Poorly designed and planned communities heighten the risk of health issues, writes Araceli Camargo, Sarah Aliko, Daniel Akinola-Odusola and Elahi Hossain in this extract from a Centric Lab report
As COVID-19 spread through the British population, a trend emerged: people from poorer ethnic minority communities were the ones most likely to be hospitalised or die as a result of the disease.
According to the Office for National Statistics (ONS), Black people in Britain are almost twice as likely to die from COVID-19 as white people, while Bangladesh and Pakistani people are 1.7 times more likely to die than white people.
The discussion of this trend correctly focused on systemic racism and inequality. This could easily be seen by those planning or designing environment as irrelevant to them, as they might not judge it to be their domain.
However, when investigating the effects of poverty, it is important to identify two elements. The first is “who” is
experiencing poverty and the second is “where” poverty is taking place.
It’s poverty, supported by racism, executed through urban planning, experienced through health
In western countries, it is predominantly poor BAME people who are forced to live in badly planned environments – places with high levels of environmental pollutants, inadequate housing infrastructure, inadequate access to blue and green infrastructure, low access to nourishing food, inadequate urban infrastructure, poor access to public transport, and poor access to adequate health resources.
These environments create health risks: for example, people living in low-income households are two to three times more likely to develop mental health problems.
To advance policies that put health at their core, poverty must be addressed and understood beyond the confines of economic statistics. Poverty is supported by racism, executed through urban systems and experienced through poor health.
For example, in East Harlem in New York (East 96th Street upwards), diabetes takes a more lethal and detrimental turn than on the Upper East Side (East 96th street downwards). In East Harlem, it causes more amputations, blindness and death than on the Upper East Side, where it is not as life-threatening or as severe.
The main differentiator is poverty: East Harlem’s poverty rate is 31.5% whereas it is just 6.1% on the Upper East Side. Furthermore, East Harlem is a predominantly Latinx and African-American area, whereas the Upper East Side is predominantly white.
This culmination of events is termed ‘structural racism’, which is defined as macro level systems (social forces, institutions, ideologies and policies) interacting with one another to generate and reinforce inequities among specific ethnic groups.
The UK is experiencing similar challenges. For instance, in England, Black and Pakistani people are more likely to live in the 10% of neighbourhoods most deprived in relation to living environment (16% and 27% respectively). Additionally, Pakistani and Bangladeshi people are more than three times more likely than white people to live in the most deprived 10% of neighbourhoods in England.
As COVID-19 disproportionately affects BAME communities, it is important to have a deeper understanding of the health disparities caused by the intersection of poverty, racism and poor urban planning. To do this, a biological framework is needed.
In our report for Centric Lab extracted here, Covid-19 and Biological Inequality: A London data study, we have mapped where BAME communities live and how that relates to COVID-19 rates. We are now proposing a framework that uses two significant factors: the physical environments people inhabit and the experiences afforded by those environments (which we’ve recently combined to create an Urban Health Index).
These are important for several reasons: they can be linked to human biology via the stress response, they are highly influenced by systemic racism, and understanding the role neighbourhoods play in health allows for a systemic solution – people can only have agency over their health when they are part of a supportive ecosystem, which includes the places they inhabit.
Understanding the role neighbourhoods play in health allows for a systemic solution
The stress response is the main link between the world around us and our health. It is a fundamental biological mechanism through which our bodies adapt to ‘stressors’ – changing conditions in the environment that threaten biological stability.
There are two overarching types of stressor: internal and external. A change within the body, such as a virus, is an example of an internal stressor.
External stressors have two further distinctions: environmental and psychological. Environmental stressors are related to the physical environment and can include air, noise, light or thermal pollutants. Psychological stressors are those that relate to experiences, such as starting a new job or losing a loved one.
The stress response is mitigated by the hypothalamic-pituitary-adrenal axis (HPA axis). When a stressor triggers the hypothalamus, the hypothalamus produces and releases corticotropin hormone. The pituitary gland then synthesises the adrenal-corticotropin releasing hormone (ACTH), which is released into the circulation. When ACTH reaches the adrenal glands, it stimulates the release of another regulatory hormone, cortisol, which circulates back to the brain in our blood.
This cycle of hormones repeats in a negative feedback loop until the body reaches stability. A process like this in which “an organism maintains physiological stability by changing the parameters of its internal milieu, matching them appropriately to environmental demands” is called allostasis.
This interaction is long-standing and it’s fundamental to how biological systems navigate and interact with all aspects of their environments. However, when someone’s stress response is chronically engaged because they are persistently exposed to stressors, the body may not reach allostasis, leading to ‘allostatic load’ (AL). This results in wear and tear to bodily systems that, over time, can impair the function of the immune response.
Herein lies one of the biomarkers in the pathology of a wide range of diseases, specifically metabolic disease (diabetes, obesity, cardiovascular) as well as mental disorders (PTSD, depression and anxiety).
