A large body of research has identified health disparities that have put ethnic minority groups at higher risk of contracting and experiencing adverse consequences of COVID-19. Initial evidence suggests differences between ethnic minority groups in their experience of COVID-19.
These differences are attributed to socio-economic disadvantage, manifesting in factors such as greater exposure to infection, higher prevalence of health vulnerability and increased likelihood of losing income.
Current evidence in this area has been produced in rapid response to an ongoing situation and is often not peer-reviewed. Often, the lack of comprehensive ethnicity data can mean that the full impact of COVID-19 on different communities is unknown.
The Institute for Fiscal Studies highlights that the impacts of the pandemic are not uniform across ethnicities, and aggregating all minorities together misses important differences. In particular, the Scientific Advisory Group for Emergencies (SAGE) notes considerable differences that exist within current ethnic categories such as ‘South Asian’. Where possible in the following rapid response, the specific effects on different communities are discussed separately. This evidence summary has preserved the terminology used in the original source to ensure consistent reporting.
In addition, it is difficult to compare the overall degree of risk between different ethnic minority groups, as the risk factors and effects of COVID-19 are intersectional. Often, people from ethnic minority groups are disproportionately impacted by multiple and inter-relating factors. For example, people from some minority ethnic groups may be more likely to have an underlying health condition and more likely to work in a job with higher occupational risk.
COVID-19 rates amongst ethnic minority groups
Many reports (including by Public Health England) have found that ethnic minority groups have the highest age standardised COVID-19 diagnosis rates, whilst White ethnic groups have the lowest. Between 28 May and 26 August, Black women were over twice as likely to test positive compared with White women, and Black men were almost three times as likely to test positive compared with White men.
The Public Health England report showed that people of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10–50% higher risk of death compared with those of White ethnicity when other factors (such as age, deprivation and region) were controlled for.
The Runnymede Trust, a UK-based think-tank for racial inequality, found that 1 in 20 people from Black and ethnic minority groups have been hospitalised with the virus, compared with 1 in 100 White people. Hospital admissions data of the first 35,000 admitted patients indicates that critical care admission was more common in those from Black (36%), South Asian (28%) and other ethnic minority (29%) groups compared with those from White groups.
The Intensive Care National Audit and Research Centre reported that Black and ethnic minority patients account for 34% of critically ill COVID-19 patients, despite making up only 14% of the population. According to a report by Public Health England, historic racism and poorer experiences of healthcare may mean that individuals from Black and ethnic minority groups are less likely to seek care when needed, which could increase the risk of severe outcomes.
In June, the Office for National Statistics released data suggesting that Black men were over three times more likely to die from a COVID-19-related death compared with White men, and two and a half times more likely in women.
The Institute for Fiscal Studies noted that unequal rates of death among ethnic minority groups are even more stark when age is taken into account. Most ethnic minority groups have a younger average age compared with the overall UK population, which should mean they are less vulnerable and should be experiencing lower (not higher) fatality rates than average.
Is this an effect of biology or health?
Researchers are conducting investigations into whether genetic components can make people more susceptible to the serious health consequences of COVID-19. However, the role of ethnicity in genetic susceptibility to viruses is highly controversial, and there is very little evidence that the disproportionate effects of COVID-19 on different ethnic minority groups have anything to do with genetics.
Instead, any existing links are more likely to be a consequence of pre-existing health inequalities, which refer to unfair and avoidable differences in health between different groups within society.
Some scientists suggest that the effects could partially be attributed to genetic variants that play a role in the body’s immune responses. Recent evidence has found that some variants affect how the body initially responds to the virus. However, there was no relationship between these variants and ethnicity.
Early research has been conducted to investigate whether vitamin D can prevent or help to treat COVID-19. The body produces vitamin D more slowly in people with darker skin, so it is possible that some ethnic minority groups are more vulnerable to COVID-19 through vitamin D deficiency. However, the National Institute for Health and Care Excellence (NICE) has concluded that there is no evidence of an effect of vitamin D levels on susceptibility to COVID-19 once other factors (such as other health conditions, social or demographic factors, and body mass index) have been accounted for.
There are also established differences in how people’s bodies respond to certain drugs, which have been shown to vary across ethnicities. These include drugs that affect ACE2 (the protein that enables coronaviruses to invade cells and replicate). However, recent studies have found that taking drugs that affect ACE2 has no impact on susceptibility from COVID-19. These drugs are often taken for pre-existing conditions such as hypertension and diabetes, which increase the risk of the severe COVID-19 outcomes. Therefore, this may be driving the perceived link between ACE2 and COVID-19.
Ethnicity is linked to the likelihood of having pre-existing conditions that increase the risk of disease severity. Compared with White British individuals over 60 years of age, people from Bangladeshi backgrounds are over 60% more likely to have a long-term health condition that makes them vulnerable to COVID-19.
