Mitigation of risk of COVID 19 in occupational settings, with a focus on ethnic minority groups: Consensus Statement from PHE/HSE and FOM *

* Summary response from Doctors in Unite to the recent statement by Public Health England, the Health and Safety Executive and the Faculty of Occupational Medicine.  A more detailed review of the consensus statement can be found here.

With thanks to the TUC: Dying on the Job.  A report into Racism and Risk at Work


Doctors in Unite feel that the recommendations are nowhere near enough to mitigate the risks of COVID 19 in ethnic minority groups.

Employers cannot be trusted to be left to their own devices to ensure that workplaces are safe. We are aware that this is an extreme example, but in the largest meat packing factory in the US, managers coerced staff to continue working when they were clearly symptomatic of COVID 19 and took bets on who would become unwell. Five of the staff died.

It is of course welcome to have culturally sensitive information in many languages to alert people of ethnic minorities to important measures that they can take themselves to mitigate their risk, but the consensus statement does not touch on the much greater impact that factors beyond the control of the individual has on their risk.

A disproportionate number of people from ethnic minority backgrounds are employed in low paid sectors such as cleaning and caring roles, where they cannot work from home. They often have inadequate PPE. Studies have shown that cleaners in hospitals are more likely to catch COVID 19 at work than clinical staff who work with COVID patients. The latter have greatly superior PPE.

To make matters worse people from ethnic minority backgrounds often live in overcrowded, multigenerational households meaning that spread of infection within communities is likely to be disproportionately high.

Neither does your statement mention the increasing evidence of the importance of indoor airborne spread in the transmission of COVID 19 and the necessity of proper ventilation in the workplace.  A detailed study of the outbreak in the Tönnies meat packing plant in Germany in June showed the importance of ventilation in such plants

Only last year the UN Special Rapporteur, Philip Aston said during a visit to the UK that:

“Policies of austerity introduced in 2010 continue largely unabated, despite the tragic social consequences.” 

We believe that the consensus statement would be much stronger if the emphasis was not focused on health education messages which put the onus on the individual to avoid catching COVID 19 but on the legal duty of employers to ensure a safe working environment and on Government to tackle the long recognised social determinants of health which lead to stark health inequalities.

A whitewash and another missed opportunity: the Consensus Statement from PHE, HSE and FOM on how best to mitigate risk of COVID 19 in occupational settings, with a focus on ethnic minority groups. *

* Detailed response from Doctors in Unite. A summary response can be found here.

With thanks to the TUC: Dying on the Job.  A report into Racism and Risk at Work

Doctors in Unite are disappointed with the recent consensus statement by Public Health England, the Health and Safety Executive and the Faculty of Occupational Medicine.  It is yet another missed opportunity to address the underlying causes of the high rates of infection and death from Covid-19 among ethnic minority workers in the UK.  The recommendations contained in the statement do not go anywhere near far enough to mitigate the risks they face from COVID 19 in the workplace.

The statement makes numerous self-evident statements like “existing workplace guidance and legislation should be reinforced across the whole workforce”, and “all individuals, including those from ethnic minority groups, should have the same approach to risk management in the workplace”, and “the approach to controlling risk should be equitable”.  While it says “employers have a legal duty to protect all workers from harm” it focusses almost entirely on individual responsibility and individual risk factors of workers, like age, sex, deprivation, obesity and diabetes.  Much of the statement concerns itself with “culturally competent” communication as though this were some new breakthrough in occupational risk mitigation, when it is simply the basic requirement to communicate clearly and respectfully with all people whatever their backgrounds.  The implication is that the disparities in infections and deaths of BME workers is down to their not understanding risks and risk mitigation, and better, “culturally competent” communication will solve the problem.

It is of course welcome to have culturally sensitive information in many languages to alert people of ethnic minorities to important measures that they can take themselves to mitigate their risk, but the consensus statement does not touch on the much greater impact that factors beyond the control of the individual has on their risk.

