How it began...
It was in April 2020 that medics started noticing that COVID-19 was not an indiscriminate killer. The first ten doctors to die in the UK from the novel respiratory disease were all among ethnic minority communities. The pattern was reported in the British Medical Journal (PDF) by Professor Kamlesh Khunti at the University of Leicester, who noted the pattern might have emerged because the UK was the first ethnically diverse country to experience a surge in coronavirus infections.
A similar story was unfolding in data collected by the Intensive Care National Audit and Research Centre. Minority ethnic groups, who make up 13% of the population according to the 2011 census, have made up around 11% of patients hospitalised with COVID-19 but over 36% admitted to critical care units.
Sadly, the ongoing COVID-19 pandemic continues to have a disproportionate impact on ethnic minority groups, with people from these groups dying in greater numbers and at younger ages than white patients. When age and sociodemographic factors are accounted for, people from minority ethnic groups are nearly twice as likely to die of COVID-19 than their white peers. Of UK healthcare workers who have died of the disease, 63 per cent came from ethnic minority communities.
Independent SAGE, an advisory group independent of the UK government that has issued regular policy recommendations during the pandemic, has described the impact of COVID-19 (PDF) on Black and minority ethnic populations as “one of the most urgent issues in this pandemic in the UK... we may all be weathering the same storm, but we are not in the same boat.”
That is a reference to the fact that ethnic minority communities are among the most socially and economically disadvantaged groups in the UK. COVID-19's devastating impact on these populations is thought to be driven by poverty, cramped housing, higher prevalence of chronic health conditions, and higher exposure to infection arising from overrepresentation in key worker jobs, and a reliance on public transport for essential work.
Why is this happening and what is being done about it?
This discrepancy in deaths, also seen in the United States, is now an urgent area of research and policy response in the UK. It has been the subject of two reports commissioned by the NHS and Public Health England, the first of which concluded in June 2020 that “the impact of COVID-19 has replicated existing health inequalities and, in some cases, has increased them.” For Sonia Saxena, Professor of Primary Care at Imperial College London and an expert on health disparities in minority ethnic groups, the current situation is a result of “intersecting pandemics, COVID-19 and endemic racism.”
Researchers around the country, including at Imperial, are now rapidly assessing the policy implications of COVID-19's inequitable impact. Speed is essential: this disease, for which there is no vaccine or guaranteed cure, is an ongoing global health emergency, with further spikes or surges in infections expected in 2020. UK Research and Innovation (UKRI) and the National Institute for Health Research announced on 29 July that £4.3m would be spent on further research.
Projects include the development of targeted digital messages to ethnic minority communities; tracking 30,000 healthcare workers to understand COVID-19 risk factors; and studying whether migrants and refugees born abroad are especially affected.
Professor Chris Whitty, England’s Chief Medical Officer and the government’s chief medical adviser, said: “With evidence showing that people from Black, Asian and minority ethnic backgrounds are more severely affected by COVID-19, it is critical that we understand what factors are driving this risk to address them effectively.”
Read on to learn about the growing evidence that the pandemic virus affects communities of different ethnicities unequally, and in a direction that widens health gaps already known to exist. There are analyses, insights and ideas from Imperial academics, among others, on how to translate clinical findings and statistics into policies that save lives and bring other benefits to communities already known to be underserved when it comes to healthcare.
What needs to happen next?
Two policy solutions stand out.
1. Immediate measures to prevent further suffering from COVID-19.
These include pinning down the risk factors for dying or suffering severely from coronavirus (this will include age and health status as well as ethnicity); risk-assessing workers who might be more occupationally exposed to infection; redeploying staff, if possible, and ensuring that those who remain exposed are protected, for example with adequate personal protective equipment. It may also involve prioritising high-risk individuals for any future COVID-19 vaccine. Some of these issues were highlighted in an editorial published by Professor Azeem Majeed, Head of the Department of Primary Care and Public Health at Imperial’s School of Public Health.
We can’t forget other inequalities among ethnic groups that already existed. All of government needs to address the underlying causes of those inequalities.
