From Snowy White Peaks to Angels
of Colour -
Ingrained Differential Outcomes of COVID-19 for a Diverse Health
Indranil Chakravorty PhD FRCP
Vipin Zamvar MS FRCS(Cth)
Keywords: BAME, Risk stratification, COVID-19,
Chakravorty, I. & Zamvar, V. (2020) From snowy white peaks to angels of colour: Ingrained
differential outcomes of COVID-19 for a diverse health workforce. The Physician 6(1) epub 24.05.2020
DOI: 10.38192/
The COVID-19 pandemic has profoundly changed the world. In an incredibly short space of time, it has
demonstrated the value of international preparedness, the coordination beyond borders from United
Nations agencies (such as the World Health Organisation), the politics of leadership and science, with a
potential to shape the destiny of billions of people across the world. We see scientists coming together,
sharing and collaborating their emerging knowledge, freely, to help nations/communities, who have
disparate challenges in combating the virus. As the pandemic ravages through continents, we also see
how the variations in the political interpretation of ‘science’ can affect the destinies of different peoples͘
Compared to China and South Korea, the experience in societies with large proportions of migrant
populations, has revealed a perhaps unpleasant angle to this pandemic, one where there are differential
outcomes within cohorts of people. There appears to be overwhelming evidence that patients from
certain minority ethnic groups have differential outcomes in disease severity and even death 1,2.
The review by Chakravorty published in this edition, explores the science behind this ‘risk’ and the
rationale for stratification.3 There are several theories critically explored in this review from biological to
demographic and socio-economic variables. This phenomenon of differential outcomes to a similar
degree is also seen in health workers, where ethnicity appears to be an independent risk, yet they are so
fundamentally different from minority ethnic population groups, in terms of exposure and background.2
It is therefore inconceivable, that their (health professionals) experience in the face of COVID-19, can be
rationalised in the same way.
Although initially thought to be related to the impact of increased prevalence of comorbid conditions,1 it
now appears to also include non-biological factors and societal variations in how people are treated
differently. This is not surprising to a significant minority, who are well aware of deeply ingrained
discrimination in many societies, and the impact this has on their lives, livelihood and health outcomes.
One hypothesis being considered is that ‘structural discrimination’ may have contributed to magnifying
the adverse impact of COVID-19 in certain populations,4 and therefore deserves a more centre stage in
our public discourse, to help us determine cause and effect.
Why whole communities in different geographical cohorts have differential health outcomes is
complicated, and perhaps dependent on multiple factors including biology, education, socio-economic
status, culture, ease of access to facilities/ resources, language and organisational or even political
This editorial cannot do complete justice to this wider question, but we wish to limit our exploration to
the wisdom drawn from a lived-experience of a well-defined cohort of health workers in the United
Kingdom who are at the forefront of the COVID-19 pandemic. We have drawn on the experience of a wide
range of health professionals through personal contacts, social networks and reported analysis of
anonymised surveys from across the health spectrum. 5 The aim of this dialogue is to raise the issues we
feel are important in understanding the differential outcomes for health workers and encourage all
stakeholders to urgently commission actions which will help to ‘save lives and save (all within) the NHS’͘
Esmail and Everington described the variation in success in interviews and career progression for Black,
Asian and Minority Ethnic (BAME) students and doctors over the last 25 years.6 In a commentary of their
experience over two decades they concluded that raising awareness of such issues is not without its
dangers; at one stage they were charged with misconduct by the General Medical Council. 6 Roger Kline,
a research fellow at the University of Middlesex Business School, has been persistent in his work raising
awareness of the differential access to care for patients, and outcomes for staff from BAME backgrounds
in the NHS.7 In 2015, the Workplace Race Equality Standards (WRES) were established and NHS
organisations were required to report on a range of metrics reflecting their culture of equality, diversity
and fairness.8 The most recent report in 2019, shows improvement, but progress remains slow and the
issues do not currently occupy enough bandwidth with senior leadership or the commissioners to speed
up implementation. 9
Why is it important to explore differential health outcomes for health workers from BAME backgrounds?
The answer is probably in the emerging evidence of high risk of disease or death among health workers
in the UK 10, 2, Southern Europe11 and USA. 12 Most alarmingly, both within the general population, and
in health workers, the outcomes appear to be disproportionately worse in those from a BAME
background. Early reviews of the risk factors from hospital admissions in the UK and USA, indicates that
several factors relating to obesity, concurrent chronic diseases, demography and social deprivation may
be important. However, in this pandemic up to 20% of health workers appear to be afflicted, a figure
much higher than in Middle Eastern Respiratory Syndrome (MERS) or SARS, and have a higher risk of
death or severe disease, than those identified in the population.11 All health workers due to the nature of
their roles, naturally face a higher risk of exposure to SARS-CoV-2 in their line of duty. Yet the observed
differential outcomes, segregated by ethnicity is difficult to explain by ‘the exposure hypothesis’ alone͘
There appears to be another missing factor ‘R’͘ In this pandemic, the letter ‘Ro’ has seen more popularity
than ever before, as politicians and citizens alike, have struggled to make sense of the reproduction
number of the ‘virus’ in understanding transmission prevention strategies, previously an exclusive
preserve of epidemiologists.
