The inquiry into disparities in the risk and outcomes of Covid-19 commissioned by the Department of Health identifies major inequalities, confirming that – contrary to the popular refrain – we are not all in this together.
Mortality risk from Covid-19 is higher among black, Asian and minority ethnic (BAME) people
The Public Health England (PHE) review confirms that the risk of dying among those diagnosed with Covid-19 is higher in those in BAME groups than in white ethnic groups.
After accounting for the effect of sex, age, deprivation and region, it found that people of Bangladeshi ethnicity were at most risk, with around twice the risk of death than people of white British ethnicity. People of Chinese, Indian, Pakistani, other Asian, Caribbean and other black ethnicity had between 10% and 50% higher risk of death when compared to white British. The risk of mortality for people of Bangladeshi ethnicity was in line with other research, by the Office for National Statistics (ONS) and Institute for Fiscal Studies (IFS), but for other ethnicities it was generally lower.
In previous years, all-cause mortality rates were lower in Asian and black ethnic groups than in white ethnic groups, PHE said, meaning that mortality risk for Covid-19 was a reversal of what had been seen in the past.
Diagnosis of Covid-19 among BAME people is also greater
When adjusted for age the highest diagnosis rates (which does not necessarily correlate with incidence) of Covid-19 were in people of Black ethnic groups (486 in females and 649 in males) and the lowest were in people of white ethnic groups (220 in females and 224 in males).
All cause deaths of BAME people during the Covid crisis have also gone up relative to white people
Unsurprisingly, compared with previous years, death rates were higher for white British people as well as BAME people for this period, although the increases were steeper in the latter group.
All-cause mortality was almost four times higher than expected among black males for this period, almost three times higher in Asian males and almost two times higher in white males. Deaths were almost three times higher in this period in black, mixed and other females and 2.4 times higher in Asian females compared with 1.6 times in white females.
Combination of factors likely be to explain disproportionate effect on BAME people
Ahead of the review, many BAME campaigners and leaders were concerned that the review would give insufficient weight to socioeconomic inequalities or structural racism and stress genetic factors, for political convenience.
The report does not seek to reach a definitive conclusion on the cause, describing the relationship between ethnicity and health as “complex and likely to be the result of a combination of factors”. But it does say that BAME communities are likely to be at increased risk of infection because they are more likely to live in urban areas, in overcrowded households, in deprived areas and have jobs that expose them to higher risk.
It also stresses that people from BAME groups are also more likely than people of white British ethnicity to be born abroad which means they may face additional barriers in accessing services because of cultural and language differences. Compared with previous years, PHE found a particularly high increase in all-cause deaths among those born outside the UK and Ireland.
It also – without pinpointing why – says that comorbidities which increase the risk of poorer outcomes from Covid-19 are more common among certain ethnic groups. People of Bangladeshi and Pakistani background have higher rates of cardiovascular disease than people from white British ethnicity and people of black Caribbean and black African ethnicity have higher rates of hypertension compared with other ethnic groups. Further it references data from the National Diabetes Audit which suggests that type 2 diabetes prevalence is higher in people from BAME communities.
Crucially, PHE says the analyses on death and diagnosis were unable to account for the effect of occupation, comorbidities or obesity – all significant risk factors in themselves. The IFS previously found that a third of all working-age black Africans are employed in key worker roles, 50% more than the share of the white British population. Additionally it said that Pakistani, Indian and black African men are respectively 90%, 150% and 310% more likely to work in healthcare than white British men.
Mortality rates in most deprived areas twice those in least deprived
The review looked at other risk factors aside from ethnicity. The mortality rates from Covid-19 in the most deprived areas were found to be more than double the least deprived areas, for both males and females, similar to previous ONS findings. This was greater than the inequality seen in mortality rates in previous years, indicating coronavirus is exacerbating mortality inequality.
Diabetes mentioned on significant number of death certificates, particularly for BAME people
In the comorbidities section, PHE says diabetes was mentioned on 21% of death certificates where Covid-19 was also mentioned, consistent with other studies. This proportion was 43% in the Asian group, 45% in the black group and higher in all BAME groups than for the white British population. Diabetes was more likely to be mentioned on the death certificate in more deprived areas. The same ethnic disparities were seen for hypertensive disease.
Nursing assistants, security guards and cab drivers have experienced bigger increase in deaths than other occupations
Nursing auxiliaries and assistants, security guards and related occupations, and taxi and cab drivers and chauffeurs were found to have experienced a relative increase in deaths in 2020 significantly higher than the average of 1.5 among people of working age (20-64). The ONS has previously reported male bus and coach drivers, chefs, sales and retail assistants, lower-skilled workers in construction and processing plants, and both sexes working in social care as having significantly high rates of death from Covid-19.
An analysis of 10,841 Covid-19 cases in nurses, midwives and nursing associates found that those from Asian ethnic groups were overrepresented but the analysis did not look at the possible reasons behind these differences, which PHE said “may be driven by factors like geography or nature of individuals’ roles”.
Greatest disparity found for age, with male sex also significant risk factor
Age and male sex were identified as risk factors for Covid-19 early on in the pandemic among patients in Wuhan, China, the centre of the outbreak. PHE found the largest disparity to be age-related. Among people already diagnosed with coronavirus, people who were 80 or older were seventy times more likely to die than those under 40.
Working-age males diagnosed with Covid-19 were twice as likely to die as females. Men made up 46% of diagnosed cases but almost 60% of deaths and 70% of admissions to intensive care units. These disparities exist after taking ethnicity, deprivation and region into account. PHE says it remains unclear what drives the difference in outcomes between the sexes but they “could be driven by different risks of acquiring the infection – for example due to behavioural and occupational factors – and by differences in how women and men develop symptoms, access care and are diagnosed, or by biological and immune differences that put men at greater risk”.