Unpicking the reasoning behind any section of society’s susceptibility or resistance to disease was never going to be easy. Yet, as Tannice Hemming discovered when reviewing the evidence behind BAME people’s seemingly higher risk of dying from Coronavirus, sometimes the truth is rather inconvenient, depending on which side of the ideological and political fence you sit.
Only eight days ago, the government confirmed that they would finally look into the issue that had been clear for several weeks. That the pictures of those who had succumbed to Covid-19 were of overwhelmingly non-white faces. The first 10 doctors to die of Covid-19 were all from the Black, Asian and Minority Ethnic (BAME) community, too.
Labour first called for a Public Enquiry on the 11th April – the Shadow Equalities Secretary, Marsha de Cordova, said the government must “urgently investigate”, decrying the “shocking underlying inequalities facing BAME communities… who are disproportionately represented [in those who are infected]”.
Her comments came after the Intensive Care National Audit and Research Centre published an audit of the first 3,883 patients who were classified as critically ill with Coronavirus. Despite BAME community members representing just 18% of the UK population, they represented over a third (33.6%) of critically ill Covid-19 patients.
Professor Chris Whitty, Chief Medical Officer, was directly asked to comment on the issue of ethnicity and Covid-19 susceptibility during a press conference on 16th April. He talked about other factors that seemed to be related to how well you fare when infected – ranging from gender and age, to underlying health conditions. What seemed “less clear” however, was “being a member of an ethnic minority group”.
“This is something we are very keen to get extremely clear” he said, suggesting that the outcome of the investigation that Public Health England (PHE) would undertake would hopefully inform “what next we can do about it to minimise risk”.
A tricky question – grouping raccoons, tigers and okapis?
The thorny issue of race – or ancestry – when related to health inequity – is far from a new predicament. Hopes to address any genetic factors present in our human susceptibility to illness were initially placed on the Human Genome Project – surely that would reveal so much about why some ethnic groups were more likely to die of specific illnesses when compared with white populations?
Back in 2015, The Atlantic published a special report on just this goal, concluding rather damningly that “we shouldn’t be looking in the twists of the double helix, but the grinding inequality of the environment”.
2003 was the year that the human genome was sequenced. Seventeen years ago. But just two years later, in 2005, Nature Biotechnology published a scathing reproach of the notion of linking racial genetics with health inequities. Harshly criticising a drug that was lauded for treating black people for heart disease (BiDil), they remarked “scientifically, race is a meaningless marker of anything. Pooling people in race silos is akin to zoologists grouping raccoons, tigers and okapis on the basis that they are all stripey”.
Race vs common ancestry – what’s the difference?
So what’s the key issue with ascribing health differences to racial genetic disparities? Isn’t race just another way of looking at common heritage? Just because two people have the same colour of skin, it doesn’t mean they’re any closer in heritage to two people with the same hair colour, when it comes to looking at their ancestry. However, a literature search rather reveals that the subtle difference between comparing races instead of comparing ancestries is often lost.
Stanford Anthropologist Duana Fullwiley told the Atlantic that the system of looking at Ancestry Informative Markers (AIMs), described as a “collection of genetic variants between four populations” (Europeans, Indigenous Americans, East Asians and West Africans) were basically just race described as ancestry – “race in a phony moustache and glasses”.
One example in the literature directly equates one with the other, defining “biogeographical ancestry” as “the heritable component of race.”
Focusing on genetics makes racial inequality a far bigger issue
What is clear, then, is that genetics might not really be reliably behind health inequity after all. There’s clear evidence showing that, for example, African-American people are more likely than their white American peers to suffer from a range of health problems including diabetes (60% more common in African-Americans), asthma (three times more likely to die), lung cancer (50% more likely to contract), and 40% more likely to die from all cancers.
But this is data from America, where the socioeconomic gap between white and black people seems to be a far larger issue than in other, similar societies. If genetic ancestry were the strongest indicator for health inequity, we would expect to see that replicated in every country and culture across the planet. Yet we don’t.
A 2004 study by Sankar and Cho et al decries an “overfocus on genetics”, suggesting that seeking to “alleviate health disparities” with that as a focus will have the “paradoxic result of actually exacerbating disparities”. Sanker and Cho et al go on to conclude that racial stereotyping within healthcare, by linking populations with health conditions, is a far bigger problem that we might think – leading to “unexamined assumptions” about various peoples’ adherence to drug therapies and their propensity to “endanger the success of treatment” with ‘undesirable’ life choice, like recreational or addictive drug abuse.
