Letter from Glasgow

The Covid-19 Pandemic and Ethnic Minorities in the UK

We all knew it was coming—a pandemic that is—we just did not know when it will happen or what the virus would be. Despite this, when Scotland and the UK went into lockdown in March 2020, I still found the experience deeply surreal. Could this be happening—being confined to your house and allowed out only if your job was essential, your journey was essential, or for outdoor exercise once a day? Moreover, we were luckier than other people who, for example, lived in crowded apartments without a garden, were trying to home school children in addition to doing their work online, or had to make a choice to self-isolate or go out to work if there was no other source of income.

The WHO had long warned about a pandemic and in the UK the National Health Service (NHS) and other organizations prepared their plans for a pandemic, dutifully updating the plans each year just as we did in NHS Lanarkshire. There were problems, of course. The premise was that the pandemic would be due to an influenza virus, as exemplified by the 2011 UK Influenza Pandemic Preparedness Strategy, rather than a coronavirus.^[1] However, the generic aspects of any plan could be adapted to pandemics caused by other viruses, for example, having access to a sufficient stockpile of personal protective equipment, to ensure older residents and care staff in care homes were given appropriate advice and support, to secure sufficient intensive therapy unit (ITU) facilities and to plan the facilities for mass casualties. Unfortunately, in Scotland, a review by Audit Scotland of the years before the Covid-19 pandemic showed that recommendations from the pandemic planning exercises of Exercise Silver Swan (2015), Exercise Cygnus (2016) and Exercise Iris (2018) were not implemented.^[2] The UK as a whole, it seems, was no better prepared than Scotland.

In the meantime, I want to consider the effects of the pandemic on ethnic minorities in the UK. If you knew nothing about Covid-19 except that it was an infectious disease and could be dangerous, public health would guess from first principles it would be worse for minority ethnic groups (including those of South Asian ancestry) in the UK. These minority ethnic groups tend to be poorer although there are differences for specific groups such those, for example, of Bangladeshi origin or of African origin. And poorer people suffer more mortality and morbidity which is the general public health ‘golden rule’ of illness and disease.^[3] It is not difficult to see why. Poorer people have a relative lack of access to healthcare, inferior quality and quantity of healthcare when they get it, and a greater risk of Covid-19 because of comorbid conditions, living in poorer, overcrowded housing and neighbourhoods, and being, disproportionately, in jobs with greater risk such as carers, shop attendants and bus drivers. For minority ethnic groups in the UK all that is reinforced by the racism they face.

During the pandemic, Public Health England (PHE) published a report in August 2020 describing the data on the risks and outcomes from Covid-19 in different groups.^[4] In summary, it reiterated what is common knowledge to public health in the UK that the pandemic ‘replicated existing health inequalities and, in some cases, has increased them’. The pandemic resulted in a greater impact for older people, males (particularly working age males), some geographical areas in England (with the highest death rates for both males and females being in London), people in deprived areas, some occupations such as security guards and taxi drivers, people in care homes, rough sleepers, people with comorbid conditions and people from an ethnic minority background. Compared to people of white ethnicity, people of Bangladeshi origin had around twice the risk of death while people of Chinese, Indian, Pakistani, Black Caribbean and other Black ethnicity had an increased risk of death of 10% to 50%.

PHE had previously been criticized for not publishing recommendations which had arisen from their report of minority ethnic groups regarding a review of pandemic data, a rapid review of the literature and feedback from stakeholders on what actions to take.^[5],[6] While PHE may have been reluctant to follow the data, Razai et al. published a succinct paper on what is required.^[7]

Razai et al. systematically outline the issues facing minority ethnic groups in the UK. They summarize the background by defining racism (including structural or institutional racism, cultural racism and discrimination), the effect of the pandemic on minority ethnic groups, the possible cause of ethnic disparities in the pandemic (including racism and social determinants of health), the effect of racism on the social determinants of health, how to mitigate the effects of the pandemic on minority ethnic groups and the need to tackle racism and discrimination. The paper concludes with four key messages: (i) differences in minority ethnic groups during the pandemic is consistent with poorer health outcomes historically for these groups in the UK; (ii) these differences are not accounted for by socioeconomic status alone; (iii) racism is a cause and perpetuator of poorer socioeconomic status and health inequalities; and (iv) tackling the pandemic and heath inequalities requires, first, a recognition of its causes, and second, leadership and resources to counter its effects. Given the historic lack of action on these issues by the UK government, no one is holding their breath until it acts.

The pandemic has turned our world upside down—health-wise, economically, socially, culturally, educationally and much more. A full assessment of how Scotland and the UK coped with the pandemic is required and that will be undertaken in due course. Suffice to say that at this point the UK appears to have among the pandemic highest mortality rates among European countries. A comprehensive, dispassionate and rigorous evaluation of the pandemic internationally is also necessary including the origins of the pandemic and the initial handling of it, the role of the WHO, the response of different countries and learning the lessons from that, the tests available, the role of contact tracing, the problem of Covid denial and how that can be countered, the development of vaccines and the roll-out of the vaccine programmes, vaccine hesitancy, the access to vaccines internationally particularly to low-income countries, the direct and indirect effects of the pandemic on populations— the list could go on but you get the picture.

To fail to learn from the pandemic and return to the status quo ante would be a cardinal folly for politicians, policy-makers and public health. This applies to all the weaknesses and faultlines the pandemic has highlighted, and in this case to the effects of the pandemic on minority ethnic groups in the UK who have suffered disproportionately.

Conflicts of interest. None declared