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Sir Michael Marmot, Director of the Institute of Health Equity at University College London, talks to Science Director Roger Highfield about why some communities are at higher risk of COVID-19.

Sir Michael conducted pioneering studies of civil servants that revealed how, as you move down the social hierarchy (from Sir Humphrey to an office messenger), your risk of illness and death rises.

His edited answers are in italic to distinguish them from my commentary.

How does your work hold up a mirror to society?

Major questions about the link between social class and mortality were posed by the Whitehall studies (one, began in 1967, followed up around 18,000 civil servants, and a second, started in 1985, studied more than 10,000). We found health follows a social gradient but the question was is this more general than British civil servants?

Everything that I have done since shows what a general phenomenon it is, which is remarkable.

We see that this is not just a question of poor health for people who are poor and good health for everybody else. The impact is socially graded.

People in the second most affluent areas have shorter life expectancy than the most affluent, and all the way from top to bottom.

In Glasgow, for example, there is a 28-year difference in life expectancy between the most and least salubrious areas. 

This social gradient is found not just in the UK but everywhere we look and even goes for non-human primates.

How does your research relate to higher death rates among BAME communities?

The Office for National Statistics (ONS) analysed all deaths in England and Wales with suspected or confirmed COVID-19 and, for a given age, men and women from all ethnic groups (except Chinese women) were at greater risk of dying from COVID-19 than white people.

The difference was particularly large for black men and women, who were more than four times as likely to die from COVID-19 than white men and women.

COVID-19 patients who are admitted to critical care or who die in hospital include a disproportionately large number of people from ethnic minorities.

One in three patients admitted to critical care with COVID-19 has been from a minority ethnic group, although they make up only one in eight of the UK population.

South Asian people are the most likely to die from coronavirus after being admitted to hospital according to a study in 260 hospitals of around 31,000 COVID-19 patients who had their ethnicity recorded.

The study by the International Severe Acute Respiratory and Emerging Infection Consortium, ISARIC, the largest of its kind, showed that people from South Asian backgrounds were 20% more likely to die than white people.

Does this mean that the position of BAME communities in the social hierarchy is central?

Yes, if you look at the report on Disparities in the Risk and Outcomes of COVID-19from Public Health England, and before that, from the Office of National Statistics, then you look at deprivation and COVID-19 mortality, it is really similar to the gradient in mortality from all causes seen in the Whitehall studies.

That suggests to me that the social determinants of health inequalities generally show a high degree of overlap with social determinants of inequalities in COVID-19.

Visualisation of Covid-19 virus
Visualisation of COVID-19 virus

How has health inequality changed in recent years?

In 2004, Sir Michael told me there was little evidence that the Government’s efforts to reduce inequalities between rich and poor were having much impact.

In 2010, he conducted a landmark review of health inequalities which concluded that reducing health inequalities would require action on six policy objectives:

  • Give every child the best start in life.
  • Enable all children, young people and adults to maximise their capabilities and have control over their lives.
  • Create fair employment and good work for all.
  • Ensure healthy standard of living for all.
  • Create and develop healthy and sustainable places and communities.
  • Strengthen the role and impact of ill-health prevention.

This year, in his ‘ten years on’ report, he found that for the first time in more than a century, life expectancy has failed to increase across the country, and is declining for women in the worst-off decile on the index of multiple deprivation.

The fact that it (social gradient) has increased in Britain gives me hope – in a bizarre kind of way – that if it can get bigger it can also get smaller.

Are there differences between the impact of COVID-19 and what you would expect from the social gradient?

My ’ten years on’ report came out in February and showed that the last decade did not serve the nation’s health well. The increase in life expectancy slowed dramatically, inequalities by deprivation and region increased further, and life expectancy for women in the poorest areas outside London went down.

In the Public Health England report, London stands out for the impact of COVID-19 whereas in my ’ten years on’ report I found life expectancy had got worse in the north-west and the north-east relative to London, and had declined for women in the most deprived deciles outside London.

