was “just like her,” and in so doing, she projected her reality onto him.”
The answer to racism is not to ignore race. It is to be actively anti-racist:
“One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no in-between safe space of “not racist.” The claim of “not racist” neutrality is a mask for racism,” Ibram X. Kendi (from How to be an Anti-Racist).
For most of us, adopting a stance of anti-racism, involves painful self-examination and challenging conversations. It should not need stating, but being BAME does not exempt me from this! Sadly even within my own community, there is a racial hierarchy and there is a need to look inwards and reflect on this.
I also believe that understanding what it means to be an ally is an important first step in the road to becoming an antiracist. Being an ally is not easy. It requires us to step out of our comfort zones and challenge discrimination where we see it but to also be mindful of scenarios where it is not so evident. There is a need to acknowledge that we may have privileges not afforded to others on the basis of their skin tone and to share the benefits of this privilege.
Learning is an essential part of this process. And this means more than completing an annual mandatory e-learning module on Equality and Diversity. Whilst still worth doing, this is not even going to scratch the surface. You may find some of the resources listed at end helpful in addressing our learning gap.
Below is a chart that I have found helpful in the process of self-evaluation in my journey to becoming an antiracist.
Chart was adapted by Andrew M. Ibrahim MD, MSc from “Who Do I Want to Be During COVID-19” (original author unknown) with some ideas pulled from Ibram X. Kendi’s work.
As Scott wood, American author and poet wrote:
“Yes, racism looks like hate, but hate is just one manifestation. Privilege is another. Access is another. Ignorance is another. Apathy is another. And so on. So while I agree with people who say no one is born racist, it remains a powerful system that we’re immediately born into…It’s a set of socioeconomic traps and cultural values that are fired up every time we interact with the world. It is a thing you have to keep scooping out of the boat of your life to keep from drowning in it…”
I have no words to better this and it stresses even more that the act of being antiracist is a lifetime commitment to self-evaluation and learning.
Empowering BAME people within healthcare
Within my current role, whilst our primary care organisation (and indeed the whole medical profession), is very diverse overall, I am the only senior BAME GP working in my immediate setting. Recent events have made me reflect on the effects of this and my own empowerment.
Being placed in a group where I am in the minority as a person of colour can be paralysing. Whilst not an issue in the safety of my immediate clinical team, stepping out of this protected zone into the large business or commissioning meetings can be daunting.
At times, these experiences have rendered me acutely conscious of my race but also my culture and its variance to that of my peers. I know I speak for myself and others when I say that when placed in an ethnically homogenous environment we have all felt to some degree that we have had to compromise ourselves to blend in. In turn this leads to one feeling apologetic or the need to justify/defend certain behaviours that do not fit into the “White” norm.
I know the reasons for my response to this specific situation are rooted in my own insecurities based on past racial discriminations. The last time I was the only BAME individual in a large group was at school, which was a traumatic time due to race related bullying. Sadly, this experience was not atypical and similar feelings and experiences can be a barrier for those from a BAME background to progressing to roles of senior leadership.
Engagement with my predominantly White colleagues on this topic has not been easy. I acknowledge that race is a sensitive topic and those from a White background can feel defensive or as if they are being attacked equally those on the other side of it are perceived as “having a chip on their shoulder/always making it about race”. Hence it is imperative that we do educate ourselves and I include myself in that.
Being South Asian and Muslim does not exempt me from having my own prejudices and unconscious biases. And simply having a diverse workforce is not sufficient to resolve this issue. In fact, I am conscious that, among BAME colleagues, there is a recognised phenomenon of “pulling up the ladder” and failing to help empower colleagues or, worse still, making their progression harder than it should be.
If we are to tackle racism, there will be uncomfortable realities that need acknowledging and challenging. We must be proactive and acknowledge a need for meaningful and sustained education and training around race and its impact within all layers of the NHS. We must translate learning from this into delivery of clinical care and consider how organisation of healthcare in culturally insensitive or inappropriate ways exacerbates health inequalities.
This will take time, effort and commitment. However, there are practical steps that we can take immediately. I have listed some suggestions below:
Leaders, including Freedom to Speak Up Guardians, should use this opportunity to specifically address the issue of racism within the NHS and invite a more open discussion of this topic
Primary care organisations should organise the collection of data in primary care similar to that of the secondary care and CCG WRES reports to support and ensure that BAME colleagues are being given equal opportunities.
Healthcare employers should ensure staff surveys specifically mention discrimination relating to race and other protected characteristics
Primary care organisations and educators should promote the concept of allyship as part of wider education for all staff on antiracism and the effects of unconscious bias.
Mentoring should be provided for BAME colleagues. For example, using the reverse mentorship programme run by Health Education England. This would pair individuals from under-represented groups with healthcare leaders from non-BAME backgrounds in the hope that alliances are created and experience and knowledge shared.
