“We all face the same storm but we are not all in the same boat” – Sonia Adesara

The session was introduced by Sonia Adesara, NHS doctor, who pointed out that Black and Asian people had been catching covid and dying from it at disproportionately higher rates than their white counterparts. Women, in particular ethnic minority women, had also been hardest hit economically and socially.

The first witness was Mary Ann Stephenson, previously a director of the Fawcett Society which campaigns for equality for women, and is the current director of the UK Women’s Budget Group.

The group had published a report at the start of 2021 (Where Women Stand) looking at the impact of the pandemic on women, which showed that while men were more likely to die from covid, women had suffered a greater social and economic impact. They were more likely to be made redundant, more likely to be furloughed, had suffered a vast increase in their unpaid work, and were more likely to be in significant debt. There had also been an increase in domestic violence, a problem which predated the pandemic and is “massively underreported.”

It was also known that women were more likely to be poor, to work in sectors like hospitality that would be affected by the pandemic, that they carried out 60% more unpaid work than men, and that closing schools and nurseries would increase that burden. In other words, the pandemic had exacerbated pre-existing gender inequalities in society and the government could, and should, have anticipated these. 

In terms of what the government could have done, Stephenson suggested several possibilities. They should have addressed the lack of financial support for people to self isolate, especially through better statutory sick pay. It should have been possible to furlough for childcare reasons. There should have been more money put into domestic violence services.

“The gaps in the Social Security system, and particularly in statutory sick pay, leave many people with no choice but to carry on going to work, even when they’re ill, because they can’t otherwise afford to keep a roof over their heads.”

Above all there should have been equality risk and impact assessments of covid policies early on.

“We put all this in our reports, but we’ve had no response from the government.”

Going forward Stephenson felt we were facing a cliff edge with the end of the furlough scheme and the end of the £20 uplift in Universal Credit and that we needed a social security system that acts as a genuine safety net. Jobs must be created for those who have lost them. In the long term, society needs to look at changing gendered norms—for example, by changing the distribution of unpaid care, especially in the home, which is at the root of so much inequality outside the home. Other countries, such as the Scandinavian countries, have managed this.

“Covid has highlighted problems that existed long before the pandemic. But the economy is not a fact of nature, we can construct it in a different way. We don’t want to go back to the way things were, we have an opportunity to do things differently, and this is the moment to do that.”

The next witness was Kamlesh Khunti, professor of primary care, diabetes, and vascular medicine at the University of Leicester. 

He felt that the scientific community had been “caught off guard” by the impact of the pandemic on ethnic minority groups, and when he did finally draw attention to it in April 2020, he said that he was accused of scaremongering. At that point 30% of those being admitted to ICU were of “non white ethnicity,” despite the fact they only made up 14% of the population.

Khunti was asked about the factors behind the disproportionate impact of the pandemic on minority ethnic groups. He listed several, including differential exposure, for instance through housing or occupation, differential vulnerability, such as through comorbidities or living in high risk environments, and poor access to care and the quality of care provided. He pointed out that minority ethnic groups have higher rates of diabetes, cardiovascular disease, and obesity. He also talked about problems with messaging for these groups, which had been poor or non-existent, and which he linked to vaccine hesitancy.

He also mentioned the initial lack of personal protective equipment (PPE) as having played a significant role in hospital acquired infection at the beginning, both for staff and patients.

Going forward, Khunti suggested prevention programmes for chronic disease such as diabetes, targeted at minority ethnic groups, with simple messages to reduce sedentary activity. These needed to be culturally accessible, for instance through the use of bilingual community workers and working with faith groups:

“Structural discrimination is an issue underlying all of this. And this is pre-pandemic. Inequitable systems, such as housing, education, employment, earnings, benefits, credit. All of this is structural discrimination that puts people at a disadvantage – ethnic minorities and non-ethnic minorities, but more so ethnic minorities.”

The next witness was Latifa Patel, NHS doctor and acting chair of the BMA annual representative body. 

Patel said that the BMA already knew through its own surveys that even before the pandemic, minority ethnic group doctors were more at risk of discrimination, bullying, and harassment. They therefore knew that if they raised concerns once the pandemic began, they were the least likely to be heard or acted upon. She gave the instance of the serious shortage of PPE, about which minority ethnic group doctors were less likely to raise concerns, knowing full well “they would not be heard.” 

