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expert reaction to PHE review of disparities in risks and outcomes in COVID-19

Public Health England (PHE) have released their report into disparities in risks and outcomes in COVID-19.

 

Prof Kamlesh Khunti, Professor of Primary Care Diabetes and Vascular Medicine, University of Leicester, said:

“This is a comprehensive review of the risk factors associated with COVID cases, severity and mortality.  It has summarised published studies and conducted descriptive analysis using surveillance data.  The findings are in agreement with what has been published previously. However, the report does not make any recommendations on how to reduce these disparities.”

 

Prof Seif Shaheen, Professor of Respiratory Epidemiology, Queen Mary University of London, said:

“This latest report from PHE is welcome, but the analyses of ethnicity as a risk factor for COVID-19 are disappointing as they do little to clarify why, for example, people of Black ethnicity have the highest rates of diagnosis and why Bangladeshis have the highest mortality rates, compared to Whites.  Whilst the mortality analyses adjusted for age and area-based deprivation, they did not adjust for other risk factors which are more prevalent in people from the BAME community, and which might explain their greater risk.  These include patient- and public-facing occupations which increase exposure risk, comorbidities such as cardiovascular disease and diabetes, obesity, and smoking which is particularly prevalent in Bangladeshi men.

“Analyses which rely on routinely collected data will not be able to take account of other risk factors such as overcrowding in the home (which will increase the risk of infection in multi-generation households), and lifestyle factors; population-based studies currently underway may shed more light on risk factors for acquiring coronavirus infection in the first place.

“We urgently need to understand what underlies the greater risk of COVID-19 in ethnic minorities, so that we can focus on modifiable risk factors and devise suitable preventive strategies.”

 

Prof Jackie Cassell, Deputy Dean, Brighton and Sussex Medical School, University of Brighton, said:

“The PHE report on Disparities in the risk and outcomes of COVID-19 pulls together a variety of data sources, all collected for different reasons and with different strengths and gaps.

“The report shows that people from a range of Black and Minority Ethnic (BAME) groups are more likely to have had a definite COVID diagnosis.  Individuals belonging to BAME ethnic groups are also more likely than white people to have been admitted to hospital with a COVID diagnosis.

“The report gives information on deaths in 2020 with a COVID diagnosis in different ethnic groups, and compares these with deaths in recent years.  Recent years are used as a ‘baseline’ of expected deaths in each group.  The increase in deaths with COVID, and in all deaths during 2020 is greater among people of BAME groups.  For example, all deaths among white men have doubled during the COVID epidemic, but quadrupled among black men compared to previous years.  Among white women, all deaths are up by half compared to what was seen in previous years, but deaths among black women have increased three-fold.

“We have much richer information on the various risk factors associated with becoming seriously ill with COVID for patients who have been admitted to hospital.  Within patients admitted to hospital with COVID, once age, sex, other medical conditions and obesity are taken into account, people in BAME groups are no more likely to need intensive care (ITU) or to die.  This suggests that BAME people who are admitted to hospital have more underlying health conditions on average than white people.

“This doesn’t however explain why more people in BAME groups are getting a diagnosis of COVID in the first place.  The report cites evidence that people of BAME ethnicity are more likely to live in urban areas, in overcrowded households, in deprived areas, and to have jobs that expose them to higher risk.  Social distancing aims to reduce risk of becoming infected by avoiding situations where transmission is most likely, where contact with other people is close or frequent.  The hospital dataset in its current form does not include information about occupation.  So we can’t use hospital data to tell us how the risk of getting COVID relates to working in an occupation involving close proximity with others, either before or after social distancing measures were introduced.

“Occupational risk is however covered by death certification data published by the Office for National Statistics (ONS) and examined in the report.  Among people of working age (20-64) there are three groups of workers in whom deaths from all causes are higher than in previous years.  These include elementary security, and road transport occupations.  Within these, deaths of security guards, and taxi drivers or chauffeurs are two and a half times higher than in recent years.  Deaths of workers providing personal care are also 80% higher than in previous years, with nursing auxiliaries up by two and a half times.

“The report also covers deaths among migrants, defined as people born outside the UK of any age, as recorded on death certificates.  These are also higher, and the increase is of a similar order to BAME deaths as a whole.”

 

Dr Saffron Karlsen, Senior Lecturer in Social Research, University of Bristol, said:

“The long awaited PHE report into ethnic differences in COVID-19 has now been released.  It is already clear that for many of us, it does not achieve all that we’d hoped.  We had expected a report dedicated to providing a more detailed examination of and some explanations for what we already know: that those with minority ethnicities in the UK are more likely to be infected with and to die from COVID-19.  The reality is that the investigation, which now only constitutes 11 pages of the 89-page report, offers very little additional information from which to make sense of these patterns.

“The report acknowledges higher rates of COVID-19 diagnosis among Black ethnic groups and higher rates of death among those with Black and Asian ethnicities.  After adjusting for the effects of differences in sex, age, area deprivation and region of residence between the groups, people of Bangladeshi ethnicity had around twice the risk of death of those with White British ethnicities.  Those with Chinese, Indian, Pakistani, ‘other Asian’, Caribbean and ‘other Black’ ethnicities also had significantly higher risks of death than White British people.