What then, are the potential contributory factors specific to health workers?
The best way to explore this would be to start with health workers and their perceptions of their own
environment. Surveys by BAPIO Institute for Health Research5, British Medical Association13,14, the Royal
College of Physicians 15 and a large study by Goldacre et al 16 all indicate that health workers are facing
varying degrees of challenges in availability of personal protection equipment, ability to provide care
while complying with social distancing and in their challenge of finding ways to avoid exposure, when
vulnerable. 5 While there appears to be an unacceptably high variation in the availability of personal
protective equipment (PPE) between clinical settings in hospital, primary care and care homes, this risk
appears to be double in those from a BAME background. 17 There are huge variations in the proportions
of workers from a BAME background in roles with lower pay and higher exposure, both in clinical and
supportive roles. Often these are workers employed by agencies contracted to the NHS and local councils
and may not have the infrastructure to provide a comprehensive occupational health risk assessment and
support. There is evidence that hospitals were prioritised by the NHS distribution networks for PPE,
perhaps erroneously assuming that the risk in care homes or primary care settings was lower. The results
of such policy decisions may be manifest in the high rate of overall deaths recorded in the UK and USA
due to COVID-19, including care homes18, when compared to China, South Korea, Germany, South Africa,
New Zealand and Australia. As the realisation of the higher rate of disease and death among health
workers has come, there have been multiple appeals by organisations representing health workers to
institute risk assessment and enhanced protection-avoidance strategies. 19
BAPIO has joined with BMA, Royal Colleges and other bodies to seek urgent action. 20 Public Health
England and NHS England/Improvement have been working with public health experts to develop and
implement such tools. Many large and progressive NHS organisations with strong BAME liaison networks
have been quick to listen to the concerns of their staff and developed tools themselves. 21 A review of
such tools undertaken by BIHR researchers as published in this journal and others 3 suggest that the
methodology appears to be simply based on biological factors with a composite weightage added for
ethnicity’͘22 This appears to be a fundamental flaw in the understanding of the vast range of potential
issues which unite health workers from a diverse social, professional, educational, cultural and religious
backgrounds who are in the ‘B ME’ category͘ It is unfathomable why such a diverse group of professionals
will have the same experience and what might be the factor uniting them to have the same ‘statistical
weightage’ in the eyes of the novel coronavirus S RS-CoV-2.
Shilpa Ross, writing for the Kings Fund report ‘We’re here and you’re there’: lived experiences of ethnic
minority staff in the NHS’ 23 describes a compilation of stories of microaggressions, exclusion, differential
treatment, stunted career progression, anxiety and even fear. There are reports of international health
workers from across the world having difficulties in obtaining support for family members, having to pay
additional tariff for access to health and restriction to changing their jobs due to Home Office regulations.
In all reports of health workers being afflicted by COVID-19 there is no information on their residence/
immigration status, but it is conceivable that a large proportion of health workers in the frontline are
facing such personal challenges.
What impact does this insecurity have on the choices they make at work? Is it possible that such
insecurities may stunt one’s ability to raise concerns or challenge unfair treatment? Anecdotes and
personal stories from many BAME staff across the country seems to suggest that there is a perceived link
between the inequality rife in some organisations and the outcome in the face of COVID-19.
NHS England is committed to meeting the WRES targets, and most senior leaders have pledged their
support for equality for their patients and staff as well as valuing the richness of diversity. There is much
more work to be done to get this message to the middle level of management and to leaders on the
frontline. It is time for the scientific community to dissect and explore the multitude of risks emboldened
within the ‘ethnicity’ factor in an objective as well as qualitative way͘ It is time for B ME leaders to raise
awareness of the particular risks to their communities and support their members to come forward to
join the B ME liaison committees being formed in different organisations, talk openly about the ‘their
lived-experience’ and help their colleagues and middle-level leaders to take urgent mitigating actions,
which are culturally appropriate. Too many lives have been lost perhaps inadvertently, in this pandemic.
SARS-CoV-2 has rather dramatically shone the light on the social, health and economic determinants of
outcomes in the general population and staff alike. This is a call for action and for ongoing research to
explore this area. Science has been underpinning the strategy of many governments during the COVID-
19 pandemic and it is imperative that ‘science has to show the way’ in mitigating the risk for BAME doctors
facing adverse health outcomes, simply by the nature of their ethnic background.
Another important issue is the inhomogeneity among the cohorts who constitute the BAME population.
For example, the umbrella term͘ “ sian” includes South East Asian, Chinese, and South Asians. Even
among people from the Indian sub-continent, there are significant social, and cultural differences
between people originating from India, Pakistan, Bangladesh, and Sri Lanka. These differences and their
impact on health outcomes need to be explored in more detail, to be able to understand better, and
mitigate the impact of differential outcomes in the BAME population.
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