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Podcast series from the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow.
Alastair Leyland:
Hello and welcome to 15 Minutes on Health Inequalities. Today, we're talking to Vittal Katikireddi about a paper he’s published outlining a framework for understanding the unequal impact of the COVID-19 pandemic on minority ethnic groups. My name is Alastair Leyland. I work at the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow and with me is
Anna Pearce:
Anna Pearce, a colleague of Alastair's and then we have
Vittal Katikireddi:
Vittal Katikireddi, also based at the MRC/CSO Social and Public Health Sciences Unit.
Alastair Leyland:
Thank you for coming Vittal. I wondered if you could start by telling us something about the motivation behind this paper.
Vittal Katikireddi:
So, if we think back to early on in the pandemic, obviously it was a new disease, we didn't really know that much about it, about who it was affecting, about the consequences of COVID-19. So, within Glasgow we were one of the first teams to look at this issue of ethnic inequalities in COVID-19. And so we’d found that often minority ethnic groups were experiencing higher risks of ending up in hospital with COVID-19 and also dying from COVID-19. So, as a consequence of that, I'd been asked to speak to some policymakers and we were finding that there was often a bit of a misunderstanding of the likely drivers of ethnic inequalities in COVID-19. So, there was often a sense that surely the explanation was genetic differences or those types of issues. Whereas, based on our previous work looking at ethnic inequalities in health from before the pandemic, generally for most common diseases you tend to see that genetic factors aren't a big driver but instead there's a whole range of social pathways that are really important. So, we were keen to try to convey this kind of understanding to policymakers and so that's really the origin of this paper.
Anna Pearce:
Thanks Vittal. So, can you talk us through the first of those pathways that you mentioned, which I think is referred to as differential exposure?
Vittal Katikireddi:
Sure. So, in some ways, when we're thinking about COVID-19 and experiencing health harms, there are different steps in the disease pathway we can think about. So, people might be exposed to the virus that causes COVID-19, so SARS-CoV-2, so that particular coronavirus might be more commonly encountered by some people than others. That's often a consequence of where people are, their social and physical environments. So, if you work in certain places, then you might expect to come into contact with the virus more often, especially if you're in a kind of public facing job. But also, depending on the nature of your housing and so forth. If you're in a house with more people, then you might be more likely to come in contact with the virus, and if you don't have access to, kind of, outdoor space and so forth, all of these types of things might influence the chance of you coming across the virus. There might be differences across ethnic groups in how often people are coming into contact with the virus.
Alastair Leyland:
And the second mechanism you talk about is differential vulnerability to disease. Can you tell us about that and how it works?
Vittal Katikireddi:
Once someone's been exposed to the virus, not everyone will then go on to actually become unwell. So, some people might not develop any symptoms at all, even though they've been infected. Other people might develop really severe disease. So, actually people have a different level of vulnerability to going from being exposed to the virus, to then actually having clinically important disease. And that could be a consequence of a whole range of factors. So, it might be about people's level of immune function. So, if someone has a very robust immune system, they might be exposed to the virus but not actually even develop any symptoms at all. Whereas other people who might have a poorer functioning immune system, and often reasons that could include having other pre-existing health conditions and so forth, those types of things might put you at greater risk of having not just symptomatic infection but also even going on to have severe disease.
Anna Pearce:
So, I think that leads us nicely on to the next couple of pathways which were related to the differential consequences of catching COVID. So, being sicker once you've got it, and then the wider consequences of being sick.
Vittal Katikireddi:
It's possible that different ethnic groups might experience differences in the prognosis from that disease. So, some people might be more likely to end up in, for example, critical care or even to end up dying. And that might be again due to, for example, having other health conditions, could be because of other things that put you at high risk of poor health more generally, so things like smoking and obesity, which might vary across ethnic groups. But also it could be a consequence of differences in the quality of healthcare as well. So, it's possible that if the health system isn't treating everyone equitably, then possibly some people are receiving poorer treatments that means that they end up being more likely to have a worse prognosis. And that poorer treatment could also be to some extent indirect as well. So, it could be about actually treatment being a bit less accessible as well, rather than necessarily an individual doctor or nurse or other health professional treating patients in different ways. It could also be about the health system not actually being as accessible to people from different backgrounds.
Anna Pearce:
And I think you also talk about the wider societal consequences once you've caught COVID in terms of impacts on employment and so forth. Is that right?
