key: cord-255600-2xs29l81
authors: Nazroo, J.; Becares, L.
title: Evidence for ethnic inequalities in mortality related to COVID-19 infections: Findings from an ecological analysis of England and Wales
date: 2020-06-09
journal: nan
DOI: 10.1101/2020.06.08.20125153
sha: 
doc_id: 255600
cord_uid: 2xs29l81

Background In the absence of direct data on ethnic inequalities in COVID-19 related mortality in the UK, we examine the relationship between ethnic composition of an area and rate of mortality in the area. Methods Ecological analysis using COVID-19 related mortality rates occurring by 24th April 2020, and ethnic composition of the population, across local authorities in England and Wales. Account is taken of age, population density, area deprivation and pollution. Results For every 1% rise in proportion of the population who are ethnic minority, COVID-19 related deaths increased by 5.10 (3.99 to 6.21) per million. This rise is present for each ethnic minority category examined. The size of this increase is a little reduced in a fully adjusted model, suggesting that some of the association results from ethnic minority people living in more densely populated, more polluted and more deprived areas. This estimate suggests that the average England and Wales COVID-19 related death rate would rise by 25% in a local authority with twice the average number of ethnic minority people. Discussion We find clear evidence that rates of COVID-19 related mortality within a local authority increase as the proportion of the population who are ethnic minority increases. We suggest that this is a consequence of social and economic inequalities, including among key workers, driven by entrenched structural and institutional racism and racial discrimination. We argue that these factors should be central to any investigation of ethnic inequalities in COVID-19 outcomes.

There is a growing body of evidence suggesting that there are marked ethnic inequalities in COVID-19 related deaths. Although UK data on ethnicity in relation to COVID-19 are sparse (as are data on ethnicity and health more generally), a report by The Intensive Care National Audit and Research Centre showed that around 35% of COVID-19 related admissions to intensive care were ethnic minority people and ethnic minority admissions were slightly more like to die in critical care (for example, 48·4% of White patients died in critical care compared with 55·3% of ethnic minority patients). 1 Further evidence published by the Guardian and Times newspapers suggested that ethnic minority people represent 19% of deaths recorded in hospital, 2 and that areas with a higher proportion of non-white ethnic minority people had higher death rates, 2 while, recent analysis of 106 healthcare workers who have died from covid-19 showed that 63% were from an ethnic minority background, and just over half were not born in the UK. 3 Given that non-white ethnic minority people made up 14% of the population in England and Wales at the 2011 Census, this suggests a marked inequality. This impression was reinforced by analysis of data released by the NHS, which suggested meaningful increases in death rates for ethnic minority people after taking into account differences in age structures and place of residence. 4 Evidence of ethnic/race inequalities in relation to COVID-19 has also been reported in the United States, where regional analyses indicate that areas with larger ethnic minority populations have higher rates of both COVID-19 infections and related deaths. 5 For example, in Michigan, a state where 15% of the population is Black, 40% of deaths are of Black people. 6 Despite this accumulating evidence, it is hard to draw firm conclusions on the extent of ethnic inequalities in COVID-19 related risks. A large proportion of the evidence discussed in media reports is impressionistic, and where statistics on admissions or deaths are collated denominators are often missing, or are crudely estimated at a national level, rather than estimated from the population from which deaths are counted. In addition, the national data used to calculate denominators are typically drawn from the 2011 Census, which is considerably out of date and almost certainly underestimates the size of the ethnic minority population. Importantly, adjustments are rarely made for the younger age profile of ethnic minority people, nor for the potentially increased exposure to COVID-19 infection that results from their greater concentration in areas with a high population density, or greater risk from infection associated with higher levels of pollution. In addition, the data published rarely differentiate between different ethnic groups, and largely ignore White minority groups, meaning that potential differences between different ethnic minority groups are missed. Finally, the count of deaths often only includes those occurring in a hospitals, disregarding those who died in community settings.

To begin to address these issues and to enhance our understanding of ethnic inequalities in COVID-19 related risks, we conduct an ecological analysis, at local authority level, of the relationship between COVID-19 related deaths and the proportion of the local population who are ethnic minority. To do this we use the most recent release of data, accurate estimates of the size and ethnic composition of the population in local authorities, and a modelling approach that accounts for some potential explanations for the higher risk faced by ethnic minority people.

