Those who are most vulnerable
Those most at risk
Those with underlying health conditions
Those over 70
Those in care homes
Those who test positive
Those hospitalised
Those who have sadly died
Those.
I’ve written already about the ‘them and us’ narrative of the COVID-19 pandemic, and the dangerous consequences of the ‘vulnerable’ label, but there’s one word that’s currently making me squirm above all others, and that word is ‘those’. So, I thought I’d use this blog post to illustrate how the term has been used extensively this year to refer to and label blanket groups of people, and explain just why it makes me go hmmm…
Of course, the use of ‘those’ in this way isn’t new, and it extends far beyond the current narrative around the virus. References to, for example, ‘those over 65’, ‘those with disabilities’, ‘those with learning disabilities’, ‘those with autism’, ‘those with dementia’, ‘those with mental health problems’ and ‘those with complex needs’ are common, and a quick Google search of local authority websites reveals headers on council web pages such as:
- Help for those who have experienced domestic abuse
- Planning for adulthood for those with SEND
- Help for those who are rough sleeping
- Help available for those struggling with hoarding
- Dentists for those with disabilities and mental illness
- Help for those suffering financial hardship
- Valentines Ball for those with disabilities and their carers
But from the initial days of the pandemic, Coronavirus seems to have been particularly associated with “those”. I’m going to explore the use and consequences of two of the most prolific terms – ‘those with underlying health conditions’ and ‘those most at risk’.
‘Most people’ and ‘those with underlying health conditions’
At a Coronavirus press conference in early February, the World Health Organisation (WHO) stated that “those most at risk are older people and those with underlying health conditions” [1] and by the end of February WHO had confirmed that “although for most people COVID-19 causes only mild illness.. older people, and those with preexisting medical conditions… appear to be more vulnerable” [2]
Around the same time, WHO also published a guide to preventing and addressing social stigma associated with COVID-19, which stated that “words used in media are especially important, because these will shape the popular language and communication on the new coronavirus (COVID-19).” [3]
As it transpired, the media largely echoed the World Health Organisation’s message, reporting that ‘most people’ will only have mild symptoms, with older people/‘the elderly’ and ‘those with underlying health conditions’ at greater risk of serious illness or death.
“Read the many media reports and a common line comes out: “Most people recover, and fatalities are largely only among those with underlying health conditions.” It is a sentiment I have heard constantly in recent days, supposedly as a form of reassurance.”
Frances Ryan [4]
The “most people” and “those with underlying health conditions” phrases are now deeply ingrained. Indeed, the standard letter sent to parents when a child in school tests positive states “please be reassured that for most people, coronavirus (COVID-19) will be a mild illness” and suggests “if you are able, move any vulnerable individuals (such as the elderly and those with underlying health conditions) out of your home” [5]. The message is about others. There’s no sense whatsoever that ‘you’ as a parent could be one of ‘those’ vulnerable individuals.
The WHO stigma guide goes on to advise that “how we communicate about COVID-19 is critical in supporting people to take effective action to help combat the disease and to avoid fuelling fear and stigma”. Looks like we messed up from the start then, didn’t we? The othering tone of those initial messages effectively wrote people off, with an underlying “they would have died soon anyway” rhetoric. It stigmatised people living with long-term health conditions (estimated to be approximately one in five of us [6]) and caused untold fear and anxiety.
“Trying to claim disabled people aren’t regularly and systemically devalued, disposed of and dehumanized is pretty tough given all the “don’t worry, Real People won’t die, only Non-People like old and disabled people will, no worries” coronavirus threads.”
Laura Dorwart [7]
It also led to the perception that “young and healthy” people won’t get seriously ill and as such should be able to “judge their individual risks” – undoubtedly influencing and impacting on people’s behaviour and the adoption of preventative and protective measures. [8][9] And with the initial herd immunity propositions and the recent debates among scientists about “shielding versus blanket policies”, we’ve seen repeated calls to segment “those who are most vulnerable” and allow “the rest of us” to “get on with our lives”. [10][11][12][13][14]
‘Those most at risk‘
“It is vital that we do everything we can to protect ourselves, our families and our friends from being impacted by the virus. But for those who are at the highest risk in our society, we have to do even more to ensure they’re kept safe… we all have a part to play in protecting the welfare of those who are most vulnerable”
Matt Hancock [15]
While there’s no doubt the media played a part in perpetuating this dehumanising narrative, the UK government firmly cemented it. A very quick and not very scientific analysis of Google search results shows the prevalence of the terms ‘those with underlying health conditions’, ‘those who are most vulnerable’ and ‘those most at risk’ compared with ‘people with underlying health conditions’, ‘people who are most vulnerable’ and ‘people most at risk’ on UK news sites and the UK government website (GOV.UK). UK news sites used ‘those’ between 1 January and 31 October this year significantly more often than ‘people’, but the UK government site showed a shocking preference for ‘those’ rather than people.
