With BME People at Higher Risk from Covid, How Do We Solve Health Inequity?

During the first reports of Covid-19, lots of WhatsApp images were shared. In immigrant communities, this is nothing new – WhatsApp health myths depicting onions that absorb flu, say, are now so commonplace that jokes about them feel tired. Some sent to me instructed people to open mouths wide to inhale vitamin-D enriched sunlight, or to swallow cloves of garlic whole.

It might be easy to write this all off as networks of messages maintained by tech-phobic comedy-aunties, but to ridicule them alone is to miss their role; these messages were borne out of a need for communities to protect themselves, out of mistrust of the system.

It's true that, at their worst, these images can perpetuate dangerous health advice, leaving communities vulnerable. But at their best, they provide a kind of PSA unavailable elsewhere. The sun-in-mouth one, for instance, comes from the fact that darker, more melanated skin allows less UVB to enter it (because melanin protects skin against UVB sun damage), and less UVB absorption means less vitamin D is produced each minute. Despite this, I've never seen a Public Health England initiative encouraging communities of colour to take daily vitamin D supplements.

We also know that migration affects our bodies – rapid diet changes and an increased consumption of high fat, sugar or highly processed food can lead to obesity, which has implications for long-term health. But how well is that being communicated?

Besides that lack of information, it's not so difficult to see why there's mistrust within the NHS itself. Data from earlier this year revealed that almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, while in May reports showed that BME nursing staff were more likely to be left without PPE than their white colleagues. This poses an obvious question: if NHS staff are racist to their own colleagues, how might they treat non-white patients?

Rianna Raymond-Williams, who works with Decolonising Contraception – an organisation advocating new approaches to sexual health – provides some context: "There's a long history of medical racism that has resulted in black bodies being terrorised, which isn't often acknowledged. In the 1800s, J Marion Sims – often coined as the 'father of modern gynaecology' – experimented on black women without anaesthesia, based on the racist assumption that black people did not feel pain. Now, more than 200 years on, data from the 2019 MBRRACE-UK report found that black women were five times more likely to die in childbirth than white women, often linked to clinicians dismissing their experiences of pain."

After a fortnight that has accelerated conversations around the detrimental effects of structural racism on public health, this historical background is important. We already know that most BME groups have poorer health than White British people – and last week, Public Health England released a delayed report showing there is between a 10 to 50 percent higher risk of death among BME Brits who have contracted Covid-19 compared to their white counterparts.

For many in my community watching the news, early conclusions were scary. That Black and brown people are somehow more genetically prone to the disease is a take-away many people might easily come to – but to tell it like that just isn't accurate (if it was, we'd be seeing far more deaths in Black-majority countries, for one). However, the fact that Black and brown communities suffer from higher levels of "pre-existing conditions", such as heart disease, obesity and diabetes, is worth interrogation.

Guppi Bola is the interim director at Medact, a charity that aims to end health inequity. Bola's area of study focuses on migrant populations that move from a "dominant brown country to a dominant white country" and the experience that "discrimination and racism has on the body".

"There's been a lot of research from the US and Canada that shows a clear link between heart disease and circularity disease in migrant populations as a result of experiencing discrimination," she told me when we spoke last year. "And that has been brought up by a rising cortisol output, which is the response your body gives to stress. That can have an impact on things like kidney function and increase of obesity over time."

The link between racism and poor health is beginning to be explored beyond anecdotal ideas or factors we might assume are a natural result of discrimination (such as a loss of sleep or anxiety). Take one case study from 2017, when NPR, The Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health asked members of different ethnic groups about "small indignities that showed uncourteous treatment", including bad service at restaurants. It found a link between these experiences and rapid development of coronary heart disease. In short: experiencing racism is bad for your health. And bad health leaves you more susceptible to the worst outcomes of Covid.

If this is what's happening inside the bodies of some of our Black and brown communities, what's happening outside? How much might the structures of the state contribute to poor health? According to the UK's Covid-19 disparity report, factors like high-density housing, overrepresentation in public facing jobs, such as TfL staff and taxi drivers, and economic deprivation all play their part too.

Natalie Creary is the director of Black Thrive, an organisation working to improve the mental health of Black communities in Lambeth.

"The connection between poor mental health in the Black community and structural inequality is undeniable," she says. "Our work is informed by data which shows Black people are more likely to enter the mental health system. We are also more likely to be turned away when we seek help, which might be why we are overrepresented in the more acute side of the system. We experience the greatest level of inequality, which impacts health outcomes and increases stressors."

So how do you shift systems in order to allow marginalised Black and brown communities to thrive? Some solutions are being drawn in the current moment of global social unrest, where Black activists are acting as frontline workers for Black lives. As protests continue across the UK, US and beyond, one central demand is to defund police forces and redistribute that money locally, in the hope it will positively improve socio-economic factors that negatively impact health.

These calls show how healthcare is deeply connected to issues of housing, pay and social deprivation, which all hit Black and brown communities the hardest. For Creary, the solutions range from relatively simple, like additional funding, to the more time-consuming: teaching people to locate racism before they can begin to tackle it. "We need to collect equalities data in a robust way," she says. "If you don't do that, you don't know who you're serving, and you don't know whether interventions are working. We need to tackle structural racism and how that manifests itself in how we design policies and the decisions about where investment should go. Black, Asian and Minority Ethnic communities must take the lead."

Dr Sujitha Selvarajah works with Race and Heath, an organisation that aims to answer a central question: How can we hold the structures that harm our health to account? "For now, if you've got lots of people on zero-hour contracts, can we implement pay protection so that they can secure income during a pandemic?" she asks over the phone. "How can Black and brown doctors ask for PPE without being branded difficult, angry, or being silenced and reprimanded? Looking forward, the NHS has a lot of work to do. They must have more diverse representation – people in leadership who look like communities they're serving."

The Covid-19 disparity report touched briefly on that last point, referencing the fact that one potential barrier to access for BME people in the UK is "cultural and language differences". What hasn't been widely acknowledged is how that point illustrates what many of us have always known: that immigrant nurses arguably work twice as hard, acting as translators and cultural navigators on top of their daily duties as medical professionals.

To reach true equity, healthcare must spread its tentacles across all sectors: we need a world in which zero-hour contract jobs come with health warnings, where GPs have a say in housing policy, where racism and its effects are a public health priority. For now, though, Selvarajah brings me back down to earth.

"PHE experts working in areas of education and transport can't afford to be utopian," she sighs over the phone. "It needs to be a reality now."

@kieran_yates