Ethnicity, health inequalities and COVID-19

It became clear early in the pandemic that ethnicity was a factor in both the impact and outcome of the disease.

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In July 2020, Public Health England (PHE) examined the extent of that impact and found that people of Black, Asian and other minority ethnic (BAME) groups were more exposed to COVID-19, more likely to be diagnosed with it and more likely to die from it than those of white ethnicity (COVID-19: Review of disparities in risks and outcomes). 

The reasons for this are multi-layered. Deprivation, low income, minority ethnicity, and poor housing are often interlinked and have all been found to be associated with an increased risk of COVID-19, demonstrating that existing health inequalities mean an inequitable starting point for how well people survive the pandemic.

Tackling London’s ongoing COVID-19 health inequalities, a blog by PHE’s regional director of public health for London, Kevin Fenton, revealed that ethnicity continued to feature alongside deprivation as a major factor in the health outcomes of communities in the city during the second wave of the pandemic.

Case rate and mortality data showed London’s Asian populations were worst affected during the second wave to early February, followed by Black communities, with both communities experiencing significantly higher case rates and deaths than their White counterparts. In England overall, it was Pakistani and Bangladeshi men who fared worst during the second wave.

There are underlying factors influencing health outcomes that affect minority communities in particular – demographics, existing conditions, health behaviours and family structures are all contributors that have been identified in national literature.

People in BAME populations are more likely to be in occupations that mean they cannot work from home so must travel to work, very often on public transport - indeed their job may involve working on public transport, coming into contact with other people on a daily basis. Many of our ethnic minorities work in health and social care, directly exposing them to the virus.

Ethnicity and COVID-19 mortality

Between April and May 2020, research by the Office of National Statistics found that individuals from Asian/Asian British background were 4.8 times more likely to test positive to COVID-19 than people of White ethnicity (Coronavirus and the social impacts on different ethnic groups in the UK).

In addition, COVID-19 death rates per 100,000 population were 2.7 and 2.0 times higher for males and females of Black-African ethnic background compared to those of White ethnicity.

In another recent report, ONS examined the relationship between ethnicity and COVID-19 mortality by building a multivariable model to take a number of factors into account (Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020).

These included age, health, geography, socioeconomic variables and occupation. Once adjusting for all these factors, the report found statistically significant raised rates of death for males and females of Black African, Black Caribbean, Indian, Pakistani and other ethnic group. 

After adjustment, compared to White males; the rate of deaths among Black African males was 2.3 times greater, for Bangladeshi males it was 1.9 times greater, for Black Caribbean males 1.7 times greater and for Pakistani males 1.6 times greater.

Pre-existing conditions

Poorer survival rates in BAME populations can be partly explained by inequalities in underlying health conditions.

The average number of pre-existing conditions for deaths involving COVID-19 between March and June was 2.1 times greater for those aged 0-69 and 2.3 times greater for those over 70 years old.  High risk conditions include chronic neurodegenerative diseases such as dementia, cardiovascular diseases and diabetes (COVID-19: Risk Factors for Severe Disease and Death).

A report by PHE in December 2020, Analysis of the relationship between pre-existing health conditions, ethnicity and COVID-19, found that among people with one or more pre-existing health condition, there were more COVID-19 cases in every ethnic minority group (apart from Chinese), than would be expected if they had the same rate of COVID-19 diagnoses as all people with the conditions.

The difference in the number of cases relates to exposure to the disease and as we have found, those from BAME communities are more likely to be exposed to the disease than those from White ethnicity.

For those with a pre-existing condition, it can be harder to access support services if they are also of a minority ethnicity. Research pre-pandemic (Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey) found that people from some minority groups – particularly Asian groups – were more likely to report poor experiences at their GP surgery. They were also more likely to report not getting enough support from other local services to help manage their health condition, and to say that they felt less confident about managing their own health, compared with white people.

Amongst deaths in hospital, NHS England data (COVID-19 Daily Deaths) show more than one in four deaths were amongst individuals with diabetes followed by one in six with dementia, one in six with chronic pulmonary disease and one in six with chronic kidney disease.

In England, three in every four adults of Black ethnicity are overweight or obese and half of those who are of Asian ethnicity. Black and Asian ethnic groups also have much higher rates of diabetes, with recent estimates showing BAME populations as having three to five times higher prevalence than those of White ethnicity.

Age, gender and ethnicity

Altogether, age, gender and ethnicity intersect in terms of inequality, with the impact greatest on women. A study by researchers at Manchester University (Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey) analysed inequalities in health-related quality of life (HRQoL) and five determinants of health in older adults across all ethnic groups in England.

They found that HRQoL was worse for men or women, or both, in 15 (88·2 per cent ) of 17 minority ethnic groups, with the impact of greater magnitude on women, than the White British ethnic group. The greatest inequalities for men and women were among the Gypsy and Traveller community.

Inequalities amongst ethnic minority groups were accompanied by increased prevalence of long-term conditions or multimorbidity, poor experiences of primary care, insufficient support from local services, low patient self-confidence in managing their own health and high area-level social deprivation compared with the White British group.

