COVID-19 has Exposed and Exacerbated Health Inequalities based on Ethnicity

Alexis Paton

COVID-19 is having a disproportionately negative impact on people from ethnic minority backgrounds in Britain. As a result, people from ethnic minority backgrounds have been more likely to become critically ill or die of the infection. Much of the discussion has centred on the shared underlying illnesses that people from ethnic minority backgrounds are more likely to have, and the emerging relationship between poor outcomes from COVID-19 and these same illnesses. However, the toll that COVID-19 is taking on people from ethnic minority backgrounds has more to do with health inequalities than anyone groups propensity for a particular underlying condition. Health inequalities arise through complex socio-economic positioning, which in turn develops from the interactions between ethnicity, living conditions, occupations, ambient air quality, area deprivation, underlying heath conditions, relative economic disadvantage and poverty.

In our recent work on the impact of COVID-19, submitted the Women and Equalities Committee as part of an inquiry into the effects of COVID-19, we argue that to address these disproportionate poor outcomes and deaths, we need to go beyond the narrowly-focused clinical concerns about COVID-19 in people from ethnic minority backgrounds, and implement policy to mitigate further harm to these groups.

Increased risks of exposure

People from ethnic minority backgrounds are more likely to live in densely populated urban areas than the white population. This means that social distancing is more difficult. This situation is exacerbated within multi-generational and/or overcrowded homes. Whilst only 2% of white Britain’s live in overcrowded homes, it is higher for all other ethnic groups, with 30% Bangladeshi households living in overcrowded accommodation. The combination of urban environments, multigenerational households, especially where housing is overcrowded mean that people from ethnic minority backgrounds are at a higher risk of infection. Measures to address overcrowding, need to be part of long-term housing policy that directly addresses the relationship between proximity and infection.

The type of occupation is also a factor that is likely to have led to increased infections. Over 50% of frontline and key workers are people from ethnic minority groups. This includes approximately 40% of doctors working in the UK. Shortages of PPE will have exacerbated the risks, especially as it does not account for the increased risks that staff from ethnic minority backgrounds have for contracting COVID-19. It is imperative that the guidance on PPE use takes into account the increased risk of COVID-19 to these frontline/keyworker staff across all sectors, or risk disproportionately exposing almost half of the medical workforce to a potentially deadly disease.

Workers from ethnic minority backgrounds are also over-represented in the transport, distribution, and retail sectors. These sectors have continued to operate, often interacting directly with the public on a daily basis.  These workers are also much more likely to be in forms of precarious work, such as on temporary or zero-hour contracts. Economic pressures, such as only receiving statutory minimum sick pay, increases pressure on workers to keep working even if they have symptoms associated with COVID-19, potentially exposing their colleagues to infection. Increasing paid sick leave for all workers, particularly those in precarious work, could help address this issue.

Underlying Health Risks

People living in areas of deprivation have a higher risk of poorer air quality, and therefore are already at higher risk from the impact of pollution. Recent evidence has shown that some communities are more likely to live in deprived areas, including 50% of Pakistani and 45% of Black African households. The over-representation of people from ethnic minority backgrounds in deprived, poor air quality areas has led to higher levels of asthma, and asthma hospital admissions. Early evidence shows that ambient air quality is associated with COVID-19 related deaths, and severe asthma is designated as a significant risk factor. Whilst the recommendation for those with severe asthma was to shield, the extent to which this is possible will depend on socio-economic factors. Current advice on avoiding public transport does reduce direct exposure to COVID-19, but an increased reliance on cars as people return to the workplace is likely to have a detrimental impact on air quality. If active travel is to be increased, large-scale changes need to be introduced as soon as possible.

Heart disease and diabetes have both been identified as pre-existing conditions associated with high-risks of dying from COVID-19. Some ethnic groups are at much higher risk for these conditions. However, the risk of developing these illnesses, and of health outcomes if you do have chronic illness, are also linked to an individual’s socio-economic position.  For example, richer South Asian people have low rates of cardiovascular disease whereas poorer South Asian people are more likely to develop these conditions.  This evidence illustrates the complexity of the relationship between ethnicity and socio-economic circumstances, and illustrates how reducing the numbers of people living in poverty will reduce these health risks and resulting deaths.

Additionally, decision-tools used by those treating COVID-19 patients often emphasis the need to consider pre-existing conditions to determine priority of care. This means that those with conditions such as cardiovascular disease may be less likely to be escalated to critical care than those without. As proportionately more people from ethnic minority backgrounds have conditions identified as important co-morbidities, this could mean that they are less likely to receive the most intensive treatments. In other words, it is important that treatment decision-tools fully consider the relationship between ethnicity, health and COVID-19 to ensure that they avoid exacerbating the underlying inequalities faced by people from ethnic minority backgrounds.

Summary

The impact of COVID-19 on the ethnic minority community must feature prominently as part of the government’s plan to step down pandemic measures and ease out of lockdown. Ignoring the detrimental relationship between ethnicity and COVID-19 outcomes will only serve to further intrench health inequalities, as this group is set to emerge from lockdown sicker, poorer and mourning more dead than white Britons. Research is needed now to determine the needs of people from ethnic minority backgrounds so that they can remain safe long-term from the disproportional effect that COVID-19 is having on these communities, and how best to implement strategies to support and safeguard this group from unnecessary exposure and risk of infection. To do otherwise is to willingly look on as people from ethnic minority backgrounds needlessly suffer and die in this pandemic.

The full report entitled Submission of evidence on the disproportionate impact of COVID 19, and the UK government response, on ethnic minorities and women in the UK, authored by Alexis Paton, Gary Fooks, Gaja Maestri and Pam Lowe can be accessed here.