The further marginalisation of groups during pandemics makes them more vulnerable; emphasis should be placed on protection and the group's vulnerability, rather than placing blame and exacerbating the marginalisation (Kapiriri, 2020)

Social stigma during pandemics can reduce likelihood of seeking help, and therefore preventing early spread (He et al, 2020)✅

Meta analyses have shown the negative impact of discrimination and racism on mental health outcomes and wellbeing, as well as CVD outcomes and maladaptvie health behaviours such as alcohol consumption (Williams et al, 2019)

Percieved discriminiation makes a larger contrivbution for racial/ethnic inequalities in mental health and self reported physical health than SES (Williams et al, 2019) (Williams et al, 2009)

Many pandemics don't differentiate based on national origin, and so while racially targetted groups have to bear the burden of the fear of getting ill (as does everyone else), they also have to bear the burden of the fear of discrimination and racism (Tessler, 2020)✅

Racism doesn't need to be aimed at the individual to trigger a stress response (Huynh et al, 2017)✅

Linked psychosis, depression, substance misuse and anger (Bhui et al 2018) (Williams et al, 2009) (Lewis et al, 2015)

A fear of racism can lead to poor health outcomes (Karlsen et al, 2004)(Williams et al, 2009)✅

This can be linked to the generally more forensic, crisis or restrictive way Black people access healthcare (rather than primary care) (Bhui et al, 2003)

An American study showed patient communication was different dependant on the patient's race; physicians were more dominant and less patient-centred with African Americans vs white (Johnson et al, 2004) This kind of communication was linked to implicit bias against Blacks (Blair et al, 2013)(Fitzgerald et al 2017)

Explicit bias like discrimination and racism is the tip of the iceberg; implicit bias might be more widespread, and therefore insidiously impact; implicit attitudes frequently diverge from explicit attitudes (Fitzgerald et al 2017)✅

Implicit Biases are amplified in physicians in response to cognitive stressors (Johnson et al, 2016)✅

Interventions during medical school may be an effective strategy to counter this (van Ryn et al, 2015)

In a review, overall, healthcare professionals associate black americans with being less cooporative, compliant and responsible in a medical context (Hall et al, 2015)

In a US study, patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice (van Rhyn, 2000)

Racial implicit bias is prevalent across healthcare workers in multiple specialities (Hall et al, 2015) (Fitzgerald et al 2017)✅

Bias is related to socio-demographic characterists of healthcare workers (Fitzgerald et al 2017)

Negative correlation between implicit bias and indicators of quality of care (Fitzgerald et al 2017)✅

Important not to neglect the presence of patient's implicit biases, and overlapping of group biases (Blair et al, 2011)

Presence of admired individuals belonging to the group in question may change attitudes and bias (Greenwald et al, 2001)

(Fitzgerald et al 2017) provides suggestions on how to combat implicit bias as a clinician, researcher, policy maker, and patient

Short term strategies may show changes, however in a review, no strategies showed long term chagnes (Lai et al, 2016)✅

While this approach can be theoretically helpful in tackling change by partially removing some of the blame for bias that may be grounded in culture, some argue that it's not right that people are not being able to be held account for racism (Goldhill, 2017)

HR departments have tried to measure implicit bias using IAT, implement programmes on this bases, however not seen significant changes (Goldhill, 2017)

Stress is linked to decreased antibody response to vaccination (Powell, 2011)✅

Health/bodily stigma is linked to reduced capability to seek help, eveni if available (Das, 2001)✅

Public health professionals must understand the neces- sary balance needed to protect the public’s health with appropriate exclusionary practices, while at the same time preventing fear, stigmatization, and discrimination of spe- cific segments of the population. (Person et al, 2004)

Example of how stigma of disease developed fear of health services is exemplified in the early 1900s black death in San Francisco Chinatown (Tansey, 2019)✅

Racism is linked to delayed reciept of healthcare, and poor treatment adherance (Ben et al, 2017)(Williams et al, 2009)

Religious behaviour and beliefs, mindfulness, emotional support can help reduce the negative effect of discrimination on heath (Williams et al, 2019) (Lewis et al, 2015)

Williams and Cooper (2019) argue that three areas need to be tackled; combat structural racism limiting the social determinants of health, plan culturally specific and appropriate preventative medicine initiatives, and increase awareness of inequalities and their impact on society, hoping to cause political and societal empathy strong enough to change. Multiple aspects of these focus on the PHE document to help address the proportionally negative effect of COVID-19 on BAME communities (PHE, 2020)

Interventions should be tested in medical environments (high exposre to stress) #

Therefore the burnout symptoms (As they lead to reduced quality of care) could be one explanation for the health disparity (Same author as original)

Be aware of terminology and explicit bias displayed by role models/superiors in medicine; a higher level of implciit bias in medical students was associated with observing remarks made by physicians with respect to african americans (van Ryn, 2015)

BAME groups had worse clinical outcomes of COVID (Pan et al, 2020)(PHE, 2020)

Cultural competance is one aspect that needs to be worked on for this to happen (PHE, 2020)