The pandemic disproportionately affects the already vulnerable
Late last year, I read an article in one of the international journals published by the Commonwealth Fund, a charitable non-partisan organization established in the US in 1918, by probably the first pioneering female entrepreneur of the modern era with a mandate to do something for the welfare of mankind.
The article spoke on “Reducing Racial Disparities in Health Care by Confronting Racism.” The coronavirus pandemic sweeping through and inflicting havoc on humanity has opened up the very truth by tearing away the cream cover hiding the ugly face of humanity within, and exposed with its vicious teeth how both implicit and institutional racism have torn down the very fabric of human civilization.
In my discussion here today, I would like to extend the scope of the topic to initiate and add economic/class disparity in the discussion, and modify the approach to the relationship between health, race, and income. My discussion will be directed towards an emphasis on the reduction and correction of health inequality imposed by racism and, in the case of Bangladesh, by economic elitism.
Let’s now see how the experts define and explain these different terms our discussion will revolve around. “Implicit racism” originates from stereotyping ethnic minorities of colour, harbours conscious/subconscious prejudices with the potential of exploding in hatred and disharmony in society.
Though this phenomenon contributes significantly, the “institutional racism,” in contrast, leads to death and destruction, and disrupts the process; it is calamitous to the progression of human civilization.
The term institutional racism was defined by Sir William Macpherson of Cluny, the retired Scottish Judge to the Queen’s Bench in the High Court. He had headed the public inquiry into the murder of Stephen Lawrence, a black youth in London, and called the allegedly corrupt police investigation that followed the murder “the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture, and ethnic origin.”
It is seen in “processes, attitudes, and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness, and racist stereotyping, which disadvantages ethnic minority people.”
The racial-based institutional disparity is constantly demonstrated in everyday life in employment, education, policing, the criminal justice system, media, and politics -- the lists are relentlessly on-going and endless. These facts have been concluded through surveys, commissions, researches, audits, and consequent recommendations and the way forward has been cited with each conclusion.
Though there has been paucity in high quality research on the views of the minority population in Britain, home to 8.5 million non-white people, racial discrimination is rampant in appointment and promotion in jobs, and entrance and access to services. Socially, publicly, and privately, ethnic minority populations are accused wrongly of lying and shoplifting, expecting to be and being abused by strangers, and treated differently and negatively because of their appearance, clothes, etc.
In the UK, there is a staggering racial disparity between unemployment figures, household average income, as well as other everyday life scenarios, unequivocally demonstrated in the government of Teresa May’s audit in 2017 titled the “Race disparity audit.” The particularly glaring disparities were in living standards, housing, work, policing, and health.
Politicians and the government have accepted defeat simultaneous to the publishing of the policies recommended for reform. The past prime minister of Great Britain, Teresa May, herself said that there was a long way to go before Britain established itself as a country that works for everyone.
The persistent inequalities continue in the policy of “stop and search” by the police, the “use of force” by police fraternities, and “deaths” during and after police contact. Recent, unfortunate but not unprecedented evidence of institutional racism once again attempts to open the conscience of humanity: The murder of George Floyd and Rayshard Brooks by police in the US and the release of the outcome data of Covid-19 in the UK and the US.
Health inequality imposed by racism
In the UK, where ethnic minorities constitute 14% of the population, the proportion of coronavirus infection and that of critically ill patients in the hospitals are disproportionately high, at around 34%.
In the US, due to paucity of data on the ethnicity of coronavirus victims, it is difficult to categorically demonstrate the real picture. However, it is obvious from the available data that a similar situation of disproportionate effect of coronavirus on ethnic minority populations in the US.
People from ethnic minorities are more likely to have underlying health conditions, making them more vulnerable to the virus; they also work in roles where they are exposed to infection, and live in conditions in which it is more likely to spread.
NHS staff from minority ethnic groups suffer discrimination and racism throughout their careers too, and of the 119 NHS staff known to have died in the pandemic, 64% were from an ethnic minority background representing only 20% of the staff in the workforce.
Though ethnic minorities pride in their substantial presence in the frontline of combating the coronavirus pandemic, data continues to expose institutional bias against ethnic minorities. Staff survey data from NHS England shows that 29% of ethnic minority staff have experienced bullying, harassment, or abuse from other staff in the past 12 months.
Another study of the consultant appointment in the NHS in 2017 showed that white doctors applied for fewer posts, were more likely to be shortlisted, and were more likely to be offered a job. On average, ethnic minority doctors in the NHS earn £10k less, and ethnic minority nurses earn nearly £3k less annually than white counterparts.
Minority ethnic group staff are systematically over-represented at lower levels of the NHS grade hierarchy, and under-represented in senior pay bands.
It is by now well established and there is evidence of compelling association between income and health, corroborated by numerous research studies. A study from Harvard University, published in the Journal of American Medical Association JAMA, objectified an incongruity of 15 years for men in life expectancy and 10 years for women between the most affluent and the poorest populations.
Poverty undoubtedly contributes to death and disease. Poor people not only are exposed to dying early, they are also touched by the plague of multiplicity of comorbid conditions. Poverty leads to poor health and ill health traps poor people into the maze of poverty, generating a never-ending vicious cycle.
What can be done?
Experts and stakeholders in the national and international arenas traditionally advocate addressing the elimination of income inequality for the correction of health disparity that in a majority of situations leads to a temporary and only negligible adjustment, reverting soon to the primordial status quo.
In addition to prioritizing income inequality, the nation can target health inequality as the dominant policy approach as Bangladesh has done in the past, successfully demonstrating the reverse, improving health status to pull its population out of poverty.
It was a real success story for Bangladesh, of colossal magnitude that had shattered the long-held assumption of experts that countries must first reduce poverty, then better health will follow, almost automatically. This was a conventional conviction held by international political and socio-economic specialists.
Remarkably, these experts were not despondent to be proven wrong by Bangladesh’s decision to reverse the order, freeing the populations first from the misery caused by ill health, followed by the economic miracle consequent to the good health of the population. The success has justly been hailed globally as the Bangladesh Miracle.
Unfortunately and regrettably, the situation reversed. In recent times, income inequality in Bangladesh has diverged exponentially. The high achievement in health indicators slowed down significantly, then plateaued, and eventually began to demonstrate declining trends in many health auguries through a catalogue of failures to recognize and establish corrective measures by people occupying the helm and upper echelon of health policy and planning.
We had the misfortune of observing the management shambles encountered in the preparedness for the battle against the virus.
There were issues with raising public awareness on the pandemic, in the timely lockdown initiatives, in their monitoring of disciplined implementation, in complete breakdown of communication and collaboration, in the management of testing, tracing, isolation, and quarantine; the debacle in the supply and provision of PPE to health care workers; and in the failure to prepare public health premises, hospitals, health centres, health complexes, and community health clinics to receive and manage Covid-19 patients.
There was mismanagement in each sector, despite the Bangladesh government’, and particularly the prime minister’s intention to successfully encounter the pandemic, born out of her patriotism and love for her population.
It is time that the leadership at the helm of national health policy, planning, and delivery of medical care concentrate on presiding over a health care system that is aimed at improving the health of the poor and vulnerable -- of high quality, efficient, devoid of dishonesty and pilferage, with people directed and the care delivered by skilled, knowledgeable, and caring individuals and teams -- or give way to experts who can.
Dr Raqibul Mohammad Anwar is a Specialist Surgeon and Global Health Policy and Planning Expert, Retired Colonel, Royal Army Medical Corps, UK Armed Forces.