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One of the most urgent issues that has arisen from the pandemic is why has Covid-19 taken a greater toll on people from Black, Asian and minority ethnic (BAME) backgrounds.
Reports during the first peak of the virus in the UK showed a relationship between ethnicity and poor clinical outcomes in Covid-19, but it was unclear whether this was due to socio-economic factors or for biological reasons.
As we move into the winter with a second peak of Covid-19 on the horizon, two important questions remain: are people from ethnic minority backgrounds more likely to catch Covid-19 and once infected, are they then more likely to die from it?
Uneven toll on BAME healthcare workers
The UK has recorded among the highest number of Covid-19 health worker deaths in the world, according to a report published by Amnesty International. It found that at least 540 health and social workers died from Covid-19 in England and Wales alone. This made the UK second only to Russia, which has recorded 545 health worker deaths.
Early studies indicate that BAME health workers appear to be significantly over-represented in the total number of Covid-19 related health worker deaths, with some reports showing that more than 60% of health workers who died identified as BAME.
Figures from the British Medical Association in June showed that although only 21% of all staff are BAME, 63% of healthcare workers who died were from an ethnic group. Of this, 64% of nurses and 95% of doctors who died were BAME.
Added to these heart-breaking figures, numerous surveys have found that BAME doctors were almost twice as likely to say they would not feel confident raising concerns than white doctors and felt pressured to work in settings with inadequate PPE where aerosol-generating procedures are carried out.
Time will tell whether enough has been done to protect these workers as Government scientific advisors warn that Covid-related deaths are set to rise.
What are the potential biological reasons for BAME deaths from Covid?
A systemic review published in the journal EClinical Medicine, and led by Dr Manish Pareek, Daniel Pan and Shirley Sze at the University of Leicester looked at the impact of ethnicity on clinical outcomes in Covid-19.
It found that there were at least 3,876 deaths of BAME individuals in hospitals in England up to 9 June, which means that, where ethnicity is known, BAME people represented 15.5% of all deaths to this point.
The researchers highlighted that early reports from China and Italy identified cardiometabolic comorbidity as an important risk factor for adverse outcomes in patients with Covid-19. Several cardiovascular diseases are over-represented in certain ethnic groups which might place them at higher risk of infection and adverse outcomes such as type 2 diabetes, hypertension and left ventricular hypertrophy.
It added that an important mechanistic explanation for the association between cardiovascular disease and Covid-19 is the expression of angiotensin-converting enzyme 2 (ACE2) receptor in the respiratory tract and myocardium. ACE2 receptor expression may be elevated in patients with hypertension treated with ACE-inhibitors or angiotensin receptor blockers, resulting in higher levels of viral entry and consequently more severe disease. Yet, the interaction between ethnicity, ACE2 activity and clinical outcome of Covid-19 still remains uncertain.
In a linked editorial to the Leicester study, El-Khatib and others suggested that there could be several explanations for the disproportionate burden of Covid-19 in ethnic minorities that include social, economic and health inequalities as well as genetic predisposition, biological or pathophysiological differences in response to infection.
They said that ethnic minorities have higher burden of comorbidities like diabetes, cardiovascular disease and morbid obesity. In addition, increased prevalence of vitamin D deficiency, increased inflammatory burdens, could increase the risk of Covid-19 disease severity in those populations
Another study examined whether the greater severity of Covid-19 amongst men and BAME individuals is explained by cardiometabolic, socio-economic or behavioural factors.
The researchers studied 4,510 UK Biobank participants tested for Covid-19 (positive = 1,326) to investigate the link between Covid-19 status and the following: cardiometabolic factors (diabetes, hypertension, high cholesterol, prior myocardial infarction, smoking and body mass index), 25(OH)-vitamin D, poor diet, Townsend deprivation score, housing (home type, overcrowding) and behavioural factors (sociability, risk taking).
It found that sex and ethnicity differential pattern of Covid-19 was not adequately explained by variations in cardiometabolic factors, 25(OH)-vitamin D levels or socio-economic factors. They concluded that factors which underlie ethnic differences in Covid-19 may not be easily captured, and so investigation of alternative biological and genetic susceptibilities as well as more comprehensive assessment of the complex economic, social and behavioural differences should be prioritised.
Confounding variables in BAME Covid-19 deaths
When the Office of National Statistics examined coronavirus-related deaths by ethnic group, they found that black people were more than four times as likely to die as white people of the same age.
Even after adjusting its figures to take into account confounding factors such as where people lived, deprivation, household composition, socioeconomic status, education, and health and disability, there were still disproportionate deaths among black and Asian people.
In its report, Disparities in the risk and outcomes of Covid-19, Public Health England came to a similar conclusion. It found that after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death from Covid-19 than people of White British ethnicity.
People of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50% higher risk of death from Covid-19 when compared to White British.
Yet, what both reports failed to do was answer why. In an editorial in The BMJ, Parth Patel, Institute for Public Policy Research, and others said that the silence concerning how structural inequalities may be fuelling this pandemic, and more importantly how these inequalities take root, is notable.
They said that although some have suggested possible underlying genetic factors or the role of pre-existing conditions such as diabetes, obesity, and hypertension, the PHE report failed to ask why these conditions are more common in many minority ethnic populations or to explore factors such as material deprivation that might explain them.
Sally Warren, Director of Policy at The King’s Fund agreed with this and said that the coronavirus pandemic exposed the stark inequalities that exist throughout our society. She said people who have been worst affected by the virus are generally those who had worse health outcomes before the pandemic, including people working in lower-paid professions, those from ethnic minority backgrounds and people living in poorer areas.
She added: “We’ve known for many years that these groups typically have worse health outcomes, but there has been disappointingly little effort over the past decade to address inequalities and improve people’s health. The scandal is not that the virus has disproportionately affected certain groups, but that it has taken a global pandemic to shine a light on deeply entrenched health inequalities.”
Healthcare professionals need to be able to voice concerns
Now as we begin to enter the second wave of the pandemic, the government and health organisations must act to protect minority ethnic groups before we see the same thing happening all over again.
We can’t be in the position were we have serious shortages of personal protective equipment or healthcare workers are forced to buy their own. We can’t have doctors saying in BMA surveys that they feel “partly or not at all protected”.
And most importantly we can’t have healthcare professionals unable to talk about shortages in protective equipment or gagged and prevented from raising concerns as reported in the Amnesty International report.
As Kate Allen, Amnesty International UK’s Director, said: “It is tragic that we’ve seen so many of our dedicated health and social care workers in England and Wales die from Covid-19. We have to understand whether these deaths were avoidable, and what led to this terrible outcome.”
We must learn lessons from the first wave of the coronavirus crisis and keep pushing for effective risk assessments to be made available to doctors and other NHS staff. It is the only way we can prevent future unnecessary deaths.
GM is launching a new health inequality section and we would like to hear the experiences of healthcare professionals both on and off the Covid frontline. For more information contact the editor at [email protected]