RAJ BHOPAL did Britain’s ethnic minorities a big favour last summer when he revealed the government had suppressed a report which suggested that structural racism could be one reason why the pandemic had caused such a high death toll among black and Asian people.
The government was fine about releasing the first part of the report by Public Health England which confirmed that the ethnic minorities, particularly Bangladeshis, were disproportionately affected by Covid-19.
But the equalities minister, Kemi Badenoch – although of Nigerian heritage herself – got up in the Commons and denied any such report existed and nor were there any recommendations that had been made by PHE.
She even attacked the BBC and its community affairs correspondent Rianna Croxford for “fanning the flames of racial division” by claiming the government was not telling the truth.
The most charitable explanation for the government’s policy of obfuscation was this was a very sensitive time as the Black Lives Matter protest over the killing of George Floyd had spilled over from the US to the UK. That had fed into the narrative that Covid deaths were also related to racism.
One man who knew for sure that the government was not telling the truth was Bhopal. In fact, he had been asked to peer review the second report in his capacity as the much respected Emeritus Professor of Public Health at the Usher Institute, Medical School, University of Edinburgh – and his responses were even acknowledged. He had to struggle with his conscience as to whether he should blow the whistle because those who are asked to peer review a document are expected to keep it confidential.
In the end, after consulting senior colleagues, Bhopal decided the public had a right to know the truth. He feared the government would in some way punish him but nothing happened.
The government quietly published the second report, with a convoluted excuse: “When the minister was referring to the lack of recommendations she was referring to the epidemiological review published on June 2. This review did not have any recommendations.”
This is true but disingenuous. The recommendations were contained in the second report which the government had earlier claimed did not exist.
Bhopal’s intervention was taken seriously because he has long been an influential figure in the field of public health. But the pandemic gave him an international profile.
Rajinder Singh Bhopal was born in Moga, a city in Punjab, in 1953, and arrived with his Sikh parents, Jhanda Singh and Bhagwanti Rakhra, in Glasgow on “New Year’s Eve 1955”.
Jhanda, whose father was a master tailor, started a wholesale clothing shop in Glasgow. Initially, the family lived in the Gorbals, one of the most notorious slums in Europe – “the reality was much worse than even the image”.
Unlike his father, Bhopal went into medicine, graduating from Edinburgh University in 1978. He entered the field of public health in 1983 and became a lecturer in 1985. For 19 years from 1999 until he retired in 2018, Bhopal held the Usher Chair of Public Health at Edinburgh University. Established in 1898, it is the oldest public health chair in the UK.
At the start of 2020, Bhopal’s plan was to work a little but largely enjoy his retirement with his wife, Roma, and see his four sons and grandchildren as often as possible. “The plan was to travel widely and enjoy life after a very long working career.”
The pandemic and the death in quick succession of his in-laws in April last year put paid to his plans. In 2019, Oxford University Press had published his last book – Epidemic of Cardiovascular Disease and Diabetes: Explaining the Phenomenon in South Asians.
“My intention was to do about one day’swork a week to keep the research and scholarship I was working on going – mostly on cardiovascular disease and diabetes but also ethnic variations in a range of outcomes. I also have leadership roles in various committees. For example, we’ve been setting up the global society on migration, ethnicity, race and health, which is now up and running.”
But when the pandemic came along, “I couldn’t just sit back and enjoy myself in my retired state. I had to get involved. As Emeritus Professor of Public Health, I have done a lot of work on respiratory infections, respiratory epidemiology, and pandemic and disease control.
So I voluntarily put myself back to work.” Everything was new at the start of the pandemic: “No one really knew the right path forward.”
He felt he had something distinctive to offer. “What I’ve been able to do is bring a public health and epidemiological perspective. It’s not just a question of how do we control Covid-19? The question is, how do we minimise the harms of the pandemic, whether in employment, housing, social and economic circumstances, health care systems, health in a wide variety of formats, whether it’s dying from cardiovascular disease – because you don’t go and get treatment – or whether it’s from illness and death from Covid-19.
“What I brought to the table was a very heavy emphasis on getting accurate epidemiological data, presented in an appropriate way that lends itself to policy formation.”
He remembers: “My very first contribution was a letter to the British Medical Journal saying the data needs to be presented far better.”
His letter was so important that in the first six months, it was “cited 28 times” by experts.
Bhopal also became a regular on radio and television. BBC World Service gave him an international profile.
What his letter argued was that it was not enough just to give the number of people who had died from Covid. “Accurate and interpretable data are essential in guiding our approach to the Covid-19 pandemic. Basic epidemiological principles are currently being flouted. Mostly….case numbers are being reported. This number needs to be converted to a proportion, using the population size as the denominator. Otherwise, how can we tell which countries are being affected the most?”