2. Long-term measures to close the pre-existing health and social gaps.
Researchers, policymakers, politicians and other stakeholders need to think long-term about how to close these gaps that have been magnified by the pandemic. For example, why are ethnic minority families more likely than white families to live in deprived areas or in cramped housing, which even in pre-COVID times were associated with poorer health outcomes? The Independent SAGE report recommended offering temporary accommodation for those who need to self-isolate or quarantine, as well as increasing the social safety net and scrapping NHS charges for migrants.
“COVID-19 has shone a spotlight on inequalities that have existed for years and made them very stark,” says Professor Majeed. “We need to learn the lessons of COVID-19 but we can’t forget other inequalities among ethnic groups that already existed, such as in education, income and housing. All of government needs to address the underlying causes of those inequalities.”
What is the evidence
that ethnic minority
groups suffer a higher
In early June, the NHS and Public Health England published a report entitled Disparities in the risk and outcomes of COVID-19 (PDF). It looked at the following factors known to affect the likelihood of diagnosis, illness and death due to COVID-19: age, sex, geography, deprivation, ethnicity and occupation.
Age is the biggest risk factor when it comes to COVID-19: among those who test positive, over-80s are seventy times more likely to die than under-40s. Men are more at risk than women: men of working age who are diagnosed COVID-19 positive are twice as likely to die as women of working age with a positive diagnosis.
When it comes to geography, diagnosis rates were higher in mostly urban areas – London, the North West, North East and West Midlands – than in more rural ones (London’s death rate was three times that of the South West, the least-affected region). In the most deprived areas, mortality rates were double those in the least deprived areas, for men and women.
COVID-19 patients of Bangladeshi ethnicity are twice as likely to die of the disease than white patients.
Ethnicity has always been a striking feature of mortality, with age-standardized death rates in the UK highest among people from ethnic minority groups. COVID-19 has exacerbated this increased risk of death.
This appears to be a combination of more diagnoses and, after diagnosis, worse outcomes. The statistics in the report illustrate clear disparities in the rates of diagnosis between different ethnic groups. Taking age into account:
The graph shows:
- 649 Black males can expect a positive COVID-19 diagnosis per 100,000 of population, compared to 224 white males.
- For females, the comparable figures are 486 Black females and 220 white females
Rates of survival after diagnosis also show differences between ethnicities. When age, sex, deprivation and region are accounted for, the following statistics emerge:
- COVID-19 patients of Bangladeshi ethnicity are twice as likely to die of the disease than white patients.
- COVID-19 patients of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity are between 10 and 50 per cent more likely to die compared to white patients.
- However, these statistics did not look at occupation, comorbidities (other illnesses, such as diabetes or cardiovascular disease) or obesity. These three factors heighten the risk posed by COVID-19.
The report went on to suggest why COVID-19 seemed to be especially targeting individuals among minority ethnic groups. First, they are at greater risk of exposure to infection because they are more likely to live in urban areas; in overcrowded households; in deprived areas; to have jobs that expose them to greater risk; and to be born abroad, which can raise language and cultural barriers.
Second, once infected, individuals among minority ethnic groups might fare more poorly because of the relatively high prevalence of other illnesses, such as diabetes, known to be associated with worse outcomes. “We know there are metabolic risk factors that affect disease progression, Professor Majeed explains. “Ethnic minority communities show a higher prevalence of metabolic risk factors, such as diabetes, impaired glucose tolerance, cardiovascular disease, high blood pressure, obesity and high cholesterol.”
INSIGHT: The international picture
The link between deprivation and severe COVID-19 impact in low- and middle-income countries has also been explored by Imperial researchers. Professor Azra Ghani and colleagues modelled how COVID-19 would spread in communities with wealth disparities. Poor communities have less access to handwashing, are more likely have jobs where social distancing is difficult and have less access to healthcare if they become ill.
By combining large-scale household surveys with a COVID-19 transmission model, the researchers estimated that the chances of dying of COVID-19 rises as incomes fall. The risk of death is a third higher in the poorest fifth of households than in the richest fifth.
What lies behind the data?
A follow-up PHE report, Beyond the Data: Understanding the Impact of COVID-19 on BAME Groups (PDF), published its findings in mid-June.
It constituted a literature review and discussions with stakeholders, identified in the report only as around 4,000 people “with a broad range of interests in BAME issues”. This resulted in a summary of possible contributing factors to higher rates of transmission, morbidity and mortality in ethnic minority groups:
- Housing challenges, such as overcrowding and multi-generational households, making isolating, shielding and social distancing difficult.