No mention of structural racism in society or racism in the workplace

The consensus statement opens by saying: “a wide range of research has explored the pathways that cause ethnic inequalities and have shown that this is a complex relationship, and the relative importance of different pathways in COVID-19 ethnic inequalities is not well understood”.  It references the paper by SAGE, Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups.

While the relative importance of different pathways or mechanisms may not yet be clear, the central theme of the SAGE paper is that structural racism determines these pathways, and their combined effect leads to the much greater impact of Covid-19 on BME people. (see diagram from the SAGE document in the appendix) The SAGE paper says, “All of these mechanisms arise from the wider social context that drive ethnic and other social inequalities, such as power relations and structural racism.”  Yet the consensus statement simply ignores this and does not mention the word “racism” once in the entire statement.  The consensus statement in fact misrepresents the SAGE paper in this regard, implying the usual “It’s very complicated and we need to do more research” response which is trotted out whenever action and real change is demanded over racial discrimination.  The statement is also extraordinarily myopic given the times we are living through, i.e. the Black Lives Matter movement, and the wider debate and reckoning with racism that BLM has engendered across UK society as a whole. 

The recent Channel 4 documentary “Is Covid-19 racist”, involved a number of high profile BME doctors, including Professor Tollulah Oni, Epidemiologist at the University of Cambridge, and member of Independent SAGE, and Dr Chand Nagpaul, Chair of the Council of the British Medical Association, who were unequivocal that discrimination at work was a direct contributor to the highly disproportionate deaths from Covid-19 suffered by ethnic minority doctors.

The consensus statement does mention “historically oppressed groups”, but only in relation to it explaining “understandable mistrust towards members of the majority culture in cross cultural interactions.”  Where is mention of current day racism and discrimination?

In an article in the New Statesman in 2018, Dr Zubaida Haque, also a member of Independent SAGE, and Deputy Director of the Runneymede Trust, wrote: “BME people are already affected by substantial structural inequalities: they are more likely to live in poorer households, more likely to face multiple disadvantages in the labour market (race, gender and religious discrimination) and more likely to have higher rates of child poverty in their households than white groups. Recent analysis by the Runnymede Trust and the Women’s Budget Group on the impact of budget and austerity cuts also shows that BME people, and BME women in particular, are the worse hit by the cuts.” 

Only last year the UN Special Rapporteur, Philip Aston said during a visit to the UK that: “Policies of austerity introduced in 2010 continue largely unabated, despite the tragic social consequences.”

To make matters worse people from ethnic minority backgrounds often live in overcrowded, multigenerational households meaning that spread of infection within communities is likely to be disproportionately high.

Where is the voice of BME workers?

The day-to-day experience, and the voice of BME workers is not reflected anywhere in the consensus statement.  There are countless reports documenting this, like the TUC’s report “Dying On The Job”, which has this to say:

“BME workers experience systemic inequalities across the labour market that mean they are overrepresented in lower paid, insecure jobs. These inequalities are compounded by the discrimination BME people face within workplaces. Our research carried out just before the outbreak of Covid-19 revealed that BME people’s experiences at work are blighted by discrimination: almost half of BME workers (45 per cent) have been given harder or more difficult tasks to do, over one third (36 per cent) had heard racist comments or jokes at work, around a quarter (24%) had been singled out for redundancy and one in seven (15%) of those that had been harassed said they left their job because of the racist treatment they received.

Yet very few had felt able to raise these issues.

As the disproportionate impact of Covid-19 on BME workers became clear, a range of individuals and organisations debated why this was the case, with a variety of explanations being put forward. Nowhere in these debates were the voices of BME workers heard. We set out to rectify this, launching a call for evidence to properly understand the issues workers were facing and what their preferred solutions were.

What people told us was shocking but not surprising as it directly reflected our research conducted before the pandemic and the experience of BME workers over the years. One in five of those who responded to our call for evidence said they had been treated unfairly because of their ethnicity at work during the pandemic and around one in six said they had been put at more risk at work because of their ethnicity. BME workers told us about being singled out for higher risk work, denied access to PPE and appropriate risk assessments, unfairly selected for redundancy and furlough and hostility from managers if they raised concerns. Workers repeatedly said that the fact that they were agency workers or did not have permanent contracts was exploited through threats to cancel work or reduce hours, both to silence them and force them to work in higher risk situations.”

