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Covid-19: PHE review has failed ethnic minorities, leaders tell BMJ

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2264 (Published 08 June 2020) Cite this as: BMJ 2020;369:m2264

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  1. Gareth Iacobucci
  1. The BMJ

A government review promised to discover why covid-19 has a disproportionate effect on people from ethnic minorities, but advocacy groups say their input was ignored, Gareth Iacobucci hears

Medical and race equality organisations have told The BMJ they are angry and frustrated that a review that set out to examine the disproportionate effect of covid-19 on people from ethnic minority groups produced no plan for protecting them from the disease.

The review by Public Health England, published on 2 June,12 promised to examine why people from ethnic minorities were more likely to contract and die from covid-19 and to make recommendations for “further action that should be taken to reduce disparities in risk and outcomes from covid-19 on the population.”

But though it confirmed previous data showing that ethnic minorities were disproportionately affected (box 1), it mentioned nothing about what could be done to reduce the disparities.

Box 1

Key findings from PHE’s review

  • Black ethnic groups were most likely to have covid-19 diagnosed, with 486 diagnoses per 100 000 population among females and 649 in males. The lowest diagnosis rates were in white ethnic groups (220 per 100 000 in females and 224 in males).

  • Death rates were highest among people in black and Asian ethnic groups. When compared with previous years, all cause mortality was almost four times higher than expected among black males for this period, almost three times higher in Asian males, and almost two times higher in white males. Deaths were almost three times higher than expected in this period among black, mixed, and other females, 2.4 times higher in Asian females, and 1.6 times higher in white females.

  • The risk of death among people of Bangladeshi ethnicity was twice that among people of white British ethnicity, while people of Chinese, Indian, Pakistani, other Asian, Caribbean, and other black ethnicity had a 10-50% higher risk of death than white British people.

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Accusations that the report was a whitewash grew after the Health Service Journal reported that an earlier draft of the review that was shared within government had a section summarising responses from more than 1000 organisations and individuals who supplied evidence to the review, many of which suggested that discrimination was contributing to the increased risk from covid-19.34

In a statement PHE insisted that nothing had been removed from the report, and the government has appointed the equalities minister, Kemi Badenoch, to take forward the agenda and produce future recommendations.5

But whether or not the report was diluted, several organisations that contributed to the report told The BMJ that they felt badly let down by its content, which they said did not reflect their recommendations (box 2).

Box 2

Ten recommendations that groups wanted to see in the review

  • It should be mandatory for NHS trusts to treat ethnic minority staff as “high risk and vulnerable” in regard to covid-19 (British International Doctors’ Association)

  • Employers should urgently carry out stratified risk assessments so that healthcare workers are not unnecessarily put at risk (British Association of Physicians of Indian Origin, BIDA)

  • Ethnic minority staff should be redeployed away from covid-19 areas in hospitals wherever possible (BIDA), and staff who have retired and returned should not be asked to work in high risk clinical areas (BAPIO)

  • An inquiry should be held into the deaths of healthcare workers (most of whom were from ethnic minorities) to help rebuild confidence in the system (BIDA)

  • Data for covid-19 cases and deaths should be disaggregated to incorporate factors such as ethnicity, faith, profession, and wider socioeconomic risk factors (BAPIO, Muslim Doctors Association, Muslim Council of Britain)

  • Research should be carried out into ethnic disparities and outcomes related to covid-19 that reflect the lived experience of people from ethnic minorities (BAPIO)

  • The government should seek to understand why inequalities exist and how racism and structural discrimination affect different facets of people’s lives and how these effects have contributed to the disproportionate death rate in BAME communities (Muslim Council of Britain)

  • Health agencies should make a strong statement acknowledging the problems of racism and discrimination in the NHS and should have a clear action plan for how to tackle them and a commitment to implement change (Muslim Council of Britain)

  • NHS England should look at changing the way in which ethnic minority staff are represented and included in decision making (Muslim Council of Britain)

  • Public Health England should expand the Workforce Race Equality Standard to also assess the impact of racial inequalities on health outcomes (Muslim Council of Britain)

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Zubaida Haque, interim director of race equality at the think tank the Runnymede Trust, a race equality expert group consulted for the report, told The BMJ that race equality groups were “dismayed and angry” with the final report. She said, “People are upset, angry, astonished, and appalled. It’s completely lacking in any plan of action on how to save lives.

“I was absolutely flabbergasted that there was not a single recommendation. At no point did they say ‘this review is part one.’ The impression was always that this would not only identify the factors that are likely to be contributing to higher risk of serious illness deaths in relation to covid-19 but find the answers.”

