Introduction
Background
National and regional evidence on the impacts of coronavirus (COVID-19) shows that inequalities in physical and mental health have widened as a consequence of the pandemic This is a result of both the direct effects of the virus, and the indirect effects through the control measures taken.1
Although this has led to an increased focus on health inequalities, particularly those affecting BAME communities,2 the reality is that these disparities have persisted for a long time The recent update to the Marmot Review3 showed that even before the pandemic increases in life expectancy were slowing down, particularly in the most deprived areas of the country and especially for women There is also a marked social gradient in healthy life expectancy, with people in the most deprived areas spending more of their lives in ill health
It has long been recognised that the conditions in which we are born, grow, live, work and age have important implications for our physical and mental health, as individuals and across wider society – and that for many citizens in the West Midlands, these conditions
are far from optimal Broadly, greater socioeconomic deprivation is associated
with poorer health outcomes This is due to the impact of deprivation on the wider determinants of health – our social, physical and economic environments Housing, employment and skills, and social connections– ‘jobs, homes, friends’ – are key, and can be interpreted in their broadest senses Again some of these effects are direct, and others are indirect, or mediated by health behaviours; for example, a lack of green space and poor air quality can have a direct impact on respiratory health and mental wellbeing, and also an indirect impact through reducing participation in physical activity.
Health inequalities across the life course
Health problems in working age and older adults reflect the impact of cumulative disadvantage across the life course Child poverty rates have increased nationally and will continue to have long-term negative impacts on the lives of children, families and communities On average, 22% of children were living in poverty before housing costs in England in 2017/18 – 30% after taking into account housing costs, and higher in areas with high housing costs This increased to 47% for children in lone parent families, and over 70% for those living in workless families 4
Taking a life course perspective to reduce health inequalities means acting as early as possible to reduce the cumulative disadvantage that begins in early childhood However, it also means recognising that there are opportunities to improve health & wellbeing at any age
Recognising the impacts of COVID-19
The Royal College of Physicians and Public Health England have worked with NHS Providers and the Provider Public Health Network to identify groups that may be disproportionately affected by COVID-19 (Figure 1) 5 These include people with protected characteristics; those who are socioeconomically disadvantaged or live in deprived areas; and inclusion health and marginalised groups
Social distancing and isolation can also have a detrimental impact on mental health and wellbeing, including through harmful health behaviours and reducing access to services and support People who misuse or are dependent on drugs and alcohol may be at increased risk of becoming infected with the virus, and infecting others They may also be more vulnerable to the impact of infection due to underlying conditions Rough sleepers are a particularly vulnerable group and are unable in the ordinary course of events to self-isolate.
Understanding population vulnerabilities, risk factors and inequalities is important to inform both the acute response phase and the recovery and repair phase over the longer term as well as mitigating the impact of COVID-19 it is important to ensure existing physical and mental health and wellbeing needs are being met, and that we continue to address health inequalities through improving the social and economic conditions in which people live
Socioeconomic/ Deprivation
- (e.g. unemployed, low income, deprived areas)
Equality & diversity
- (e.g. age, sex, race, religion, sexual orientation, disability, pregnancy & maternity
Inclusion health & vulnerable groups
- (e.g. homeless people; Gypsy, Roma & Travellers; sex workers; vulnerable migrants; people who leave prison)
Geography
- (e.g. urban, rural)
Figure 1: Groups that may be disproportionately affected by COVID-19 (adapted from PHE/RCP, 2020)
The Regional Health Impacts of COVID-19 Task & Finish Group
The Regional Health Impacts of COVID-19 (RHIC) Task & Finish Group was convened in June 2020 to focus on the relationship between the disparities in the health
and economic impacts of the pandemic identified by the PHE review and wider health inequalities in the WMCA Region The group includes representation from the WMCA, PHE, local authorities, the NHS, universities and the voluntary & community sector
An interim report6 was published by the WMCA and the PHE Population Intelligence Hub for the RHIC group in August 2020 This included analyses of population vulnerabilities, risk factors and inequalities, and occupational inequalities intersected with ethnicity which are discussed in the following section The interim report also identified stakeholder concerns around the upcoming challenges facing the West Midlands over the coming months and the unique opportunities for action and partnership working presented by the pandemic
The report was accompanied by a call for evidence7 which sought to understand experiences and impacts of COVID-19
among individuals and communities; challenges and barriers for citizens, communities and organisations; examples of good practice in improving accessibility; and changes in approach and further support needs A variety of reports, quantitative data and qualitative feedback was received in response to the call for evidence, which have informed subsequent sections of the report A thematic analysis of qualitative submissions can be found in Appendix 2
Aims and purposes of the report
This report is divided into three sections to describe the extent of health inequalities in the WMCA region and opportunities for action, considering the relationship between health and wealth and the impacts of the COVID-19 pandemic It should be viewed alongside the State of the Region report,8 which focuses on the economy and growth
Part 1 - of the report describes the health of the people who live in the West Midlands It shows where change was needed even before COVID-19, and how existing inequalities have been exposed and exacerbated by the pandemic
Part 2 - discusses how change can happen to build community resilience and embed prevention across all we do It considers a new approach, taking full advantage of the many opportunities presented by
a Combined Authority and its partners – and emerging opportunities following the COVID-19 pandemic
Part 3 - sets out priority areas for action and next steps, with a series of commitments for action from key partners
Comment on Black Asian and Minority Ethnic (BAME) phrase and representation
In the aftermath of the PHE reports on adverse impact
of Covid-19 on Black Asian and Minority Ethnic (BAME) communities, there has been an important debate around the appropriateness of the use of the phrase BAME as a collective for all ethnic minorities The use of BAME has been debated for a few years9,10,11 and the phrase is mainly used in the UK, while the US prefer to use “person of colour” to identify the collective 12 While useful in relating to national policy documents, there are a number of reasons why the phrase is problematic
First, if the only qualification for inclusion in BAME is being non-white, then we miss out on many ethnic minority groups that identify as White Other, such as Roma people, Traveller communities or some Turkish or Arab communities 13Black British Academics have also argued that using BAME ‘reproduces unequal power relations where white is not a visible marker of identity and is therefore a privileged identity’ 14,15 Secondly, experiences of people within the BAME categorisation are quite different, owing to their group identities and journeys within the UK The nuances between South Asian groups’ experiences and also between Black African and Black Caribbean are important, and these are in danger of being masked with a collective phrase such as BAME16 There are also issues of intersectionality and multiple disadvantage within groups, based on gender, language, religion and/or sexual orientation
Different phrases are used to describe people from ethnic minority backgrounds, but even the phrase ‘ethnic minority’ is contested Some suggestions have included the use of ‘racialised communities’ as an alternative, to describe groups of people who have essentially been at the receiving end of structural racism or othering While others have opted to spell out BAME to indicate a heterogenous group and then go even more granular and state Pakistani, Bangladeshi or Vietnamese instead of Asian or Nigerian or Jamaican instead of Black or Black African or Caribbean
Given there is a lack of a clear alternative, it seems there is still usefulness in the use of BAME classification, as it ensures consistency with current wide usage amongst public bodies and many other institutions It is important to acknowledge the discourse and sensitivities around the classification and continue to use BAME as a collective phrase until a widely used alternative is agreed upon