Since we don’t see that those of African descent in other cultures outside of the USA are similarly afflicted with the same or similar rates of higher susceptibility to diseases (Sanker and Cho et al, 2004), there can really only be one, more complicated and intertwined answer – and that’s environment.
Coronavirus and its effects on BAME communities – what IS the cause?
What the director of the Center of Population Genetics at the University of Arizona – Rick Kittles – told The Atlantic back in 2015 still holds true today. That’s what’s so inconvenient about this truth: “the vast majority of health disparities are due to social, behavio[u]ral, and environmental components.”
“Although the hypothesis of genetic predisposition may seem plausible taken one disease at a time, when faced with the pattern as a whole, the probability that the black disadvantage is primarily genetic becomes remote. Rather than postulating a genetic cause for each condition, a more parsimonious explanation would suggest a common-source exposure to a disease-promoting environment. Likewise, a universal characteristic of the syndromes that vary across ethnic groups, with the exception of prostate cancer, is a strong social class gradient.” – National Research Council (US) Panel on Race, Ethnicity, and Health in Later Life; Anderson NB, Bulatao RA, Cohen B, editors.
Returning to the UK, the most recent work has been done by Khunti, Singh, Pareek and Hanif, who wrote in the BMJ, on April 20th, that the ‘preliminary signals must be explored urgently’. They welcomed the announcement that PHE and the NHS will be looking into a review of the evidence and posited that there could be some non-socioeconomic reasons for the racial disparities we are witnessing.
Susceptibilities – aside from cultural and lifestyle differences – that they suspect include a BAME prevalence of Vitamin D deficiency (presumably due to difference in melanin production), vaccination differences (when people were born and vaccinated outside of the UK jabs schedule) and suspected differences in “the expression of angiotensin converting enzyme 2” (ACE-2 protein, which is the receptor that Covid-19 binds to).
Cultural differences in the way we all live and work
The way that ethnic minorities live and work in the UK was a major discussion point in the article, with the authors discussing the likelihood of BAME communities living in larger groups, with extended families, differing from the “2.4 children” model more common in white families whose households are conventionally limited to just the nuclear family. Poor housing and the likelihood that those from lower socioeconomic backgrounds will be exposed to a higher risk working in low-paid, yet essential jobs, will make social distancing measures harder to follow.
They suggest a mixed methods research model to try to unpick the environmental factors from any biological differences – in an attempt to “fully understand the complex interplay between the various biological, social and cultural factors” that we’re seeing in the images of those we have lost.
Whatever Public Health England decide, once their review is complete, the answer is less likely to be a drug therapy that can target some kind of racial disparity in our lungs and more a social investigation into the way that racial inequalities mean distinct disadvantages. It will shame us all into looking more deeply into what institutional and constitutional racism means for health and the future of our populations. Perhaps then, and only then, we will start to truly appreciate the lethal consequences of unconscious bias within healthcare and a dearth of action on inequality within the very infrastructure of our institutions, beliefs and cultural practices.
It’s not really news and it’s not the answer that many people will be looking for. There will be no easy fix. No special drug specifically for an arbitrary, colour-segregated subset of humanity.
It’s a stark reminder and a reiteration of the aforementioned notion that race really is a non-scientific, societal construct that should be consigned to the history books. It’s literally killing people. We’ve known that for years.
References where not already linked within the text
Illuminating BiDil. Nat Biotechnol 23, 903 (2005). https://doi.org/10.1038/nbt0805-903
Sankar, P., Cho, M. K., Condit, C. M., Hunt, L. M., Koenig, B., Marshall, P., Lee, S. S., & Spicer, P. (2004). Genetic research and health disparities. JAMA, 291(24), 2985–2989. https://doi.org/10.1001/jama.291.24.2985
National Research Council (US) Panel on Race, Ethnicity, and Health in Later Life; Anderson NB, Bulatao RA, Cohen B, editors. Critical Perspectives on Racial and Ethnic Differences in Health in Late Life. Washington (DC): National Academies Press (US); 2004. 8, Genetic Factors in Ethnic Disparities in Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK25517/