As countries around the world struggle to contain coronavirus (COVID-19), there is growing recognition that rather than being a great leveller, the pandemic may exacerbate existing inequalities (see also the recent Health Foundation long read on inequalities). Understanding is advancing very rapidly as researchers publish new studies every week.
This article sets out some of the key points emerging from recent research on COVID-19 and health inequalities. It reviews the evidence that black and minority ethnic communities are at greater risk of catching and dying from the virus. It also considers the reasons why these groups are at greater risk. The economic impacts of the pandemic on black and minority ethnic groups are not covered.
Are black and minority ethnic people at greater risk of catching and dying from COVID-19?
There is clear evidence that black and minority ethnic groups are at higher risk of dying from COVID-19 than the rest of the population though that risk may not be the same for all ethnic groups. Data from the ONS published on 7 May show that, after adjusting for age, men and women of black ethnicity were at highest risk. They were more than four times as likely to die from COVID-19 compared to people of white ethnicity (Figure 1).
The ONS data cover all registered deaths (from 2 March to 10 April) and are linked to census records, so only capture people whose ethnicity was included in the 2011 census. A number of other studies have been done on COVID-19-related deaths occurring in hospital (eg Aldridge et al, the IFS, the OpenSAFELY Collaborative). These too have consistently found increased risk for some ethnic minority groups, particularly for people of black ethnicity and of Indian, Pakistani and Bangladeshi origins. The Intensive Care National Audit and Research Centre also showed that 34% of COVID-19-related admissions to intensive care were for ethnic minority people, while they only account for 13% of the population of England and Wales.
The research done so far relies primarily on mortality and hospital data. This means it is not yet known how much is due to an increased risk of being infected in the first place, versus a higher risk of dying from the disease once infected. Both factors almost certainly play a part.
People from black and minority ethnic groups are likely to have been more exposed to the virus (see below) but the true scale of this will not be known until the results of large infection and antibody studies become available. Even then, surveys will not produce accurate estimates for different ethnic groups unless sampling is boosted in minority populations.
There is certainly evidence emerging that, once infected, people from black and minority ethnic groups are at greater risk of poor outcomes. One study of patients in a London hospital found that (after adjusting for age, co-morbidity and severity of illness at admission), black patients had a higher risk of death (odds ratio 1.83, confidence interval 1.02–3.30) than white patients. There is also evidence that black and ethnic minority health and social care workers have been more likely to die of COVID-19 than their white colleagues.
Why do black and minority ethnic people have a higher risk of dying from COVID-19?
The answer to this question is complex. Ethnic inequalities in health in the UK have been extensively documented before COVID-19. A wide variety of explanations for these have been examined, ranging from upstream social and economic inequalities to downstream biological factors. Teasing out the contributions made by different factors is difficult, particularly because they do not all act independently; for example, living in more deprived areas which have more air pollution increases the risk of having an underlying respiratory illness. Given the complexity of the systems that produce poor outcomes for black and ethnic minority groups, there is a real risk that the imprudent use of statistical adjustment techniques in studies of COVID-19 deaths may obscure the role of some upstream issues.
Experts in the field point to racism as a ‘fundamental cause’, affecting health in multiple ways. A strong evidence base has demonstrated that racial discrimination affects people’s life chances through, for example, restricting access to education and employment opportunities. Black and minority ethnic groups tend to have poorer socioeconomic circumstances which lead to poorer health outcomes. In addition, the stress associated with being discriminated against based on race/ethnicity directly affects mental and physical health through physiological pathways.
Studies of COVID-19 so far have suggested that people from black and minority ethnic communities are more likely to be exposed to the virus because they tend to live in more densely populated urban areas where the virus has spread fastest, and are more likely to be key workers, especially in London (Figure 2). Some minority ethnic groups are more likely to live in over-crowded accommodation increasing risk of transmission within households. Once infected, many of the pre-existing health conditions that increase the risk of having severe infection are more common in black and minority ethnic groups.
Several studies have started to examine the contribution of different factors to the disproportionate mortality being experienced by black and minority ethnic groups. One study using the linked electronic records of 17 million NHS patients found that risk of death from COVID-19 was strongly associated with being male, being older, a range of prior medical conditions (especially uncontrolled diabetes and asthma) and deprivation. After adjusting for all those factors black and Asian people still had around double the risk of dying from COVID-19.
Similarly, recent ONS analysis adjusted for factors including: region, deprivation, socioeconomic position, education, and disability. Adjusting for all these factors reduced their estimate of increased odds of death for black men and women from 4.2 to 1.9 compared to white people.
It is interesting that the increased risk remains after taking this range of factors into account. But there is a real risk that in adjusting for a wide range of factors, without considering how they are inter-related, this kind of analysis may miss some of the most important upstream drivers of that increased risk.
It is clear that black and minority ethnic groups are being hit harder by the COVID-19 pandemic than others, exacerbating existing inequalities. Further epidemiological research is needed to establish the extent to which this is due to increased rates of infection and why, after being infected, such patients appear to have poorer outcomes. There is also a need for further research on the economic impacts of COVID-19 on black and minority ethnic communities, which may be very long term.
If policy responses to COVID-19 are to benefit black and ethnic minority communities as much as others, there is a real need for future studies to consider fundamental, societal issues – such as the role of racial discrimination and economic disadvantage – in how they theorise and measure the impact of COVID-19 on ethnic minority communities. There is also a need for any studies to value insights from ethnic minority community members themselves, that researchers reflect the diversity of the communities they are studying, and to ensure that black and minority ethnic participants are meaningfully involved in the research effort.
Ultimately, any new research must go beyond explaining and understanding, and also provide tangible strategies to aid action by local and national system leaders. The government has rightly launched an investigation into this issue, but there is already enough evidence to justify action to protect black and minority ethnic communities from this pandemic.
With thanks to James Nazroo and Abdul Razaq for their helpful comments at review stage.
Tim Elwell-Sutton (@tim_esPH) was Assistant Director of Strategic Partnerships in the Healthy Lives team at the Health Foundation.
Mai Stafford is Principal Data Analyst at the Health Foundation.