BAME, the NHS and Covid-19, where do we go from here ?
We have read your article BAME and NHS with interest and reflected on the subject. We present a summary of our open letter to NHS CEO.
BAME, the NHS and Covid-19, where do we go from here?
The COVID-19 pandemic has ravaged the entire world. UK data indicate a disproportionately high attack rate among BAME (Black and Minority Ethnic). The mortality among BAME healthcare workers is also significantly higher (1). The reasons for this skewed presentation are obscure. We have reviewed current knowledge to investigate this higher risk. We suggest steps to reduce the risks in this vulnerable group in this crisis.
A literature search looked at the possible role of genetic susceptibility, socio-economic factors, higher prevalence of adverse lifestyle factors and lack of adequate physical exercise, presence of co morbidities like diabetes mellitus, hypertension, cardiac and cerebro-vascular diseases which lead to higher mortality risk. Vaccination practices including childhood vaccination coverage and socio-cultural factors were also explored.
The ethnic minority population of the UK was 13% at the time of the last census in 2011 (2). However, the first 10 doctors in the UK to die from covid-19 were identified as being from ethnic minorities (3). Furthermore, observational data from the national ICUs show that a third of covid-19 ICU patients are from an ethnic minority background (1).
Interestingly, factors that are now identified as markers of higher morbidity and mortality in COVID-19 have long been recognised as important risk factors for increased cardiovascular morbidity and mortality in South Asians in the US (4).
A meta-analysis of six studies involving 1527 patients by Li et al (5) from China reported that 57.8% of the patients were males. The most prevalent cardiovascular metabolic co- morbidities were hypertension and cardio-cerebrovascular disease followed by diabetes They also found that the the proportions of hypertension and cardio-cerebrovascular diseases were both significantly higher in ICU/severe patients compared to the non-ICU/severe patients.
ACE2 is an important target for SARS-CoV(6), and molecular modelling has shown high structural similarity between the receptor-binding domains of SARS-CoV and 2019-nCoV (7). ACE2 expression is highly tissue-specific, mainly expressed in the cardiovascular, renal and gastrointestinal systems, with a small amount expressed in lung cells. Therefore, in addition to coronaviruses causing pneumonia through ACE2 receptors in lung epithelial cells, possible viral effects on myocardial tissue are also likely; hypoxemia may also be an important cause for cardiac injury; Huang et al (8) who also found that ICU patients had much higher concentrations of inflammatory factors than non-ICU patients, suggesting that the cytokine storm was associated with disease severity. In addition, repeated floods of catecholamines due to anxiety and the side effects of medication can also lead to myocardial damage (5)
It is well established that BAME are prone to metabolic, cardiovascular and cerebrovascular disease. This is partly explained by the higher incidence of hypertension and diabetes, but genetic factors are also known to play a role. These same factors are now known to predispose a person to severe Covid 19 infection with a potential of an adverse outcome.
A sensible view has been expressed by a BMJ Editor (9). In Dr Helen Salisbury’s words “Acting on a precautionary principle, we need to reassign older, male, ethnic minority doctors to non-face-to-face duties before we lose many more of our colleagues ”.
There has been significant discussion & literature suggesting that BAME doctors are not treated equally by the NHS. Following a GMC self appraisal last year it was reported that “NHS ‘treating minority ethnic doctors as outsiders’”(10). As recently as on 12th February 2020, a leading national newspaper reported “Ethnic minority doctors face systematic disadvantage”(11). It will be fair to say that it is possible that BAME doctors are more hesitant in expressing themselves within the NHS. Or they may be less demanding of the facilities available to them at the workplace. Consequently, in an era of acute shortage of PPEs, they may not uniformly be supplied with essential PPE. These observations may well apply to non medical staff in the NHS and social care sector.
These alarming observations have encouraged the UK Government to institute a much-needed enquiry into this subject (12). However, these enquiries and additional research will take time to complete.
Time is very critical for the NHS and its workforce and the NHS itself. We therefore make the following recommendations that could yield immediate benefits:
1. Centralised Monitoring: A centralised register of BAME health care workers affected by Covid-19 should be instituted. This should include general demography e.g. age, sex, ethnicity, place of birth, country of birth, time lived in UK, social class parameters, marital status, details of co morbidities, substance usage and medications. The register should be anonymised and be in the public domain.
2. Local Monitoring and Protection: The available NHS Trusts occupational risk assessment tools are variable and inconsistent and do not incorporate ethnicity as a risk factor. This must be replaced by a centrally administered assessment, with ethnicity included as a risk factor and appropriately weighted. Adherence to risk assessment should be mandatory before redeployment of staff to front line.
3. Management Instructions: It is critical that the NHS managers are firstly made aware and instructed on the importance of dealing with BAME PPE requirements & health concerns in a sensitive and fair manner. This includes ensuring fair and effective supply of PPEs for this vulnerable group of healthcare workers.
4. Public Health Impact: The guidelines and model followed by NHS could have a larger public health impact on limiting this disease in vulnerable sections of the population in UK.
Implementation of measures to safeguard BAME doctors will inevitably reduce the workforce available on the front line. More than half of the workforce in some regions is from BAME communities.
Reduction in effective frontline manpower will create challenges to an already stressed health service. Urgent planning and modelling is imperative in preparation for a possible second and subsequent waves of this pandemic.
Mr Shiv Mohan Bhanot MBBS, MS, FRCS
Consultant Urological Surgeon, King George and Queens Hospitals,
Goodmayes, IG3 8YB
Prof. Mukul P Agarwal MBBS,MD
Ex Professor, Department of Medicine
University College of Medical Sciences
University of Delhi, Delhi, India
Prof. Mohan Nair MD; DM
Coordinator and Head
Department of Cardiology
Holy Family Hospital, New Delhi, India
Dr Rajat Bhushan MBBS, FACE, FNLA
Consultant Endocrinologist, Total Healthcare
Baton Rouge, Louisiana, USA
2. Office of National Statistics UK, 2011 census. 2011
4. Statement From the American Heart Association: Circulation Volume 138, Issue 1, 3 July 2018, Pages e1-e34
5. Clin Res Cardiol. 2020 Mar 11 : 1–8.
6. Science 2005; 309:1864–1868
7. Lancet 2020 Feb 22;395(10224):565-574.
8. Lancet 2020 Feb 15;395(10223):497-506.
9. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1572 (Published 21 April 2020)
12. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1562 (Published 17 April 2020)
Competing interests: No competing interests