BAME frontline workers should also get priority for Covid-19 vaccine

Evidence shows that those of BAME origin are amongst those at highest risk of infection and death  from COVID 19. People of BAME origin often work in low paid employment in jobs where it is not possible to work at home such as cleaners, carers and bus drivers. These are also jobs which put workers in close, protracted contact with the public. Doctors in Unite believe that when a safe vaccine against COVID 19 becomes available that those in such high risk roles should be prioritised to receive it and they should be recognised as front-line staff.

In the NHS, it is usual for low paid jobs to be contracted out to private corporations and these outsourced workers, for example in NHS domestic services and portering,  do not get treated on a par with directly employed staff. While it has been shown that clinical staff in intensive care units have been well protected against Covid 19 with high quality risk assessment, PPE, air purification and more, other front line clinical workers, especially outsourced BAME workers, have had high mortality.  

In addition, public facing workers of BAME origin often live in overcrowded, multi-generational households. Potential exposure to COVID 19 at work not only puts them at risk, but their extended families.

Doctors in Unite believes that these high risk, front-line workers should be among those at the front of the queue to receive a safe COVID 19 vaccine,  and applauds the International Workers of Great Britain for their  groundbreaking court victory over health-and-safety protection for workers in the gig economy.

See article here on IWGB’s court victory here: https://morningstaronline.co.uk/article/b/union-hails-groundbreaking-court-victory-over-access-to-ppe-for-gig-economy-workers

Doctors in Unite Statement: Government guidance on shop opening and return to work is unsafe

We believe easing of the lockdown, and the active encouragement to return to work, is premature and unsafe given the high rate of ongoing infection1, that the R0 value is very close to, and in some areas is above 1 and the test, trace and isolate system is months away from being properly functioning.  In addition, the return to work will disproportionately expose lower paid and BAME workers to increased risk of Covid-19 infection, the very groups who have already been hit so hard by this deadly disease.

The return to work however is being implemented by the government and indeed further plans are to be announced shortly, so it is important to look at the guidance.  There is separate guidance for schools which will not be discussed here, however the general principles will apply to schools too.

The government’s guidance for 8 sectors of the economy, “Working safely during coronavirus”2 gives us serious cause for concern.   It fails to take into account the way Covid-19 transmission occurs indoors, the time spent in enclosed spaces and the need to ensure proper ventilation.  The very high risk faced by BAME staff is not mentioned.  The guidance also downplays the importance of face coverings as well as weakening the 2m rule, making it advisory rather than a requirement.  There is frequent use of the phrase “whenever possible” throughout the guidance, creating uncertainty and allowing room for employers to choose whether or not to implement the provisions.  There is sensible advice in the guidance, such as the need to carry out a risk assessment of the workplace, on home working and on handwashing, use of sanitisers and cleaning and disinfection.  However these do not make up for the many deficiencies, which will result in people who work in offices, shops and other enclosed work places up and down the country, doing so in unsafe conditions and being exposed to Covid-19. 

Indoor transmission of Covid-19

Apart from early “super-spreader” events outdoors, transmission of Covid-19 is essentially an indoor phenomenon3, both through droplet spread and microdroplet aerosol spread4.  The 2m rule is of limited value: if people occupy the same enclosed space for any length of time, and ventilation does not meet required standards, aerosolised viral particles from an infected individual can spread through the available space and may be breathed in by anyone occupying that space.  A single cough can project over several metres, tens or even hundreds of millions of viral particles into the air5 and will contribute to the creation of an “aerosol rich environment” in an enclosed space.  The longer people occupy this space the greater the risk of inhaling sufficient viral load to get infected.  Even if strictly observed, the 2m rule will not offer sufficient protection in this situation. 

A number of studies have shown that enclosed indoor environments can result in high levels of transmission.6, 7, 8 They show one or two infected individuals can lead to a large number of other people being infected, even if they are several metres away from each other. 

