When the first reports of NHS staff losing their lives to Covid-19 appeared in newspapers, one aspect of the impact of the disease was evident from the pictures alone. All of the first ten doctors to be named as having died from coronavirus in the UK were from ethnic minority backgrounds.
As the death toll rises, it is becoming clear that this is not a coincidence. The Health Service Journal recently identified 119 deaths of NHS staff, and from the 106 of these people that could be verified as active health workers, 63 per cent were from black, Asian and minority ethnic (BAME) backgrounds. While 20 per cent of nursing and support staff in the NHS are BAME, this group accounts for 64 per cent of Covid-19 deaths. Among NHS medical staff, 95 per cent of those who died came from 44 per cent of the workforce that has an ethnic minority background.
Separate analysis by Sky News found on 22 April that 72 per cent of all health and social care staff who have died with Covid-19 are BAME.
Deaths among ethnic minorities in the general population appear to reflect this. BAME people account for 34 per cent of the patients admitted to UK intensive care units with Covid-19. This contrasts with most recent estimate from the Annual Population Survey that 13.4 per cent of the UK’s population is non-white.
The most recent NHS England data shows that black people, who make up 3.1 per cent of the population, are dying from the virus at almost double the rate that would be expected, comprising 6 per cent of fatalities.
Why is this happening, and is there anything the government can do about it?
On 16 April, the government launched an inquiry, led by the UCL professor of epidimiology and public health Kevin Felton, into this disturbing trend. But it should have come as no surprise to the government or health authorities that those with ethnic minority backgrounds are being hit particularly hard by coronavirus. Data from the US going back to 1950 has shown that African Americans are more vulnerable to flu epidemics, and emerging data from the Centers for Disease Control and Prevention (CDC) suggests this is equally true for Covid-19.
In both countries, evidence suggests that the most important factors are not genetic, but socioeconomic. Persistent health inequality is at least partly to blame for the disproportionate toll of Covid-19 on the BAME population.
Black, Asian and other ethnic minority communities are more likely to work in lower-paid jobs, to live more densely populated areas and more crowded housing and to have poorer access to healthcare and public health information.
People from BAME backgrounds also face a socioeconomic vulnerability to contracting novel coronavirus, as they are likely to work in jobs that bring them into contact with other people. In London, 28 per cent of Tfl’s operational staff and 44 per cent of cleaners are BAME, while ethnic minorities are over-represented in the NHS at a national level.
“It is no surprise that a pandemic such as this is going to impact those on the sharp end of inequality… Unfortunately, Britain’s black and minority communities are at that sharp end,” says Jabeer Butt, chief executive of the Race Equality Foundation, who until 18 months ago was on the NHS Equality and Diversity Council since it was created in 2010.
He adds: “Poorer quality work, poorer housing, these are all having a negative impact on people’s ability to manage their health and wellbeing… we know over the last ten years, the quality of accommodation for black and minority ethnic communities has deteriorated, with overcrowding and so on”.
Butt says health inequality should be taken into account in the policy and advice on treating Covid-19 patients. “You would have thought clinical guidance would have highlighted this as a risk factor,” he says, so that ethnicity and the greater risk it correlates to “would be part of the decision-making” around a patient’s care.
He identifies the “lack of leadership” on the impact of Covid-19 on ethnic minorities as “institutional racism”.
Why, then, are doctors – whose jobs are typically well paid and secure – experiencing the same increases in risk?
Certain chronic health conditions are more prevalent among some ethnic groups than others. Some of those are known risk factors with Covid-19, such as the higher incidences of high blood pressure and diabetes among black and Asian communities.
Scientists are also looking into how vitamin D levels interact with Covid-19, following the hypothesis that vitamin D helps regulate the sometimes fatal inflammatory response caused by the virus. Our bodies make vitamin D in response to sunlight, and higher levels of melanin in the skin lower the rate at which the body creates it, so vitamin D deficiency in some BAME individuals could be a potential factor.
Michael Barrett, a professor of biochemical parasitology who is working at the new Lighthouse Laboratory Covid-19 testing facility in Glasgow, notes that “the government started formally recommending vitamin D last week” as a way of mitigating the extra time spent indoors due to lockdown.
While he warns that vitamin D’s role in fighting the disease is “just a hypothesis, and could be wrong”, Professor Barrett notes that there are “well-known links between vitamin D deficiency and a number of different diseases”.
