COVID-19 patients who are admitted to critical care or who die in hospital include a disproportionately large number of people from ethnic minorities. In the UK, one in three patients admitted to critical care with COVID-19 has been from an ethnic minority group, although they make up only one in eight of the UK population.
The excess risk of severe COVID-19 to people from ethnic minorities is visible not only in hospital admissions, but also in the community. In a national cohort of 6 million veterans in the USA, Black and Hispanic individuals were more likely to be tested and to test positive for COVID-19 than Whites. In the UK, the Office for National Statistics (ONS) analysed all deaths in England and Wales with suspected or confirmed COVID-19. Comparing people of the same age, men and women from all ethnic groups (except Chinese women) were at greater risk of dying from COVID-19 than White people. The difference was particularly large for Black men and women, who were more than four times as likely to die from COVID-19 than White men and women.
Can these differences be explained in terms of exposure to coronavirus infection, or susceptibility to severe illness and death following infection, or both?
Age and geography
People in ethnic minority groups are more likely to live in areas with higher exposure to coronavirus infection, which could result in more cases of COVID-19. On the other hand, ethnic minority populations tend to be younger on average than the UK population, and younger people are less susceptible to severe illness following infection. The total numbers of deaths recorded in hospitals are similar per capita for Black African and White ethnic groups. But taking into account both age and geography, deaths are nearly four times higher among Black Africans than among White British people.
Underlying health conditions
People with underlying health conditions, once infected with coronavirus, are at greater risk of serious illness from COVID-19, whatever their ethnic identity. However, it has been suggested that a greater burden of conditions such as diabetes and heart disease among some ethnic groups could also explain why they tend to suffer more severely from COVID-19. A study of 17 million adult NHS patients in England, of whom 5,683 died in hospital with COVID-19, found that Black or Asian people had twice the risk of dying compared with White people (taking age, sex and population size into account). However, differences in underlying health conditions among Black and Asian people, obtained from primary care records, were able to explain only a quarter of the excess deaths from COVID-19.
Exposure to COVID-19 infection at work
The risk of COVID-19 also differs by occupation, and some jobs are more frequently done by people from certain ethnic groups. People doing ‘front-line’ jobs, like transport workers, come into contact with the public more frequently and may therefore be more exposed to infection. For instance, Bangladeshis and Pakistanis are more highly represented than other groups among transport workers, but it is not yet known whether they are also at higher risk of infection or illness.
People from ethnic minorities make up 21% of the total NHS workforce but represent 63% of healthcare workers who have died of COVID-19. Ethnic minorities working in the NHS could be more exposed to infection, but exposure might not explain all of the extra risk: deaths among health staff from ethnic minorities are unexpectedly high within different groups of healthcare workers – such as doctors or nurses – who would be exposed to coronavirus in the same way.
Social, economic and household conditions
According to the ONS, factors such as overcrowding, illness and disability, geographical location, rural or urban living, local levels of deprivation, socioeconomic class and house ownership together explain about half the excess risk of death from COVID-19 for ethnic minorities as compared to White people. For example, 30% of Bangladeshi households and 16% of Pakistani households in the UK are defined as “overcrowded”, which may increase the risk of COVID-19 infection and severe disease. The lived experiences of individuals, including discrimination and stigma, are also likely to be important in understanding how social and economic factors cause differences in the risk of illness and death from COVID-19.
Ethnicity is based on identity rather than biology, but biological factors could contribute to the observed differences between ethnic groups. For example, vitamin D deficiency is more common among individuals with darker skin and is a possible risk factor for COVID-19. Genetic differences in the expression of ACE (angiotensin-converting enzyme 2, the cell-surface protein to which the coronavirus binds to enter cells) could also affect susceptibility to COVID-19. We do not yet know whether these factors help to explain ethnic differences in the severity of COVID-19.
Exposure to infection or susceptibility to disease?
It is clear that people from ethnic minority groups have a higher risk of severe illness and death from COVID-19 than White people, especially those from Black Caribbean and Black African communities. Some of the excess risk can be explained by greater exposure to coronavirus infection at home or work, and some by a higher risk of serious COVID-19 disease linked, for example, to underlying health conditions.
But much of the disadvantage faced by ethnic minorities remains to be explained: further research will determine what combination of factors leads to higher coronavirus infection rates and/or more severe outcomes of COVID-19 among ethnic minorities.