Dipesh P Gopal and Sonia Adesara call for action now
It was welcoming to hear about the plan for a formal review to investigate the disproportionate numbers of people from an ethnic minority background who have been affected by covid-19. A report by the intensive care national audit and research centre (ICNARC) found that 33% of 9347 patients (correct as of 29 May) who were admitted to intensive care were from ethnic minority backgrounds and 16% of total national deaths (correct as of 29 May) from coronavirus have been in people from ethnic minority backgrounds, despite only making up 14% of the UK population. The coronavirus mortality risk was 62% higher for Asian people and 71% higher for black people compared to white people even when controlling for age, gender, body mass index, co-morbidities and deprivation. This effect on the ethnic minority population has been mirrored in NHS staff and multiple American states. Such differences in mortality in the UK cannot be accounted for by non-hospital deaths such as in care homes, but may be explained by key worker roles. However, disparities in health outcomes and mortality rates between ethnic minority communities and the white British population are nothing new.
Within the UK, South Asian children have a lower asthma incidence, but both black and South Asian people have 2-3 times higher risk of hospital admission compared to white people. The National Cancer Patient Experience Survey showed that patients from minority backgrounds feel less likely to be involved in their care and less supported. For Asian women and black women the risk of maternal mortality is twice and five times that compared to white British women respectively. Black British men have 7 times higher the risk of psychosis and black British people are 4 times more likely to be detained under the Mental Health Act compared to white people. The most obvious question is why.
Innate biological and genetic factors have been suggested as a cause of high coronavirus mortality and morbidity for ethnic minority communities. This included racial genetic differences in angiotensin-converting-enzyme (ACE) receptors, but these have not been validated in more comprehensive work. Furthermore there is further evidence of greater genetic variation within races than between races. Others suggested low vitamin D levels, but a pre-pandemic meta-analysis of 11321 participants showed vitamin D supplementation was associated with a mere 12% decrease risk in respiratory infections. We also know that socio-economic factors significantly impact a person’s health to a greater extent than healthcare access or biological/genetic factors.
Ethnic minority communities have lower disability-free life expectancy (DFLE) at birth, higher infant mortality, higher unemployment, higher work stress (30% vs 18% white communities) and almost double the rates of poverty after housing costs (45% vs 26% for white communities). This is against a background of widening disparities in health and life expectancy between the wealthiest and most deprived communities in the UK. This coincides with cuts to public spending which have disproportionately impacted women from ethnic minorities. These inequalities are also evident in the USA. Socio-economic vulnerabilities are further exposed by this pandemic and the choice to “stay at home” is a luxury not afforded to all. Many families without financial security are forced to continue working or face destitution. In the words of Michael Marmot, “People are not poor because they make poor choices. Poverty leads to poor ‘choices’ or, more precisely, no choices.”
We must ask ourselves uncomfortable questions about how we see others and whether we treat people differently. Why did members of the public inflict racist abuse onto Chinese restaurants as the pandemic unfolded? Or reject Uber rides from East-Asian looking people over others at the epidemic stage? Many academics attribute this to “unconscious bias”—the way we see others differently—to which clinicians are not immune. We must acknowledge our own biases. However, bias cannot be a scapegoat and bias training alone is insufficient. We must speak out when people of different races are treated differently: racism. As Angela Davis said, “it is not enough to be non-racist, we must be anti-racist.”
The NHS Workforce Race Equality Standard (WRES) is making headway addressing racial inequalities within workforce and leadership. Issues around differential attainment, bullying, disproportionate GMC referrals, and feeling less able to raise workforce safety concerns are especially important given doctors and nurses from ethnic minorities have been disproportionately affected by inadequate personal protective equipment (PPE) during this pandemic. Healthcare teams may wish to implement a cultural safety model to mitigate influences of biases and power imbalances that propagate racial disparities.
We need our politicians to listen to us about the harmful association between cuts to public services, such as healthcare and local authorities, and worsening inequalities. Perhaps Virchow said it best “Medicine is a social science, and politics nothing but medicine at a larger scale”. Cuts to public services disproportionally affect our ethnic minority communities even outside of a pandemic and these inequalities are exacerbated during a pandemic. However, we shouldn’t be waiting for a pandemic to implement change. To paraphrase H James Harrington, to improve outcomes we must measure those outcomes to understand why they occur. We look forward to the race equality observatory recently launched to measure racial differences in health and healthcare which is now very necessary. The result of PHE’s formal review on the disproportionate impact of covid-19 on ethnic minority healthcare workers is now urgently needed. Greater equality in society benefits even those with the least to gain.
Dipesh P Gopal (@dipeshgopal), GP and Honorary Research Fellow, Queen Mary, University of London, UK.
Sonia Adesara (@soniaadesara), GP registrar, London
Recommended resources: We would recommend anyone interested in this topic to visit the helpful BMJ collection of papers called “Racism in Medicine” and the 5 minute video on “Learning from the experience of BME cancer patients: bias”.
Competing Interests: DG is an honorary trainee member of the Late Effects Group of the National Cancer Research Institute (NCRI) and honorary research fellow at the Barts and The London School of Medicine and Dentistry. SA is a former National Medical Director’s Clinical Fellow (2018/19).