The letter went on: “When the rate of disease is highly variable by age, as in Covid-19, we need to examine age specific mortality and morbidity and case fatality rates. Given the sex differences, these rates also need to be stratified by sex. Age adjustment, by either the direct or indirect method or statistical models, is too crude when the rates are highly variable across age groups, although it is better than the overall or crude rates that we are currently seeing, invariably in the media but also in professional journals.
“We are being misled about the potential dangers (or not) by using overall or crude death rates. The Chinese overall mortality proportions, for example, will not apply to countries with older age structures, such as Italy or the UK, where mortality will be higher. The Italian proportions will not apply to much of Africa, where the average age of the population is low. Data should be published in 10-year age groups or, even better, five-year age groups.
“The data are likely to be reassuring for parents and young people and the opposite for older people. The results are likely to be much more informative than the widely disseminated and extremely crude estimate of 1-2 per cent mortality or even lower, which is mostly based on China’s experience. We can and must do better.”
As an eminent academic, Bhopal’s backing on pandemic policy was sought by two opposing camps, called the “John Snow” and “Great Barrington” declarations.
The former said: “We must try and eradicate this virus. We must suppress it with everything we have. We need to try and get the number of cases close to zero.”
The other side argued: “We should be protecting older people and those at high risk. And we should let other people, especially the young who are hardly affected by this infection, get on with their lives and developing their careers and education.”
Bhopal chose to join neither camp. Instead, in April he wrote a 3,500-word paper on how to get out of lockdown. It used an intriguing German word: “The Covid-19 pandemic has placed us in zugwang – a position in chess where every move is disadvantageous and where we must examine every plan, however unpalatable.”
This, too, attracted international attention. For example, he was asked about zugwang when he was interviewed by Karan Thapar on Indian television.
Bhopal tells GG2: “There’s a position where your position is so bad that there’s not even one good move. So you have to choose from many bad moves.
“We’ve had one of the longest and most severe lockdowns in the world already. That was a very bad move. Coming out of lockdown was also a very bad move because the virus springs back. So everything seemed like a very bad move, he said.
“Maybe another chess analogy is you do have to plan ahead. Even a middle grade player like me has to think sometimes up to 10 moves ahead. But world champions can sometimes see 20 moves ahead. We do need to plan well ahead rather than planning week by week or month by month.”
He poses the question: “In practical terms, what does it mean? There are some issues that the south Asian population needs to know. If you’re living in a multi-generational household, the older people in that household have to be protected. So there’s social distancing we must continue to do whenever possible. Masks have a modest effect, but they have symbolic value as well. They remind that we’ve got a problem. We must continue to follow the guidelines. Hygiene is critical. The knowledge that these infections occur indoors has been known for decades. So let’s spend as much time as possible outdoors. We should open our doors and windows to make sure there’s plenty of circulation of air. If you are speaking to your grandparents, speak to them from the side, not from the front and keep three feet away at least.
Think about wearing a mask when you’re speaking to older people. These practical things are sensible – and we should continue to do them.”
He adds: “People have tried to shake my hands and I just say, we’ll do that in 2025. Shaking hands is a thing of the past. It’s gone. We are back to old customs of ‘Sat Sri Akal’ with hands clasped or ‘Namaste’ or ‘Salaam Alikum’.”
He outlines three characteristics of the Covid-19 pandemic.
“Firstly, is it not a blessing that our next generation, our youngsters, have been spared? If you’re between 18 and 25, it’s a bit like getting flu. If you’re under 18, it’s less severe than flu.
“Number two, the immunity is much stronger than anyone had dreamt of. People who’ve been infected can go back to the front line because they’re very unlikely to get it a second time this season. So they can be to some extent Covid warriors. Number three, if you get this infection, and you’re over 80, 90 per cent of people will survive.”
He points out: “I don’t want to give anyone the wrong impression. I take this infection very seriously. I wrote my own advanced directives in April last year: what has to happen to me if I’m seriously sick and dying. I also wrote my own obituary. So I would not have done those two things if I wasn’t taking this seriously. On the other hand, I have also written that we shouldn’t be scared of it. There’s no need to petrify the population. We have to get the fear out of our hearts because that’s the worst thing of all. You’ve got to find the right balance in your own life.”
His view, which has influenced the debate hugely, is: “The Covid-19 pandemic is going to be with us for a long time as it needs to be controlled globally, not just in the UK. Somewhat miraculously, effective and safe vaccines were already available in late 2020. I pay tribute to the scientists, technologists, the companies and governments who have made this astonishing feat possible.
“Even with vaccines, however, it will be a long time before we can get back to pre-pandemic normality. We can, however, be optimistic for the future now, even although there will be many challenges ahead."
