Socioeconomic and cultural factors may explain the increased mortality risk from COVID-19 among people from Black, Asian, and Minority Ethnic (BAME) backgrounds, argue UK experts who call for better health messaging for, and protection of, those working in frontline occupations.
Moreover, individuals from BAME communities should be better represented in clinical trials, and they need to be given a voice in the NHS so they understand they will be treated equally.
The experts were speaking during a session dedicated to the impact of the COVID-19 pandemic on BAME communities as part of the Diabetes UK Professional Conference: Online Series on November 24.
Opening the session, Dr Tahseen Chowdhury, Department of Diabetes and Metabolism, Royal London Hospital, noted that while the virus does not discriminate in terms of who is infected, some people face a much higher risk of adverse outcomes.
It has been shown that people with type 1 and type 2 diabetes have an increased mortality risk from COVID-19, with the effect exacerbated in those with reduced glomerular filtration rate, increased body mass index, and a history of stroke or heart failure.
Diabetes and COVID-19 'Not Good News'
Dr Chowdhury said the "bottom line" is that a "diagnosis of diabetes is not good news for outcomes of COVID-19," and it is "even worse for those with poorer glucose control, and even worse for those with comorbidities".
In term of ethnicity, he said he was "really shocked" when it was shown that 94% of healthcare workers who died as a result of COVID-19 were from a BAME background.
Further work has underlined that COVID-19 related deaths are significantly increased among individuals from all BAME backgrounds versus White individuals.
Dr Chowdhury said it is already known that BAME populations have more diabetes, hypertension and cardiovascular disease and have higher infant and maternal mortality.
They also have greater barriers to accessing healthcare and delayed treatment for heart attacks, for example, and consequently have poorer outcomes and increased rates of premature death.
Other factors could include overcrowded housing with multigenerational families, he suggested, and higher exposure to jobs with an increased risk of COVID-19 such as carers, healthcare workers and taxi drivers, and also institutional racism.
However, Dr Chowdhury pointed out that official statistics show people from the most deprived backgrounds are more than twice as likely to die from COVID-19 as those from the least deprived backgrounds.
The social determinants of health include where we are born, how we live and where we work, which together create an un-level playing field for people and is seen in statistics showing that individuals in the North East and North West of England have worse overall life expectancy than those living elsewhere.
"Importantly, we’ve known this for over 170 years," Dr Chowdhury said, noting that Rudolf Virchow observed in 1848 that disease epidemics could only be eliminated through tackling social inequality.
Dr Chowdhury argued that COVID-19 may have widened health inequalities, with online consultations and education potentially worsening access to healthcare and exacerbating the so-called inverse care law, in which those who need healthcare the most get the least amount of care.
He also asked, with COVID-19 vaccines on the horizon, "should non-White and poorer socioeconomic classes be offered vaccination earlier?"
Complex Factors
In the next presentation, Tushna Vandrevala, associate professor in health psychology, Kingston University, Kingston Upon Thames, Surrey, reiterated that a number of complex social and cultural factors could explain the increased COVID-19 mortality risk among BAME individuals.
She and colleagues therefore set out to explore attitudes towards, and access to, COVID-19-related public health messaging by interviewing 30 individuals from BAME communities and 30 stakeholders.
The results showed there are a number of misconceptions about the risks of contracting and dying from COVID-19, and anxieties around working in jobs with increased exposure to the virus and living in multigenerational households.
There were also fears around losing income as a result of having to self-isolate and not being able to access support via the furlough scheme, as well as the cost of buying hand sanitiser and disposable face masks.
In addition, there were issues around cultural values and social norms being affected by the COVID-19 pandemic, particularly around attending funerals and paying respects to family.
Some respondents said that much of the guidance and messaging around COVID-19 reinforced White privilege, as those in BAME communities are typically unable to work from home and have to do "dirty, demeaning or deadly jobs".
There were also concerns that, if they were to fall ill, they would not receive the same level of care as other ethnic groups and would not be seen as a priority for treatment.
The result was that people felt they should rely on their own community for both messaging and help around COVID-19.
Dr Vandrevala said that to overcome these potential barriers and ensure BAME communities do not feel "othered" when accessing healthcare services, "engagement strategies" need to be developed to build trust.
Moreover, BAME groups need to be represented and given a "voice", she said, adding that "we need to make sure that health-related communication is for them, with them [and] about them".
Suggested behaviours around COVID-19 also need to be "culturally compatible", and fears around testing and isolating should be addressed.
"Perhaps what’s salient," Dr Vandrevala said, "is that we do this from an insider perspective, that we use ethnic professionals within the NHS to pass on messages to the ethnic communities, that we are part of the NHS and the NHS welcomes them."
Risk Assessments
In the final presentation, Dr Sarah Ali, consultant diabetologist, Royal Free London NHS Foundation Trust, and trustee of the South Asian Health Foundation (SAHF), went further.
She said that ethnic minority workers in both the public and private sector should receive "priority testing for COVID-19" and be offered an occupational risk assessment.
There should also be more inclusion of ethnic minorities in clinical trials and collection of ethnicity data should be mandatory in reporting processes.
Longer term, Dr Ali argued that health, occupational and housing inequalities need to be tackled, while social security provisions need to be strengthened to meet the needs of the most vulnerable in society.
She suggested that places of worship and religious festivals should have local guidelines for the use of face coverings and social distancing, and a risk assessment of the safe number of worshippers be conducted.
Dr Ali and her colleagues at SAHF have also developed an infographic with recommendations for individuals from the South Asian community that are "culturally tailored" and in different languages.
She underlined that "we need to become more culturally competent, and we need to develop a comprehensive, multisectorial approach that will help us tackle the multiple and complex structural, biological and behavioural reasons that have been driving the disparities of COVID-19 on BAME groups".
No funding declared.
Dr Ali declares being a Principle Investigator for the MODIFY study, sponsored by Innovate UK and Perspectum Diagnostics.
Diabetes UK Professional Conference: Online Series: Abstract: Inequalities, deprivation and the impact on BAME communities during the coronavirus outbreak. Presented November 24.
