There are approximately 6 million cases of Coronavirus disease (COVID-19) worldwide, with approx. 370, 000 confirmed deaths, according to the World Health Organisation as of 1st June 2020. Approximately 270, 000 cases are in the UK with approx. 38, 000 deaths. Following the death of the first 10 doctors, who were all Black, Asian and Minority Ethnic (BAME), Public Health England was urged to carry out an investigation on the high BAME death rate.
Since then, numerous reports have continued to show further disparities in the death toll amongst the BAME population compared to White. Overall, the British BAME death rate was found to be 2.7 to 3.5 times higher than in their white counterparts. In addition to this, data from the Intensive Care National Audit and Research Centre showed that although BAME people make up 14% of the population, they are 34% of critically ill COVID-19 patients in intensive care. Several reasons behind these findings have been speculated in official reports and the media. This article is to highlight findings from various reports explaining why the BAME community are more adversely affected than any other within the UK.
So what factors are contributing to the disparity in death rates?
There have been several discussions and reports outlining both health and non-health related causes of the higher death rates within the BAME community.
Let’s begin with health-related factors. Health inequalities have existed before COVID-19, these will inevitably be heightened during a pandemic. Diabetes, hypertension, heart and kidney disease are known to be more prevalent among BAME populations. The Institute for Fiscal Studies (IFS) report (May 2020) found that Bangladeshis are more than 60% more likely to have long term health conditions, making them more vulnerable, accounting for the increased morbidity and mortality rates. It is clear that the government and the NHS need to produce tailored educational resources for our BAME community and formulate preventative measures to reduce the prevalence of these conditions.
COVID-19 has been seen to increase the risk of thromboembolism and autoimmune phenomena in some patients. These are more prevalent in BAME populations; making our community once again more vulnerable.
As mentioned briefly, health disparities between BAME populations and their white counterparts have existed for many years. The MBRRACE-UK 2019 study showed that maternal mortality rates amongst black women, who account for 4% of women giving birth in the UK, was 38 per 100,000 versus 7 per 100,000 among white women, who account for 80% of births in the UK. This fivefold increase in maternal deaths is disproportional to the prevalence of morbidities amongst black women. We cannot place differences in health as the sole cause.
Now that we have covered the health-related factors, let’s discuss those that are non-health related.
The IFS report also discussed economical differences between white and BAME groups by observing household structures and occupational profiles. They showed that:
More than two in ten Black African women of working age are employed in health and social care roles
Indian men are 150% more likely to work in health and social care roles than their white British counterparts
While the Indian ethnic group make up 3% of the working-age population of England and Wales, they account for 14% of doctors.
BAME groups account for a high proportion of key workers and are more likely to live in a multigenerational household. This increase in exposure leads to an increased risk of morbidity and mortality due to transmission at work and therefore in their own homes. However, it is important to note that this would not be contributing factor if key workers had access to good quality personal protective equipment whilst working on COVID-19 wards.
Although the reasons listed in several reports may contribute to the disparities, statisticians at the Office of National Statistics showed that once factors such as socio-economic status, occupation, health and household composition, among others, had been fully adjusted for, the disparities persist. So, the question is what else is leading to these inequalities? Are there systemic, institutional factors that are having an impact on BAME health outcomes? To ignore this question and not investigate would be an act of disservice to our BAME community.
Systemic discrimination within the NHS is an issue that has been discussed and raised before by independent organisations such as the King’s Fund and the British Medical Association (BMA). A survey, with over 2000 respondents, was distributed by ITV in May to BAME healthcare workers regarding BAME death rates. Half of the respondents felt that alongside health, discriminatory behaviour also played a role, such as the unfair deployment of BAME staff to COVID wards compared to their white colleagues. Feelings of fear and of being unheard were common, resulting in half of the respondents not feeling comfortable to raise their concerns on issues such as deployment. Dr Chaand Nagpaul stated that BAME doctors felt “twice as likely not to raise concerns because of fears of recrimination”. In these circumstances, the concerns would surround having access to adequate PPE. The fear of recrimination is worsened by the lack of representation in senior roles across NHS departments.
“This is a real concern, and it's about a culture in the NHS that has existed for a while, and it needs to be addressed.” - Dr Chaand Nagpaul, Chair of the Council of the BMA
Dr Nagpaul also highlighted that English is considered as a second language for a substantial proportion of the BAME community, resulting in reduced accessibility to services such as 111 and reduced comprehension of information leaflets and government advice (which are written and spoken in a limited selection of languages). It is well-known that the UK is a diverse country, highlighting the need for resources that serve our population in order to mitigate these difficulties.
Dr Zubaida Haque, deputy director of Runnymede Trust recently stated regarding the most recent PHE report released this week. "It’s wholly disappointing and dissatisfying to find the government has, not only, not addressed the causes for why BAME people are disproportionately dying, but that there’s not a single recommendation." This is not an uncommon opinion.
With the recent events surrounding the Black Lives Matter movement, it is important to remember that for things to improve, we must speak up about these injustices, racial or otherwise, and strive for equity by finding and implementing solutions. This can only be achieved by becoming aware of our implicit bias and unawareness, both as institutions and individuals, and working together. This cannot be another lost opportunity to address the inequalities present in our healthcare system.
Article written by Dr Felicite Mukeshimana, junior doctor in London/Wessex