In early March, the government issued advice for “those most at risk from COVID-19” [16]. The Treasury announced “support for those affected by Covid-19” in the 2020 Budget [17], Boris Johnson advised “all those over 70 and those with serious medical conditions against going on cruises” [18] and the Department of Health and Social Care issued new guidance to “ensure older people and those with pre-existing conditions and care needs who receive support are best protected” [19].
Just a few days later, in a statement to parliament, Health and Social Care Secretary Matt Hancock described the two overriding aims of the government’s action plan to contain, delay, research and mitigate the virus: to “protect the NHS”, and “to protect life by safeguarding those who are most vulnerable” [20]. The next day, “those who are over 70, have an underlying health condition or are pregnant” were “strongly advised” to significantly limit face-to-face interaction with friends and family [21].
On 21 March the government published a “full list of those falling into the extremely vulnerable group” and announced “a raft of new measures… for those considered to be extremely vulnerable” – including shielding “those with serious conditions” and plans to “deliver groceries and medicines for those most at risk from the virus” [22].
The Coronavirus Act received Royal Assent on 25 March, with provisions to “prioritise care and support for those who need it most” [23] and simplify “the procedure for discharge from an acute hospital setting for those with a social care need” [24].
Towards the end of March, the government introduced daily press briefings, with regular references to “those who have contracted the virus”, “those who have tested positive”, “those hospitalised in the UK” and “those who have sadly died”. Ministers repeatedly expressed their “deepest condolences to the families and friends of those who have passed away” and stressed their “thoughts and prayers” were with “the families and loved ones of those who have lost their lives”. [25]
And in the final daily briefing in March, Duchy of Lancaster Michael Gove committed “to ensure that we support not just the 1.5 million most vulnerable to the disease but all those who need our help through this crisis, those without social support, those in tough economic circumstances, those who need the visible hand of friendship at a challenging time” [26], and the raft of measures continued.
Communities Secretary Robert Jenrick announced measures to protect “those sleeping on the streets”, “those at risk of rough sleeping” and “those staying in night shelters” [27], and Secretary of State for Business and Energy Alok Sharma announced emergency measures “to protect the domestic energy supply of those most in need” [28].
Minister for Care Helen Whately was “delighted that NHSX is partnering with Facebook to make it easier for those in care homes to keep in touch with friends and family” [29], Home Secretary Priti Patel announced support for “those in danger of domestic abuse” and “those trapped in the horrific cycle of abuse” [30], and Housing Minister Christopher Pincher published new guidance for social landlords – referencing “those fleeing domestic abuse”, “those who need a more settled home”, “those fleeing abusive relationships”, “those living in un-safe accommodation” and “those who are vulnerable during this time” [31].
And Health and Social Care Secretary Matt Hancock launched the Adult Social Care Action Plan, “to reduce outbreaks in care homes, support care staff and providers and maintain independence of those receiving care” [32]. The plan refers to “those who fund their own care”, “those being discharged from hospital”, “workers, their families and those that they care for”, “those on Working Tax Credit”, “those on Universal Credit”, “those who require health and care services”, “those in care homes”, “those with sensory impairments”, “those who are least able to advocate for themselves”, “those being newly referred to Community Health Services” and “those who have been hospitalised with the virus”. [33]
Since then, the government’s briefings, press releases, news stories and speeches relating to COVID-19 have continued to refer to ‘those’, including “those worse affected by the disease”, “those suffering from poor mental health”, “those without”, “those isolated”, “those with special educational needs and disabilities” and “those shielding”.
When Boris Johnson announced the latest national restrictions, the accompanying press release referred to “you”, “your household”, “families”, “parents”, “children”, “single adult households”, “young people”, “carers” and “patients”. But get to the paragraph on shielding, and it’s straight back to dehumanising references to ‘those’:
“The clinically vulnerable, or those over the age of 60, should be especially careful to follow the rules and minimise contacts with others. Those who are clinically extremely vulnerable should not only minimise their contacts with others, but also not go to work if they are unable to work from home.” [34]
So what?
So, you could read this post as a catalogue of the “unprecedented support” [35] put in place over the last few months to protect people from the virus or from the measures to control it.
Or, you could re-read this post, and every time you see the word ‘those’ highlighted in bold, acknowledge that conscious decision to say or write ‘those’ instead of people, when people could have been said or written every single time.
Language is powerful. It reflects our values and our feelings, and in turn the way we think and the way we behave. The words we choose matter.
Every one of ‘those’ is a human being. A person. An individual. But individual personhood and unique identity is erased by that one, dehumanising, five-letter word. People who have died are denied an identity too, referred to as numbers, ‘daily deaths’, ‘COVID fatalities’ and, yes – ‘those who have sadly died’.