So, London was relatively better off in terms of health equity whereas for COVID-19 it was worse off – that suggests, aside from the general effect of health inequality, you have to consider specific factors in the capital that are related to COVID-19.

London is a big, crowded metropolis, an international centre and the like.

You would expect COVID-19 to have started in London and spread to deprived areas, for instance in the north-east and the north-west, such as Barrow in Furness, this is what we have seen.

If all else had been equal, other than the social gradient, would fewer people of BAME COMMUNITIES have died if the pandemic had struck a decade ago?

I am not sure. Ten years ago, we still would have had people doing front line jobs, and living in crowded multi-generational households. I said that with COVID-19 there was the general issue of health inequalities and then influences specific to COVID-19.

Those specific influences – jobs, crowding – would still have applied.

Did you study BAME Communities in this year’s health equity study?

We said what we could about BAME communities in the ‘ten years on’ report. Because ethnicity is not recorded on death certificates, you cannot get mortality statistics on BAME communities, without special linkage studies such as that recently carried out by the Office of National Statistics.

When we could get data on BAME communities, we commented on it but we lamented the fact that it is not routinely available.

We focused on early child development, education, employment and working conditions, having enough money to live on and healthy sustainable places to live and work.  We found that austerity and the rolling back of the state, which was done in a regressive way, likely had a higher impact on health and health equity.

We are planning to use same categories to examine the impact on inequalities in health of the pandemic and the societal response to the pandemic, notably lockdown.

What do you make of official reports on BAME communities and the pandemic?

The first Public Health England report, for example, was criticised for not answering the question, explaining the link.

But it showed that for Black British people, there was a twofold excess mortality from COVID-19, most of which went away in multivariant analysis, notably when they adjusted for deprivation.

For political reasons perhaps it did not want to be too explicit, but to me, it said that for Black British people, deprivation explains much of the excess of COVID-19 deaths in Black British communities.

So, when we see the phrase ‘adjusted for deprivation/confounding factors’, it is glossing over the problem of health inequalities?

Note what ‘adjusting for deprivation’ means. The excess in COVID-19 mortality is very much in evidence.

Because of systematic disadvantage – racism – black people are more likely than the general population to be in deprived circumstances.

The second PHE report goes a good deal further and identifies what should be labelled structural racism as a cause of excess COVID-19 mortality in BAME communities. It reports the voices of the communities affected, and makes recommendations.

How does deprivation put people at higher risk?

People often say BAME communities are “more likely to die” from the coronavirus, but there are two questions that have to be answered: are people from minority ethnic backgrounds more likely to catch COVID-19 and, once they have caught it, are they then more likely to die from it?

One way is by higher incidence but we don’t have very good or systematic data because we have not done widespread testing and early on, people were told not to get tested but to go home and self-isolate, so we don’t know who got it and who did not.

A colleague’s son lost his sense of smell but otherwise was well.  My colleague had a mild fever. Are they cases or not cases? We don’t know.

However, it seems highly likely that people in more deprived circumstances would have a higher incidence, even though we don’t know for sure. However because of crowding, front line occupations, not being able to afford home delivery of food and the like, there is greater exposure.

I have come across the example of a nurse who lives in a one-bedroom flat with her two children and her husband. When she comes home from the hospital, the first thing she wants to do is to get her clothes into the laundry and get into the shower.

But her children want to give her a hug, you know. It is all right to say use a separate bathroom, but who has got a separate bathroom living in a one-bedroom flat?

Why are BAME communities at higher risk of severe illness when infected?

Thinking about biological mechanisms is important and interesting and may tell us how deprivation does its damage, but let’s take a wider view.

To me, the higher risk they face is likely to work through greater exposure and greater severity. Linked, in part, to comorbidities such as diabetes, hypertension and obesity and vascular disease.

There may also be less good biological defence mechanisms in people who are deprived and this could be due to chronic stress, as was shown by Robert Sapolsky’s studies on non-human primates.

I emphasise a lack of control in life as a source of chronic stress. Disempowerment can mean that you have not got the money to feed your children, and that is pretty stressful.

Looking beyond COVID-19 at health inequalities, more generally, one does not have to appeal to stress pathways.

