This publication builds on our March briefing on Covid and how it affects Black, Asian and Minority Ethnic people and communities. The limits of effective action mean we have had to update and reissue this briefing. We consider the known risks, what can be done to address them, the wider determinants, the knock-on effects on the health and wellbeing of Black, Asian and Minority Ethnic people and communities, and the NHS and broader response so far.
What we know about COVID-19 and the risk factors relating to it
We have come a long way in the past months in understanding who is at greater risk of contracting Covid, and of dying from it.
The NHS lists people with the following conditions as being at “high risk”
- have had an organ transplant
- are having treatment for cancer
- have blood or bone marrow cancer
- have had a bone marrow or stem cell transplant in the past 6 months, or are still taking immunosuppressant medicine
- have been told by a doctor they have a severe lung condition (such as cystic fibrosis, severe asthma or severe COPD)
- have a condition that means they have a very high risk of getting infections (such as SCID or sickle cell)
- are taking medicine that makes them much more likely to get infections
- have a serious heart condition and are pregnant
And the following as being at “moderate risk”
- are 70 or older
- have a lung condition that’s not severe (such as asthma, COPD, emphysema or bronchitis)
- have heart disease
- have diabetes
- have chronic kidney disease
- have liver disease
- have a condition affecting the brain or nerves (such as Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy)
- have a condition that means they have a high risk of getting infections
- are taking medicine that can affect the immune system (such as low doses of steroids)
- are very obese (a BMI of 40 or above)
- are pregnant
Particular professions are at greatest risk of infection and death, including healthcare, transport and security workers.
A large number of infections occurred in care homes. Other institutional settings, such as prisons, homeless accommodation, and secure mental health facilities are also at greater risk due to the large numbers of people with poor health and long-term conditions that are in a predominantly communal space.
We know that Black, Asian and Minority Ethnic people are disproportionately affected by Covid. Our analysis with the New Policy Institute in June showed the risk of death from COVID for Black, Asian and Minority Ethnic people is 12% higher for working-age and 19% higher for age 65 plus than for White British people. However, higher levels of pre-existing conditions such as blood pressure and diabetes in Black, Asian and Minority Ethnic communities do not explain this difference.
When we looked at the risk of infection, we calculated the average risk of infection (confirmed by a test) for Black, Asian and Minority Ethnic people to be 56% higher than White British for working-age and 69% higher for those aged 65 plus.
How do these risk factors affect Black, Asian and Minority Ethnic people and communities
Particular groups of Black, Asian and Minority Ethnic people have higher rates of long term conditions associated with COVID19 fatalities, such as high blood pressure and diabetes.
African Caribbean people have higher prevalence of high blood pressure, and South Asian people (particularly first generation) have higher prevalence of Coronary Heart Disease (British Heart Foundation). South Asian people are up to six times more likely to have Type 2 diabetes (Diabetes UK). African Caribbean, South Asian, and people of Mediterranean origin are also more likely to have Sickle Cell Disease, which is one of the conditions identified by the NHS as being at highest risk of mortality relating to COVID19.
Read our briefing on ethnicity and heart disease.
Read our briefing on sickle cell and thalassaemia.
Read our briefing on long-term conditions, ethnicity and poverty.
Read our briefing on anti-microbial resistance and ethnicity.
While Black, Asian and Minority Ethnic groups as a whole tend to be younger than White British people, there are particular Black, Asian and Minority Ethnic communities that have higher averages ages such as Irish and Jewish communities. Seven per cent of African Caribbean people are aged 70-79 with a further three per cent aged 80 or more. This compares to eight percent 70-79 and seven per cent 80+ for the White British group.
Read our briefing on the health of Irish people in Britain.
Black, Asian and Minority Ethnic people are more likely to be key workers and/or work in occupations where they are at a higher risk of exposure. These include cleaners, public transport (including taxis), shops, and NHS staff (Cabinet Office, 2019). Within the NHS, Black, Asian and Minority Ethnic people are 40 per cent of doctors and 20 per cent of nurses nationally (and 50 per cent in London). Black, Asian and Minority Ethnic people are also 17 per cent of the social care workforce, rising to 59 per cent in London, with particular groups such as Eastern Europeans and Portuguese workers often being less visible but a significant part of the workforce.
