Ethnicity and covid-19

Dear Editor,

We read with interest Patel el al.'s editorial emphasising the silence around structural inequalities which propel the inequality in the morbidity and mortality between white and BAME patients during the COVID-19 pandemic (1). Clearly there is no “quick fix”. This is a complex issue with BAME people at the intersection of multiple risk factors; inadequate accommodation increasing transmission (2,3,4), socioeconomic deprivation and pre-existing comorbidities increasing illness severity (5), institutional racism leading to poorer care (6,7), illiteracy (8), and mistrust of authority (9) impairing the success of screening programmes and Track and Trace. These will take time to tackle but we need to ensure representation of BAME people in policymaking immediately and openly discuss how the disproportionate impact of policies being developed now will have on BAME people, in order to build trust, reduce discrimination and safeguard BAME patients and healthcare workers.

Stay Home, Stay Safe?
As Anderson and colleagues (10) highlight, socioeconomics goes some way to explain why COVID-19 outcomes are worse in BAME than white people. Living in more overcrowded accommodation (2), a 48% increase in BAME homelessness between 2012 and 2017 (3) and shared facilities in emergency accommodation (4) all make responding to the “stay home, stay safe” message more difficult and less effective in BAME than white populations. Furthermore, people from BAME or homeless backgrounds are more likely to have comorbidities (5), meaning that they are at increased risk even if the government’s help was adequate.

Track…
The Track and Trace system is not equally accessible to all populations. Access via internet or phone is required to utilise this system (11). The over-representation of BAME people in poverty means they will have less access to this system. (12) Self-test kits require individuals to read, which isn’t always the case in the proportion of BAME people for whom English isn't their first language. As of 2011, 11% of foreign-born adults had limited English skills (8). This causes barriers to testing, tracing and accessing care. Identifying and giving the right information to these populations and making sure we have information in a language they can understand is essential.

… and Trace
Dodds and Fakoya (9) explain how distrust and misinformation impact the uptake of testing programmes. This concept also extends to the use of Track and Trace measures, disproportionately effecting the BAME population. The World Health Organisation emphasises the importance of testing to combat COVID-19 (13). It is imperative that the BAME population are engaged in this strategy. However, this need is undermined by years of disregard for BAME issues in society, evidenced by recurrent reports from which recommendations remain unactioned (14). Even the Public Health England report into how COVID-19 has disproportionately affected BAME people has been accused of diluting evidence from 1000 stakeholders who supplied evidence to the report (15). How do we expect the BAME community to trust the Track and Trace strategy when their trust has been eroded in this way?

Protecting BAME Healthcare Professionals
Due to the disproportionate rate of mortality of BAME individuals (16) and the challenges such staff face in discussing safety concerns and speaking out about PPE and testing issues (17), the recommendation that BAME staff be redeployed away from the frontline in hospitals seems valid (15). Clearly protecting staff is a priority. Unfortunately, this policy may distract from the real issues around NHS culture and how complaints and concerns are raised; BAME voices should be able to be heard without fear of consequences. Unfortunately removing BAME healthcare professionals also risks increasing racial bias in care for patients. Two systematic reviews (6,7) demonstrate that, although the majority of healthcare professionals are biased against “dark-skinned” or “non-white” people, which is likely a symptom of growing-up in a biased society, when broken down by ethnicity, white people are more likely to harbour the racial bias than BAME people. This bias is unconscious and this is not about blame, but it does lead to real differences in care. Redeployment of staff needs to be accompanied by measures to tackle such bias and space for reflective discussions to do so.

Conclusions
No-one expects discrimination to be solved overnight. The population is able to recognise that these are complex challenges and engage in debate around them. Presenting easy solutions makes for snappy headlines and fake news, but not meaningful change. Thoughtful open discussion around policy making instead of reactionary responses, representation of BAME people in policymaking, and considering the less palatable impacts of such policies is essential now. Taking steps now to tackle these compounding risk factors which unequally disadvantage BAME people is essential as we move towards further economic depression. Only by acknowledging the institutions and barriers that deny BAME people access to equal health care can we begin to dismantle them and begin to rebuild trust in the government once more. In the fight against COVID-19, we need to ensure that the BAME community is reached, for the benefit of BAME people and for the benefit of the whole of society.