The longer someone lives in a polluted environment, the longer the stress response will engage
To fully understand the biological mechanisms behind the disproportionate number of deaths in BAME communities in London, AL needs to be contextualised to where BAME communities live and their experiences resulting from those environments.
As well as experiencing higher levels of poverty, ethnic minorities disproportionately live in areas with higher levels of air, noise and light pollution, lower levels of green spaces, and higher exposure to urban heat island effects. All of these can be classified as stressors.
The stress response to air pollution engages at first contact, triggering one of the earliest biological responses to the pollutant. The response will continue until exposure has ended, so the longer someone lives in a polluted environment, the longer the stress response will engage, risking AL.
Housing is another physical environment where poverty is experienced and another source of stressors. Poverty often means living in inadequate homes that have poor ventilation, are overcrowded and have poor basic infrastructure (no running water, poor heating/cooling). These conditions require the stress response to engage.
For example, overcrowding has become a topic of interest as it is contributes directly to the spread of COVID-19. However, it is not just a question of contagion – overcrowding also has stress pathways that can contribute to poor health. Overcrowded spaces are often noisier because of human activity happening in close proximity. This noise can cause the stress response to engage, and it can change the body’s blood pressure. They can also be psychologically stressful for a multitude of reasons: a lack of privacy, personal space, psychological safety or restorative space.
Poor housing and poverty also present other psychosocial stressors – external demands that exceed people’s perceived abilities and resources to adequately respond. For instance, a psychosocial stressor is lacking financial resources while still having to provide for rent, food or childcare. Others include having insufficient heat to keep a household warm or not having the comfort of secure long-term shelter. Psychosocial stressors have biological correlates of AL.
Experiencing stress is a natural part of life, but living in impoverished environments exposes people to persistent stressors, risking AL, which heightens the risk of disease. Persistent and disproportionate exposure to environmental and psychosocial stressors is a ‘biological inequality’ – that is, it puts a burden on the stress response, contributing to its dysregulation (AL) and making people more susceptible to a wide range of diseases.
BAME communities are more at risk because of the environments in which they are forced to live because of systemic racism and inequality
There are two pathways between COVID-19 and susceptibility. Firstly, biological inequality makes BAME people more susceptible to diabetes, asthma, depression and obesity. These are all risk factors for COVID-19, as they cause inflammation in the body through dysregulation of the immune system, which is linked to AL. This increases the risk of contracting COVID-19, as well as the severity of symptoms and the likelihood of death.
The second pathway is through AL. Someone may not seem to have an underlying disorder, but because of biological inequality, their stress response is more likely to be significantly dysregulated. Black communities are twice as likely to die of COVID-19, even when adjusting for health.
There are two caveats here. Firstly, susceptibility is not the same as determinism – being susceptible to a disease does not mean that you will certainly develop it as there are many other factors that contribute to disease pathology. For example, having emotional support can offset some of the effects of neuroendocrine, metabolic and inflammatory profiles that tend to develop after exposure to acute and persistent stress.
Secondly, it is not being BAME that is a health risk – it is the conditions and environments with which BAME communities are forced to engage. BAME communities are more at risk because of the environments in which they are forced to live because of systemic racism and inequality.
To map susceptibility and COVID-19 in BAME communities in London, we combined four data sets. The Index of Multiple Deprivation (IMD) is the official measure of relative deprivation in England. It follows an established methodological framework in broadly defining deprivation to encompass a wide range of living conditions: income (22.5%), employment (22.5%), education (13.5%), health (13.5%), crime (9.3%), barriers to housing and services (9.3%), and living environment (9.3%). People are considered to be living in poverty if they lack the financial resources necessary to meet their needs, whereas people are deprived if they lack any kind of resources, not just income. Due to the robustness of the IMD, we used it as a proxy for psychosocial stressors related to living in areas of deprivation.
The Stress Risk Score (SRS) is a scale used to measure environmental stress risk factors, based on proxies for noise, air, light, and thermal pollution. It uses a meta-analysis of how each stressor engages with the stress response, specifically AL. SRS runs from zero to four, with zero a less polluted area and four being highly polluted across four environmental stressors.
These high correlations indicate a strong relationship between deprivation and death from COVID-19
Areas of Health Risk (AHR) is a calculation based on combining IMD and SRS to determine where there is a susceptibility to disease based on exposure to environmental and psychosocial stressors.
The Office for National Statistics (ONS) database was referred to for demographic data: age-standardised mortality rates for all causes and deaths involving COVID-19; deaths per 100k between 1 March and 17 April 2020; and the 2011 England and Wales Census on BAME population density per 100k.
We averaged the IMD, SRS and AHR for each borough, then calculated Pearson’s correlation coefficient (r) for COVID-19 cases and each of the IMD 2019 to map structural racism.