“Unfortunately, what the report can say is greatly overshadowed by what it can’t.  This is partly due to methodological issues.  The ethnicity classification used in most of the tables is extremely crude and has likely concealed important differences in these experiences.  This is despite the authors themselves singling out the particular disadvantage of Bangladeshi people, including compared with others in this ‘Asian’ category.  The report authors also argue that the patterns they present contrast starkly with ethnic variations in ‘all-cause mortality’ in previous years.  They offer no suggestion as to why this might be but it may be a simple problem of not comparing like with like.

“Most disappointing is the complete lack of any attempt to investigate what might be driving these inequalities.  We already know, from existing ONS and IFS reports, that socioeconomic position is an important part of the explanation for ethnic inequalities in experiences of COVID-19, while co-morbidities appear less so.  Such findings concur with a wealth of existing evidence regarding explanations for ethnic inequalities in other health conditions.  This existing research consistently shows that what explains ethnic health inequalities are societal, not genetic or cultural, in origin.  But the PHE analyses barely touches on this.

“Rather than detailed analysis, we are presented with a selection of results from other research which draws attention to lives lived in urban, overcrowding and deprived dwellings, funded by jobs which expose them to higher risks.  Proposed explanations for the higher deaths among those with minority ethnicities who are infected with COVID-19 draw attention to the higher rates of cardiovascular disease and diabetes in some groups.  The reasons for these poor living conditions, higher-risk jobs and co-morbidities are not explained.  We are left to assume that this concentration of people in poorer environments and worse health is therefore unproblematic.  Natural or cultural differences caused by something inherent to these ethnic minority groups themselves.  Likewise, we are told that there may be ‘additional barriers in accessing [health] services that are created by, for example, cultural and language differences’.  We are not told about the wealth of evidence documenting the ways in which those with minority ethnicities are persistently excluded from the education, employment and other opportunities which will enable them to attain good jobs or decent housing.  Or the prejudice which prevents them from acquiring those lower risk jobs, that better housing, or high-quality health care which comes so easily to others, even when they have the skills and the rights to have them.  Or the ways in which these negative experiences produce the stress that drives these ‘co-morbidities’.

“We cannot distance the experiences of those with minority ethnicities with COVID-19 in the UK, or the US, from the deaths of George Floyd and others.  It is the same institutional and individual racism, repeated and reinforced throughout history and across contemporary society, which explains them both.  Until we acknowledge it, we cannot hope to address it.”

 

Dr Riyaz Patel, Associate Professor of Cardiology, UCL, said:

“This is a detailed and significant attempt to describe the various associations that have been observed relating to disparities and COVID19.

“It confirms much of what we know already from previous reports, partly because many of the same data sources were also used here, although the availability of some additional datasets linked together allowed the group to gauge a few incremental  insights to add to the wider picture.

“Unfortunately despite the extensive work, the report still cannot explain why certain groups are at more risk of having worse outcomes.  For example, the team found that after adjusting for age, sex, deprivation and region, Bangladeshi people were at highest risk of death from COVID19.  However, medical conditions were not available to use in the models, and we know that diabetes is especially common in this group and is itself a significant risk factor as revealed later in the analysis of death certificates.  The report states this is a planned future analysis so hopefully we will learn more from that.

“Putting the various sections of this report and prior data together, increasingly it appears as though COVID19 magnifies existing socioeconomic disparities that BAME and other groups face.  Structural and societal factors still determine where people live, the conditions they live in, the work they do, the medical conditions they have and it is likely these all combine to lead to a greater and possibly cumulative exposure to the virus, followed by an impaired ability to fight it and ultimately survive.”

 

Prof Alison Sinclair, Professor of Molecular Virology, University of Sussex, said:

“The report from Public Health England presents and integrates data from multiple surveillance systems.  It shows that the risk of dying from COVID-19 in England is not the same for all of us.

“The highest risk of dying from COVID-19 is linked to being a man and being older.  Regional differences are also found with urban areas faring worst.  People born outside the UK and Ireland and those in BAME groups are also at higher risk.

“The simple answer as to why is that we can not be sure yet.

“There may be several factors responsible for the differences and each of the at-risk groups may require a different explanation.

“These factors include genetics.  In the case of increased risk for men the different genes on the sex chromosomes – one X and one Y chromosome for men compared to two X chromosomes for women may contribute either by influencing the way the virus replicates in our bodies or the activity of our immune system.

“Diabetes has been linked to deaths from COVID-19 and it is found to be twice as high in BAME groups than others and is coupled with obesity which also links with a poor outcome from COVID-19.

“But societal as well as biological differences may also play a role.  There is evidence that workers with a high degree of contact with people have a higher risk, and part of the increased risk for BAME groups may be compounded by cultural and language differences as more of this group than the white ethnic group were born abroad.

“The data is important and the at-risk groups that it identifies will help to understand COVID-19 and formulate ways to improve responses to it.”

 

https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/889195/disparities_review.pdf

 

All our previous output on this subject can be seen at this weblink:

www.sciencemediacentre.org/tag/covid-19

 

Declared interests

None received.

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