References
1. Patel Parth, Hiam Lucinda, Sowemimo Annabel, Devakumar Delan, McKee Martin. Ethnicity and covid-19 BMJ 2020; 369 :m2282
2. Overcrowded households [Internet]. Ethnicity-facts-figures.service.gov.uk. 2018 [cited 18 June 2020]. Available from: https://www.ethnicity-facts-figures.service.gov.uk/housing/housing-condi...
3. Garvie D. BAME homelessness matters and is disproportionately rising – time for the government to act | Shelter [Internet]. Shelter. 2017 [cited 18 June 2020]. Available from: https://blog.shelter.org.uk/2017/10/bame-homelessness-matters-and-is-dis...
4. Garvie D. Self-isolation? Try it as a homeless family living in one room | Shelter [Internet]. Shelter. 2020 [cited 18 June 2020]. Available from: https://blog.shelter.org.uk/2020/03/self-isolation-try-it-as-a-homeless-...
5. Cappuccio F, Barbato A, Kerry S. Hypertension, diabetes and cardiovascular risk in ethnic minorities in the UK. The British Journal of Diabetes & Vascular Disease [Internet]. 2003 [cited 18 June 2020];3(4):286-293. Available from: https://journals.sagepub.com/doi/abs/10.1177/14746514030030041101?journa...
6. Hall W, Chapman M, Lee K, Merino Y, Thomas T, Payne B et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health. 2015; 105(12):2588-2588.
7. Maina I, Belton T, Ginzberg S, Singh A, Johnson T. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine. 2018.
8. Fernandez-Reino M. English language use and proficiency of migrants in the UK - Migration Observatory [Internet]. Migration Observatory. 2020 [cited 18 June 2020]. Available from: https://migrationobservatory.ox.ac.uk/resources/briefings/english-langua...
9. Dodds, C. and Fakoya, I., 2020. Covid-19: ensuring equality of access to testing for ethnic minorities. BMJ, 369, p.m2122.
10. Anderson Geoffrey, Frank John William, Naylor C David, Wodchis Walter, Feng Patrick. Using socioeconomics to counter health disparities arising from the covid-19 pandemic BMJ 2020; 369 :m2149
11. NHS test and trace: how it works [Internet]. GOV.UK. 2020 [cited 18 June 2020]. Available from: https://www.gov.uk/guidance/nhs-test-and-trace-how-it-works
12. Palmer G, Kenway P. Poverty rates among ethnic groups in Great Britain [Internet]. Joseph Rowntree Foundation; 2020 [cited 18 June 2020]. Available from: http://www.poverty.org.uk/wp-content/uploads/2018/09/ethnicity-findings.pdf
13. Covid-19 Strategy Update [Internet]. World Health Organisation; 2020 [cited 18 June 2020]. Available from: https://www.who.int/docs/default-source/coronaviruse/covid-strategy-upda...
14. Aitken A, Butcher B. Six reports in four years but what action has been taken? [Internet]. BBC News. 2020 [cited 18 June 2020]. Available from: https://www.bbc.co.uk/news/53053661
15. Iacobucci Gareth. Covid-19: PHE review has failed ethnic minorities, leaders tell BMJ BMJ 2020; 369 :m2264
16. Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Service Journal [Internet]. 2020 [cited 18 June 2020];. Available from: https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analys...
17. Nagpaul C. The disproportionate impact of covid-19 on ethnic minority healthcare workers - The BMJ [Internet]. The BMJ. 2020 [cited 18 June 2020]. Available from: https://blogs.bmj.com/bmj/2020/04/20/chaand-nagpaul-the-disproportionate...

Dear Editor

The debate on ethnicity and covid-19 is welcome and important because of its disproportionate impact on ethnic minorities. Almost the entire issue of The BMJ has been devoted to it. Racism is real and prevalent. A level playing field is important. But, is it simplistic to conflate Covid-19 outcomes with racism? There is a larger proportion of BAME people in low socioeconomic groups who have higher incidence of chronic disease and obesity; and this is argued to be a consequence of explicit or implicit racist policies. But, the proportion of BAME people is higher than the national average in urban areas most affected by Covid-19. More elderly people live in one household (partly for cultural reasons) with the younger generation who regularly use public transport in big cities.

