COVID-19 and Black, Asian, and Minority Ethnic Communities: A Complex Relationship Without Just Cause

Abstract

Emerging evidence has indicated a negative and disproportionate impact of COVID-19 on Black, Asian, and minority ethnic (BAME) communities. Previous studies have already reported that biological and social risk factors increase disease susceptibility, particularly in BAME communities. Despite frontline workers in ethnic minority communities in the United Kingdom’s National Health Service attempting to quell the pandemic, disproportionate numbers of BAME physicians and other health care workers have died of COVID-19. This unprecedented situation highlights ethical and moral implications, which could further augment the impact of the pandemic on their mental health. While the government attempts to mitigate the rate of virus transmission, certain key factors inadvertently augment the negative impact of the pandemic on the mental health and general well-being of BAME communities. This study examined the available literature to explore the association between, and the wider impact of, COVID-19 on BAME communities. Furthermore, this study aims to raise awareness and provide a deeper insight into current scientific discussions.

The Disproportionate Impact of COVID-19 on Black, Asian, and Minority Ethnic Communities

The first 10 health care professionals in the United Kingdom to die of COVID-19 were from the Black, Asian, and minority ethnic (BAME) communities. This raised concerns of a potential association between ethnicity and a disproportionate impact of COVID-19 on these communities [1-3]. The Intensive Care National Audit and Research Centre published UK data sets from April 10, 2020, showing that one-third of COVID-19 patients admitted to critical care units belonged to an ethnic minority group. Among 3883 COVID-19 patients, 14% (n=486) were Asian and 12% (n=402) were Black [4]. Similarly, The Guardian [5] reported that among 12,593 patients, 19% (n=2393) of those who died of COVID-19 in hospital up till April 10, 2020, were from BAME communities. These data are discordant to those of BAME individuals in the general population in the United Kingdom (14%) [1,6]. In addition, The Washington Post [1] reported that in the United States, Black-majority counties have 3-fold the number COVID-19 cases and almost 6-fold the number of COVID-19–related deaths compared to White-majority counties. However, caution should be exercised when generalizing across different health care systems [1]. A Public Health England (PHE) report [7] acknowledges the disproportionate impact of COVID-19 on BAME communities, reporting increased mortality, despite the absence of measures to potentially address the concerns identified therein.

Deaths Among National Health Service Health Care Professionals in BAME Communities

On March 12, 2020, chief medical officers in the United Kingdom elevated the country’s risk status from moderate to high, and on March 23, 2020, the prime minister imposed a nationwide lockdown [8]. Since then, 181 National Health Service (NHS) workers have died of COVID-19 [9]. This figure, however, mainly relies on reports from hospitals within England only. Numerous reports have claimed that approximately 62%-75% of COVID-19–related deaths among health care workers occurred in BAME workers [1,2,4]. This is alarming because only one-third of NHS physicians in hospitals or community services in England belong to Asian (27.2%) or Black (6.95%) communities [10].

Disease Susceptibility and Predictability in BAME Communities

Many experts, including Duncan Young (professor, Intensive Care Medicine, University of Oxford), Dr Riyaz Patel (associate professor, Cardiology, University College London), and Naveed Sattar (professor, Metabolic Medicine, University of Glasgow), have suggested that ethnic minorities are at an increased risk of SARS-CoV-2 infection, severe disease, and poor outcomes owing to socially and biologically relevant reasons [11]. First, ethnicity could play a major role in disease transmission owing to cultural, behavioral, and societal differences including those in health-seeking behaviors [12], cohabiting lifestyle [13], and lower socioeconomic status. The disease transmission risk is further increased among NHS workers. Furthermore, individuals in ethnic minority communities are disproportionally employed in fields including those associated with public transport or delivery services, where there is a known, markedly higher risk of virus transmission. It is also common for BAME households to have several generations cohabiting within close confinement as culture and family are potentially important aspects of identity in these communities. Thus, it could be challenging for BAME communities to follow social distancing protocols [14,15]. Furthermore, complexities in other comorbidities such as diabetes, hypertension, and cardiovascular diseases are commonly associated with South Asians [11]. Another theory is based on the similarities observed between the risk of morality during the last major influenza crisis—the H1N1 epidemic—and ethnic minority communities in 2009-2010 and during the first postpandemic season of 2010-2011 in England. From this data set, 67 of 337 (19.9%) individuals were from BAME communities. Furthermore, ethnic minorities have been at a higher mortality risk than the Caucasian population during the 2009-2010 pandemic, with individuals of Pakistani descent being at the highest risk [16].

In addition, early studies on the disproportionate prevalence and severity of respiratory diseases among BAME communities suggest predictable health outcomes based on socioeconomic status [17]. Social stressors and environmental adversity appear to be linked to an elevated risk of cardiovascular disease and other comorbidities [16]. According to Carol Cooper, the head of equality, diversity and human rights at Birmingham Community Healthcare NHS Trust [18]:

Many of us knew that BAME people would be overrepresented - given their proportion of the population - in the mortality and morbidity figures because of the comorbidities that exist in our communities, because of the location of our communities in terms of the workforce being on the frontline [and] because of the amount of people that are caught in the poverty trap and live in households that have higher occupancy.

Despite previous warnings and the need for public health authorities to identify at-risk populations, a literature review indicated that only 2 of 29 (7%) publications reported disaggregated data on ethnicity (case series without ethnicity-specific outcomes) [13]. The countries that initially reported the highest number of COVID-19 cases did not report data on ethnicity [13]. Researchers in the United Kingdom did not acquire or publish information on ethnicity until concerns of an association between COVID-19 and ethnicity began to emerge [3,13,19]. As is the case in many diseases, researchers and policy makers do not often consider ethnicity as a core factor until deaths among BAME communities become prominent in mortality data or media reports.

In addition to reports from the United Kingdom [11], those from the United States have indicated that chronic conditions such as diabetes, asthma, hypertension, kidney disease, and obesity are more common in Black American than in White American populations [20]. These conditions are associated with poor outcomes in COVID-19 cases. Moreover, Kirby [20] reported:

The risks of COVID-19 to Indigenous communities could not be clearer. More than 1 in 3 Indigenous Australian adults report having either cardiovascular disease, diabetes, or renal disease, and onset of these diseases often occurs 20 years earlier than the non-Indigenous population.

The NHS Long Term Plan has identified and prioritized more common conditions including diabetes, hypertension, and obesity, but has overlooked other, more specific health conditions that increase disease severity in BAME communities, such as asthma and kidney and cardiovascular diseases [21,22]. Similarly, these conditions do not seem to be prioritized by US health care authorities [23].

Inequalities and Their Psychological Impact

Stress-related physiological and general psychological responses, such as recurrent experiences of discrimination, can significantly impact health by increasing the risk of heart disease, diabetes, and infections [24]. The PHE report of 2020 [22] asserts that this pandemic did not generate health inequalities but merely exposed and exacerbated the longstanding health and socioeconomic inequalities affecting BAME communities in the United Kingdom. Although this statement might hold true, perceptions of the underlying causal relationships vary greatly and are difficult to unravel [7]. Compared to the United Kingdom, hate crimes against Asian Americans have increased in the United States [25]. A study from the

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