In my view, Britain has always had a thorny relationship with race and immigration, and this is magnified in the NHS.

The NHS has relied on migrant labour using colonial ties to fill its ranks such as nurses from the Windrush generation or doctors from the Indian subcontinent. 43% of senior NHS doctors and 47% of junior doctors are from Black, Asian or Minority Ethnic (BAME) groups ¹. In London, 67% of the adult social care workforce is from minority ethnic group backgrounds ². These people, or their ancestors, came to the UK expecting a chance to build their lives here. Many have been successful and helped shape the NHS.

The “healthy migrant effect” has been described. Migrants have better health than the majority in the host country ³ and use less public services ⁴. The Home Office’s Migration Advisory Committee found ‘no doubt that EEA migrants contribute more to the health workforce than they consume in health care’ ⁵.

However, in my experience, migrants often feel their contribution is not recognised. In the politically charged atmosphere of the Brexit referendum and its fallout, immigration has suddenly been thrust to the forefront of our collective consciousness. I can picture the infamous ‘breaking point’ poster and others. The message I hear is that state benefits are being siphoned off from native, white hard-working families and immigrants are changing the composition and culture of the country. Policies were called for to “keep out” so-called ‘low skilled’ migrants, many of whom would probably have worked in the NHS. Immigrants have been referred to as ‘citizens of nowhere’, and warned that the NHS is not for them. It is a national ‘not an international health service’. The lack of details on how NHS and care workers will be exempt from the “Immigration Health Surcharge” only compound this feeling ⁶.

COVID-19 made us suddenly reliant on people who were previously ‘invisible’. Immigrants who staffed the supermarkets, drove the buses, cleaned the streets and kept essential services going, were rightly lauded for their efforts. But these very key workers were becoming ill and seriously ill at that. Reports of deaths of BAME people including NHS and care staff from COVID-19 started to emerge. I remember it beginning with the deaths of two Sudanese doctors and then more and more BAME NHS and care staff. Of at least 169 front-line health and social care workers in England and Wales known to have died because of COVID-19, 63.9% were BAME⁷. By latest estimates more than 200 have now died and the number continues to grow ⁸. 

I became apprehensive and was conscious of growing fear amongst my colleagues. The Royal College of Physicians (RCP) found 48% of all doctors who responded to its survey were either concerned or very concerned for their health, a figure that rose to 76% among BAME doctors. Nearly two-thirds were worried about passing the virus on to others at home ⁹.

This fear became grave concern with the publishing of the report “Disparities in risks and outcomes for COVID-19” on June 2^nd 2020 ¹⁰. The analysis of survival among COVID victims was shocking. Accounting for the effect of sex, age, deprivation and region, found Black males in England and Wales are 4.2 times more likely, while black women are 4.3 times more likely to die after contracting the virus. People of Bangladeshi ethnicities had around twice the risk of death than people of White British ethnicity and Pakistani, Indian, and mixed ethnicities also had an increased risk of death involving COVID-19.

On the backdrop of these stark disparities, the sense of community and appreciation for the NHS continued to grow. Rainbows were pasted on every front window. People came out at 8pm every Thursday to clap for carers, to thank them and show their appreciation. There was talk of NHS staff being heroic and fighting the virus. For me, the military terminology has always been problematic. When you call someone a hero and send them into war, you normalise them dying. The other problem with calling people heroes is it places an onus upon them to behave in a particular manner.

In my view, many were reluctant to put themselves and their families at risk. Everyone was aware of the pressure to be a hero but this came with real risks to their own health and to the health of their families. With limited political leadership and no real plans to protect the BAME community, people were rightly concerned. They felt pressured to carry on working on the frontline to live up to these expectations and maybe were put in positions they did not want to be in. For the opposite of a hero is a coward and no one wants to be that.

But what was the ‘heroic’ thing to do? Would it be more heroic to show compassion for ourselves and our colleagues in these circumstances? To be able to work constructively showing good clinical leadership so that all members of the team feel valued and protected. Sometimes heroism might be the courage to voice one’s concerns and to decide to take a step back from the challenge. The risk of catching Covid-19 in a healthcare setting will never be neutralised but it can certainly be minimised, especially for those more vulnerable.

So, whether you feel valued for your contribution as an immigrant, really seems to depend on which day of the week you were asked the question.  Are immigrants viewed as an asset or a drain on society? Heroes, statistics, or beloved family members? Mixed signals from our political leadership have not helped us feel valued. It feels as though while some things have changed, nothing has really changed.

The visible show of public appreciation has certainly helped demonstrate the gratitude some feel towards our frontline workers. I hope that this crisis will have at least one silver lining in that maybe people will look beyond race or immigration status and be able to appreciate what each and every individual offers to society. In this way, we might start making some progress towards healing this divide that has existed for so long. As clinical leaders, we can take this further by empowering people to speak up. We have to look after ourselves and each other, so we can better look after our patients.

References

1. https://www.theguardian.com/world/2020/apr/03/uk-doctors-coronavirus-deaths-highlight-crucial-role-bame-medics
2. https://www.kingsfund.org.uk/blog/2020/04/ethnic-minority-deaths-covid-19
3. Helgesson M, Johansson B, Nordquist T, Vingård E, Svartengren M. Healthy migrant effect in the Swedish context: a register-based, longitudinal cohort study. BMJ Open. 2019;9(3):e026972. Published 2019 Mar 15. doi:10.1136/bmjopen-2018-026972
4. https://journals.sagepub.com/doi/abs/10.1258/jhsrp.2010.010097
5. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/741926/Final_EEA_report.PDF
6. https://commonslibrary.parliament.uk/research-briefings/cbp-7274/
7. https://www.telegraph.co.uk/news/2020/06/08/bame-coronavirus-deaths-black-ethnic-minority/
8. https://www.theguardian.com/world/2020/apr/16/doctors-nurses-porters-volunteers-the-uk-health-workers-who-have-died-from-covid-19
9. https://www.rcplondon.ac.uk/news/what-are-we-learning-workforce-about-impacts-covid-19
10. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/890258/disparities_review.pdf

Dr Saurabh Jain 

Saurabh Jain is a Consultant Ophthalmic Surgeon and the Clinical Director of Services at the Royal Free London NHS Trust in London, UK. He is the Training Program Director for the London School of Ophthalmology and Health Education England. He has recently been awarded the Fellowship of the Higher Education Academy (FHEA) by University College London. He is a senior examiner for the Royal College of Ophthalmologists, International Council of Ophthalmology and the European Board of Ophthalmology.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.