Proactively encourage BAME colleagues to pursue leadership opportunities. The NHS leadership academy has courses aimed at supporting BAME individuals progressing within the work place, i.e. the “ Stepping up” and “Ready Now” programmes.
Practical steps such as recognising a wider range of religious holidays in organisational timetables, thus empowering people and making them feel valued within the organisation.
Use Health Equity Audit to look at the uptake of primary and secondary prevention and health outcomes by ethnicity, then take steps to address any inequities identified
Ensure information is provided in a range of languages and interpreters are easily accessed
Ensure that patient councils include a range of individuals and voices that reflect the demographic make up of the patient body, including by ethnicity
Ensure that the way that illness presents in different groups is recognised and that clinical staff are aware of how symptoms and signs vary across BAME and white ethnicities
Build alliances with organisations that already provide services for the most vulnerable members of the BAME community, for example inclusion health providers and the VCS
The tragic events in the USA and the Black Lives Matter movement have created huge momentum in what is most likely a once in a generation moment. I know having these conversations with our teams, calling out racism in all its forms and adopting a stance of active anti-racism will be difficult. We have to remember that this is about us coming together so that the minority can be part of the majority and receive fair and equal treatment.
There are many excellent books, films, documentaries covering the topics discussed in this blog. The list below suggests a few that may be of interest and/or provoke further reflection and debate. Please note that a number of these resources include graphic and distressing material that some will find difficult to read, hear and/or watch.
Non Fiction –
Why I’m No Longer Talking to White People About Race by Reni Eddo-Lodge. Based on Reni’s blog post of the same name that went viral back in 2014. A must read book exploring what it means to be a person of colour in the UK today.
The Good Immigrant. A collection of essays featuring people such as Riz Ahmed, Bim Adewunmi, Vinay Patel, Eddo-Lodge and many others exploring race and immigration.
Inglorious Empire by Shashi Tharoo. Tharoo is an Indian politician and diplomat, whose book examines the effects of British colonialism on India and challenges some of the post-colonial myths about the British Empire.
White Privilege by Kalwant Bhopal. This book explores the myth of a post-racial society.
Black and British: A Forgotten History. David Olusoga. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long (right back to the Roman empire) and interwoven history of the UK and people whose origins lie in Africa.
Between the World and Me by Ta-Nehisi Coates. A letter to his son exploring questions about race in the USA today.
Girl, Woman, Other by Bernadine Evaristo. Booker prize winning novel exploring the interconected stories of twelve characters raising questions about race and feminism.
Queenie by Candice Carty-Williams. Darkly funny and candid. Covers a huge range of topics include race, mental health.
Americanah by Chimamanda Ngozi Adichie. The novel explores the story of a Nigerian woman who moves to the USA for university, caught between the two cultures and countries.
Homegoing by Yaa Gyasi. This novel explores the story of two sisters with different destinies: one sold into slavery and one marrying becoming the wife of a slave trader.
13th, a Netflix documentary exposing racial inequality within the criminal justice system. Title comes from the 13th Amendment, (the abolition of slavery in the USA).
When They See Us, a mini-series from Ava DuVernay about the Central Park Five (uncomfortable viewing including detailed descriptions of rape and scenes of violence).
Black and British: A Forgotten History.David Olusoga. Available on BBC iplayer. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long and interwoven history of the UK and people whose origins lie in Africa. He has also presented a series exploring ‘Britain’s Forgotten Slave Owners’ which is also available on BBC iplayer.
Selma, a film that chronicles the marches of the Civil Rights Movement.
The Hate U Give, a film based on the YA novel offering an intimate portrait of race in America.
It has shone a light on the great divides in our society. Everyone can catch it, everyone can die from it but the impact of the virus and the necessary measures to control its spread is not shared equally across society.
Our response will require kindness, caring and compassion. The current upsurge in these values should give us cause for hope during an otherwise very difficult time for many people. And they will be most needed where suffering is greatest.
What is interesting about the risk of death or hospital admission from the virus is that it almost perfectly tracks your current risk of death. So, if you are already sick, from a BAME background, grew up in poverty or already older you are more likely to develop serious symptoms and/or die.
The economic impacts will be most acutely felt by those with the fewest resources: people in low paid jobs, people who have chronic mental or physical illness, people on temporary or “zero hours” contracts and those who are living from pay check to pay check. It is also likely that those in low paid manual jobs (e.g. supermarket, social care, construction workers etc) will be less able to socially distance by working from home and, hence, less able to minimise the risk of Covid-19 infection. Those who are now confined to home in poor quality or cramped housing will have the most miserable experience and those living in the least affluent, vibrant and green surroundings will suffer the biggest fall in wellbeing.