“This approach is literally dehumanizing people. People’s lives deserve to be so much more valued than being whittled down into a number at a press conference”.
Sue Robins [36]
‘Those’ suggests different. Separate. Other. Not like ‘us’. Maybe not so important. Possibly not so human. Definitely not so visible. And once you’re not so visible, your life becomes that bit less valued. And once you’re seen as less valuable, you’re a whole lot more vulnerable. Once you’re written out of the story, you’re effectively written off.
Vulnerable, not valuable: blanket rules for blanket groups
There’s no doubt that many difficult and painful decisions had to be made in the initial peak of the COVID-19 pandemic, but there’s overwhelming evidence that instead of these decisions being made on an individual basis, blanket rules were applied to the blanket groups of people identified as ‘those’.
There are numerous accounts of the blanket application of do not attempt resuscitation orders to “those in care homes” and “those with learning disabilities or autism” [37] leaving “some groups including the disabled, frail, elderly and those with chronic long-term conditions… scared that if they become ill they could be denied treatment” [38].
There’s also evidence that as hospitals got busier, “admission criteria and the people that were being admitted significantly changed to not admitting those that were elderly” [39][40].
The NICE guideline [41] stating that all adults should be assessed on admission to hospital using the Clinical Frailty Scale prompted concerns that “those with a score as low as five – those seen as “mildly frail”, who often need help with transportation, heavy housework and medication… might not be considered appropriate for critical care and might be steered towards end-of-life care instead if their condition deteriorated” [42].
There’s also evidence of the use of a COVID-19 decision support tool to prioritise access to potentially life-saving treatment, which “used a number of factors that meant men, the old, the frail and those suffering from underlying illnesses were less likely to be admitted to intensive care” [43].
The blanket instruction to “urgently discharge all hospital inpatients who are medically fit to leave” [44] meant that 25,000 people, “including those infected or possibly infected with COVID-19 who had not been tested”, were discharged into care homes between 17 March and 15 April.
And the blanket rules around shielding and bans on visits to hospitals and care homes have caused untold damage and trauma.
There are also examples of “those who are most vulnerable” being written out of the picture of “those who have sadly died”.
Between 10-24 April, care homes reported 4,343 deaths from coronavirus, but deaths of “those in care homes” weren’t included in daily official figures of COVID-19 deaths until 29 April [45].
NHS England initially said data on “deaths of those with learning disabilities and autism” from COVID-19 wouldn’t be published until 2021, but following pressure from the Labour’s shadow secretary for social care Liz Kendall and leading charities, the Care Quality Commission published data on deaths of people with a learning disability in early June [46][47]. Just this week, NHS England have reported estimates that 692 per 100,000 people registered as having a learning disability died with COVID-19 between 21 March and 5 June, a death rate 6.3 times higher than the general population [48].
Us, not them and us
Back in February, the World Health Organisation warned that “stigma can undermine social cohesion and prompt possible social isolation of groups, which might contribute to a situation where the virus is more, not less, likely to spread.” [49]
In a week that has seen the news that more than 50,000 people have died after testing positive for coronavirus in the UK, with Wednesday reported as “the deadliest single day of the pandemic since May” [50] and a “record” 33,470 people testing positive on Thursday [51], it’s clear that the narrative has to change.
It’s time to tell a different story. People, not ‘those’. We, not me. Us, not them and us.
References
[1] WHO Emergencies coronavirus Press Conference 6 Feb 2020, World Health Organisation, 6 February 2020
[2] Coronavirus disease 2019 (COVID-19) Situation Report – 36, World Health Organisation, 25 February 2020
[3] A guide to preventing and addressing social stigma, World Health Organisation, 24 February 2020
[4] Coronavirus hits ill and disabled people hardest, so why is society writing us off? Frances Ryan, The Guardian, 11 March 2020
[5] I can’t find the original source of this letter. I first saw the phrases in a letter I received as a parent, but Google either phrase and you’ll see numerous examples of the same text.