Death rates are taken from ONS 5 th May 2020 release of deaths in England and Wales, by local authority. 7 (Local authorities are government organisations officially responsible for all the public services and facilities for both individuals and business in an area.) This release includes all deaths, including those that occurred in community settings, that occurred up to 24 th April and that were . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted June 9, 2020. . https://doi.org/10.1101/2020.06.08.20125153 doi: medRxiv preprint registered by the 2 nd May. Only those deaths recorded as involving COVID-19, a recording that is based on any mention of COVID-19 on the death certificate, are included. These figures do not include deaths of those who reside outside England and Wales, or deaths where the place of residence is either missing or not yet fully coded on the death certificate. There were 27,287 COVID-19 related deaths in England and Wales by 24 th April, as recorded on 2 nd May.

To provide the denominator to calculate COVID-19 related death rates by local authority the ONS 2018 mid-year population estimates are used. 8 These data estimate the England and Wales population as 59,115,809, meaning that the COVID-19 related death rate for England and Wales was 46·16 per 100,000 as of 24 th April 2020.

To examine the association between COVID-19 related deaths and proportion of the local population who are non-white ethnic minority across local authorities, we use linear regression models with COVID-19 related death rate as the dependent variable. The main predictor variable, the proportion of the population who are ethnic minority, was taken from the ETHPOP estimates for 2018 (we used the 2018 used rather than those for 2020 in order to match in time with the ONS population estimates used for total population size). 9 These estimates are based on sophisticated modelling of change in the ethnic composition of the population at local authority level, accounting for births, deaths and migration both into the UK and within the UK. This is done separately for different ethnic groups, the categories used being: White British/Irish/Traveller; Indian; Pakistani; Bangladeshi; Chinese; Other Asian; Black African; Black Caribbean; Other Black; Mixed; White Other; and Other. For 2018 this model estimates that the England and Wales population was 77% White British/Irish/Traveller. Given the relatively small population sizes of ethnic minority groups and their concentration in particular regions of England and Wales, the analysis conducted here combine ethnic minority groups into four categories: Asian (Indian, Pakistani, Bangladeshi, Chinese, Other Asian); Black (Black African, Black Caribbean, Other Black); White Other; and Other (Mixed, Other). For the more detailed modelling all of the ethnic minority groups are combined together and compared with the White British/Irish/Traveller group. In each case, these variables are modelled as a continuous variable that captures a 1% increase in the concentration of the group in a local authority.

The following covariates are included in the analysis: percentage of the population who were aged 70 or over (using the ONS 2018 mid-year population estimates); 8 population density (number of people per square kilometre, using the ONS 2018 mid-year population estimates); 8 the 2019 Index of Multiple Deprivation score; 9 and levels of pollution as marked by population-weighted annual mean PM2.5 (anthropogenic) concentration for 2018 (ugm-3). 11 We use linear regression models to predict variation in COVID-19 related death rate across local authorities. First simple, descriptive models are used to show the association between each ethnic minority category and risk of death, and the association between each covariate and risk of death. Then we included all the predictor variables to show the fully-adjusted relationship between COVID-19 related deaths and the proportion of the local population who are ethnic minority. Table 1 presents the results of the crude descriptive models, showing unadjusted coefficients for the relationship between proportion of the population in a local authority who are of an ethnic minority group and the COVID-19 related death rate. For ease of interpretation the coefficients have been estimated as the change in number of deaths per million for a 1% rise in proportion of the population who are in the ethnic group. Although descriptive in nature, this analysis indicates a . CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 9, 2020. . https://doi.org/10.1101/2020.06.08.20125153 doi: medRxiv preprint marked inequality between areas, with a rise in the ethnic minority population in an area related to a statistically significant higher rate of COVID-19 related death. This is present for each of the ethnic categories shown in the table, and also present for each sub-category in a disaggregated analysis (not shown but available from the authors). Most confidence can be placed on the estimate for the total ethnic minority population, which combines all of the other groups, because the population size is relatively large and more evenly distributed across local authorities. This coefficient shows that for every 1% rise in proportion of the population who are ethnic minority COVID-19 related deaths increased by 5·10 (3·99 to 6·21) per million. Table 2 presents a descriptive analysis of the relationship between covariates and COVID-19 related death rates in a local authority. Each of these area characteristics are significantly associated with risk of death, with population density, Index of Multiple Deprivation and level of pollution all increasing risk. However, surprisingly, the proportion of the population who are aged 70 or older, a risk factor for COVID-19 related death, is negatively associated with risk of death, although the effect is very small. Subsequent analysis (not shown, but available from the authors) revealed that this was possibility a result of the negative correlation between the proportion of ethnic minority people and the proportion of people aged 70 and over in an area.