Are these issues not relevant to the much greater rates of infections and deaths of BME workers?

Grossly inadequate health and safety monitoring and enforcement in the workplace

Employers cannot be trusted to be left to their own devices to ensure that workplaces are safe or to report occupational exposure to Covid-19.  For example, employers in the Leicester garment factories failed to protect Asian workers against Covid-19, while exploiting workers and paying illegal wages well below the minimum wage.  Widespread under-reporting of infections in the food processing industry goes on; one study found there were at least 30 times the number of cases as those reported by employers under the RIDOR regulations.  In the US an extreme example of employers acting with impunity over workers’ safety, occurred in one plant run by Tyson, the largest meat packing company in the US, when managers coerced staff to continue working when they were clearly symptomatic with COVID 19 and took bets on who would become unwell. Five of the staff died.

It is perhaps not surprising that practices like this occur, when the ability to regulate the workplace, the responsibility of HSE and Local Authorities, has been so severely weakened by cuts over the last decade, as well as a culture of “health and safety being a burden to business” encouraged by the government.  In 2015 the government issued a press release which said: “Boosting business by easing health and safety burden – 84% of rules scrapped or improved”.  The TUC estimates that in the past decade HSE inspections have fallen by 70%, and prosecutions for breaches by 82%.   The situation is so dire that statistically, each workplace can expect to be inspected by the HSE once every 275 years.  Local Authority enforcement of health and safety law and practices has been “eviscerated……Local authorities issued 80 per cent fewer health and safety enforcement notices in 2018-19 than they did in 2010-11.”  

Lack of regulation negatively impacts all workers, but more so BME workers as they are more likely to be in insecure work, and less likely to have the protection of trade unions

The impact on workers of a severely weakened regulatory framework is also not mentioned anywhere in the consensus statement.

BME workers face greater workplace exposure to Covid-19

A disproportionate number of people from ethnic minority backgrounds are employed in low paid sectors such as cleaning and caring roles, where they cannot work from home. They are often in public facing roles and often have inadequate PPE.  Earlier this month the High Court found the UK has failed to grant workers in the gig economy the rights they are entitled to under EU Health and Safety law. This includes the right to be provided with Personal Protective Equipment (PPE) by the business they are working for, and the right to stop work in response to serious and imminent danger.  The case was brought by the International Workers of Great Britain (IWGB) a union representing mostly Black, Asian and Latino workers, who are twice as likely to be on these zero-hour contracts compared to their white peers.

A study at the University Hospital Birmingham showed that cleaners in the hospital were more likely to catch COVID 19 at work as front-line medical staff who work with COVID patients.  ICU and theatre staff had less than half the seropositivity rates, and they have greatly superior PPE.  The study also showed that BME health care workers had twice the seropositivity rate of their white colleagues, and that this difference persisted after the results were corrected for deprivation, indicating that greater workplace exposure was the reason.

The TUC report “Dying on the job” spells out how racism in the workplace results in this greater exposure.  Where are any of these practices mentioned in the consensus statement or any recommendations made how to tackle them?

Inadequacies in existing workplace guidance also not addressed

The consensus statement also does not mention the importance of indoor airborne spread in the transmission of COVID 19 in the workplace, and the necessity of proper ventilation.  Existing government guidance was until recently very poor on this issue (it essentially said “open windows and doors where possible”); it now refers to the newly updated HSE guidance on ventilation, which is much better. However, without additional resources to improve ventilation and without a regulator to monitor and enforce the new ventilation guidance, it is difficult to see how things will improve for many workers currently working in risky environments. Workplace guidance has also not caught up with the scientific evidence on aerosol transmission in other respects, even though official PHE guidance recognised this 2 months ago.  The fact of aerosol spread makes a mockery of the “1m plus rule”, i.e. workers should wear a mask or increase ventilation only if they cannot socially distance by 2m.  The consensus statement simply endorses existing guidance; indeed it says it should be reinforced.  We would ask, why do there continue to be hundreds of workplace acute respiratory infection  incidents of Covid-19 every week if the current guidance is effective? 

