Professor Sir Michael Marmot, director of the Institute of Health Equity, University College London, recently said that ‘the pandemic has highlighted and amplified inequalities in our society that lead to inequalities in health’.
Public Health England recently published a report based on a descriptive review of data on disparities in the risk and outcomes from COVID -19. The largest disparity found was by age. Among people already diagnosed with COVID -19, people who were 80 years old or older were seventy times more likely to die than those under 40. The risk of dying among those diagnosed with COVID-19 was also higher in males than females, higher in those living in the more deprived areas, and higher in those in Black, Asian, and Minority Ethnic (BAME) groups than in White ethnic groups.
The most striking finding that caught my eye is the fact that even after accounting for the effect of sex, age, deprivation, and region, people of Bangladeshi ethnicity had around twice the risk of COVID-19 death when compared to people of White British ethnicity. People of Chinese, Indian, Pakistani, Other Asian, Caribbean, and Other Black ethnicity had between 10 and 50% higher risk of death when compared to White British. Bangladeshis are one of the largest immigrant communities in the UK. Among many other Southeast Asian migrant populations, why Bangladeshis are a particular target of the coronavirus needs thorough scientific examination.
Being a Bangladeshi-Irish man, I panicked. I thought let’s look for some clues as to why this is happening in England. What better source can one imagine other than the Marmot report? This is of course Prof. Marmot’s famous report ‘Health Equality in England: The Marmot Review 10 years on’.
Unfortunately, this is a 172-page long report which I had no intention to go through to find out why Bangladeshi’s are dying of COVID-19 much more than others. So I searched for ‘Bangladesh’ in the report and found the following:
1. Bangladeshi ethnicity has the lowest life expectancy while non-British whites have the highest.
2. Asian and mixed ethnic groups – had significantly lower disability-free life expectancy (DFLE) at birth than white British men or women. The lowest DFLEs observed were for Bangladeshi men. DFLE is the average number of years an individual is expected to live free of disability.
3. Analysis of inequalities among older people, aged 60 years and over shows that even after accounting for social and economic disadvantage, in this age group minority ethnic groups (including Bangladeshis) are more likely than white British people to report limiting health and poor self-rated health.
4. ‘Average health-related quality of life score’ for people aged 65 and older, by ethnicity 2012/13- 2016/17, Bangladeshis are one of the low scorers on the graph.
5. There are wide variations in poverty rates by ethnic groups. In 2018, 33 percent of people living in households headed by someone of Bangladeshi ethnic origin were in the most deprived quintile compared to 15 percent of the White population (housing costs raising poverty rates considerably).
6. Overcrowding is more likely to be experienced by minority ethnic groups in all socioeconomic groups. Only two percent of White British households are overcrowded, compared with 30 percent of Bangladeshi households and 15 percent of Black African households. Overcrowding might occur as a result of multiple generations of a family residing in one home.
I did not have the heart to find out more about what has been described there for the Bangladeshi ethnicity living in the UK in this report.
You can see for yourself, all the ingredients that you need for coronavirus to attack the most fragile and vulnerable population are there already, pre-existing over a long period of time.
What you see here are only the socio-economic deprivation data, the very similar data that you will see coming from the US for the black minority, and their death rate which resonates with what is happening in the UK.
Comorbidities that had a significant role in the Covid-19 death were reported to be much higher in all ethnic minority groups. Special categories of occupations that carried more risk of Covid-19 death were predominant in the ethnic minority groups including Bangladeshis living in the UK.
Moreover, we have not looked into the possibility of any biological factors as yet. Are there any particular predisposing biological condition/genetic susceptibility that Bangladeshi ethnicity carries that made them a soft target for the COVID -19? No one knows as yet. For example, Vitamin D deficiency has been proposed as an independent risk factor for COVID -19 deaths.
How Vitamin D deficiency relates to COVID -19 is elaborately described in the ‘Vitamin D deficiency in Ireland – implications for COVID -19. Results from the Irish Longitudinal Study on Ageing (TILDA) 2020’ report. In a nutshell, Vitamin D is crucial for the immune system to act properly especially in the elderly population. Numerous studies have shown that vitamin D deficiency leads to increased susceptibility to respiratory infections. Vitamin D supplement has been shown to protect elderly people from having flu and chest infection.
An Indonesian study described 780 confirmed cases of COVID-19, of which 380 died and 400 survived. Of the dead cases, 46.7% had Vitamin D deficiency and 49.1% had Vitamin D insufficiency. The remaining 4.2% had normal vitamin D levels.
A recent paper published in a local journal described a study conducted in a large hospital in Bangladesh where a total of 793 patient’s blood Vitamin D level reports were analysed. The majority (62.0%) were between 21 and 60 years of age. Eighty-six percent had low levels of Vitamin D, 61.4% had deficiency and 24.1% had insufficiency (deficiency 0 to <20 ng/ml, insufficiency 20 to <30 ng/ml). Numerous studies suggest that Bangladeshi young adults may suffer from chronic Vitamin D deficiency.
These data indicate that people of Bangladeshi ethnicity were already deficient in Vitamin D in their system. Coming to the UK obviously didn’t help due to its weather (lack of sunlight in winter). One can only speculate, this will add more to the already existing risk factors such as low socio-economic conditions, co-morbidities, etc.
I have been wondering, how susceptible I am to Covid-19 here in Ireland? Are we also at the bottom of economic deprivation in Ireland as it is in the UK? Do we also live in multi-generational, over-crowded households here in Ireland? How many of us are in the frontline occupation? These data are not available for us in Ireland.
Bangladesh has produced some of the finest epidemiologists over the last decades. Many of them are working in Bangladesh. Others are working in prestigious institutions all over the world. I hope they will learn how epidemiological reports unveil the weaker spots in a society and then policies can be prepared accordingly.
Arman Rahman, MD, MPH, PhD is Translational Research and Engagement Manager, Precision Oncology Ireland (POI)