COVID-19 chart series
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 risk of COVID-19 related death is more than four times as high for people of black ethnicity than for those of white ethnicity after adjusting for age
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.