She added, “These communities have been living in fear. There’s a lot of people who are feeling very hurt, very confused, and very frightened, because there’s nothing worse than telling people, ‘Yes, it’s true that you are more likely to die,’ . . . and that that’s it.”

Haque, who is also a member of the independent SAGE group set up as an alternative to the government’s Scientific Advisory Group for Emergencies, said she was unhappy that only 11 of the review’s 89 pages focused on ethnicity, with the remainder looking at obesity, age, sex, and other factors.

She said, “It was supposed to be a review about racial inequalities and covid-19. At no point at the time did they say that only one eighth of the report would be on ethnicity.”

The fact that PHE’s analysis excluded variables that were likely to be contributory factors to the disproportionate effect on ethnic minorities, such as comorbidity and occupation, rendered the report “wholly inadequate,” Haque added.

“Damp squib”

Ramesh Mehta, chair of the British Association of Physicians of Indian Origin, agreed this was a major flaw in the “damp squib” of a report.

“We were hoping this report would give us an idea of why the problem is there, but what it has told us is what we already knew. It didn’t discuss comorbidities. They’ve come up with a very bland review that is not much use. It is a washout.”

The association wrote to PHE, the chief medical officer, and NHS England outlining its concerns about the high number of ethnic minority people dying from covid-19 and was subsequently invited to discuss the issues with senior health leaders. But Mehta said, “So far we haven’t seen much impact of our presence or comments apart from the letter from Simon Stevens [asking NHS trusts to risk assess ethnic minority staff6]. We expected our views to be represented.”

On Friday 5 June the BMA coordinated a meeting with representatives from 13 organisations representing ethnic minorities, medical staff from overseas, and religious groups to discuss the disproportionate impact of covid-19.

Chaand Nagpaul, the BMA’s chair of council, said, “The PHE review failed to provide any answers as to why covid-19 is having such a catastrophic impact on BAME [black, Asian, and minority ethnic] healthcare workers—and crucially offered no recommendations on how to protect them right now.

“The BMA, along with all of the organisations in attendance, is calling on the government to take urgent action to protect our BAME colleagues on the front line.”

The British International Doctors’ Association was one of the groups at the meeting. Chandra Kanneganti, its national chairman, told The BMJ that the association submitted five key recommendations to PHE, which were not reflected in the report. “The report is lacking actions to protect the healthcare workforce. It’s a well known fact this is already happening. Lives are at risk: we need action now,” he said.

Other groups that made recommendations to PHE’s review included the Muslim Doctors Association, the NHS Religion Equality Advisory Group, and the Muslim Council of Britain.

Hina Shahid, a GP in London and chair of the Muslim Doctors Association said, “The failure to analyse systemic and structural factors, the exclusion of data on protected characteristics such as religion and disability as well as important insights from extensive stakeholder engagements that repeatedly highlighted the role of discrimination and disadvantage, and the lack of any practical recommendations are all deeply concerning and disappointing. Our colleagues, relatives, and friends have died. It makes us feel as though our lives and contributions to society don’t matter.”

Harun Khan, secretary general of the Muslim Council of Britain, said, “To choose to not discuss the overwhelming role structural racism and inequality have on mortality rates and to disregard the evidence compiled by community organisations, while simultaneously providing no recommendations or an action plan, despite this being the central purpose of the review, is entirely unacceptable. It beggars belief that a review asking why BAME communities are more at risk fails to give even a single answer.”

Haque drew parallels between the lack of action to protect ethnic minority groups from covid-19 and the Black Lives Matter movement. “People separate it and think it’s different, but it’s not different at all. The reason people have been distraught at the tragic death of George Floyd is because black and ethnic minority lives are treated as though they are second rate, as though they matter less.

“All the data was coming out showing that BAME people were much more vulnerable to covid-19. To produce a report that has no recommendations about how you’re going to save the lives of those who are disproportionately dying is not only insensitive but essentially saying, ‘We think your life matters less.’ What else can you think? This is a matter of life and death. And they have shown a complete disregard for people’s lives.”

PHE’s John Newton, who co-led the review, said, “There is a great deal of background and detailed information [in the report] we think will be helpful. What we would like to do is get a lot of discussion about all these with the various groups involved in responding to it. It is not easy to go directly from the analysis to making recommendations, and we need to get the report widely disseminated and discussed before deciding what needs to be done, but clearly there are some fairly obvious conclusions that can be drawn, even from the data we have.”

Badenoch insisted that the government was “taking seriously” the report’s initial findings. But she added, “However, it is also clear that much more needs to be done to understand the key drivers of the disparities identified and the relationships between the different risk factors.

“That is why I am now taking this work forward, which will enable us to make a real difference to people’s lives and protect our communities from the impact of the coronavirus.”

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