The racial socioeconomic divide remains a demographic feature of European countries, which in fact have done a lot more address these disparities, still maintaining reasonable immigration and asylum policies. Social spending by the UK government (similar to other developed countries) is about 23% of its GDP; while that share in Indonesia, India and China is 2%, 2.5% and 7% respectively. Are the latter countries more racist (discriminatory) because the poor BAME people (compared to the better-off) in those countries have even bigger burden of ill-health? Yes, more can be done and better, but not all by the government. It has been suggested that the positive correlation between social spending and social well-being holds up to a point: the curve levels off starting at around 25% and may even drop off at higher proportions [1]. The success of the social spending (income redistribution) depends on feeling of social cohesion. Moreover, some BAME people (not enough) do move out of socio-economic deprivation over time, though the overall number or percentage may appear static.

This is not to deny that BAME people and NHS workers face implicit racial prejudice. The NHS is trying to address this issue. It is far more common for patients to have overt racial prejudice against the NHS staff, and the Health Secretary has said this is unacceptable. But, it seems grossly unfair to say that NHS policies provide unequal access to health care for patients based on where they live and their race [2]. In liberal democratic societies, some responsibility also lies with the patients. It also seems a prejudicial broad-brush generalisation to claim that NHS staff have discriminatory attitudes towards BAME patients with Covid-19 [3]. This remains to be proven and if at all, hopefully may be a rare occurrence with minor over all contribution. The UK government and the scientific community may have made errors in response to Covid-19; but both the BAME and white communities have suffered.

Statement of interest: The author has no conflict of interest to declare.

References
1. Pinker S. Enlightenment Now . Penguin Random House UK; 2019. p. 97-120.

2. Kar P. Covid shows diabetes services need parity. BMJ 2020; 369:m2154

3. Kar P. Covid-19 and ethnicity: why are all our angels white? BMJ 2020; 369:m1804.

Dear Editor,
A few months on since various professional bodies raised alarm bells due to disproportionate deaths in ethnic minorities during the COVID-19 pandemic (BMA 10th April), we now have enough published evidence to show that COVID-19 affects the BAME community unfavourably.
The Office of the UK National Statistics, University of Oxford, the London School of Hygiene & Tropical Medicine (LSHTM) and an analysis of the NHS data at University College London (UCL) have all confirmed that people from ethnic minorities have a higher risk of death due to COVID-19 infection [1],[2],[3]. The Institute of Fiscal Sciences (IFS) report found that the death rate for people of Black African descent was 3.5 times higher than for white British people, while for those of the Black Caribbean and Pakistani descent, the death rate was 1.7 times and 2.7 times higher, respectively [4]. Similar observations can be seen from reports in the United States of America [5]. It has already been reported that two-thirds of UK healthcare workers who have died from COVID- 19 were from ethnic minority backgrounds, including 18 of the 19 doctors (94%), 35 (75%) nurses, and 27(56%) support workers [6].
Since it’s announcement of the enquiry into these deaths on 16th April, the NHS England confirmed the observations of professional bodies and hospital trusts and subsequently issued a risk assessment tool for healthcare workers on 21st of May. Public Health England’s (PHE) review on 2nd of June was expected to look at the root cause analysis and produce an action plan to ensure the vulnerable communities and staff are protected. As the author has mentioned, there are clear pointers as to why there are these disparities, yet the government has failed to acknowledge it and missed an opportunity to produce a concrete plan. How much more evidence do we need? How many more people must die?
Over 40,000 lives have been lost to this pandemic, with disproportionate numbers from ethnic minorities. Similarly, the vast majority of healthcare workers that lost their lives were from ethnic minority groups, yet there is no concrete plan on how to prevent further catastrophes. The pandemic is not over. With an ease in lockdown restrictions, there is an expectation of a surge of new cases. The research by Flaxman et al, published in ‘Nature’ this month quotes “We are very far from herd immunity. The risk of a second wave, if all interventions are abandoned, is very real.” He added, “We are only at the beginning of this epidemic, and claims that it is all over can be firmly rejected.” They claim less than 5% of the British public is infected [7]. If this is true, then we are entering a danger zone when the lockdown is lifted. Even after so much evidence about the disparities COVID-19 has exposed, there is no plan to act. It is high time to take concrete action. Both the already published reports and the author have highlighted a number of factors which are likely to contribute to excessive deaths in ethnic minorities. In addition to addressing the sociocultural factors, both immediate and long-term, health agencies must promote early case hunting among ethnic minorities, including prioritisation for access to repeated COVID-19 testing. Early health checks in primary care (including care homes) must be provided, those at risk must be shielded and early hospitalisation should be promoted to ensure prompt access to treatment. We must rapidly analyse and learn from the mortality data on COVID-19 both from hospitals as well as in community and address factors we may not have taken heed of during recent months.
A number of recommendations have been provided by representative groups which have not been acknowledged in the PHE report [8]. Each hospital should have a BAME assessment lead physician, to assess BAME COVID-19 patients, as a matter of urgency. Ethnicity has to be considered as a separate risk factor for COVID-19-related serious complications. There should be early ITU assessment and encouragement to offer clinical trial drugs and further prospective research. Similarly, BAME healthcare workers should be treated as high risk from the outset and all NHS staff should have early assessment of the specified risk factors, so they can be appropriately protected. This will ensure that vulnerable staff are not put at risk. The government should also refrain from returning retired doctors to work in frontline jobs and any staff that decide to volunteer, should have a pre-assessment done to mitigate the risk. On a long-term basis the NHS must have a plan to address the misrepresentations of BAME staff in the managerial roles of the NHS and involve them in decision making to regain their confidence.
With just over two months until the beginning of a new academic year, Britain’s metropolitan cities will soon be flooded with students from across the country, and potentially overseas. The risk that this presents is immense. The notorious ‘fresher’s flu’ now seems trivial in comparison to the danger that students face. With cities such as London and Birmingham hosting huge numbers of students from BAME backgrounds, we must plan ahead. From the close living proximity of student accommodation, to the sharing of public spaces by thousands of students on a daily basis, the potential for infection rates to rise is too great to ignore. It would be naïve of us to assume that a university education can be replaced by a few digital lessons. Measures, such as early testing and quarantining, must be taken to ensure that students can continue their studies, without the fear of taking the virus home to families of high risk groups.
It is distressing for at risk communities to hear that they have proven more likely to die, and then telling them there is nothing we can do. This can be likened to giving an acute leukaemia patient their diagnosis and then telling them there is no plan to treat them. The plethora of evidence cannot be ignored. It is the responsibility of PHE to publish a detailed report of it’s assessment and include recommendations from numerous race equality groups and individuals and force immediate further discussion. An urgent action plan is needed, with a particular focus on the factors which likely increase the risk of BAME communities e.g. occupation, comorbidities.
While the conscience of the world has been shaken by the death of George Floyd and recent events have forced people to reflect on their attitude towards ethnic minorities, we strongly believe that the anguish across the world has been further heightened due to the pandemic’s discriminatory effect on ethnic minorities. The political think tank of the world must deal with the former, but we as health care professionals and national health agencies must do our part to show that, yes, the lives of ethnic minorities matter.