[6] Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study, Andrew Clark et al, The Lancet, 15 June 2020
[7] Trying to claim disabled people aren’t regularly and systemically devalued… Laura Dorwart, Twitter, 2 March 2020
[8] The ten most dangerous coronavirus myths debunked, Anna McLaughlin, Kings College London, 8 April 2020
[9] Coronavirus: Is it time to move on and get back to normal life? Fergus Walsh, BBC News, 28 August 2020
[10] The ten most dangerous coronavirus myths debunked, Anna McLaughlin, Kings College London, 8 April 2020
[11] Coronavirus: Is it time to move on and get back to normal life? Fergus Walsh, BBC News, 28 August 2020
[12] Covid-19: Experts divide into two camps of action—shielding versus blanket policies, BMJ, 2020;370:m3702, 21 September 2020
[13] Great Barrington Declaration
[14] It is genuinely possible to shield the vulnerable from Covid, while the rest of us go back to normal, Jay Bhattacharya, The Telegraph, 20 October 2020
[15] Major new measures to protect people at highest risk from coronavirus, Press release, Ministry of Housing, 21 March 2020
[16] Government outlines further plans to support health and social care system in fight against COVID-19, Press release, Department of Health and Social Care, 8 March 2020
[17] Support for those affected by Covid-19, Guidance, HM Treasury, 11 March
[18] Prime Minister’s statement on coronavirus (COVID-19): 12 March 2020, Speech, Prime Minister’s Office, 12 March 2020
[19] New adult social care guidance to protect the most vulnerable against COVID-19, News story, Department of Health and Social Care, 13 March 2020
[20] Controlling the spread of COVID-19: Health Secretary’s statement to Parliament, Oral Statement to Parliament, Department of Health and Social Care, 16 March 2020
[21] New guidance for households with possible COVID-19 infection, News story, Department of Health and Social Care, 17 March 2020
[22] Major new measures to protect people at highest risk from coronavirus, Press release, Ministry of Housing, 21 March 2020
[23] Coronavirus (COVID-19): changes to the Care Act 2014, Guidance, Department of Health and Social Care, 31 March 2020,
[24] Coronavirus Act 2020: explanatory notes, HM Government, 2020
[25] For example
Foreign Secretary’s statement on coronavirus (COVID-19): 30 March 2020, Department for Transport, 30 March 2020
[26] Chancellor of the Duchy of Lancaster’s statement on coronavirus (COVID-19): 31 March 2020, Speech, Cabinet Office, 31 March 2020
[27] £3.2 million emergency support for rough sleepers during coronavirus outbreak, Press release, Ministry of Housing, Communities and Local Government, 17 March 2020
[28] Government agrees measures with energy industry to support vulnerable people through COVID-19, Press release, Department for Business, Energy & Industrial Strategy, 19 March 2020
[29] NHS works with tech firms to help care home residents and patients connect with loved ones, Press release, Department of Health and Social Care, 9 April 2020
[30] Home Secretary’s statement on domestic abuse and coronavirus (COVID-19): 11 April 2020, Speech, Home Office, 11 April 2020
[31] New guidance for social landlords on essential moves, Press release, Ministry of Housing, Communities and Local Government, 27 April 2020
[32] National action plan to further support adult social care sector, Press release, Department of Health and Social Care, 15 April 2020
[33] COVID-19: our action plan for adult social care, Policy paper, Department of Health and Social Care, 16 April 2020
[34] Prime Minister announces new national restrictions, Press release, Prime Minister’s Office, 31 October 2020
[35] Prime Minister’s statement on coronavirus (COVID-19): 22 October 2020, Speech, Prime Minister’s Office, 22 October 2020
[36] People are not numbers, Sue Robins, 21 September 2020
[37] Learning disabilities should never be a reason for a Do Not Resuscitate order, Julie Bass, Health Service Journal, 25 April 2020
[38] The truth about do not resuscitate orders, Shaun Lintern, Independent, 8 April 2020
[39] Revealed: how elderly paid price of protecting NHS from Covid-19, George Arbuthnott, Sunday Times, 25 October 2020
[40] Elderly people with coronavirus ‘denied hospital beds and left to die in care homes’, Jennifer Williams, Manchester Evening News, 4 April 2020
[41] COVID-19 rapid guideline: critical care in adults, NICE guideline [NG159], National Institute of Health and Care Excellence, 20 March 2020
[42] Coronavirus: Anger over ‘terrifying and discriminating’ intensive care guidance, Disability News Service, John Pring, 26 March 2020
[43] Revealed: how elderly paid price of protecting NHS from Covid-19, George Arbuthnott, Sunday Times, 25 October 2020
[44] Important and urgent – next steps on NHS response to Covid-19, Letter, NHS England and NHS Improvement, 17 March 2020
[45] Care home fatalities to be included in daily coronavirus death tolls, The Guardian, 28 April 2020
[46] Ministers act after claims covid deaths of disabled and autistic people being ‘ignored’, Rebecca Thomas, Health Service Journal, 6 May 2020
[47] CQC publishes data on deaths of people with a learning disability, Care Quality Commission, 2 June 2020
[48] People with learning disabilities had higher death rate from COVID-19, Press release, Public Health England, 12 November 2020
[49] A guide to preventing and addressing social stigma, World Health Organisation, 24 February 2020
[50] UK coronavirus death toll passes 50,000 after rise of 595 in one day, Andrew Woodcock et al, The Independent, 12 November 2020
[51] Covid: UK daily cases reach new high of 33,470, BBC News, 12 November 2020
Rewriting social care 