Large outbreaks of Covid-19 have occurred in workplaces, many involving large numbers of BME workers, where inadequate ventilation is thought to play an important role.  A detailed study of the outbreak in the Tönnies meat packing plant in Germany in June showed the importance of ventilation in such plants, and demonstrated it was factory working conditions and not individual worker behaviour which was responsible for this large superspreading event.

It is the responsibility of employers to address issues like ventilation in the workplace, and to provide all workers with face coverings of appropriate specification to reduce risk of spread.  The consensus statement says nothing of these issues either, and while employers continue not to implement them, further outbreaks will continue to occur to the detriment of all workers.

Conclusion

The consensus statement offers nothing new and in fact is retrogressive.  None of the major determinants of occupational risk are discussed and the emphasis is focused on health education messages which put the onus on the individual to avoid catching COVID 19, and any individual risk factors workers may have.  Workplace guidance is seriously flawed in important respects, and the regulatory framework is barely functional.  Hundreds of Covid-19 infection incidents occur each week in the workplace.  All workers suffer the consequences.  There is also studious avoidance of the issues of racism both in the workplace and structural racism in society at large.  The voice of BME workers is yet again not heard.  The statement can safely be called a whitewash; it does nothing to draw attention to these issues or the failure of employers to ensure a safe working environment, or the failure of Government to tackle the long recognised social determinants of health which lead to stark health inequalities.

29 November 2020

Appendix

Structural racism in ethnic minority Covid-19 infection and mortality

If image is indistinct please see page 4 here.

From: Drivers of the higher COVID-19 incidence, morbidity and mortality among minority ethnic groups, 23 September 2020.  Paper by the ethnicity sub-group of the Scientific Advisory Group for Emergencies (SAGE).

We must stop being polite about Test and Trace— there comes a point where it becomes culpable *

Source: https://covid.i-sense.org.uk/

Test and Trace is a disaster and doctors should voice outrage, not remain silent.

We must stop being polite about the national Test and Trace service. Its privatised design by politicians is a lethal mistake. Yet the media is awash with statements implying that we should “allow” time for it to be improved. It cannot improve in its present state. Both the media and our profession appear complicit in allowing systematic misinformation, egregious miscalculation, delay, and diversion of public funds, to benefit private companies. We all want to pull together in a collective effort and we are wary of rocking the boat. But there comes a point when being silent (and being polite is a kind of silence) becomes part of the problem. 

A year ago Richard Horton of The Lancet urged doctors to consider non-violent direct action over our collective failure to address the environmental crisis. The government is failing to manage both the environmental crisis and the pandemic. This means that the covid-19 crisis is a likely precursor of environmental collapse. Horton’s exasperation is caused by the profession’s acquiescence. Our silence at the ineptitude of our government’s handling of covid-19 is as serious as our silence over the environment. 

The national Test and Trace is a disaster. Its design means that it cannot possibly contain outbreaks of covid-19. It is obsessed with testing at the expense of all the other necessary links in the chain of actions needed to control outbreaks. It fails to detect asymptomatic people and those who are unwilling or unable to be tested and it ignores false negatives. This means that before it starts, it has potentially missed up to 80% of those who are infectious. It then loses cases at each of the stages of informing the index case, collecting information on contacts, reaching those contacts, and then persuading them to self-isolate. Probably less than 20% of those advised will effectively self-isolate. The national Test and Trace fails dismally to find cases at the start of the process and then fails dismally at the other end of the process in supporting people through the difficulties encountered in trying to effectively self-isolate. It is likely that less than 5% of the contacts of those who are currently infectious with covid-19 self-isolate effectively. We as tax payers are paying billions of pounds for this failure.