Finally, Table 3 presents the full model, with each of the risk factors present. Once all variables are included, only the proportion of the population who are ethnic minority remains statistically significant. The estimated coefficient for proportion ethnic minority is a little reduced compared with the unadjusted figure, going from 5·10 (3·99 to 6·21) to 3·69 (1·57 to 5·82), suggesting that some of the ethnic minority association results from ethnic minority people living in more densely populated, more polluted and more deprived areas.

. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 9, 2020. . https://doi.org/10.1101/2020.06.08.20125153 doi: medRxiv preprint 

To illustrate the significance of these findings, if we take the average England and Wales COVID-19 related death rate as 46·16 per hundred thousand, for a local authority with twice the average number of ethnic minority people (using 2018 ETHPOP estimates this would be an increase from 23% to 46%) would have a predicted COVID-19 related death rate of 57·89 per hundred thousand (46·16+(23*5·10/10)), an increase of 25%. While a local authority with a small proportion of ethnic minority people, say 3% rather than 23%, would have a predicted death rate of 35·96 per hundred thousand (46·16-(20*5·10/10)), a decrease of almost a quarter.

The analyses presented here provide the strongest evidence to date on ethnic inequalities in COVID-19 related mortality in England and Wales. Findings from these analyses show a clear association between an increase in the proportion of ethnic minority residents in a local authority and an increase in mortality related to COVID-19. Of importance is that this analysis provides robust and up to date denominators for the ethnic minority population, a comprehensive and recent count of deaths, examines the situation for different categories of ethnic minority groups, and that it includes adjustments for other factors that might explain the association between ethnicity and risk, including those that have been shown to be associated with increased mortality from COVID-19, such as pollution, 12 or that have been found to be risk factors for mortality at the neighbourhoodlevel, such as deprivation, 13 and population density. 14 However, it is important to bare in mind that these analyses are ecological, so inferences cannot be drawn about individuals from these aggregated data. This means that the increased risk of mortality identified may be shared to a certain extent among different ethnic groups in the area, although the evidence of an association between increased risk and each of the categories of ethnic minority group examined is suggestive of the risk not being equally shared between ethnic minority and ethnic majority people living in an area. In addition, we can draw from existing evidence documenting ethnic inequalities across a range of socioeconomic, mental health, and physical health outcomes, [15] [16] [17] including non-COVID-19 related mortality, 18 to support the likelihood that ethnic minority residents suffer from an increased risk of exposure and vulnerability to COVID-19 infection and related mortality, and whose increased risk, therefore, is likely to be a key factor driving these findings.

There has been much public debate about what might be driving apparent ethnic inequalities in risk of COVID-19 related complications and death. Most of these discussions point towards the role of underlying social and economic inequalities that are faced by ethnic minority people. That is, most ethnic minority groups are more vulnerable to, and have poorer prognosis from, COVID-19 infection, because they are more likely to: be poorer; have poorly paid and insecure employment; live in over-. CC-BY-NC 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted June 9, 2020. . https://doi.org/10.1101/2020.06.08.20125153 doi: medRxiv preprint crowded housing; and live in deprived neighbourhoods with high rates of concentrated poverty and increased pollution levels. 19 The fully adjusted model, which shows a reduction in the coefficient related to proportion of the population who are ethnic minority once factors such as these are taken into account, provides some support for these possibilities. However, it is important to note again that these are ecological analyses, so do not account for the very likely possibility that ethnic minority people have poorer circumstances than others living in the same area.

Ethnic minority people are also more likely to be employed in sectors that increase their risk of exposure to COVID-19. An over-representation of ethnic minority people can be found working in transport and delivery jobs, as health care assistants, hospital cleaners, social care workers, and in nursing and medical jobs. Not only do these occupations increase risk of infection, some of these are also occupations that have been the last to receive supplies of personal protective equipment. People in these occupations have now been deemed key workers, but for decades ethnic minority people working in these jobs have endured job insecurity, low pay, and discrimination.