- Occupational exposure, especially for key workers.
- The use of public transport to get to and from work.
- Historic racism and poorer healthcare experiences, possibly fuelling a reluctance to seek care when needed, to speak up about risk, or to request protective equipment.
These factors, stakeholders told the report’s authors, can be traced back to longstanding inequalities that are partly rooted in deprivation. Individuals among minority ethnic groups are more likely than the white population to live in poorer socioeconomic circumstances, which is itself associated with worse health outcomes. Economic disadvantage is strongly associated with the prevalence of smoking, diabetes, high blood pressure and obesity, all of which in turn are risk factors for more severe COVID-19 illness.
What practical steps can be taken now to save lives and reduce illness?
This is a priority for Professor Majeed, who says he ticks several risk boxes when it comes to his own chances of contracting COVID-19: he is in his fifties, from a minority ethnic background and, as a part-time GP in south London, a patient-facing key worker.
COVID-19 has shone a spotlight on inequalities that have existed for years and made them very stark.
The overarching policy objective, he says, should be to get the infection rate as low as possible: “If the infection rate is low, then your risk of contracting the virus is low, and that benefits everyone. That’s why it’s important to suppress COVID-19 through testing, contract tracing and quarantine.
“But we should also be doing risk assessments. If you’re a 55-year-old doctor with diabetes and high blood pressure, then should you be on the frontline? The same principles apply to other sectors, whether it’s transport or retail. It’s about risk assessing workplaces and staff properly and putting people in an appropriate setting, particularly older males with certain risk factors. It’s also about protecting people: PPE, perspex shields on tills, good hygiene practices, cleaning down surfaces and wearing masks.”
Professor Majeed, along with others including Professor Khunti and Oxford University’s Professor Trisha Greenhalgh (an early champion of masks) has been part of an NHS England working group to create a Risk Reduction Framework, a scheme to assess COVID-19 risks to NHS staff and adaptable to other sectors.
The Risk Reduction Framework uses the following factors to assess an individual’s risk: age, sex, ethnicity, pregnancy and underlying health conditions known to be COVID-19 risk factors (hypertension, cardiovascular disease, diabetes, chronic kidney disease, obesity).
If a Black hospital porter and his white colleague are exactly matched in every way except their ethnic background, would it be fair to put the white porter on the front line and redeploy his Black colleague elsewhere?
“It could be a problem to be seen to be protecting ethnic minorities,” Professor Majeed admits. “But that is why an objective risk score is so important.
"Another factor is personal protective equipment (PPE). When healthcare staff are equipped with high-quality PPE and trained to use it properly, the risks of infection and death become much lower.”
Risk assessments and redeployment decisions, he adds, need to be done sensitively, taking cultural considerations and employees’ wishes into account. He also points out that, across all ethnicities, the risk to young people is very low.
INSIGHT: Professor Sonia Saxena on ethnicity, race and the BAME label
Every individual has a unique perception of their own ethnicity. Each ethnic group has their own culture.
Each country has their own rich diverse mix of peoples that has grown up as a result of historical migration, settlement and acculturation.
This is the insider view that anthropologists call ‘emic’ and is considered the only valid way to form labels to identify ethnic groups.
Now think about the label BAME - it stands for ‘Black, Asian and minority ethnic’. The problem with the BAME label is that this category is an outsider view. Does anyone refer to themselves as BAME? Or feel an affinity with it? If this label is not owned by us we will tend to reject it.
BAME or BME has become a convenient way for political and organisational leaders to lump everyone into a single group - ‘them’ or ‘others’ - rather than acknowledge the vast array of different groups. For example, ‘black’ alone demands the dichotomous opposite ‘white’.
In Britain, it disguises the presence of racism and disparities. One example from my own profession is that you will find south Asian minority groups well represented in decision making committees within medical professions but black British doctors in leadership roles are rare.
We like to put people into boxes, because it tidies everything up. What I have never understood is why some people find difference so challenging. Context is all important when I am asked that inevitable question that comes eventually to all people of colour, ‘Where are you from?’
If I am anywhere outside of Britain I will say London, because it is where I have lived most of my life and I think of as home. If I am in Britain, I will say ‘why do you ask?’