Read our BMJ Open article on race and gender within the NHS workforce.
Black, Asian and Minority Ethnic people are overrepresented in some institutional settings including prisons, mental health inpatient units, and homeless accommodation. This potentially puts them at greater risk of contracting COVID19. All of these settings are associated with poorer physical health and long-term conditions, so it is likely there will be an impact from that.
Read our briefing on race, mental health and criminal justice.
Black, Asian and Minority Ethnic men tend to have poorer access to healthcare for a range of services, including mental health, screening and testing. There is also evidence that poor mental health often acts as a further barrier to accessing other health services. Some groups of Black, Asian and Minority Ethnic men, such as Bengali men, continue to have persistently high rates of smoking, and are at a higher risk of the respiratory and cardiovascular conditions associated with it.
Read our briefing on smoking and Black, Asian and Minority Ethnic communities.
Our colleague, Dr Nigel de Noronha, found that Black, Asian and Minority Ethnic people were disproportionately dying in hospital.
What can be done to reduce those risk factors
The Covid-19 BAME Evidence Gathering Taskforce report suggested that the voice of the BAME community has simply not been heard or considered in the way our health systems are designed and delivered, and many also felt that there were failings in the way information was communicated to them.
For example, our colleagues at the Wai Yin Society, a large Chinese community organisation in Manchester came across a shielding letter that was sent in English to a vulnerable Chinese couple without being translated. In another case, a shielding letter was sent to someone who had been dead for several years, causing upset and distress to the family. Both cases point to issues in the quality of information being used by the NHS, and its use in addressing specific health access needs, such as language.
A deeply concerning issue we uncovered in our work with the New Policy Institute was the low rate of testing among some particular groups. Pakistani and Bangladeshi men and women, as well as men of all ethnicities are underrepresented in tests.
Within the workplace employers should be mitigating the risks faced by their employees. Prof Roger Kline has written for us about the need for employers to conduct risk assessments, specifically addressing what is known about the risks faced by particular groups such as Black, Asian and Minority Ethnic employees. He also highlighted the key role that “hospital acquired” infections have, accounting for 89 percent of healthcare workers with covid and 21 percent of inpatients. Kline also points out that in order to address the specific risks faced by Black, Asian and Minority Ethnic staff, the wider issues of racism within the workplace need to be taken into account. For example, the disproportionate number of Black, Asian and Minority Ethnic staff in lower graded and front-line roles, and the research that shows they are less likely to raise concerns about safety.
The wider determinants of health
The coronavirus pandemic has highlighted stark racial inequalities in the wider determinants of health, particularly in housing, employment, and access to green space.
Health inequalities are more pronounced among Black, Asian and Minority Ethnic people already (Marmot, 2020). Recent work on mortality in the UK has highlighted the projected lower life expectancy among Pakistani and Bangladeshi people in particular (Marmot, 2020). Higher rates of poverty, the experience of discrimination, poor employment and access to health services all feed into these inequalities. Poverty is twice as high in Black, Asian and Minority Ethnic groups on average, and much higher in specific groups, making them vulnerable to changes in prices or rents (JRF, 2017). Black, Asian and Minority Ethnic families also tend to be larger on average, which places additional stresses on space within the home and on bills and finances as a result.
Read our briefing on race equality and health inequalities.
Read our briefing on tackling health inequalities in London.
Housing deprivation is experienced at different levels across Black, Asian and Minority Ethnic communities, but is generally higher than for white British groups. For example, White Gypsy and Irish Traveller households are seven and a half times more likely to experience housing deprivation than White British households. Black African households are 75 per cent more likely to experience housing deprivation and Bangladeshi households are 63 per cent more likely to experience housing deprivation (de Noronha, 2015). These figures are even higher when we look at Black, Asian and Minority Ethnic elders (de Noronha, 2019).
Read our briefing on housing and elder Black, Asian and Minority Ethnic people.