Vittal Katikireddi:
Exactly. So, after people experience COVID, obviously you ideally hope that someone gets better quickly and that's them back to their full level of health. Unfortunately, we know that's not the case for a sizable proportion of people. It can take quite a while to recover after COVID and so the adverse consequences on health can be sustained. But also the social consequences of that poor health might differ across different social groups and different ethnic groups. So, if you're in a, if you like, a white collar, more professional job, then you might be able to more readily return to work or work from home or have a more flexible form of working that allows you to keep your job, keep money coming in and so forth. Whereas if you're in a more manual job with an insecure contract, so, for example, if you're on a zero-hours contract, you might not end up having money coming in or being able to go in to do your shifts. And we know that often ethnic minority groups are more likely to be in insecure employment, so there may well be differences in the social consequences of experiencing COVID across ethnic groups.
Alastair Leyland:
Your final two mechanisms are about control measures that were introduced during the pandemic. Can you briefly say something about these?
Vittal Katikireddi:
When we were in the really, kind of, acute phase of COVID and experiencing very high rates of infection and increasing rates of infection, often it was necessary to introduce public health control measures to reduce infections. And if that's done quite early on, then hopefully you will reduce the level of infections to something much more manageable, and that has benefits both for health and the economy. However, there are adverse consequences of introducing control measures. So, for example, the lockdown measures. Thinking about how some of these consequences might affect different groups of people in different ways can be quite important, at least in terms of trying to plan to reduce inequalities, or at least minimise them as much as possible. So, for example, when schools close, it may well be that some social groups are more likely to not have broadband at home, to be digitally excluded, and so forth. So, taking action to try to reduce that and minimise adverse consequences of control measures becomes really important. The other thing to remember, as well, is that sometimes when control measures are introduced, they may not be equally effective for everyone. So, one of the control measures that was introduced was to try and stay at home when possible and to only meet people in more outdoor spaces with much better levels of ventilation than you have indoors. But, of course, that means that if you don't have easy access to outdoor space, such as a garden, then you might be less likely to be able to meet your friends and family in that, kind of, more low risk environment. So, the effectiveness of control measures is likely to differ across social groups as well. That's what really the last two pathways were about.
Alastair Leyland:
So, that leads on to my next question which is do you think any one mechanism is more important than the others?
Vittal Katikireddi:
I would say that all of the pathways do play a role and I think it also depends on what health outcomes you're thinking about as well. Because, some of the framework is about the indirect health harms of COVID and of the pandemic, rather than just necessarily the COVID hospitalisations and deaths themselves. However, if you're focused just on the COVID hospitalisations and deaths, I would say that differences in exposure do seem to be important. So, that probably does reflect differences in the nature of work environments. Also differences in things like accessibility of PPE equipment, so making sure that early on there were challenges in everyone having access to the kind of personal protective equipment you would expect. I do think that was a particularly important pathway.
Anna Pearce:
So, this framework was originally created quite some time ago now for thinking about health inequalities and how they rise in the general sense. Do you have any reflections having adapted it for the specific purpose of looking at ethnic inequalities during the pandemic?
Vittal Katikireddi:
The original framework is hugely helpful for thinking about health inequalities in general terms. I think that when it came to think about ethnicity, thinking about issues around structural racism is probably a bit more important than when thinking about other axes of inequality. The other thing that I think was useful for us in the context of COVID, and also thinking about the role of policies, was to actually not just think of the drivers of inequalities but also the consequences of policy actions for inequalities. So, thinking about how interventions themselves might be differentially effective, and how they might have their own adverse consequences as well. So, I think those two aspects were probably more relevant in the context of COVID and when working with policymakers.
Alastair Leyland:
We always like to finish these podcasts by asking about the implications of the work for health inequalities. Now, we've obviously talked quite a lot about health inequalities, but is there anything else you'd like to add?
Vittal Katikireddi:
One thing that strikes me is, I think often in health inequalities research, but also probably amongst kind of policymakers and practitioners, there's a tendency to focus on a specific axis of inequality or dimension of inequality. So, for example, socioeconomic inequalities in health or ethnic inequalities in health. I do wonder if we could maybe do a bit more on trying to think across the multiple axes of health inequalities rather than necessarily all being focused only on our particular areas.
Alastair Leyland:
Yeah, nice point.
Anna Pearce:
Yeah, I think we'd both agree with that wouldn’t we? OK, well, thanks, Vittal. We've really enjoyed chatting with you today. And thank you to everyone listening. As always, you can find details of the paper that we've been discussing today and the biographies of everybody involved in this conversation in the podcast notes. And all of our other podcasts from our series can be found on most of the major platforms by searching for 15 Minutes on Health Inequalities. Thanks.