Ventilation

The consideration of ventilation in the guidance is inadequate and vague, and fails to take into account the challenges of making indoor spaces safe from Covid-19. It does say face-to-face meetings should be held “outdoors or in well-ventilated rooms whenever possible.”  There is no mention of ventilation however in relation to workplaces and workstations, where large numbers of workers will spend most of their day.

Improving ventilation is mentioned in the government’s guidance for transport operators, as follows: “Organisations should consider how to increase ventilation and air flow. Where possible, transport operators and businesses should ensure that a fresh air supply is consistently flowing through vehicles, carriages, transport hubs and office buildings.”   Once more we see “where possible” and there is also a distinct lack of detail about the technical requirements for effective ventilation to eliminate this highly infectious new pathogen from public transport provision.  This will not lead to safe conditions for travel for the public.

Organisations with ventilation systems are advised to check them to see if they require servicing or adjustment “for example, so that they do not automatically reduce ventilation levels due to lower than normal occupancy levels.  Most air conditioning systems do not need adjustment, however where systems serve multiple buildings, or you are unsure, advice should be sought from your heating ventilation and air conditioning (HVAC) engineers or advisers.”  There is no technical guidance here about type of ventilation required, and issues like the number of air changes per hour etc.  And what of premises were there is no ventilation system?

The absence of guidance on ventilation is all the more surprising given the detailed advice on this from Public Health England: “Covid-19: Infection prevention and control guidance”.9 While this is written for health care settings and much of the detail is not applicable, the facts of known asymptomatic spread of Covid-19, the aerosol route of transmission of the virus, and the ongoing high level of community infection mean that all indoor spaces are a potential hazard.  The general principles of this guidance should therefore apply to all indoor spaces, but they do not appear to have been considered, apart from that stated above.

BAME staff

Nowhere in the guidance is the very high risk from Covid-19 for BAME people mentioned.  Death rates are 4 times as high for some BAME groups, yet section 2.1 in the guidance for shops, on “Protecting people who are at higher risk” makes no mention of this.  The risk of dying from Covid-19 for people with diabetes, (included in the “clinically vulnerable” group of the population requiring extra protection) is exceeded by that for people of a BAME background.  This cannot be right, and as long as serious risks like this are not addressed, the current high death rates will continue.

Social distancing

There is over-reliance in the guidance on the 2m rule to keep workers safe, and as we have said, throughout the guidance this is weakened by the phrase “where possible”.  Where 2m distancing is not possible employers should “manage transmission risk” by among other things, “using back-to-back or side-to-side working whenever possible”.  Sitting side-by-side or back-to-back will not prevent people from breathing in aerosolised virus, as the studies clearly demonstrate, and people do not rigidly stick to one head position, they move around and turn especially when speaking to those around them.  This weakening is consistent with the constant drip feeding in the media suggesting that the 2m rule is not really essential, compromising the social distancing message overall still further.

A recent study in the Lancet showed that reducing distances is associated with increased risk: infection risk doubles when the distance between people is halved from 2m to 1m10.

Face coverings

The government’s recent about turn on the wearing of face coverings is welcome, as belated as it is.  However, the advice on face coverings in the return to work guidance almost seems to be designed to put people off from wearing them: “There are some circumstances when wearing a face covering may be marginally beneficial as a precautionary measure.”  Again, this is reproduced throughout the guidance documents. 

We recognise there will be some areas and job roles, and for some individuals, where it is not practical or advisable, but face coverings should be worn everywhere in the workplace as a means of source control for transmission of Covid-19, unless there is a demonstrable reason not to do so.

Duration of time, activity levels and size of work space

These three further risk factors for indoor transmission are also not considered in official guidance.  The longer the time people spend together in an enclosed space the greater the risk of inhaling sufficient virus to become infected.  Similarly, the smaller the space the greater the risk.  In addition if people are highly active, for example through physical exertion leading to heavy breathing, or laughing or shouting, excretion of virus is significantly increased from infected individuals, adding to risk of infection in an enclosed spaces.