People from a South Asian background (including Indian, Pakistani, Bangladeshi or Sri Lankan) are more likely to develop coronary heart disease than White Europeans. People from an African or African Caribbean background are at a higher risk of developing high blood pressure. All of the above groups more commonly have Type 2 diabetes than other ethnic groups.
A study of 35,000 hospital admissions in England, Scotland and Wales found that mortality rates were 20% higher in patients from a South Asian background compared with White patients, despite the patients admitted to hospital being 12 years younger on average. This was partially explained by a higher prevalence of diabetes.
A rapid review by Public Health England found that 10.8% of COVID-19 related death certificates mentioned end-stage organ failure (such as kidney disease). These rates were substantially higher in Black (18%) and Asian (16%) fatalities
The increased likelihood of pre-existing health conditions across ethnic minority groups is most likely due to health and social inequalities. It is likely that health inequalities have also led to a higher prevalence of smoking and obesity, which also present greater health risks to the severity of COVID-19.
Social inequalities
Commentators, including the United Nations and Dr Omar Khan (former director of the race equality think-tank Runnymede Trust), have suggested that COVID-19 does not itself discriminate but does expose existing inequalities within society.
Many stakeholders (including the Mayor of London and The Health Foundation) have advised that the virus is not a “great leveller” as the consequences are not the same for everyone. In addition, COVID-19 and measures related to it may widen social inequalities further.
Almost all ethnic minority groups are more likely to live in urban and deprived areas, which have been most affected by COVID-19. For example, people of Pakistani ethnicity are over three times as likely to live in the most overall deprived 10% of neighbourhoods compared with those of White British ethnicity.
Researchers have suggested that these areas may have higher rates of infection because people are living in close proximity and/or with reduced healthcare access.
Housing
There is evidence that people from ethnic minority groups are more likely to live in inner-city areas that are more polluted. According to a study by Imperial College London, the worst air pollution levels were seen in ethnically diverse neighbourhoods, defined as those where more than 20% of the population were non-White.
The Office for National Statistics identified air pollution as a potential contributing factor to the disparity of COVID-19 outcomes, as it can cause breathing difficulties and other long-term conditions in the lungs and the heart.
A recent study of 400 COVID-19 patients admitted to a Birmingham hospital noted that BAME patients were more likely to be admitted from regions of higher air pollution and lower housing quality.
A recent academic study found that those from ethnic minority groups and larger households had an increased likelihood of testing positive for COVID-19. The Runnymede Trust also identified how over-crowding and multi-generational housing challenges can make it difficult for ethnic minority communities to shield or self-isolate effectively. UK Government statistics show that the highest rates of overcrowding are in Bangladeshi (24%), Pakistani (18%), Black African (16%), Arab (15%) and Mixed White and Black African (14%) background households. In comparison, only 2% of White British households are classified as over-crowded.
Healthcare access
COVID-19 disparities between different ethnic minority groups may be due to reduced access to healthcare. Analyses by the Institute for Public Policy Research indicate that the ten most deprived authorities in England (including Birmingham, Hackney and Nottingham) have experienced 15% of all public health budget cuts in the past 5 years. According to census data, many of these areas are more ethnically diverse than the population average.
A report by the Runnymede Trust found that key government public health messaging, such as ‘Stay Home, Save the NHS, Save Lives’ was not reaching all ethnic minority communities. This may be partially attributed to language barriers for those who speak English as a second language. The BBC Asian Network published health advice explaining what COVID-19 is and how people can protect themselves, as well as information about staying healthy during Ramadan. The videos were produced in seven South Asian languages, including Hindi, Urdu and Tamil.
Evidence also shows a lack of cultural competence in healthcare provision, and stakeholders suggest that the delivery of public messaging should be reconsidered to ensure it reaches all communities, particularly the communities that are most at risk.
The Independent Scientific Pandemic Influenza Group on Behaviours (SPI-B) has released guidance on public health messaging, which includes translating into a range of suitable languages and using audio files or animations to cater for reading difficulty. They also advise local authorities to actively engage with the community to produce culturally diverse messaging and to establish themselves as a trusted source of communication.
Occupational risk
Research suggests that individuals from Black and ethnic minority groups are more likely to have had to work outside of their home during the national lockdown, and are more likely to work in occupations with a higher risk of COVID-19 exposure, such as health and social care. For example, 41% of people of African origin were estimated to be working outside of their home during lockdown, compared with 27% of White workers.
In addition, those from Chinese, Indian, Pakistani, Bangladeshi, Black African and Black Caribbean backgrounds were over twice as likely to use public transportation to travel to work compared with people from a White background.
Ethnic minority groups are over-represented in front-line healthcare worker roles and appear to have been disproportionately affected by COVID-19 compared with their White colleagues.
Healthcare staff from Black and ethnic minority groups were less likely to be able to access personal protective equipment (PPE), less likely to receive PPE training and less likely to speak up about PPE-related concerns compared with their White colleagues.
