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.

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