May 12, 2020

Around the world, people are dying from Covid-19 in staggering numbers. As of today, there have been more than 250,000 confirmed deaths from the disease, and the emerging data suggests that the suffering disproportionately falls not only on the elderly, but also on ethnic minorities, the poor and marginalised. These groups suffer and die from the coronavirus much more than we would expect given their share of the population.

In Brazil, in India and in the Arabian Gulf, migrants or the native poor have been devastated by the coronavirus. In Sweden, suburbs containing large immigrant populations are believed to be the hardest hit. In New York city, black and Hispanic residents make up a disproportionate number of deaths, and in Singapore, migrant workers living in dorms make up the majority of the country’s cases.

In the UK, the latest reports from the IFS, ICNARC, the Wellcome Trust and the ONS all come to the same conclusion: ethnic minorities and the poor are the most vulnerable to being hospitalised, requiring critical care and dying from the disease. The ONS, which collects data on mortality from all-causes using death certificates, estimates that black people in the UK are four times more likely to die of COVID-19 than white British people.

Although the Government has launched an official inquiry into the causes of these disparities, the likely reasons are already well-understood: ethnic minorities are more likely to come into contact with more people who are infected, they are more likely to work in essential services, more likely to live in dense areas, and more likely to live in crowded homes.

For example, some ethnic groups are much more likely to work in occupations that the Government has deemed essential during the lockdown: 32% of black African and 26% of black Caribbean people of working age are employed in these essential services, compared to 21% of white British individuals. That they come into contact with more people than they would if they were forced to stay at home means they have a higher chance of contracting the infection.

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This is not all, however, since ethnic minorities and the poor are also affected by the behaviour of people around them, and are more likely to live in geographical areas where their neighbours also have a heightened risk of infection.

London and Birmingham, for example, have been hit hard by the disease, and Black and Minority Ethnic (BAME) people are overrepresented in these cities compared to the rest of the country. But even accounting for that, large urban areas like London and New York still exhibit substantial fragmentation in where ethnic minorities live, which is easily discernible using interactive graphics such as these. This segregation has likely resulted in entire geographical pockets becoming more vulnerable to the disease, which exacerbates the ethnic disparities that we see in ICUs and deaths.

In the US, prisons (which are disproportionately black) have seen an explosion in coronavirus cases. The New York Times estimates that the largest local outbreaks have occurred in jails in several counties and states, and that almost every state prison system has at least one infection among inmates or staff, where social distancing is difficult if not impossible.

It is not hard to see how the ethnic demographics of local outbreaks will be reflected in overall national statistics — they already are. An extreme example is of foreign migrant workers living in dormitories in Singapore, where between 10 and 20 men typically inhabit each room. Out of the country’s more than 15,000 total cases, these workers make up 85%, despite being only 3% of the population.

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Crowded conditions within households exacerbate the spread of the disease between family members and flatmates. In the UK, less than 2% of white British households live in housing with more residents than rooms, while that figure is 16%, 18% and 30% among black Africans, Pakistanis and Bangladeshis respectively.

On top of all these risk factors, ethnic minorities are also overrepresented in health and social care roles, which expose them to even higher risks of infection, from people they are caring for. Essential workers and healthcare staff, who are often in contact with both infected individuals and the general public, can spread the disease in the general population much faster than if everyone had the same average number of contacts.

By now, you might be wondering why I haven’t mentioned medical conditions as a possible cause of ethnic disparities in deaths. After all, some ethnic minority groups are more likely to suffer from obesity, diabetes and cardiac disease.

Last week, a large cohort study led by Ben Goldacre and Liam Smeeth was published online. By collecting detailed NHS medical data from a sample of 17 million adults, the researchers were able to estimate the effects of various medical conditions on the risk of dying from Covid-19.

The ethnic disparities in deaths are so considerable that they do not go away when researchers account for the level of deprivation in the areas where people live, or when researchers account for age, smoking status, obesity, diabetes, cardiac disease, respiratory disease or even all of these conditions together.

The data suggests that, when it comes to an individual’s risk of dying from Covid-19, being black is associated with approximately as much risk as having chronic respiratory disease, even after accounting for the medical risk factors people could have.

But don’t obesity, cardiac conditions and respiratory illnesses increase an individual’s risk of dying from the disease substantially? How could it be that these conditions don’t account for all the extra risk that black people face from dying of Covid-19?

The answer is that these risk factors are related, primarily, to a person’s risk of dying once they have contracted the virus. But ethnic minorities and the poor are more likely to be infected by the virus in the first place, so the risk of death is magnified.

The cause of this disparity in risk factors is not entirely clear, but one popular theory is that black people are disproportionately at risk once they have the disease because they are more likely to have insufficient vitamin D. But this, too, is confounded by the fact that they were more likely to be infected to begin with.

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So we would observe ethnic disparities in deaths if there were disparities in exposure, even if there were no differences in people’s likelihood of dying once they had been exposed to the virus. To study the latter risk, we would need to look at the chances of dying once infected (that is, the infection fatality rate) in different ethnic groups. This is information that we lack in Britain, and can only approximate, given the absence of mass-testing.

For now, the unfortunate reality is that the UK still lacks face-masks, mass-testing, central quarantining, PPE and many other measures that could have helped avert these localised outbreaks and can still help reduce their impact. As I explained in March, early action was urgent. It could have prevented the virus from reaching many vulnerable areas entirely, where transmission and deaths can flare up quickly, amplifying the risks for everyone.

There is no way to turn back time now, of course, but there are still lessons to be learnt, actions to be taken, in order to stamp out the virus as far as possible and prevent another wave of disease.

We can reduce the risks from working in essential services with widespread PPE, reduce the risks from poverty with targeted transfers, and reduce the risks from living in vulnerable neighbourhoods with face-masks. We can even limit the risks from living in crowded households by providing centralised quarantining, for anyone who tests positive and for people they have been in contact with, once the lockdown has reduced the number of infected people sufficiently.

Apart from these lessons, the experiences of the last few months should force us to take seriously the importance of protecting the vulnerable from preventable suffering. In the case of an infectious disease, it is suffering that can all too easily spiral out of control.

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