“Credible studies have looked at people with vitamin D deficiencies and found they are more vulnerable to a range of respiratory diseases,” he adds.
One such study was conducted by David Grimes, a former consultant physician in the North-West who has been looking at excess mortality among the BAME population for 30 years. Dr Grimes studied vitamin D levels in the town of Blackburn, and found more serious average vitamin D deficiency among British Asians than the white British population.
“These tests could be done in any hospital,” Dr Grimes tells me. “It wouldn’t cost much. There is an inertia and ignorance surrounding these deaths.”
Roger Kline, a research fellow at Middlesex University and author of the 2014 paper “The Snowy White Peaks of the NHS”, specialises in workforce culture and racial discrimination in the health service. “Some groups of staff are more likely to be at risk, with long-term health conditions like hypertension [and] diabetes,” he says.
These staff may at the same time face higher risk; “We also know that BAME staff are more likely to be on the front line, outside of very strict PPE [personal protective equipment] areas – BAME nurses are more likely to be lower-grade, for example,” he says. “There are simple things that could have been done – where staff have additional risks, make sure they don’t go into hot Covid areas.”
Kline’s research has shown that BAME doctors are less likely to be in the most senior positions, and to feel safe speaking up about problems in the workplace. “BAME hospital staff are less likely to be listened to, [and] more likely to be bullied” he explains. “In some cases I’ve heard that BAME staff have been reorganised to Covid areas.”
Some hospital trusts have identified these specific workplace issues and changed their approach. The New Statesman has seen a letter sent to BAME staff by the chief executive of the Somerset NHS Foundation Trust, Peter Lewis, after the government’s review was announced. It includes “the decision to include BAME colleagues into the vulnerable and at-risk group”. The letter also encourages BAME staff “to feel confident discussing any concerns you may have about Covid-19 and the impact on you and your family with your managers”, and reassures them that sick leave will not “affect your job role or future progress”.
For too many people, however, this awareness has come too late. “This should not have been a surprise,” Kline says, of the number of ethnic minority health workers dying. “People are asleep at the wheel… Those who are deciding look different from those who are dying. This doesn’t prove they’re racist – it just shows the need for diversity.”
The final element that contributes to higher risk for BAME people during the pandemic is geographical. The last census was in 2011, so we lack up-to-date population data at a local level. But viewing that census data against the NHS England ethnicity data on critically ill Covid-19 patients, a disproportionate effect on BAME people – though not at the same scale as the national disparity – is evident.
Chart by Ben Walker
Analysing data at a local level introduces areas that are suffering for other reasons. For example, while the London boroughs of Harrow and Brent (with ethnic minority populations of 58 per cent and 64 per cent respectively, according to 2011 census data) have the highest death rates in the UK, the third-highest rate is in South Lakeland, Cumbria – a largely rural area with a 98.2 per cent white population, but a median age that is nine years older than the UK as a whole.
The areas with above-average ethnic minority populations closely correlate to urban areas. Of the ten worst-affected areas, eight are located in cities and seven have higher than average BAME population. And not all ethnically-diverse areas are being equally impacted. Local authorities categorised by the ONS as “Ethnically Diverse Metropolitan Living” outside of London do not show above average Covid-19 deaths. Meanwhile the “Urban Settlements” category – where 88 per cent of the population is white – join the “London Cosmopolitan” boroughs in showing more deaths than the average population.
Despite making up just 7 per cent of local authorities, ethnically-diverse areas in London account for near 17 per cent of fatalities. Ethnically diverse areas outside of London, however, make up 10 per cent of local authorities but account for 4 per cent of fatalities so far.
Table by Ben Walker
So BAME people, who are more likely to live in cities in the UK, also face a series of environmental disadvantages – higher population density, air pollution, greater dependence on public transport – in a pandemic of infectious respiratory disease.
Worse still, while the impact of these factors is obvious, little is being done to quantify their effects. Only 7 per cent of official reports into Covid-19 deaths and patterns globally record ethnicity, according to a study in the Lancet by Dr Manish Pareek, from the University of Leicester. “Given previous pandemic experience, it is imperative policy-makers urgently ensure ethnicity forms part of a minimum dataset,” he wrote.
Dr Grimes agrees. “The government is failing in two ways – failing to identify ethnicity as a risk factor, and failing to tell us who is dying, and what their ethnicity is. They are dying every day, excessively. You could classify it as racism.”