There is a ready explanation for why your children might suffer in the form of inadequate nutrition, which in the UK, might mean they are obese and in other countries, malnourished and have problems with brain development and the like due to poor nutrition.

I have heard people on the front line say that many people admitted to critical care with COVID-19 have been obese, and how much is comorbidity I don’t know.

The fact is that there is huge variability in the response, with some people who have been in hospital for two months.

The Prime Minister, Health Secretary and Chief Medical Officer all declared themselves to have COVID-19 around the same time. The latter returned to work quite soon, while the Prime Minister was near death and had a really miserable experience.

These three high-status individuals had very different responses. How much of that was due to dosage, how much to obesity (relevant when it comes to the PM), I don’t know.

Variability of response is a very interesting question and there is almost certainly more to it than I am saying.

Higher rates of severe COVID-19 infections in BAME populations are not explained by socioeconomic or behavioural factors, cardiovascular disease risk, or by vitamin D status, according to one study based on 1326 COVID-19 cases recorded in the UK Biobank.

The findings, published in the Journal of Public Health, suggest that the relationship between COVID-19 infection and ethnicity is complex (summary).

However, the ISARIC study of 31,000 patients admitted to hospital with COVID-19 concluded that South Asians are at greater risk of dying in part due to a higher prevalence of pre-existing diabetes.

Are there communities at particular risk?

Public Health England concluded: ‘After accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity.

People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10% and 50% higher risk of death when compared to White British.’

In the Public Health England report, when you adjust for deprivation, the excess deaths go away in the Black community but not in the Bangladeshi community. Some say it is to do with genetic factors.

Maybe. But it could be the index of deprivation does not capture the reality of people’s lives, for instance, if they are more likely to live in multigenerational households or work in care homes or other frontline occupation.

I suspect the deprivation index does not capture all of multi-faceted reality.

Does talk of genetic factors, lack of vitamin D and so on ‘pathologise blackness‘ and distract from racism?

Wouldn’t it be convenient if you could blame high mortality in BAME communities on lack of Vitamin D?

You could then ignore the many aspects in which people’s lives are blighted by the societal reaction to their ethnicity.

Crowding? No, it’s sunshine. Working as a driver, and hence sharing the high COVID-19 mortality of drivers? No, it’s lack of supplements.

Suppose it were true that Vitamin D was playing a role, racism and discrimination would still exist.

Lack of vitamin D is not likely to play much of a part in police targeting black youths.

I doubt that Stephen Lawrence’s parents would be in any way consoled by knowing their son’s vitamin D status before he was murdered by white thugs.

Presumably, health inequalities affect deprived white communities too?

This is not unique to Black British people but deprivation in the population as a whole. That is very clear.

Part of the link between COVID-19 and deprivation is you see that people lower down the social hierarchy are sicker – for example, type two diabetes has a dramatic social gradient.

If that puts you at increased risk of severe disease, that could partly explain the link with deprivation.

Visualisation of Covid-19 virus
Visualisation of Covid-19 virus

Can social hierarchy explain all the risks faced by BAME communities?

Before I attribute everything to deprivation, I have got to confront why doctors of BAME communities seem to be at higher risk.

There is an overrepresentation of high-status individuals – doctors from BAME communities and Chaand Nagpaul, British Medical Association council chair, himself south Asian, speculated that perhaps BAME communities are more likely to be on the front line, or less likely to complain about inadequate PPE.

Can we do anything about this cause of early death?

Though inequalities across Europe are remarkably consistent, the slope or gradient varies, so inequalities are less in some areas and bigger in others, and that is encouraging.

If they were all the same, you would say we can’t do anything about it.

The thrust of Health Equity in England: The Marmot Review Ten Years On was that there is a great deal that we can do. My colleagues and I laid out specific recommendations for the government and others.

