The impact of Covid-19 on Domestic Violence and the Black, Asian and Minority Ethnic Community

The Coronavirus disease, also known as Covid-19, which is purported to have started in Wuhan, China, was declared a pandemic on 11th March 2020. In the UK, the government, together with the National Health Service (NHS), have taken various approaches to prevent and slow down the spread of coronavirus. These included imposing a ‘lockdown’ of the country (e.g. closure of schools, businesses, parks, leisure centres, and tourist attractions), along with the emphasis on handwashing, social distancing, the use of face masks and only permitting essential travel within the UK and between the UK and other countries. These approaches have been undertaken to varying extents and within different timeframes across the four nations of the UK. Like many other countries worldwide, the UK was not prepared for such a pandemic which resulted in the inability to assess the most appropriate approach to contain the spread. For example, the availability of Personal Protective Equipment (PPE) for frontline workers, particularly those in health care. As the crisis continues several striking social issues have emerged which may, in part, be a consequence of the measures taken. These include the escalation in domestic violence (DV) and disproportionate burden of disease among the Black, Asian, and Minority Ethnic (BAME) community. The impact of Covid-19 may persist in the longer time if appropriate measures are not put in place to address the health inequalities in time.


INTRODUCTION
An infectious coronavirus known as Covid-19 emerged in Wuhan, China in December 2019, and was declared a pandemic on 11 th March 2020. 1 The virus is believed to spread through the droplets of saliva and nasal discharge from infected persons coughing, sneezing, or breathing rapidly and heavily. Although its symptoms can vary, the most common is respiratory illness, which can range from mild to life-threatening. It is estimated that up to 80% of carriers of the virus are symptomfree at the time of testing. For some, this means that they go on to develop symptoms a few days after testing, and for others, they appear to remain symptom-free, and so can unknowingly pass the disease to others. Whilst many young people appear to only experience mild expressions of the disease, the elderly, and people with underlying health issues (e.g. cardiovascular disease, diabetes, chronic respiratory disease, and cancer) are more prone to the life-threatening impacts of Covid-19. 2 However, there is emerging evidence, that some of those who only develop relatively mild symptoms of the disease appear to be severely affected by the life-limiting impacts of post-COVID chronic fatigue syndrome/Myalgic Encephalomyelitis (CFS/ME) in the months after infection. 3,4 Impact of Covid-19: Domestic Violence and other health problems Several approaches have been taken to minimise the spread of Covid-19. Schools, offices, restaurants, businesses, and transport links were closed. Grocery stores introduced socially distanced queuing, permitting only one member of a household to enter the shop in any one visit, one-way systems, no-touch policies, and contactless payments. With the lockdown imposed by the government, people were required to stay at home and only go out for essential reasons, such as buying medicine and groceries and for reasonable daily exercise in the outdoors. However, people with health conditions recognised as placing them at risk of experiencing the worst manifestations of the disease that can only be treated through the use of ventilators were asked to take extra precautions, known as 'shielding'. These people, and those who live the same household, were advised to remain in their homes and not have any face-to-face contact with other people. Unfortunately, the impact of these necessary lockdown measures (e.g. isolation, stress, loss of routine, and social support structures), combined with the impending sense of uncertainty about the future appear to have negatively affected the physical and mental health of the people.
During the lockdown, women and children have been the most at risk of domestic violence (DV). 5 The home may have never been a safe place to live for those who find themselves in an abusive relationship. It is the place where most of the domestic and family violence occurs. 6 However, the lockdown has led to an increase in conditions associated with a high risk for severe violence, including isolation, stress, job insecurity, and risky levels of alcohol consumption, particularly amongst those with dependent children. 7 The lockdown is likely to have exacerbated violence in abusive relationships that pre-dated the Covid-19 lockdown. Additionally, it has led to the onset of violence in previously violence-free relationships due to the unfamiliar and unpredictable stressors of lockdown. The impact of living in such an abusive or violent relationship is also magnified by the lockdown since it makes it difficult for the victim to leave the relationship, to speak out against the perpetrator, or to seek somewhere safe to live. Co-habiting with an abuser during lockdown also means the perpetrator has greater freedom to act violently without coming to the attention of others. 6 Reports have shown that DV has escalated in the UK and internationally during the lockdown. A recent report in The Guardian (2020), 8 highlighted there has been a rise in DV worldwide. Brazil has seen a rise in DV by 40% to 50%. In Spain, the calls to helplines increased by 20% in the first few days after the lockdown was imposed and Cyprus saw a rise of 30%. Similarly, in the UK, within the first seven days of the announcement from the government about the lockdown and social distancing, calls to the Domestic Violence Helpline increased by 25%. 9 The number of visits to the 'Refuge' website increased by 150% the same week. 6 In Australia, after the stay at home order came into force, there was a 40% drop in crime levels overall but a 5% increase in the domestic violence calls. 10 Additionally, internet searches looking for support concerning domestic abuse also rose by 75%. 11 As a consequence of the pandemic and the lockdown measures, people are experiencing several behavioural and health issues such as anxiety, depression, eating disorders, sleeping disorders, gastrointestinal problems, and substance misuse. The uncertainty about how long this crisis will last, and the unpredictability about the future, are proving to be a mental trauma and a cause of tension for many. 12 Additionally, both those who are working on the frontline and making life-ordeath decisions in unfamiliar circumstances and those who are in the relative safety of their own homes appear to be negatively impacted. For example, healthcare workers treating the Covid-19 patients are suffering from high levels of stress from having to decide which patients will be offered the benefit of lifesaving treatment at the expense of other patients who will inevitably die without such intervention. 13 The findings from previous pandemics show that 30% of the children who were quarantined or isolated were at risk of developing post-traumatic stress disorder. 13 All these stresses and the resultant strain bring tension into the family structure.

