Covid-19: Increased risk among ethnic minorities is largely due to poverty and social disparities, review findsBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4099 (Published 22 October 2020) Cite this as: BMJ 2020;371:m4099
All rapid responses
Re: Covid-19: Increased risk among ethnic minorities is largely due to poverty and social disparities, review finds. Does this reflect longstanding racial health inequalities?
I read with avid interest Iacobucci’s article on the government’s report and subsequent views on the association between poverty and social disparities to the increased risk of Covid-19 amongst ethnic minorities.
In particular, the article includes Raghib Ali’s response that he "saw no evidence that structural racism had contributed to the higher risk of infection and death in ethnic minorities” despite the fact “Public Health England had suggested in its June report”. (1) In reply, I believe that in order to truly address the social injustice from racial health inequalities of Covid-19, we must recognise the existence of structural racism prior to the pandemic. (2)
It has been long established that British non-white ethnic groups are more likely to suffer from poor health compared to their white counterparts (3, 4). Not only are the former more likely to suffer from poor general health (5), but also report higher illness rates of a life-limiting, long-term nature. Ethnic groups are also more likely to be from a lower socio-economic status (SES) and not in employment, or if they are, overrepresented in professions such as social work. All three of these groups are associated with an increased risk of infection and mortality (6-9).
However, following adjustment for SES, Harding and Balarajan found associated health risks became non-significant for Bangladeshis and reduced for Black Caribbeans, whilst still remaining high for Black Africans (10). Thus, principally, our understanding of racism must begin, not from merely a ‘White on Black’ approach, but more broadly along a spectrum from intra-ethnic to interethnic racism (11,12).
Based on the above, racism can be considered in the current context of COVID-19. Indeed, the government report acknowledges the presence of biological and environmental risk factors for Covid-19. (1) Yet, to what extent can these two be separated? If, racial inequality still stands true despite SES inequality, it’s plausible to question the vulnerability to Covid-19 ethnic individuals have compared to their white colleagues even in high income fields in Britain. This would be the best-case scenario, albeit still problematic, given the protective factors such as large housing conditions and low reliance on public transport. (6)
As increasing evidence emerges on the disproportionate effect of Covid-19 on British non-white ethnicities, the dialogue must broaden from categorical, distinct risk factors to address the deeper, widespread systemic problems at its roots. This requires moving beyond single-issue spotting and analysis, considering the possibility of interactive and accumulative effects ethnic communities may experience through multiple modalities of discrimination. Investigations into the interplay of these known risk factors, in turn, may aid us with a greater understanding of the frameworks within our society upholding longstanding racial health inequalities.
1. Iacobucci, G. 2020. Covid-19: Increased risk among ethnic minorities is largely due to poverty and social disparities, review finds. BMJ , p. m4099. doi: 10.1136/bmj.m4099.
2. Gee, G. and Ford, C. 2011. STRUCTURAL RACISM AND HEALTH INEQUITIES. Du Bois Review: Social Science Research on Race 8(1), pp. 115-132. doi: 10.1017/s1742058x11000130.
3. Department of Health (DH). Tackling health inequalities: 10 years on—a review of developments in tackling health inequalities in England over the last 10 years. London: Department of Health, 2009.
4. Becker E, Boreham R, Chaudhury M, et al. Health survey for England 2004. The health of minority ethnic groups. London: The Information Centre, 2006.
5. Bécares L. 2013. Which ethnic groups have the poorest health? Ethnic health inequalities M 1991 to 2011. Centre on Dynamics of Ethnicity (CoDE) Briefing. Manchester: Manchester University
6. Rebekah L. Rollston, D. 2020. The Coronavirus Does Discriminate: How Social Conditions are Shaping the COVID-19 Pandemic. Available at: http://info.primarycare.hms.harvard.edu/blog/social-conditions-shape-covid [Accessed: 26 December 2020].
7. Hussein, S. 2011. British Black and Minority Ethnic groups’ participation in the care sector. Social Care Workforce Research Unit, Kings College London. Available at: https://www.kcl.ac.uk/scwru/pubs/periodical/issues/scwp15.pdf [Accessed: 26 December 2020].
8. Public Health England. 2017. Public Health Outcomes Framework: Health Equity Report - Focus on ethnicity. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploa... [Accessed: 26 December 2020].
9. Office of the High Commissioner for Human Rights. 2020. Racial Discrimination in the Context of the COVID-19 Crisis. Available at: https://www.ohchr.org/Documents/Issues/Racism/COVID-19_and_Racial_Discri... [Accessed: 26 December 2020].
10. Harding S, Balarajan R. 2000. Limiting long-term illness among black Caribbeans, black Africans, Indians, Pakistanis, Bangladeshis and Chinese born in the UK. Ethn Health. ;5:41–6.
11. Mac an Ghaill, M. 1999. Contemporary Racisms and Ethnicities: Social and Cultural Transformations. Buckingham: Open University Press.
12. Clark, R. 2004. Interethnic Group and Intraethnic Group Racism: Perceptions and Coping in Black University Students. Journal of Black Psychology30(4), pp. 506-526. doi: 10.1177/0095798404268286.
Competing interests: No competing interests
Re: Covid-19: Increased risk among ethnic minorities is largely due to poverty and social disparities, review finds, but vitamin D status also contributes
The findings regarding SARS-CoV-2 positivity by race/ethnicity from the Quest Diagnostics data set are useful regarding racial/ethnic variations in risk of COVID-19 . This assumes that COVID-19 and SARS-CoV-2 positivity have the same relationship to serum 25(OH)D concentrations and poverty and social disparities, which may or may not be the case.
Mean serum 25(OH)D concentrations for different racial/ethnic groups in the U.S. can be used to estimate the effect of vitamin D status on the risk of COVID-19 . Figure 2 in Ref. 1 shows that Black non-Hispanics with 25(OH)D <20 ng/ml had a 19% SARS-CoV-2 positivity, Hispanics with 25(OH)D concentration = 21 ng/ml had 15% positivity, while white non-Hispanics with 25(OH)D concentrations near 26 ng/ml had a positivity near 8%. If black non-Hispanics had a mean 25(OH)D concentration near 26 ng/ml, it is projected that they would have a positivity of about 17%.
Thus, the contribution of vitamin D status to positivity higher than for white non-Hispanics is 2%/(19%-8%) ~20%, while that for Hispanics is 2%(15%-8%) ~30%. Thus, while disparities in vitamin D status do not explain much of the ethnic/racial differences in SARS-CoV-2 positivity, if black non-Hispanics were to raise their mean serum 25(OH)D concentration to 50 ng/ml, they could lower risk by about 40%, Hispanics by ~50%, and white non-Hispanics by ~25%.
1. Kaufman, H.W.; Niles, J.K.; Kroll, M.H.; Bi, C.; Holick, M.F., Sars-cov-2 positivity rates associated with circulating 25-hydroxyvitamin d levels. PLoS One 2020, 15, e0239252.
2. Ginde, A.A.; Liu, M.C.; Camargo, C.A., Jr., Demographic differences and trends of vitamin d insufficiency in the us population, 1988-2004. Arch Intern Med 2009, 169, 626-632.
Competing interests: I receive funding from Bio-Tech Pharmacal, Inc. (Fayetteville, AR, USA)