Conclusion

Official guidance on return to work is inadequate and will leave very many people exposed to risk of infection with Covid-19.  Making workplaces safe in the era of Covid-19 is nigh impossible given the scale of changes required with ongoing high levels of viral transmission in the country.  The only way to keep people safe at work is to drive down transmission to much lower levels and have in place a reliable and highly efficient test, trace, isolate and support system.  Current government plans are very risky and threaten to drive a second wave of the pandemic in the UK.

References

  1. Estimated to be 17,000 new infections per day by the MRC Biostatistics Unit on 5 June 2020. https://www.mrc-bsu.cam.ac.uk/now-casting/
  2. https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19
  3. https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1.full.pdf
  4. https://science.sciencemag.org/content/early/2020/05/27/science.abc6197
  5. https://www.pnas.org/content/early/2020/05/12/2006874117
  6. https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article#tnF1
  7. https://wwwnc.cdc.gov/eid/article/26/8/20-1274_article
  8. https://www.latimes.com/world-nation/story/2020-03-29/coronavirus-choir-outbreak
  9. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/886668/COVID-19_Infection_prevention_and_control_guidance_complete.pdf
  10. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2931142-9

Doctors in Unite Statement, 10/06/2020

The hostile environment is inconsistent with government commitments on child health and the fight against COVID-19

Charging those with uncertain immigration status for NHS services was introduced as part of Theresa May’s ‘hostile environment’. Non-payment of bills can result in being reported to the Home Office and used as a reason for not being granted settled status. This system remains in place during the Covid-19 pandemic, actively discouraging health care seeking with the threat of immigration enforcement.  Among around 618,000 people are living in the UK but without the documentation to prove a regular immigration status, and it is estimated that 144,000 of them are children (1), half having been born here. The legislation over charging introduced by the Tory government under the spurious pretext of targeting ‘health tourism’ represented an unprecedented departure from the founding principles of the NHS and among other consequences undermines child health (2).

On a global scale, the numbers of people forcibly displaced from their homes because of conflict, persecution, natural disasters and famine reached 68.5 million by the end for 2017 and continues to rise. Children make up over half the world’s refugees and, like other asylum seekers and undocumented migrants, they are exposed to multiple risk factors for poor physical and mental health throughout their migration experience (3). NHS charging regulations undermine the government’s stated commitments to child health as well as obligations to children under the United Nations Convention on the Rights of the Child (Article 24), and also contradict recommendations outlined in the UN Global Compact for Migration, signed by the UK in 2018 (2).

A briefing paper from Medact (https://www.medact.org) written to support those campaigning against the hostile environment in the NHS (4) argues that the health system functions as a foundation for societal wellbeing and a platform for the expression of ethical behaviour. The NHS was founded on the principle of treating everyone in the country regardless of status, wealth or origin. The idea that people can be either eligible or ineligible to access care contradicts the central reasoning behind collective provision in which pooling finances through general taxation shares risk and ensures equity in healthcare for all (4). This is brought into sharp focus by the current challenge set by coronavirus. While it has been argued that services for treatment of infectious diseases, including the tests required to diagnose them, are in fact exempt from charges, people do not present with a ‘diagnosis’ but with symptoms. This means that for many, fear of incurring charges will still prevent them from seeking care for themselves or their children. As we move once again towards much needed contact tracing as a crucial element in disease containment, it has been pointed out that for this to be viable, all sections of the community must be willing to be contacted by the NHS or public health staff (5). Unlike the UK, the Irish government has declared that all people—documented or undocumented—can now access healthcare and social services without fear. Undocumented immigrants and asylum seekers in Portugal have been granted the same rights as residents, including access to medical care, and in South Korea they can be tested without risk of deportation (5). Once again it appears that public schoolboy concepts of British ‘exceptionalism’ are facilitating racism and inequity with negative effects on the entire population.