Black, Asian and Minority Ethnic people are more likely to live in overcrowded and poor quality housing. Just under half of overcrowded households are Black, Asian and Minority Ethnic (de Noronha, 2015). The problem is worse in London where Black, Asian and Minority Ethnic groups are two to three times more likely to be overcrowded than White British households.
Read our briefing on housing deprivation and Black, Asian and Minority Ethnic people.
Eighty thousand households share accommodation. This is at least five times more likely for Black Africans, Chinese, other black, Arab, other white and other Black, Asian and Minority Ethnic groups (de Noronha, 2015).
Black, Asian and Minority Ethnic communities often have poor trust in health services, often due to past poor experiences. This is compounded by government policies such as health charging. The Covid-19 BAME Evidence Gathering Taskforce reports that a fear of inequitable treatment that might be received in the NHS deterred many in the BAME community from asking for help quickly enough, resulting in many suffering in silence for too long. It also found that a stigma around Covid-19 began to grow in the BAME community, contributing to conspiracy theories and the wish of some families to attempt to remove the label of Covid-19 on death certificates. When seeking treatment, the BAME community experienced a healthcare system that was overwhelmed and struggling to cope.
Concerns have already been raised around the impact of health charging and the hostile environment. While there is a ‘public health’ exemption within the charging regulations, there is evidence to show people delay life-saving treatment even when experiencing acute symptoms (DOTW, 2018). So it would seem reasonable to believe that people with cold and flu-like symptoms who are routinely not eligible for free NHS care (or believe they are not) will not access health services.
‘Knock on’ effects
The disruption to health services caused by Covid means a range of other health risks are likely to get worst. For example, breast cancer screen was paused in March and by September an estimated 1,000,000 women had missed a screening as a result. Even though children are less likely to be affected by Covid, they experienced health risks due to the pandemic. Referrals to Child and Adolescent Mental Health Services (CAMHS) fell dramatically when schools closed.
Maternity services continue to be a concern. Black, Asian and Minority Ethnic women have poorer maternity outcomes, including maternal death. The recent State of Care report highlighted this disproportionality in deaths. Covid restrictions mean that pregnant women were more likely to miss scans and appointments, and were not able to have their birth partner present when they went into labour or on post-natal wards. Black, Asian and Minority Ethnic pregnant women are also more vulnerable to contracting covid, with 55 percent testing positive in research done by Oxford University and leading NHS England to urge trusts to prioritise their reviewing and admission to hospital.
Traditions, religious and cultural practices
Covid and the responses to the pandemic have had an impact on communities and families observing traditional, religious and cultural practices that contribute to their wellbeing.
For example, disrupted the traditions and processes for grieving which compounds the trauma of loss and creates increased mental health risks.
Similarly, the response to covid has had an impact on specific religious and cultural celebrations observed by many Black, Asian and Minority Ethnic people, for example the restrictions at Easter were highlighted by African-led and Caribbean-led churches as proving to be very challenging. The second national lockdown will cover the period of Diwali, observed by predominantly South Asian Hindu and Sikh communities, whereas several of the local lockdowns in northern England coincided with the Eid-Al-Adha, which is observed by Muslims. The latter was particularly criticised due to the short notice and poor communication of the local lockdown, placing many individuals, families, and communities in impossible situations, and leaving them open to being accused of causing or exacerbating the problem.
Early on in the pandemic there were high-profile cases of racist abuse and violence by members of the public against people of East Asian appearance and heritage, often with the assumption that they were Chinese. The experience of racism and discrimination has an impact on the mental health of victims, as documented in our report on mental health disparities.
Racism can also deter people from accessing crucial services. Wai Yin in Manchester documented a case where a young woman with children who had fled an abusive relationship experienced racism in the temporary housing she was placed in, specifically including comments about her being Chinese and having Covid. She felt so unsafe that she moved back in with her abuser, before being supported to leave and find somewhere else to leave.
Far right and racist organisations have also been using the coronavirus crisis to direct hate towards minority communities through circulating misinformation: read more here.
There were also issues repatriating British citizens, mostly of Pakistani origin, from Pakistan. This has generated significant criticism of the government response: read more here.