Impact of COVID-19 on BAME
Black, Asian, and Minority Ethnic (BAME) groups have come to be recognised as having a higher risk of death and infection from Covid-19 compared to their White British counterparts. Thus, they carry a disproportionate burden of disease. 14 The London and West Midlands, where the highest levels of BAME reside, have seen the highest concentration of cases of Covid-19. 9 Research by the Intensive Care National Audit and Research Centre 15 , which was based on 5993 patients from the intensive care units, showed that there were 1.63 times more Black patients in the intensive care than expected (10.6% vs 6.5%). Similarly, there were 1.25 times more Asian patients than would have been expected (15.3% vs 12.2%). Although doctors from BAME community comprise only one-third of those working in the National Health System (NHS), most of them who died from Covid-19 belonged to a BAME group. 8 Although there is no conclusive evidence on why BAME groups are more at the risk from Covid-19, factors such as health issues could play a role in linking the BAME with the unnecessary burden of Covid-19. 16 Some of the examples of health issues are that people from Pakistan and Bangladesh have higher rates of cardiovascular disease as compared to their White British counterparts. 17 Black Caribbean and Black African people seem to have higher rates of hypertension compared to other ethnic groups. 18 Also, the data from the National Diabetes Audit 19 shows people from BAME have a higher prevalence of type 2 diabetes. Socio-cultural factors may also be partly responsible for this disparity in risk. For example, BAME communities are more likely to live in multi-generational households which permits the more rapid spread of the virus, to work in industries and positions where they are in contact with members of the public and were not originally seen as needing PPE (e.g. taxi and bus drivers, care home workers, etc.), they are more likely to experience economic deprivation, and they often experience difficulties and delays in accessing healthcare due to living in deprived areas.
A finding published by Public Health England 20 , also confirms the replication of health inequalities among the BAME population. The fact that NHS shares data with the Home Office for immigration enforcement purposes could act as a barrier for accessing the service provider among the BAME group. 21 Although patients diagnosed with Covid-19 are exempt from the healthcare charges, not all the migrants are aware of this. 9 It is also possible that many of the BAME are born abroad 22 which means they may face cultural and language barriers in accessing the healthcare services, or in fully understanding the government guidelines that have been developed to prevent the spread of the virus.
Some members of the BAME population have developed distrust in people from outside their community groups. 23 They share their health concerns and other problems such as experiences of domestic violence with their informal networks of close family, friends, and ethnic minority group members rather than approaching the health and social care professionals. 24 They seem to rely more on self-help, religion, family, and close friends as opposed to disclosing their problem and seeking help with the health care professionals and other service providers. 25 Could this be one of the possibilities why BAME communities are facing the disproportionate burden of Covid-19? It is important to explore whether these factors influence the disclosure and help-seeking practices of BAME community members.
Previous studies exploring disparities in health have shown that factors found to predict health inequalities are similarly associated with risk for violent victimisation and perpetration. 26 While much of this research has focused on social-economic inequality, these issues tend to resonant with the disparities experienced by the BAME communities. Thus, we might anticipate that this pandemic will have an equivalent impact on rates of DV as it has had on disproportionately impacting on the BAME community.
According to Southall Black Sisters (SBS), one of the leading charities in the UK that helps BAME women escape DV, they experienced a 49% increase in calls in the week before the lockdown and a further 16% rise in the calls to the charity's national helpline in May 2020 as compared to the previous month. 27 Hannana Siddiqui, the head of SBS expressed concern that due to lockdown, charities such as SBS are unable to fundraise, and their usual donor organisations are inundated with applications that may not be as culturally sensitive or competent as SBS. Thus, due to the high volume of competition, charity organisations such as SBS may miss out on vital funding from the donors. Eventually, culturally sensitive organisations such as SBS will be left to dealing with the disproportionate number of cases, without sufficient funding to respond in an effective and timely manner. This will potentially leave BAME victims of domestic violence and their children without the support needed to escape and move on from abusive domestic contexts. The councillors and mayors who have BAME community members residing in their constituencies need to liaise with culturally snsitive organizations to develop a clear action plan to mitigate against the health and social ravages of Covid-19 in ways that are culturally and linguistically appropriate.