Long before the Covid-19 pandemic, the Faculty of Public Health (FPH) had raised concerns about the potential for under-diagnosis and under-treatment of infectious diseases arising from the charging policy (6). Medact called on care providers to undertake detailed research into the impact of both charging and identity checks on patients’ health and on a hospital’s ability to meet its equality duty, and other legal obligations including professional duties of care that staff have towards their patients. It also called upon the Department of Health and Social Care (DHSC) to commission a full independent inquiry into the impact of the Regulations on individual and public health; and publish their own internal review of the 2017 Charging. Unfortunately these things have not happened, although members of Medact in conjunction with paediatrician colleagues have themselves recently published a revealing investigation into attitudes towards and understanding of UK healthcare charging among members of the Royal College of Paediatrics and Child Health (RCPCH) (7). 

From 200 responses by healthcare staff, it was evidence that there was a lack of understanding of current NHS charging regulations and their intended application, with 94% saying they were not confident about which health conditions are exempt from charging regulations and one third reporting examples of how the charging regulations have negatively impacted upon patient care. The survey identified 18 cases of migrants being deterred from accessing healthcare, 11 cases of healthcare being delayed or denied outright, and 12 cases of delay in accessing care leading to worse health outcomes, including two intrauterine deaths. The authors of the study concluded that NHS charging regulations are having direct and indirect impacts on migrant children and pregnant women, with evidence of a broad range of harms. Additionally, that they are unworkable and are having a detrimental impact on the wider health system, as well as conflicting with its staff’s professional and ethical responsibilities (7).

In 2018, the RCPCH joined with the Royal College of Physicians, the Royal College of Obstetricians and Gynaecologists and the FPH to call on the DHSC to suspend the National Health Service (Charges to Overseas Visitors) Regulations 2015 and the National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017, pending a full independent review of their impact on individual and public health (8). Following the publication of the recent survey (7), the RCPCH reiterated its opposition to charging, observing that: “This policy has, sadly, placed vulnerable groups at risk of worsened health outcomes as they choose to delay or deter seeking treatment” (9). On a broader front, the Institute of Race Relations has publicised how the appallingly overcrowded and unhygienic housing offered to some asylum seekers and their young children is putting them at increased risk of Covid-19 infection (10). Sixty cross-party MPs have now written to the health secretary, Matt Hancock, calling for the suspension of charging for migrants and all associated data-sharing and immigration checks, which they say are undermining the government’s efforts to respond to the pandemic (11). We should all reiterate this call and insist that these demands are implemented with immediate effect.

  1. Dexter Z, Capron L, Gregg L. Making life impossible – how the needs of destitute migrant children are going unmet. The Children’s Society, 2016. https://www.childrenssociety.org.uk/what-we-do/resources-and-publications/making-life-impossible-how-the-needs-of-destitute-migrant
  2. Russell NJ, Murphy K, Nellums L, et al. Charging undocumented migrant children for NHS healthcare. Arch Dis Child 2019;104;722-723
  3. Stevens AJ. How can we meet the health needs of child refugees, asylum seekers and undocumented migrants? Arch Dis Child 2020;105:191-196
  4. https://www.medact.org/2019/resources/briefings/patients-not-passports/
  5. https://www.bmj.com/content/368/bmj.m1284/rr
  6. https://www.fph.org.uk/media/2158/final-fph_briefing_nhschargingregs_1.pdf
  7. Murphy L, Broad J, Hopkinshaw B, et al. Healthcare access for children and famiies on the move and migrants. BMJ Paediatrics Open 2020. https://bmjpaedsopen.bmj.com/content/4/1/e000588
  8. https://www.rcplondon.ac.uk/news/royalcolleges-support-suspension-nhs-overseas-visitor-charges-pending-review
  9. https://www.rcpch.ac.uk/news-events/news/migrant-charges-unworkable-say-paediatricians
  10. http://www.irr.org.uk/news/asylum-in-the-time-of-covid-19/
  11. https://www.independent.co.uk/news/uk/home-news/coronavirus-undocumented-migrants-deaths-cases-nhs-matt-hancock-a9470581.html

John Puntis, co-chair of Keep our NHS Public (KONP)