Professor Sonia Saxena
The ‘ethnic gradient’ in medicine
Doctors are a fascinating case study when it comes to understanding the more structural reasons why individuals among minority ethnic groups might be at heightened risk of severe illness and death. Given that medicine is universally regarded as a prestigious, well-paid profession requiring a high level of education, for doctors of all ethnicities, how come so many doctors from minority ethnic communities have died?
Professor Majeed explains that, while doctors from minority ethnic groups backgrounds might not be socioeconomically or educationally disadvantaged, they might still live in multigenerational households and have underlying health issues.
But another phenomenon might be at work: the ranks of medicine become increasingly white the higher up one goes up the medical hierarchy. “The more senior jobs tend to be filled by white doctors so there are more doctors from minority ethnic groups working on the frontline. There’s an ethnic gradient in medicine, just as there is in nursing and other healthcare professions.”
This potentially points to a deeper reason why minority ethnic groups, particularly in health and social care, have been hit hard in the COVID-19 pandemic: structural racism.
What role does racism play in health disparities?
Professor Sonia Saxena, a GP and academic who focuses on the health of women, children and other vulnerable groups, is committed to reducing ethnic health disparities across the life course.
UK policy responses to ethnic diversity are ambivalent, fragmented, confused and often harmful.
In the UK’s health system, with universal coverage for all, there should not be any health disparities, particularly for children born in the UK. Yet, she says, children from black African Caribbean and south Asian households tend to have higher attendance rates for illness in GP surgeries, but get less preventive care meaning that chronic conditions such as asthma can worsen; Black women are five times more likely than white women to die from complications in pregnancy and childbirth; and adults from south Asian and black African Caribbean minority groups have higher rates of chronic conditions such as cardiovascular disease and cancer.
These patterns cannot simply be down to higher genetic risks. There are disparities at every step in the path to developing disease, health behaviours and in seeking health advice and getting through the health system.
She recently contributed to the British Medical Journal’s special issue on Racism in Medicine, co-authoring an analysis stating that “UK policy responses to ethnic diversity are ambivalent, fragmented, confused and often harmful”. The special issue was jointly guest-edited by Mala Rao, Professor of Primary Care and Public Health at Imperial. Professor Rao has been instrumental in setting up the new NHS Race and Health Observatory, which aims to rapidly develop policies to eradicate race inequalities in healthcare. Professor Rao spoke about the challenges in a recent BMJ podcast, explaining, for example, that the pandemic revealed that ethnicity is not routinely recorded on death certificates.
Professor Saxena says her work is geared around “dismantling structural racism”. This is the kind of discrimination, usually unseen and often unintended, that permeates all levels and sectors of society, particularly institutions and workplaces. It results not only in health inequalities but also with individuals among minority ethnic groups crowding the lower ranks of many professions and being absent at senior levels.
Professor Saxena felt there were hints of this, even in the PHE reports, in the public discussion of COVID-19 in minority ethnic communities: “The interpretation was that people from south Asian or black African Caribbean groups have poorer genes that make them more vulnerable to this virus, and to chronic conditions such as diabetes and cardiovascular disease.
"But there is also a rhetoric that uses science that to suggest people from black and Asian groups at risk of poor health are uneducated and responsible for their poor health, that they have poor health behaviours and eat too much and reproduce too much. This is racism.”
There is no evidence yet on whether genetics has a role to play in the impact of COVID-19 on ethnic minority communities. Many suggest discrimination is a likelier explanation than DNA. Ethnic minority communities, for example, are disproportionately exposed to infection through their jobs. Professor Saxena says: “We think of COVID-19 as a threat to everyone but of course it isn’t because it’s so strongly linked to exposure. It has affected certain occupational groups, such as healthcare, nursing, social care, porters, transport workers, even caterers at events. These are people in the service of others.
“It’s wonderful to clap them, better if you can pay them, and better still if you can keep them safe and protect them. And it would be best of all if we could get rid of structural factors that prevent a fairer representation of all communities at all tiers of society.”
Professor Khunti, who kickstarted the urgent investigation into the impact of COVID-19 on ethnic minority communities, says “structural racism may contribute to deprivation and the prevalence of key worker roles but we don’t have any direct evidence of this except possibly in the NHS.”