Lesson learnt from past similar events and outbreaks
Findings from the study on 'what happened in New York City after 9/11 (the 2001 attack on the World Trade Centre)', 28 shows that people exposed to stressful experiences tend to drink heavily. Not only that, but the people with existing drinking habits continued with increased binge drinking even 5-6 years after 9/11. Similar, findings are emerging from studies examining alcohol consumption during lockdown in the UK. 7 Contributing factors to the increase in alcohol consumption in the current context are the loss or fear of losing loved ones, job loss and insecurity, reduced income, restrictions on activities that ordinarily help people to cope with the strains of everyday life (e.g. visiting gyms, eating and socialising in pubs and restaurants, escapism through music and art shows and events, shopping, etc.) This kind of 'lockdown' situation is first of its kind. People now have more unstructured time on their hands but limited space and opportunities in which to spend this. Additionally, many people will be spending unprecedented, long, uninterrupted lengths of time with partners and children at a time when they feel confused, stressed, and/or bored. Not knowing how to manage and handle this crisis constructively could lead some individuals to adopt binge drinking or frequent drinking as a coping mechanism. Excessive drinking is often causally linked to the perpetration of family violence. 29 The findings from the studies on previous epidemics, such as Ebola, Cholera and Zika viruses, have found that these outbreaks led to environments conducive to the perpetration of domestic violence. 30

CONCLUSION
No country was prepared for such a pandemic as Covid-19, so the UK was not the exception. As this is a challenging time for everyone, hard to reach groups such as BAME, women, and children are those mostly likely to be in vulnerable situations. Although the UK government together with the NHS is working hard to prioritise the support for these marginalised groups, more attention needs to be given to identify and support people living in abusive and/or violent households. There is a priority need to establish and address the factors associated with the higher incidence of Covid-19 among the BAME communities. It is important to identify the factors that hinder BAME from using mainstream support organisations. Such information can then be used to redesign mainstream services to be more inclusive of the needs and desires of the BAME service users and/ or to justify significantly increasing the resource allocation to BAME specialist service providers.