These individuals are all part of the same group: the poorest in society.
Michael Marmot recently reminded us that, in the UK, the poorest 10% of households have less than 30% of their income remaining after deducting housing costs and the cost of healthy food. They also have very little wealth to fall back on in times of economic crisis. The implications are clear: loss of income due to Covid-19-related unemployment or illness will cause destitution among those who are already struggling to get by.
Health inequalities were already widening before Covid and these divides are now likely to be accelerated by another economic crisis, massively compounded by a virus that kills those already suffering from chronic illness and multimorbidity, the rates of which already follow a sharp social gradient.
Covid has taken the social determinants of health, which have insidiously been working away behind the scenes, slowly eroding peoples’ health and wellbeing, and exploded their impact into full view. Our civic, community and healthcare resources have been degraded by a decade of austerity, as have many aspects of the welfare safety net. Covid has triggered substantial reinvestment but we must not let these issues disappear back into the shadows as the crisis recedes.
The response to Covid has been to put the whole NHS on an acute footing, aimed at treating a single disease, whilst trying to also provide care to the non-Covid acutely unwell. This means that planned primary care, which can narrow the health gap by 10-20% if access is good and quality high, has been temporarily suspended (or at least deprioritised). Because the system was already at capacity, and because capacity was already inadequate in the most socioeconomically deprived communities, it will take a long time to catch up after this crisis. After Covid we will discover a massive pool of morbidity, mortality and unmet demand. Mental illness that existed before this crisis will also sharply deteriorate due to increased stress and isolation plus a temporary withdrawal of face to face primary care.
GPs also know that the aftermath of social trauma can last years or even decades and blight peoples’ whole lives. GPs have spent years trying to help people traumatised by war, tragic events, childhood neglect or mistreatment, crime or domestic abuse. Covid will leave thousands, perhaps hundreds of thousands, of people traumatised by its direct effects or as a result of vulnerable people being left isolated in toxic social situations, where the abuse or mistreatment they have suffered becomes temporarily inescapable.
The long tail of this crisis are neatly summarised here:
So how can we respond?
If there is a positive thing to take away from the Covid crisis it is the outpouring of kindness, the renewed recognition of the contribution of people with jobs whose value may have been forgotten or overlooked, a huge injection of investment into healthcare and social welfare and a revived willingness to think about the needs of others.
We might reflect on J.B. Priestley’s words:
“We don’t live alone. We are members of one body. We are responsible for each other.”
An Inspector Calls, 1945
So how should we respond in primary care?
As our colleagues at Citadel Healthcare in Greater Manchester remind us, for general practice, we should go back to basics: “find the sickest, and give them the best care”. And we must double down on our efforts to do this during and after Covid-19.
We will have to catch up peoples’ chronic disease management – prioritise the poorest, who can be identified by integrating the available databases on socioeconomic deprivation with primary care records and by examining chronic disease data (time to collaborate with our wonderful colleagues in public health – at Fair Health we are also trying to create some resources to make this easier for practices, watch this space!). Also prioritise those things that have the biggest impact on health outcomes – start with cardiovascular disease prevention. Perhaps revise where to focus your efforts by working through our learning modules.
Now will be the time to adopt an approach based on “Trauma Informed Care”. You can read more about this in our learning modules on this site and on the “A Better NHS” blog (see resources below).
Use the Primary Care Network DES to invest in social prescribing to try and deal with some of the acute social issues that Covid will exacerbate and use this to build better links with your local Voluntary and Charitable Sector, who may need your support and advocacy more than ever
Collaborate with the “social determinants of health workforce” more than ever:
The social workers, teachers, school nurses and health visitors who will be helping safeguarded children during and after the crisis
The Citizens Advice Bureau, debt advisors and Department for Work and Pensions operatives who will be needed more than ever to help people through the multiple domestic financial crisis that Covid will create
Organisations providing care for people who are homeless, refugees and other vulnerable groups to ensure they can access very strained services in the post Covid world
Drug and alcohol services, whose users won’t have been able to socially distance and access support as easily during this crisis
The nurses and carers out in the community supporting our most vulnerable
Remember that primary care organisations are anchor institutions for many communities – just being there is so important: you can hold onto the memories of how Covid impacted your community and you can hold the NHS leadership and politicians to account for their decisions, their efforts to address health inequalities and future readiness for a pandemic or the slower health “emergency” represented by growing health inequalities
Try and ensure that information about Covid and the social safety net that is being created is accessible to all by providing information in multiple languages and formats (see resources for free translations of material provided by Doctors of the World)
As illustrated above, the Covid crisis will have a long tail, perhaps stretching out over many years, this is where health equity focussed primary care will be needed most