According to The Centre for Mental Health’s report, Young Black men’s mental health during COVID-19:

Disruption to education is widening inequalities experienced by young Black men, who are more likely to be excluded and have their grades underpredicted. Young Black men aged 16-25 are amongst the hardest hit by job losses and are more likely to report a fall in income because of lockdown. COVID-19 enforcement and policing are disproportionately affecting young Black men, who are much more likely to be stopped and searched and issued fines for breaching lockdown measures. As a result of some of these challenges, young Black men are at risk of higher levels of mental distress during the pandemic compared to other groups.

 

Recent analysis from the Office of National Statistics (Why have Black and South Asian People been hit hardest by COVID-19) shows that less than 1 in 50 households of a White ethnicity were multigenerational compared to over half of Bangladeshi households and more than a third of Pakistani households.

Overcrowding increases the chance of viral transmission because keeping a safe physical distance from others isn’t easy. It also reduces a person’s ability to self-isolate. Multigenerational overcrowded housing may put those in older or more vulnerable groups at higher risk of infection. Reports from cities such as Leicester, site of the first area-focused lockdown in July 2020, highlighted the effect of the pandemic on crowded housing and deprivation.

View the proportion of households with at least one person aged 70 years or older by ethnic group (ONS annual population survey 2018)

Multigenerational and overcrowded housing

People from minority ethnic communities are more likely than those of white ethnicity to live in overcrowded multigenerational housing, making transmission of the virus easier, quarantine from household members and shielding for vulnerable groups harder.

Higher occupational risk

The intersectionality between occupation and ethnicity and COVID-19 can’t be ignored. ONS data shows that Black and minority ethnic groups suffered an impact to their mental health, incomes and life expectancy that left them more vulnerable to the coronavirus pandemic. People from minority ethnic groups were likely to be working longer hours than their white counterparts and less likely to be furloughed.

According to the Institute of Fiscal Studies (Are some ethnic groups more vulnerable to COVID-19 than others?) a working age person of Black-African ethnicity is 50 per cent more likely to be a key worker than a White British counterpart and nearly three times as likely to be a health and social care worker. Amongst women, the highest rates of death were observed in nurses, care workers and home carers – of which 13.2 per cent are from Black ethnic backgrounds.

Among security guards and related occupations, which is regarded as a job with one of the highest infection risks – 15 per cent of staff were from Black ethnic backgrounds followed by 11 per cent from Bangladeshi or Pakistani background.

Moreover, amongst taxi drivers and chauffeurs, who are also high risk, around one in three taxi drivers are from Bangladeshi or Pakistani background. Of the 17 specific occupations among men in England and Wales found to have higher rates of death involving COVID-19, 11 out of 17 have statistically significantly higher proportions of workers from Black and Asian ethnic backgrounds. Those of Indian ethnicity make up only 3.2 per cent of the working age population, but more than 14 per cent of doctors.

Ethnic minority men are overrepresented in eight out of the ten highest death rate occupations; this is particularly true for taxi and cab drivers. Pakistani men are 70 per cent more likely to be self-employed than the White British majority and the incomes of self-employed workers are more uncertain.

In addition, men from minority ethnic groups are more likely to be affected by the shutdown: Bangladeshi men are four times as likely as White British men to have jobs in shut-down industries, for example, the restaurant sector (Are some ethnic groups more vulnerable to COVID-19 than others?).

Vaccine hesitancy

According to ONS data, Coronavirus and vaccine hesitancy, 13 January to 7 February 2021, more than four in 10 Black or Black British adults reported feeling hesitant about the COVID-19 vaccine. Some of the reported concerns related to side effects, long term health effect and questions on how well the vaccine works. Other ethnic groups also show more hesitancy about the vaccine than White groups.

Conclusion

It is clear that ethnicity alone is the main driver for the impact of COVID-19 amongst minority ethnic communities, but rather the combination of other factors that are prevalent within ethnic groups. 

Deprivation has been shown to be a key driver for high transmission and impact of the virus. BAME communities are more likely to live in densely populated areas with overcrowded housing. This makes household isolation much more challenging and increases the risk of intra-household transmission.  Moreover, those from BAME communities are also more likely to live in a multigenerational house where grandparents, parents and children all live together. This may contribute to explaining higher death rates in BAME populations where vulnerable older adults or those in shield categories may find it harder to isolate. 

Underlying health conditions such as diabetes, obesity, cardiovascular disease and chronic kidney disease which have been shown to be associated with higher mortality rates are all more prevalent in BAME communities. 

Finally, occupational risk has been shown to have played a key part in driving infection, particularly in the first lockdown period. Occupations classed as critical which continued during lockdowns were often staffed by a higher proportion of those of BAME background such as healthcare workers, taxi drivers and security guards. 

While it is difficult for councils to know what interventions to implement, it is clear that structural change is necessary. Reduce deprivation and much of the associated problems dissipate to an extent. This means greater support for education and employment in order to aid recovery and make progress against health inequalities.

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