References

1. Office of the National Statistics. https://www.ons.gov.uk/ accessed (17th April 2020),

2. OpenSAFELY: factors associated with COVID-19-related hospital death in the linked electronic health records of 17 million adult NHS patients doi: https://doi.org/10.1101/2020.05.06.20092999)

3. Aldridge RW, Lewer D, Katikireddi SV et al. Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data [version 1; peer review: awaiting peer review]. Wellcome Open Res 2020, 5:88 (https://doi.org/10.12688/wellcomeopenres.15922.1)

4. Platt L, Warwick R. Are some ethnic groups more vunerable to COVID-19 than others? Institute for Fiscal Studies, Nuffield Foundation. 2020

5. GOV.UK, Ethnicity facts and figures: NHS Workforce. . Available at
https://www.ethnicity-facts-figures.service.gov.uk/workforce-and-busines... nhs-workforce/latest#by-ethnicity. Accessed on 29th April 2020, 2020.

6. Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed. Health Serv J 2020 Apr 22. https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analys....

7.Flaxman S, Mishra S, Gandy A, et al., Imperial College COVID-19 Response Team. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe. Nature2020;(Jun). doi:10.1038/s41586-020-2405-7. pmid:32512579

8.Gareth Lacobucci Bmj 2020;369:2264

Authors

1. Dr Farooq A Wandroo MD FRCP FRCPath, Consultant Haematologist, Honorary Senior Lecturer, University of Birmingham Medical School, UK
2. Dr Roshan A Khuroo MBBS MRCGP DFFP, Principle General Practitioner and GP trainer West Midlands Deanery, Community Based Medicine tutor, University of Birmingham and Aston University
3. Ifrah Farooq, University College London Medical School, Second year

All authors are members of a minority ethnic group, British Kashmiri Medical Association.