COVID-19 and Health Inequality

This piece is part of HWO’s feature on ‘Apocalypse Then and Now’. The feature brings together radical reflections and historic perspectives on catastrophe and calamity. How have crises (both real and imagined), and responses to them, shaped our world?

COVID-19 is not an equal opportunity disease. Even as politicians, managers, and UN officials give us pep talks about how we’re all in this together, segments of our society are having vastly different experiences of this pandemic. Rather than proving to be any sort of ‘great leveller’, coronavirus is instead running its course along the inequalities that have long furrowed our society, claiming the lives of those at the bottom – people from BAME backgrounds, the poor, the disabled, the old, and the disenfranchised – at a much higher rate than the white and the wealthy.

Our ministers might do well to simply revisit the results of a 1980 government investigation into the state of the nation’s health. The report of the Working Group in Inequalities in Health, known informally as the “Black Report” after Committee chairman Sir Douglas Black, declared that inequalities had not only seen no reduction since the 1948 institution of the NHS, but had in fact deepened, with death rates between social tiers widening over the decades.

‘Our NHS’, envisioned at its inception as an ark that would buoy the poor and the vulnerable to the same health footing as the privileged, had failed in one of its core missions. Now, forty years after the Black Report, we can see in the daily death toll how our national health remains moored to our historical inequities. Extending free, comprehensive health care to all has not created a society more equal in health. Instead, the NHS has acted as one of the many – even if unwitting – cultural incubators of the very inequities it was designed to ameliorate. It is an open secret that care across the NHS is not equal. The white, wealthy, and well-educated still tend to receive higher quality treatment and more compassionate care.

Perhaps the less well-known story of inequality that COVID-19 has revealed, however, is the story of inequality within the NHS. There is no protection from social inequality to be found here either. The effect of the novel coronavirus on workers has reflected that in the rest of society, with doctors and nurses from BAME backgrounds disproportionately leading the death rates. While people of colour account for approximately 21% of NHS staff, 63% of those who have died from coronavirus have been from BAME backgrounds. Perhaps most starkly, 95% of the doctors who have died have been people of colour.

The reasons for this disparity are complex and as yet under examined, but one cause is the class system found in the health service’s internal structure. Though it might have been naïve to think that the introduction of the NHS in 1948 could have levelled the social playing field, it was certainly an opportunity to flatten some of the hierarchies in hospitals and other healthcare settings that had become increasingly entrenched over the preceding 150 years. Nye Bevan wanted the health professions – doctors and nurses alike – to become salaried employees of the state. But surgeons, physicians, and general practitioners resisted, insisting on the historical exceptionalism they had come to value, even despite its relatively recent vintage. They and the institutions they were attached to negotiated a different relationship to the new National Health Service and perpetuated the working cultures they had been accustomed to.

Hospitals are unrepentantly hierarchical institutions. At the bottom of the pecking order are the non-clinical workers – men and mainly women who tend to be employed on less secure, temporary, and precarious contracts with limited union protection, and who come from already disadvantaged groups with far less social, economic, and political capital than doctors or nurses. Cleaners, porters, and ancillary healthcare workers have also become increasingly likely to be contracted out, paid by companies external to the NHS and not afforded the same labour protections as others hired ‘in-house’. At no time is this ideal. In this current pandemic, it has meant that they are also at the bottom of the list – the least well protected – when it comes to things like the distribution of PPE.

Why, though, are BAME doctors and nurses also dying at faster rates than their white counterparts? Presumably they are, at the very least, on parallel contracts and entitled to the same quality and quantity of protective equipment. Could it be that good education, good salaries – even being one of our nation’s ‘heroes’ – are also not the health levellers we have so often taken them to be? We know that racism permeates British society. It permeates the NHS too. After all, while the government’s recent report on disparities in the risk and outcomes of COVID-19 demonstrated that people of colour are at markedly higher risk of dying from coronavirus, there is no mention of racism – structural or otherwise – anywhere in the text. We must do better.

These inequalities don’t stop at death’s door. When NHS workers started succumbing to COVID-19, the first to be counted and mourned were the doctors. Then, only after several nurses had perished, did the government start taking note of their names as well. Now, nearly thirty healthcare support workers, almost ten administrative staff, approximately ten porters and cleaners, and five paramedics have also died. While these other ‘key workers’ have been increasingly acknowledged by the press and by those clapping for ‘our carers’, it is unclear, for example, whether the families of some of these dead workers are to be included in the government’s life assurance scheme for ‘frontline’ staff.

The introduction of the health service in 1948 was a missed opportunity to flatten these institutional hierarchies and inequalities. If it could not ameliorate inequality in society at large, the NHS could have at least attempted to show in its own structuring how it might be stamped out. After the current crisis has abated, we must commit to finishing what the NHS’s architects set out to do – make our society more equal in health. On an institutional level, this means that our healthcare workplaces must be restructured so that that everyone within them is treated with equal respect and entitled to equivalent benefits. On a societal level, and at the very least, we need to be more honest with ourselves about the limited capacity of free medical care (available, in theory, to all) to deliver equal health. If that were the case, we’d be in a very different place now than we were in the 1940s. The COVID-19 pandemic has shown that perhaps, we’re not so far away from that pre-NHS world as we might like to believe.