Police were given extra powers to enforce lockdown restrictions and issue fines for non-compliance. However, as with other police powers such as stop and search, these have been disproportionately used against Black, Asian and Minority Ethnic people, and young black and Asian men specifically.
Black, Asian and Minority Ethnic community organisations
Black, Asian and Minority Ethnic community organisations have been placed under enormous strain in responding to Covid, particularly given the disproportionate impact on the communities they serve. These organisations have been in a fragile condition for the past decade, with many having had funding cut by local authorities as a result of austerity policies in the 2010s.
We spoke to several organisations early into the first lockdown and they described how they have been able to transfer some face to face services online and by phone, while coping with staff and volunteers having to self-isolate. All are concerned about both the long-term impacts of the pandemic and its knock-on effects on their communities, and their continued survival as organisations.
The Foundation has been able to support 21 organisations through our dementia project. The programme assisted those voluntary and community organisations struggling due to Black, Asian and Minority Ethnic individuals and families living with dementia. Some of the organisations supported provide telephone and online services advice and emotional support. Others provide culturally appropriate volunteer schemes to offer practical support with everyday tasks, hot cultural food, and some are offering enhanced advocacy in appropriate languages, so that Black, Asian and Minority Ethnic people living with dementia can better engage professionals and agencies.
In addition, the Foundation developed a national resource of written, spoken and audio translations of the latest guidance and communication (such as shielding advice), as part of the programme. Access our translated resources here.
Black, Asian and Minority Ethnic businesses
There is evidence that Black, Asian and Minority Ethnic businesses face particular challenges as a result of the pandemic. These include being concentrated in parts of the economy, such as restaurants, that have been badly affected, and struggling to access support. A report by the All-party Parliamentary Group (APPG) for BAME business owners found that two-thirds said they had been unable to access government funding. Many of these business owners’ reported their mental health was suffering due to the impact of the pandemic on their livelihood.
Incidents of domestic violence have risen during lockdown. In April, the charity Refuge recorded a 700 percent in calls to their helplines. According to the charity, 1.6 million adults, mainly women, experienced financial abuse at the hands of a partner for the first time in lockdown. Black, Asian and Minority Ethnic people already face barriers to domestic violence services and it is likely they will continue to struggle to access them.
NHS and broader government support
While there was interest from health services in the higher risks faced by Black, Asian and Minority Ethnic people at the start of the pandemic, it did not appear to be a significant factor in designing the response.
The development of NHS Volunteer Responders was just one example, with no recording of ethnicity of the people volunteering and, as importantly, no recording of community language skills combined with no way for referrers to note that those needing support required a responder with community language skills.
The approach to the healthcare workforce was equally problematic, with risk assessments not carried out, ill-fitting PPE or worse, lack of PPE, and a slow response to the mounting evidence of a disproportionate numbers of deaths of black, Asian and minority ethnic staff.
The response from government was deeply problematic in that, on several occasions, it has sought to minimise or dismiss the existence of structural racism. That filtered through to the investigations into disproportionality, which meant the reports published by Public Health England drew criticism for failing to reflect the input from consultation events or initially publishing recommendations.
The urgent action announced in NHS England phase 3 letter included specific actions to address racial inequalities in covid, restore NHS services in an “inclusive” way, accelerate preventative programmes, and improve the quality of data to ensure the effectiveness of these responses are being monitored. This is welcome but otherwise key issues are still not addressed, such as protecting the income of people who need to isolate.
Summary and call to action
We know a lot more about Covid than we did in March. Black, Asian, and Minority Ethnic communities are at greater risk of contracting and dying from Covid. In order to reduce this inequality, there must be urgent action to:
- Address the barriers to isolation, such as secure income and housing
- Ensure public and private sector employers are supported to manage the risks faced by Black, Asian, and Minority Ethnic employees
- Increase the support channelled through Black, Asian, and Minority Ethnic -led voluntary and community organisations
- Implement the Urgent Health Inequalities actions detailed by Simon Stephens in the phase 3 letter.
The Foundation has collected a range of materials on Covid translated into different community languages here and there is an Easy Words and Pictures information leaflet here.