The data indicates high correlations between COVID-19 deaths and IMD 2019 by borough (r=0.73), COVID-19 deaths and BAME population density (r=0.83), and IMD 2019 and BAME population density (r=0.62) (see Table 1). Moreover, there was a medium to low correlation between SRS and BAME density and SRS and COVID-19 deaths (r=0.21 and r=0.23 respectively).
These high correlations indicate a strong relationship between deprivation and death from COVID-19, and highlight a possible increase in the number of deaths from COVID-19 among BAME communities.
In terms of biological inequality, environmental stressors have a medium to low correlation (r=0.21), whereas psychosocial stressors correlate highly (r=0.73). This could indicate that psychosocial stressors could play a more significant role in AL than environmental stressors do; it could also indicate psychosocial stressors are more prevalent and persistent than environmental stressors.
No causal relationships can be inferred from the data, but we can tentatively propose that deprivation and structural racism may be causes of the high number of deaths from COVID-19 in BAME communities.
Figures 1, 2 and 3 show various aspects of structural racism in London. They overlay data about deprivation and pollution on BAME population density.
There is a strong correlation between death rate and health risks (see Figure 4). For example, Hackney and Tower Hamlets both have high death rates and high health risks. This indicates that identifying hotspots before the pandemic could have been useful in deploying extra resources to those areas.
The maps also indicate that susceptibility, although a strong factor in disease pathology, is not deterministic – other factors are also at play, such as jobs, emotional support through social cohesion, diet and other health indicators.
Identifying hotspots before the pandemic could have been useful in deploying extra resources to those areas
Conversely, Figures 6 and 7 indicate that BAME communities could be experiencing unique health inequalities. They could be living in these areas for longer, the jobs they hold could also be exposing them to further stressors, or they may have poorer access to health facilities. This is worthy of further investigation.
The limitation with any borough-level analysis is the direct relation between individual lifestyles and risk factors, as some factors are too nuanced to be analysed at such a large scale. The way to overcome this limitation is by ecological research and interventions that incorporate more personal information, demographics and individual risky or compromising behaviours such as commuting, exercise, travel or smoking.
It is important to note that this is a preliminary analysis of COVID-19 and how it relates to biological inequality brought on by systemic racism. Nevertheless, it does highlight future needs, investigations and actions. Future studies could examine more deeply: variations in environmental stressors and COVID-19 cases, especially in areas that have higher levels of air and thermal pollution; the full death rates after the second wave; specific social demographics such as children, the elderly, men and women; and the long-term effects of COVID-19 in these areas, including the trauma of directly experiencing deaths and illnesses among members of their community and how children are affected by this as they age.
The COVID-19 pandemic has highlighted the fragility of the healthcare systems in many countries and has shed light on the differences in health accessibility and susceptibility of various communities in large cities. The unexpected increase and spread in cases, as well as the high mortality rates compared to Asia-Pacific countries, question the preparedness of Western countries to tackle health emergencies, which are bound to increase with future natural disasters due to climate change.
We have shown there is a relationship between COVID-19 and levels of deprivation and pollution in London, the worst-hit area of the UK. We predict the correlation between the three will increase further, reflecting areas of health emergencies. We urge governments and local councils to direct resources for improving health to these areas of risk in the near future. They must also acknowledge that workers and members of the community who cannot afford to self-isolate due to their contributions to the community are a susceptible population and address this in any future community health infrastructure.
The high mortality rates question the preparedness of Western countries to tackle health emergencies, which are bound to increase
The pandemic should serve as a lesson in how to prevent and contain future health emergencies. Pandemics and epidemics are likely to take place at the same time as natural disasters, which will hinder efforts to contain the spread of diseases because of people being displaced. Lack of adequate housing, epidemics and natural disasters pose great threats to the future of human health and life and need to be addressed immediately.
We have a chance to further the narrative of how we must approach community health to make our cities more resilient. This information can mobilise change from the bottom up, through community activism. Citizens can now ask local governments for better housing and urban realm design, especially as they will need to prepare for a second wave of COVID-19.
Policy and urban planners and designers of the urban realm must take responsibility to improve areas of biological inequality, which make people susceptible to disease. This is especially relevant as many councils and planning authorities move towards health-based drivers and metrics.
London is not a city that has health resilience and will be vulnerable to crises, whether pandemics or climate change.
Araceli Camargo is the co-founder and lab director of The Centric Lab; Sarah Aliko is a computational neuroscientist at The Centric Lab; Daniel Akinola-Odusola is head of data at The Centric Lab; Elahi Hossain is a neuroscience researcher at The Centric Lab
The Centric Lab is a neuroscience lab focused on understanding how the built environment presents risks for certain health issues, such as depression, anxiety, obesity, and PTSD
This piece is an extract, read the full report
View Centric Lab’s Urban Health Index