Archive for August, 2021

In London, we have been talking with different communities about vaccines. We wanted to learn from their experiences so we can better serve their needs. One consistent theme we have heard loud and clear is the role of racism.  Questions of “Why isn’t the systemic racism that results in health inequalities for Black people…not being given the same attention as the push for this vaccine?” We are no longer only talking about vaccines.

Throughout the pandemic, we have seen the devastating and inequitable impact COVID-19 has had on populations in UK and worldwide. Last year, Public Health England (PHE) published a review of health disparities from COVID19, and Beyond the Data report, based on stakeholder feedback. [i] It comes as no surprise that people from ethnic minority backgrounds continue to face poorer outcomes and access to health and care. [ii] What we are seeing is an exacerbation and amplification of existing health inequalities. These inequalities, which are unjust and avoidable, are not new. What is new is the attention these injustices have garnered and the opportunity to make a true and lasting difference in how we work with our diverse communities.

The reasons underlying these ethnic health inequalities are complex. Consider multigenerational households, now a known risk factor for transmission of COVID19, particularly for Asian households. In non-pandemic times, an older family member living with their children and grandchildren are protected from social isolation, leading to better physical and psychological health. They also provide childcare and support for working parents and transfer of skills from one generation to the next. This myriad of interconnecting socioeconomic factors are well-defined in the socio-ecological model, encapsulated in the Dahlgren and Whitehead diagram which is emblematic of the public health approach.

In our conversations with Londoners, the pernicious effect of discrimination, stigma, and most of all, structural racism resonated in all the voices we heard. Racism, in different forms, shapes the conditions we live in, and has been called one of the causes of the causes of the causes.[iii] As well as colouring the canvas of people’s lives, it cuts and obstructs their progress throughout the lifecourse, interweaving a path of cumulative disadvantage through multiple mechanisms. Not everyone from ethnic minority groups are born to disadvantage, nor do they stay in disadvantage, but it is the intersectional nature of race, gender and socioeconomic position that makes it harder for people from ethnic minority backgrounds to thrive. The impact of racism, and identifying racism as a public health issue[iv], has led us to integrate racism into the Whitehead and Dahlgren model. It is time to reform the public health agenda and recognise the connection between structural racism and racialised disparities in health.

Reducing health inequalities is core public health work.  If we accept that racism plays a causative role in health equalities, then developing a deeper understanding of possible links between racism and health is a prerequisite for interventions that target health inequalities at a community and individual level. Addressing racism is central to eliminating racialised health disparities, and therefore, should be central to public health research and practice,

As we reflect on the past year, and work to build back lives and livelihoods, now is the time to listen, the time to collectively work and amplify unheard voices, the time to take action and dismantle the White hegemony that has reverberated in the policies and organisations around us. Within PHE London public health colleagues who have insights as community members have collaborated co-design solutions with communities according to their needs, and not to fulfill our needs to deliver vaccinations or tests. We aim to help the system work more proportionately, ensuring that we build trust and strengthen relationships so we’re in a better position to support all our communities to thrive and be resilient should the next pandemic or health threat occur. We will listen and ask what would have worked better, how we could have worked better and what we can do from now to be better.

Dr. Jennifer Yip

Leah de Souza-Thomas

[i] Public Health England. Disparities in Risks and Outcomes from COVID19. June 2020 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf

Public Health England: Beyond the Data: Understanding the impact of COVID-19 on Black, Asian and Minority Ethnic groups. https://www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities

[ii] Mathur R et al. The Lancet  Apr 2021. Ethnic differences in SARS-CoV-2 infection and COVID-19-related hospitalisation, intensive care unit admission, and death in 17 million adults in England: an observational cohort study using the OpenSAFELY platform


[iii] From Sir Michael Marmot reported by The Guardian wed 7th April. UK public health expert criticises No 10 race report ‘shortcomings’ | Race | The Guardian

[iv] ADPH Policy position: Supporting Black, Asian and minority ethnic communities during and beyond the COVID-19 pandemic

Adapted from Dahlgren and Whitehead, 1993 showing racism as a driving force for social determinants of health.  Though social determinants are universal, racism is one of a range of driving forces that exists in our societies and that acts on these determinants.

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