In addition, ethnic minority people are more likely to have the underlying health conditions that have been linked to increased risk of COVID-19 related complications and mortality, such as asthma, diabetes, high blood pressure, and coronary heart disease. 20 These health conditions are sociallypatterned, so that the social and economic inequalities faced by ethnic minority people described above, lead to an increased risk of developing these health conditions. 15 As a result, we would argue that the increased risks associated with COVID-19 infection faced by ethnic minority people are now a core component of wider ethnic inequalities in health, and these negative consequences are amplified by long established pre-existing ethnic inequalities in health, both of which are driven by social and economic inequalities.

Behind this complexity, however, is a key consideration that is typically absent from investigations into ethnic inequalities in health -that the social and economic inequalities that are faced by ethnic minority people are driven by entrenched structural and institutional racism and racial discrimination. 21 An explanation of ethnic inequalities that stops at social and economic inequalities and doesn't acknowledge how these inequalities have been, and continue to be, shaped by historical processes underpinned by racism, will be limited in its ability to generate an understanding of, and solutions to, ethnic inequalities. A myriad of studies in the UK and elsewhere have now documented the role of racism in patterning inequalities in education, employment, income, housing, and proximity to pollution. [22] [23] [24] [25] [26] In addition, experiences of racial discrimination have been linked to a numerous mental and physical health outcomes, including asthma and hypertension. 17, 21, 27 Importantly, these processes do not operate in isolation, they co-occur and sequentially lead to deepening inequalities in many domains across a person's life course, and are transmitted from one generation to the next. 28, 29 Excluding racism -the root of ethnic inequalities in COVID-19 infections and related mortality -from scientific and policy discussions around the determinants and implications of the coronavirus pandemic can lead to dangerous and ineffective investigations and policy interventions. These include un-evidenced reductionist approaches which question whether ethnic inequalities in COVID-19 may be due to biological/genetic or cultural differences, a line of thinking that risks taking us back into a time of scientific racism, but which is, for example, reflected in a recent call for research on this issue. 30 Before we respond to such an agenda we should ask ourselves the simple question: 'what could possibly be the biological or cultural similarities between an ethnic minority family living in Tower Hamlets, London and another living in Detroit, Michigan, both of whom face an increased risk of COVID-19 related complications and mortality?' More likely than shared genetic and cultural risks, is that they will both live in disinvested neighbourhoods with high levels of pollution and concentrated poverty, with insecure and underpaid employment, and in overcrowded conditions with substandard levels of housing. Chances are they have had their lives shaped by institutional and structural racism, and have experiences of racial discrimination deeply embedded in their lives. These are the similarities that policy and research efforts should be paying attention to. Given this, the increased risks faced by ethnic minority people should not have been unexpected, as appears to have been the case, they could and should have been anticipated.

That Public Health England is reviewing ethnic inequalities in COVID-19 related outcomes could be an important shift of focus, especially when contemporary policy work around inequalities in health have largely ignored the question of ethnicity. 31,32 However, it is crucial that this review considers how current inequalities relate to longstanding ethnic inequalities in health and in doing so the question of racism must not be side-stepped. Similarly, the review must also focus on the greater harm done to ethnic minority people as a result of Government responses to the coronavirus pandemic and move quickly to consider how these greater harms might be mitigated. The justification for the pandemic measures is that their estimated effect on reducing the impact of the COVID-19 pandemic on the NHS, by protecting its capacity to provide care for people who become seriously ill as a result of a COVID-19 infection, would offset their acknowledged extremely negative economic, social, health and psychological impacts. That is, the negative is on average judged to be worth the estimated direct health benefits. However, the situation facing ethnic minority people is far more precarious than 'the average', as detailed above, meaning that these measures are certainly having a more negative effect on ethnic minority people. In addition, some of the more punitive dimensions of 'lockdown', such as changes in the Mental Health Act, 33 police surveillance, and discontinuity in the clinical management of pre-existing conditions, are also going to more adversely impact those with racialised identities.

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We are grateful for the support provided by Caelainn Barr, Editor, Data projects, Guardian News and Media, and Niamh McIntyre, Niko Kommenda and Antonio Voce, Data projects, Guardian News and Media.

The analyses presented here make use of publically available data. Links to the data are provided with the paper.