During this second lockdown the country is paying a massive economic price, people are enduring enormous social disruption, and more lives are being lost. When the numbers of cases are reduced again by this second lockdown, unless there are root and branch changes, the national Test and Trace is likely to fail to prevent a third or even a fourth lockdown. Yet the government continues to expand the single link of testing while neglecting the other links in the long chain of find, test, trace, isolate, and support as described by Independent Sage. Surely, doctors should be standing up at every opportunity and on every platform to object vociferously to a massive failure of public health management? Instead, we are embarrassed to watch senior doctors be bullied by politicians who are out of their depth.

The mistakes the government has made in managing the pandemic are legion, but the national Test and Trace service is the single biggest and most persistent mistake. Plans for massive expansion of testing have some merit, but will be ineffective without each of the other links in the chain being properly organised. A big testing programme will not identify people who are unwilling to be tested because they just cannot afford to be found positive.

We have learnt many things about covid-19 this year. For example, it is spread more by aerosol than by touch, masks are helpful in decreasing spread and treatment with dexamethasone is effective for seriously ill patients. Most important of all however, is that track and trace services that are properly organised, generously funded, and locally run, can control and eliminate the virus from a population, as has happened in New Zealand and other countries.

Should we not listen to our own emotional responses? Societal problems are not caused only by bad people, but by good people remaining silent. It’s time for the medical profession to pull together and show nothing less than moral outrage. The privatised national Test and Trace system must be brought back under the control of the NHS and local public health experts with support from general practice as outlined by Independent Sage. Assessment of patients prior to and after testing by professionals, must be put in place. Primary care is best placed to provide this. There must also be meaningful financial and social support for those self-isolating, some of whom will need hostel or hotel accommodation to be able to do this. Full independent audit of every stage of this chain of interventions is required. We must show our outrage now to enable effective isolation of cases and contacts during November and December. Without this we will be stuck in a cycle of repeated lockdowns.

Bing Jones, former Associate Specialist in Haematology, Sheffield. 

Jack Czauderna, former GP Sheffield.

Paul Redgrave, former Director of Public Health, Sheffield.

On behalf of Sheffield Community Contact Tracers

*This is a reprint of an article that appeared in the British Medical Journal. Dr Jack Czauderna is a member of Doctors in Unite.

Revealed: Boris Johnson’s controversial policy chief leading secretive NHS task force

Munira Mirza heading up group meeting ‘daily or weekly’ to plan ‘radical NHS shakeup’. Open Democracy 19.11.20

Boris Johnson’s government has for the first time confirmed the existence of a prime ministerial task force which is reportedly planning a “radical shake-up of the NHS”.

Freedom of Information disclosures to openDemocracy show the new “No.10 Health and Social Care Taskforce” reports to a Steering Group chaired by Munira Mirza, the influential head of Boris Johnson’s policy unit, and that it “met weekly” from July to September with a further meeting in October.

Mirza, a political appointee who previously worked for Johnson when he was London mayor, has no background or policy experience in health.

The disclosures also reveal that whilst some Department of Health officials do attend the task force, it is led by four senior civil servants based at the Treasury, and none of whom are from the Department of Health.

The government has not published any information about the task force’s existence, work, terms of reference or membership – and has refused to answer questions about the nature of its work.

However in July, The Guardian reported that Boris Johnson was planning a “radical and politically risky reorganisation of the NHS” – in response to “frustration” with the NHS’s performance during the COVID crisis.

And in September, the Financial Times reported that inside sources had revealed an interdepartmental health task force with a wide remit, “determining what the health service’s goals should be”.

The government has previously claimed that rumours regarding the work of the task force are “pure speculation,” and did not even formally confirm its existence, insisting that instead: “As has been the case throughout the pandemic, our focus is on protecting the public, controlling the spread of the virus, and saving lives.”

Not only is the group now confirmed to exist, but Mirza’s leading role and the lack of leaders from the Department of Health suggest that its work is politically focused.

