Notes on: Marmot, M., Allen, J., Goldblatt,
P., Herd, E., Morrison, J. (2020) Build
Back Fairer: The COVID-19 Marmot Review The
Pandemic, Socioeconomic and Health Inequalities
in England Executive Summary. https://www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review
Dave Harris
This is their response to build back better — they
want to build back fairer. They don't want to
re-establish the status quo that existed before
the pandemic. They also want to build on the
Marmot Review of 2010. Since 2010 improvements in
life expectancy in England have stalled. 'Life
expectancy follows the social gradient — the more
deprived the area of the shorter life expectancy.
This gradient has become steeper… There are marked
regional differences and these have increased…
Mortality rates have increased for people aged 45
to 49'. Healthy life expectancy gradients are even
worse. Large funding cuts are largely responsible.
Inequalities in Covid mortality rates follow a
similar social gradient.
There are 'shockingly high Covid 19 mortality
rates among British people who self identify as
black, Bangladeshi, Pakistani and Indian' ( 6).
Much of this, 'but not all' can be attributed to
living in deprived areas and being more exposed at
work and at home, but 'these conditions are
themselves the result of long-standing
inequalities and structural racism' [their main
claim -- not sure what it is based on though].
There is also evidence that many people from these
groups 'have not been well protected at work, and
less well protected than their white colleagues'.
[They refer largely to 'BAME groups']. They say
there has been poor management of the pandemic,
and government policy has contributed to a
widening in inequities, especially policies of
austerity. They see no contradiction between the
economy and health, they argue for societal change
including changing patterns of work and require
extra investment especially in public health. They
recommend policies to give children the best start
in life, 'all children' [a general policy 'for
all', a bit like Sewell].
They're also worried about the climate crisis, but
they identify short-term implications for the
current spending review. They advocate a national
strategy, and a policy to address regional
inequalities.
International comparisons show that England had
higher mortality rates and higher excess deaths
from Covid in the first half of 2020. Underlying
health conditions have raised the risk of
mortality including 'socio-economic inequalities
and regional inequalities, especially in the
north-west and north-east. Living conditions and
poor quality housing are particularly associated,
so are occupations including working in health and
social care, and area of residence'. BAME
identity increases mortality risks, affecting the
exposure of occupations and insufficient
protection at work. Cumulative risks involve
'being male, older, and BAME with an underlying
health condition, working in a high-risk
occupation and living in a deprived area in
overcrowded housing' (10)
[They do consider some of the difficulties of data
where deaths reporting Covid appeared on the death
certificate to a varying extent, and not in all
cases, and there are problems of recording excess
deaths, which included cases where Covid went
undiagnosed. Nevertheless they include
international comparisons of average excess
mortality which shows England to be in a
particularly bad situation. There is a connection
with other diseases such as dementia and
Alzheimer's, and other chronic diseases. England
is not alone in showing that mortality rates from
all causes are hitting more deprived areas, and
that these inequalities had been increasing —
'between March and July 2020 [they] would double
in the most deprived areas compared with the
least' (14)
[Lots more data on region and occupation — the
worst ones were 'caring, leisure and other service
occupations' (17) and in more detail 'taxi
drivers, chauffeurs and security guards' often
with a 'high proportion of BAME workers' (18) .
BAME workers reported more negative experiences
'related to discrimination and safety in the
workplace during Covid, especially Pakistani and
Indian key workers'. This has long been
highlighted as a problem. 'Many' BAME respondents
were concerned about raising them, especially
healthcare workers. Healthcare workers had
'particularly high rates of death involving Covid'
[BAME ones?] Living in a deprived area outweighed
occupational differences.
BAME groups generally had higher mortality risks
and were disproportionately represented in high
risk occupations, are more likely to be living in
deprived areas and had more underlying health
conditions that increase their risks 'such as
diabetes', but 'all these conditions are the
result of long-standing inequalities and
structural racism' (19) [because even after we
account for age, geography, socio-economic factors
and health, we are still left with higher
mortality rates among those with black African
ethnicity, a study shows, and the same for 'all
ethnic groups' that is nonwhite ones compared to
white — the graph actually shows diminished
differences for females as well [so, technically,
long-term residual explanations are the evidence
for structural racism]. The data seems to be based
on the 2011 census, and the ONS study of Covid
related deaths by ethnic group. Black Africans
seem to display the greatest differences, followed
by Bangladeshis and black Caribbean, with Chinese
at the bottom, [especially Chinese females who
have virtually indistinguishable rates from their
white counterparts] (20).
Their policy turns on 'proportionate
universalism', 'making whole communities safer
with extra focus on higher risk areas', like urban
areas or overcrowded ones. The government has said
it will prioritise older people in care home
residents for early vaccination, but working age
people in occupations at risk should also be
prioritised. Adequate PPE should also be available
and adequate financial support (21).
[I am not going to go through all the details. I
have given the gist. For the purposes of
commentary on Sewell, the point keeps being
reiterated:
'Mortality risks from Covid-19 are much higher
among many BAME groups than white people in
England… And these risks are the result of
long-standing inequalities and structural racism'
(10)
'Structural racism means that some ethnic groups
are more likely to be exposed to adverse social
and economic conditions in addition to the
everyday experiences of discrimination — causing a
"robbery of resilience"' (64)
'These [higher rates of mortality are] related to
their disproportionate experience of high risk
living and working conditions. These are partly
the results of long-standing impacts of
discrimination and exclusion associated with
systemic racism [and] not being sufficiently
protected with PPE and safety measures' (66) [but
note that 'most major religious groups have higher
rates of mortality from Covid-19 than people who
do not follow a religious faith. Some of this is
explained by high numbers of Bain groups following
a faith and by attendance at religious gatherings
[or the other way around?]'.
If I summarise them accurately, another difference
turns on the direction of travel of the policy
recommendations. Sewell constantly say their
direction is 'downstream' from the data on
inequality towards the effects on families
especially (to the anger of critics who claim this
means blaming single-parent families). Marmot says
they want to analyse 'upstream', to direct
attention at what causes the inequalities --and in
their case it is structural racism. This depends
on an argument of residues as we have seen and
runs into difficulties of relying on the broad
BAME classification as pointed out by Sewell -- it
ignores differences within ethnic minorities, some
of whom have not suffered so many socio-economic
inequalities. Here we have some interesting
puzzles -- Marmot says black Africans have
suffered most from Covid-19 although in Sewell
they are not the lowest achieving groups. There is
no mention of Gillborn's most underachieving
groups -- white Irish and Travellers, or anyone
suffering from 'xeno-racism'. Did they not have
higher rates or were they just not recorded by
ethnicity?
As before, it is a shame these two approaches have
been set against each other by activists like
Olusaga -- together they might give a broader
picture eg upstream and downstream, on selective
aspects of discrimination when combined with other
factors etc
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