How can we prevent enduring, unequal transmission of Covid-19 in specific communities and places? Some answers to this question come from a recent report by the ethnicity subgroup of Sage on the causes of the tragic loss of life among Bangladeshi and Pakistani British communities in the second wave of the pandemic.
While all minority ethnic groups remained at greater risk of death from Covid-19 compared with white ethnic groups in the period from October 2020 to January 2021, Bangladeshi and Pakistani groups were at the greatest risk. The Sage advice, which I led on, uncovered the effects of inequality and policy on health outcomes and the urgent measures needed to support hard-hit communities and prevent future tragedies.
The recent Commission on Race and Ethnic Disparities reports that this was a result of “risk of infection”, “as opposed to ethnicity alone being a risk factor”. To the contrary, our findings show that multiple disadvantages faced by ethnic groups join together to produce infection and death from Covid-19.
Bangladeshi and Pakistani groups experience more chronic, debilitating health conditions at a younger age due to health disparities. They mainly work in jobs in small-scale retail, transportation and hospitality, leading to greater exposure to Covid-19. Being precarious employees or business owners means that they are less able to negotiate paid sick leave or to stay home when unwell.
They are more likely to live in crowded housing providing social support to older and younger family members under one roof. This increases risks of transmission within families from workplaces and schools, and prevents self-isolation of sick family members. Stigma and racism are common experiences, due to their ethnic and religious identity, causing physiological effects on health outcomes and creating a barrier to accessing services.
These risks came together in a devastating way during the second wave. Hospitality and retail were kept open longer during the second wave at the time that the new Kent variant was spreading, and no central effort was made to enforce protections for employees in these workplaces. Furthermore, financial support was insufficient to support small family businesses and the self-employed in stopping work: Treasury schemes offered loans that small, precarious businesses did not want to risk taking, and the self-employed were only supported at a level linked to the previous year’s taxation, which may have failed to cover a family’s needs. For those who needed to self-isolate, payments were difficult to apply for and too small to risk the loss of wages.
When it came to families, no public health advice or support was provided to advise multigenerational households on how to keep relatives safe from transmission. The government interventions which did occur, around Eid and Ramadan, only served to intensify stigma and disempower groups from seeking help and services. They also threatened social cohesion, which as a recent study shows, supports uptake of Covid-19 measures in deprived areas.
Taking lessons from the second wave for any future outbreaks is vital. The first instruction is that any delay in future interventions or rush to reopen society is likely to disproportionately affect ethnic minority groups. A cautious policy is also a fairer policy.
Occupational risks could be reduced by legal requirements for Covid-safe workplaces. Alongside this, enforceable rights to sick leave for precarious employees, self-isolation payments in line with the minimum wage, and workplace vaccination schemes with paid time off for vaccination could help reduce transmission. The Treasury could offer grants instead of loans or tax-linked amounts to the lowest rated businesses and self-employed, to support any businesses too risky to remain open.
Household risks could be reduced by offering advice on safe behaviours in caring and domestic work; along with practical support. Stigma and racism need to be acknowledged within our national and local public services as direct drivers of unequal health outcomes. When local interventions are carried out, central and local communications should not identify, and therefore stigmatise, specific communities and their households as risky.
Finally, none of these measures can be achieved without greater community consultation and collaboration. This needs to be funded over the long term so that local authority outreach, community champion networks and third-sector organisations can flourish. After the unequal deaths of the pandemic, we need to rebuild through mutual recognition and equal provision of health for all.