Jackie Applebee, Chair of Doctors in Unite, told openDemocracy, “It is shocking that people with no background in health are meeting regularly to determine the future of health and social care. COVID-19 has surely shown us that putting people with no health experience in charge of the NHS is a disaster.”

Meanwhile Tamasin Cave, a lobbying expert, has called Mirza “a political hire who is unqualified to mess around with the NHS”. She also questioned the timing: “Why are they doing this now, given how much the NHS – and the country – has on its plate already?”

The revelations come as concerns are mounting about post-COVID pressures on the NHS.

Kailash Chand, former deputy chair of the British Medical Association, told openDemocracy. “The waiting lists have built up to an awful level, and they’ll use that as an excuse to bring the private sector in, as they did under the previous Labour government.”

He described Boris Johnson as “dangerous” and having “no faith in public services.”

Secrecy ‘the worst possible way’ to do NHS reform

In their Freedom of Information responses, the Department of Health, the Treasury and Number 10 have all denied having a full record of who has been attending the task force and steering group meetings.

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, has criticised the government’s secretive approach as “the worst possible way to design a major reform.”

“Secrecy encourages groupthink. The government rightly stresses the importance of public and patient involvement and co-production with users when designing new models of care. It is bizarre to reject these ideas for the really big decisions.”

What today’s disclosures do show is that the task force’s civil service policy lead is Adrian Masters. An alumnus of the management consultancy McKinsey, Masters played a key role in shaping the last major piece of NHS legislation, the 2012 Health and Social Care Act.

McKinsey was reported to have drafted large parts of that bill, which was criticised as enabling increased fragmentation and private sector outsourcing of large parts of the NHS.

The task force also includes William Warr: Johnson’s health advisor and a former lobbyist at the firm of Lynton Crosby, who masterminded numerous Conservative Party election campaigns and Johnson’s successful 2008 London mayoral bid.

Warr described the NHS as “outdated” in a Telegraph article penned shortly before he and Johnson entered Downing Street last year, suggesting that the incoming prime minister should ask himself: “If I created the NHS today from scratch, what would it look like?” Warr answered: “Nothing like the monolith we have today.”

Boris Johnson’s first Queen’s Speech in December last year promised to “bring forward detailed proposals” and “draft legislation” to “accelerate the Long Term Plan for the NHS, transforming patient care and future-proofing our NHS.”

The British Medical Association (BMA) has characterised this Long Term Plan as a “plan for a market-driven healthcare system”.

Kailash Chand, the former BMA deputy chair, told openDemocracy he believed the purpose of the task force was part of a wider effort to drive forward more NHS privatisation: “These people are really clever at bringing these things in disguise. This is essentially about getting us towards… big pickings for private companies. It’s not going to happen overnight but this is the road map.”

Referring to McKinsey’s regular NHS recommendations that were implemented under the Cameron government, he said: “McKinsey were brought in previously to recommend financial savings. The easiest way for hospitals to achieve those targets was to cut beds, cut nurses and the salary bill. And we’re still suffering today.”

Political appointments

Boris Johnson has faced criticism for appointing political allies with no health experience to key roles in the COVID-19 response. Test and Trace head Dido Harding, another former McKinsey employee and Tory peer, is in the process of taking over a large portion of the soon-to-be-abolished Public Health England’s remit, the government announced in August. She has also been tipped as favourite to take over as chief executive of the English NHS from the current incumbent, Simon Stevens, next year.

Stevens’ own proposals for major NHS reform last year attempted to allay fears about further privatisation, though campaigners raised concerns that they could make outsourcing less transparent.

Both the Department of Health and the NHS now appear to be taking a back seat in policymaking. Stevens is not on the task force, and none of the four top senior servants in charge comes from the department.

Open Democracy approached Munira Mirza, Adrian Masters, Number 10 and the Treasury for comment, but all have declined to respond by the time of publication.

This is a reprint of an aricle in Open Democracy by Caroline Molloy 19.11.2020: https://www.opendemocracy.net/en/opendemocracyuk/revealed-boris-johnsons-controversial-policy-chief-leading-secretive-nhs-task-force/

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