INSIGHT: Could vitamin D be the missing link?
Minority ethnic communities are known to be at risk of vitamin D deficiency. Public Health England recommends supplements for people with dark skin, who need more exposure to sunlight than lighter-skinned people for their bodies to manufacture a healthy dose.
Vitamin D, needed for good bone health, has been theorised to reduce the risk of acute respiratory infections. There is no direct evidence that vitamin D can cut the chances of infection with Sars-CoV-2, the virus that causes COVID-19. However, Public Health England confirmed in June that its Scientific Advisory Committee on Nutrition will examine this issue.
Adrian Martineau, Professor of Respiratory Infection and Immunity at Barts and Queen Mary University in London, co-authored a 2017 review on the link between vitamin D and respiratory infections. In June he told the British Medical Journal: “It’s unlikely that ethnic disparities in COVID-19 outcomes will be explained by a single factor. My hunch is that socioeconomic and structural factors will be more contributory than biological ones.”
The importance of appropriate health messaging
While the UK population as a whole heeded the message to stay away from the NHS, individuals among minority ethnic groups might have been additionally scared off by headlines about the dangers posed by COVID-19 to their communities.
On top of that, Professor Saxena says, there was a failure from the top to communicate: “None of the COVID-19 health messaging was translated into language other than English and messages from the government were framed in jingoistic rhetoric reflecting a lack of cultural awareness at every stage.”
Our response to COVID-19 is an opportunity to refocus on improving everyone’s health, and disparities need to be removed now.
In addition, lockdowns closed places of worship and community centres, where many people receive health messages, marginalising many households. Doctors from some minority ethnic organisations such as the British Association for Physicians of Indian Origin provided their own translations.
Professor Saxena says: “Child visits to emergency departments have fallen by 90 per cent. Children and young people with chronic conditions like asthma and diabetes may be slipping behind on reviews of their conditions. More than 60 per cent of families are delaying vaccinations. One disease should not completely dominate the health system. Our response to COVID-19 is an opportunity to refocus on improving everyone’s health, and disparities need to be removed now.”
1. Give power and voice to minority groups
At all levels of society, starting with ensuring senior decision-making committees (including in Westminster) have better representation and diverse composition. This needs to be legislated for and rigorously implemented. No more ‘manels’ or all white parliamentary groups.
2. Overhaul monitoring and gather better information
With the help of communities themselves, that provides more sophisticated ontology than simply ‘Black’ and ‘Asian’.
No decisions or policies to be made regarding minority groups without consultation.
4. Strengthen primary care to protect the health of minority communities
During and after COVID-19: prevent exposure to disease, promote health, identify and treat chronic disease.
5. Prioritise access to a COVID-19 vaccine for high-risk communities
6. Educate the whole population about racism and bias
Redress past injustices and correct distortions of history.
7. Eliminate inequalities by ensuring fairer access to education, employment and healthcare for minorities
Over-exposed and under-protected: finding a way forward
By every health measure – diagnosis, severe illness, death – minority ethnic communities are suffering disproportionately in the COVID-19 pandemic. These groups are already at the sharp end of existing health inequalities, with higher rates of cardiovascular disease, diabetes and obesity than the white population. Underlying illnesses are linked to poor COVID-19 outcomes.
Structural factors, including structural racism, magnify the ethnicity-related health impact of COVID-19.
It is unclear yet whether genetics plays a role but investigators around the country, including at Imperial, are increasingly turning to social and economic factors to explain the discrepancy. This idea is captured succinctly in the title of the report issued in August by the Runnymede Trust, a UK race equality think tank, on the way that COVID-19 has devastated ethnic minority communities: Over-Exposed and Under-Protected. Individuals from these communities, the report says, are more likely to: work outside the home and in key worker roles; use public transport; live in overcrowded or multi-generational households; be unaware of coronavirus health messages. The report also finds that individuals among ethnic minority groups are less likely than their white counterparts to be given protective equipment.
This raises the possibility that structural factors, including structural racism, magnifies the ethnicity-related health impact of COVID-19. As well as the immediate need for risk assessments for workers of all ethnicities, long-term policies must address the injustice of individuals among ethnic minority groups being over-represented in the kind of low-paid, highly exposed jobs that put them in harm’s way.
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