As reliable data on COVID-19 emerges, one thing has become clear: not everyone is affected in the same way. Some groups in society have been hit particularly hard by this pandemic.
Several risk factors have emerged, but one of the most important is ethnicity. Several studies have shown that those in the UK from Black, Asian and minority ethnic (BAME) backgrounds are far more likely to test positive for COVID-19 and require hospitalisation.
The problem is significant. The last UK census suggested that around 14% of the population identify as BAME, yet 15.6% of patients critically ill with COVID-19 are from Asian backgrounds and 9.6% from Black backgrounds. The overall risk of COVID-related death is estimated to be 10-50% higher in BAME people, with social inequality being a likely cause.
But the story gets worse. The pandemic is also changing how routine healthcare is being delivered, which risks disadvantaging those who are already worse off. This means COVID-19 could disproportionately affect BAME people’s health, even if they don’t catch the virus.
A potential compound effect
The coronavirus has forced the delivery of primary care in the UK to change. Providing healthcare remotely – known as “telemedicine” – has become standard during the pandemic. Its roll-out has been remarkable, but we shouldn’t assume that access is equal.
BAME people already engage with health services at lower rates, for a number of reasons. Cultural factors such as religious beliefs, stigma around specific conditions and a lack of trust in care providers all have an influence. These factors also contribute to lower health literacy – that is, the extent to which an individual is able to locate, understand and use health information – which further lowers engagement with health services. Language barriers can also be a problem.
Digitalisation, if not well-planned and tailored to BAME people’s needs, risks adding a further obstacle and simply exaggerating these issues around access.
Indeed, research suggests that digitalising health services can worsen existing health inequalities. Research in the US has also shown that minority ethnic heritage and low economic status negatively impact whether older people access health information online.
This isn’t the only knock-on effect for BAME people either. COVID-19 may also make it harder to get an organ transplant. Overall, an estimated 516,000 surgeries have been cancelled in the UK because of the pandemic, creating a huge backlog.
Around one-third of those awaiting a transplant in the UK are of BAME heritage, and adults from BAME communities already wait the longest for donor organs. Partly this is because of need – end-stage renal failure is three to four times more common in Black and South Asian populations than white ones, for example – but it’s also partly due to low rates of donor registration. Again, religious and cultural reasons and lack of trust in health systems are thought to be responsible, as well as a lack of awareness around donation.
All told, some researchers predict that waiting time for BAME people could increase to up to three years as the system catches up on operations and transplants pushed back by COVID-19.
What can we do about this?
Amidst such disparity, COVID-19 offers the chance to rethink, reshape and accelerate how we address these sorts of longstanding inequalities in health.
Health disparities rest on many factors, but a key part of any solution should be better engagement with BAME communities, to ensure that health-related messages – whether about controlling COVID-19, or the need for more BAME organ donors, or how to protect against common diseases such as diabetes – reach those who need to hear them most, and that people access health services when they need to.
Simply translating information is not a solution; it’s merely a starting point. Translation alone doesn’t overcome issues of mistrust between different groups in society that might stand in the way of accessing health services. Nor does it solve access issues for those with limited literacy skills in their language of origin.
More involved approaches – such as communicating through key members of the community and working with diverse organisations have been effective ways of reaching BAME groups with health messages in the past.
Yet tailored health approaches have lagged behind in this pandemic, showing that we need to do more. We can speculate that areas such as Leicester and Bradford, which ended up under local lockdown and have higher rates of both deprivation and BAME inhabitants, might have benefited from such interventions earlier on.
Re-engineering a system that is inequitable is complex, and doing something to improve it has been a repeated promise. Engaging better with those who are most disadvantaged seems like a sensible starting point.
Shivani Sharma is affiliated with the National Black, Asian and Minority Ethnic Transplant Alliance (NBTA) and receives funding from the British Renal Society for work on health inequalities.