Minority ethnic patients also had specific needs, in particular due to poor experiences in accessing healthcare and poorer health outcomes. She felt that communication with them throughout the pandemic had been “wholly unacceptable.”

“You should try and aim (your messaging) at the most disadvantaged and make that your baseline. We know that didn’t happen.”

Patel pointed out that virtual platforms had rapidly become the norm in the NHS. They had put minority ethnic groups at a disadvantage due to requirements of good WiFi and good English language. They assumed that everyone was contactable via a mobile phone, which is often not the case for low income families on pay-as-you-go contracts. Privacy has become a serious problem for multigenerational families, with people resorting to consultations in cars and bathrooms in order to have privacy. Patel felt that many had not kept appointments because of this.

“Space is a privilege which not everyone could afford.”

Patel said that the BMA had called from the beginning for risk assessments for frontline staff, and for adequate PPE, and that these problems still had not been properly addressed. NHS staff did not feel safe and valued, and record numbers were reporting burn out and talking about leaving the NHS.

Finally she addressed vaccine hesitancy among minority ethnic groups. Patel said there was already a lack of trust in the government before the pandemic, arising from historical issues such as Windrush and Brexit, along with disparities in access to healthcare and poor messaging for minority ethnic groups, which had all contributed to vaccine hesitancy.

Going forward she wanted to see a reduction in health inequalities affecting minority ethnic groups, and much better messaging.

“We know that communication throughout this pandemic from the government has been wholly unacceptable.”

The next witness was Aliya Yule, who works for Migrants Organise which is a charity that supports refugees, asylum seekers and others without status. Yule said that there are between 800,000 and 1.2 million people in the UK classed as “undocumented” (also labelled by the government and right wing press as illegal migrants). The majority of them arrive on a legal basis, and then became undocumented in various ways such as not being able to pay for regularisation of their status or loss of the employment that allowed them to be here.

They are the target of the government’s “hostile environment” policies, which means that their immigration status is checked whenever they need to access any of the services that are needed “to live a dignified and normal life.”

“The hostile environment makes life incredibly difficult for people who don’t have the right immigration papers. And as we know, this affects not just those who don’t have legal status, but can affect people who are unable to prove that they have legal status, such as those from the Windrush scandal.”

This means they are “incredibly fearful” about approaching these services even when in need. The NHS for instance charges some migrants up to 150% of the cost of care, according to a complex set of rules and exemptions, and some instances of non-urgent treatment require payment upfront. That means if you can’t pay, you don’t get the treatment. Of particular concern to undocumented migrants is the fact that the NHS shares patient data with the Home Office, including around debts accrued due to needing treatment. If you have a debt to the NHS, your future immigration applications can be prejudiced. Many hospitals also use debt collection agencies to chase migrants who have these debts. In addition, hospital patients with foreign sounding names are checked by Overseas Visitor Managers and asked to prove their entitlement to NHS care. 

Yule gave several examples of undocumented migrants who were too fearful to seek help despite being ill with covid and who had died at home as a result. They were entitled to free care for covid, but they didn’t know it because the government hadn’t publicised it. 

Yule mentioned the abysmal and traumatising conditions in which some asylum seekers are kept, with no possibility to socially distance and no ready access to GP services. Covid had “ripped through” some of these communities. 

Finally she mentioned the “immigration health surcharge” which migrant workers have to pay even if working in the NHS. This could amount to an extra £4000-6000 on top of visa charges. This had resulted in some workers, on whom the NHS depends, being split up from their children.

Going forward she felt that the government was becoming ever more hostile to migrants. 

“This is really about scapegoating a group of people, blaming migrants for the erosion and defunding of our public services by saying, it’s those people who come here who steal our hospital bed, who steal our school places, who steal our jobs, blaming the most marginalised and making it then extremely difficult for those people to speak out about what is happening to them. it creates a group which the government can blame for their problems.”

The major theme to come out of this session was familiar from previous sessions. The pandemic has shone a light on and exacerbated inequalities and discrimination which already existed in society, affecting women, minority ethnic communities, and undocumented migrants. As a result these groups had suffered disproportionately. The government had failed to predict this despite evidence presented to them via various organisations, and had failed to take action even after being given the evidence.

Jacky Davis, consultant radiologist, founder member of Keep our NHS Public, panel member of the People’s Covid inquiry.

Competing interests: none declared.