As a general practitioner, Julian Tudor Hart lived and worked in south Wales. He pioneered much of what now constitutes modern routine preventive care, seeking out those most in need. His research from the 1960s onwards in Welsh mining communities showed that medical care was often not available to those with greatest need: the most deprived in society. Today we are seeing a corollary to this with the imposition of restrictive Covid-19 lockdown measures that target the most deprived – those who can least afford to endure them. The government has now announced trial payments for some people on low incomes who must self-isolate, but more is required.
In the week ending 8 August, there were 110 positive cases of Sars-CoV-2 per 100,000 in the town of Oldham – breaking through the 50 cases threshold that puts it on the government’s “red alert” watchlist.
Each week Public Health England (PHE) publishes a Covid-19 report that summarises information from the surveillance systems used to monitor the pandemic in England. Currently, 28 local authorities are on the at-risk watchlist following the weekly Local Action Committee meeting. In 18 of them, households are not allowed to mix. While weekly rates in Oldham have come down, they are still among the highest.
The current watchlist is dominated by areas of deprivation: Bradford (ranked the 13th most deprived local authority in England), Blackburn with Darwen, Hyndburn, Oldham and Leicester are at the top of the watchlist. They are all in the top 10% of the most deprived areas in England.
The higher number of detected cases in these deprived areas is highly predictable. A built environment provides numerous opportunities for transmission of infection: high population density and overcrowded housing present the ideal conditions. In England, about 3% of the population live in overcrowded accommodation; this is much more prevalent among lower-income households. And while 2% of white households experienced overcrowding from 2014 to 2017, that number is much higher in ethnic minorities – it shoots up to 30% in Bangladeshi households.
Oldham town has a greater proportion of minority-ethnic residents than Greater Manchester or England: one in 10 of the population is of Pakistani heritage, one in 14 of Bangladeshi heritage. These communities primarily live in the most deprived areas and have already been disproportionately affected by the pandemic. The death rate among people of Bangladeshi heritage is twice that of white people even when accounting for age, sex, and levels of deprivation. The risk for other ethnic minorities is 10-50% higher than for white people.
PHE’s review in June promised to discover why the infection had such an unequal effect on people of different ethnicity. However, the report has been widely criticised for mentioning nothing about what could be done to improve the situation or suggesting plans for protecting at-risk groups.
Are the restrictive measures, therefore, justified? The current watchlist level is based on an arbitrary figure that does not represent how we have assessed epidemic levels of community infection in the past.
An epidemic is said to occur when weekly GP consultations for new episodes of flu-like illness exceed 400 per 100,000. This figure, therefore, refers to a person who has symptoms and is presenting to healthcare. On the contrary, current PCR testing is being used as a screening tool: in affected areas, testing is on the increase due to hypervigilance and active case-finding strategies that include knocking on doors. This strategy frequently picks up asymptomatic people.
The watchlist figure of 50 per 100,000, therefore, does not consider the impact of the disease. Only nine people are currently in hospital with Covid-19 across the Pennine Trust hospitals that cover Oldham, Rochdale (also on the watchlist) and North Manchester. Increased testing leads to more detection of the virus, but it has not necessarily translated into infections that cause symptomatic disease. Many of those who have tested positive would be classed as weak positives – their risk of transmitting the disease further is low.
Politicians’ urge to intervene is a sign that the test-and-trace programme has failed. But restrictive interventions are often too quickly deployed. Nevertheless, there is a radical need to improve living conditions; improve access to health and social services; address the urban environmental exposures that contribute to infectious outbreaks; and rethink the social factors that cause high infection rates in deprived areas.
Tudor Hart died in 2018. He is best known for his “inverse care law” that showed the availability of good medical care tends to correspond inversely with the need for it in the population served. The case for improving health outcomes in deprived populations is clear. But there is a pressing need for our politicians to think carefully before deciding what to do next and consider the wider needs of the people affected by such restrictive measures.