A second report from Public Health England carries a list of ‘requests for actions’, not endorsed by PHE itself, which include:

  • Better data collection about ethnicity and religion, including having this recorded on death certificates.
  • Supporting further research with the participation of all communities to understand the increased risk and develop programmes to reduce it.
  • Improving BAME groups’ access to, experiences of and outcomes from NHS and other services – using audits, impact assessments and better representation among staff.
  • Developing risk assessments for workers in front line roles from BAME communities.
  • Producing culturally sensitive education and prevention campaigns to rebuild trust.
  • Ensuring that COVID-19 recovery strategies address inequalities to create long-term change.

Sounds like we need a root and branch reform of society– is that realistic as the nation reels from COVID-19?

The “Build Back Better” idea is that we should see the present health, social and economic crisis not only as a threat but as an opportunity.

My ‘ten years on’ report made clear that health and health inequalities in England before the pandemic were far from where they should be.

If the rate of health improvement had slowed down over the last 10 years, it meant that society had stopped improving. I already thought that we needed a reset.

The fact the government has thrown aside the ‘austerity orthodoxy’ of 2010 and the last decade, and said ‘whatever it takes’, means we have the opportunity to think what would building a fairer society look like.

What do we want as we emerge from the pandemic? It is time for a broad national conversation.

HOW HAS THE PANDEMIC AFFECTED deprived AREAS?

Lower-income households are twice as likely as high-income households to have increased their use of consumer credit during the pandemic, and are 50 per cent more likely to be saving less than usual, leaving them particularly exposed to the resulting economic crisis.

I talked to Ajit Lalvani of Imperial College London, Science Museum Group Trustee and Chair of the Bromley by Bow Centre, BBBC, in Tower Hamlets, one of the most deprived areas which also has one of the highest proportions of Bangladeshi people. His edited responses are in italic.

Each of these factors – socioeconomic deprivation and being Bangladeshi – are associated with a two-fold increased risk of death from COVID-19, independently of each other – so most residents of the area around the BBBC have a four-fold increased risk of dying.

All this makes BBBC very relevant to the current pandemic.

I’ve chaired the board of trustees at the Bromley by Bow Centre for six years. It is the best example I know of how to improve health and wellbeing by tackling the social determinants of health.

Thanks to Michael Marmot, we know the huge impact of these social determinants and we know what they are. But there are few examples of how to effectively address them and thereby reverse health inequalities.

Indeed, health inequalities have increased not diminished in the UK since Marmot’s landmark report a decade ago.

Bromley by Bow uses the local community’s own attributes to improve people’s lives and health and the resilience of the community through focussing on a few essential priorities. It uses various means to help people to have a decent home, find a meaningful job and be connected with others.

Attaining these fundamental goals transforms people’s lives and improves their wellbeing health, reversing ingrained health inequalities.

How has Bromley by Bow responded to COVID-19?

Bromley by Bow has begun its own locally managed community-based test, trace, isolate and support programme to prevent a lethal second wave of COVID-19 infections in the community.

Given the two-fold increased risk for Bangladeshis (the predominant ethnic group at Bromley by Bow) and the two-fold increased risk for socioeconomically deprived regions (Tower Hamlets has very high levels of deprivation), protecting the community from further incursions of coronavirus is especially important.

It’s typical of the Bromley by Bow ethos that the community mobilises to do the best for itself without relying on external support, whether from national or local government.

This is part of the reason why it’s recognised by Public Health England as an exemplar for sustainable public health for the future.

HOW CAN I FIND OUT MORE?

The latest picture of how far the pandemic has spread can be seen on the Johns Hopkins Coronavirus Resource Center or Robert Koch-Institute.

You can check the number of UK COVID-19 lab-confirmed cases and deaths along with figures from the Office of National Statistics.

David Spiegelhalter of the Winton Centre for Risk and Evidence Communication in Cambridge provides his own updates.

There is more information in my earlier blog posts (including in German by focusTerra, ETH Zürich, with additional information on Switzerland), from the UKRI, including this section on minority ethnic groups, the EUUS Centers for Disease ControlWHO, on this COVID-19 portal and Our World in Data.

Last year, the Science Museum hosted a discussion of the toxic fiction that is ‘race science’.

The Science Museum Group is collecting objects and ephemera to document this health emergency for future generations.