Written evidence submitted by Age UK (CVB0030)
1 Introduction
1.1 Age UK is a national charity that works with a network of partners, including Age Scotland, Age Cymru, Age NI and local Age UKs across England, to help everyone make the most of later life, whatever their circumstances. In the UK, the charity helps more than seven million older people each year by providing advice and support. It also researches and campaigns on the issues that matter most to older people. Its work focuses on ensuring that older people have enough money; enjoy life and feel well; receive high quality health and care; are comfortable, safe and secure at home; and feel valued and able to participate.
1.2 The Women and Equalities Committee wants to explore the pre-existing inequalities facing Black and Minority Ethnic (BAME) people and how these inequalities have impacted on their vulnerability to the virus.
1.3 There is now an established body of evidence that people over 65 are both at greater risk of experiencing severe symptoms and have a lower likelihood of recovery from COVID-19; with the oldest age groups, and those living with cardiovascular and respiratory conditions being at greatest risk. Older people in need of care and support – whether at home or in a care home – have been rendered exceptionally vulnerable by virtue of their circumstances.
1.4 There is also, a growing evidence base showing that older people from BAME communities are disproportionately represented in hospital cases and fatalities from COVID-19. This raises three questions:
- Are there certain risk factors which make older people from BAME communities more vulnerable to contracting COVID-19?
- Are there certain risk factors that make older people from BAME communities more vulnerable to serious illness and death from COVID-19?
- To what extent are these two ‘risk’ groupings, shaped by structural racism and inequality?
Data collection and population
Estimating BAME populations can be challenging as annual population estimates produced by the Office for National Statistics (ONS) do not include ethnicity. Consequently, the Census 2011 is the most recent and reliable data source.[1] What we know from the Census 2011 is that the proportion of people from BAME communities has increased from 8% in 2001 to 14% of the total population in 2011, which means that the numbers of older people from ethnically diverse communities is increasing.[2]
2 The impact of COVID-19 on older BAME people: what the data tells us
2.1 In England and Wales, from the start of the COVID-19 epidemic until 15 May 2020, there were 4,326 BAME people who have died from COVID-19; 73.5% of BAME people who died from Covid-19 were aged 65+.[3]
2.2 Most BAME populations are younger on average than the white population, and when these age differences are taken into account, the chances of BAME people dying of COVID-19 were higher than those of white people. For example, by 15th May 2020, 256 black males and 120 black females of every 100,000 died of COVID-19, compared to 87 white males and 52 white females.[4]
2.3 The following graph shows age-standardised mortality rates for people aged 65+, by sex and ethnicity. The starkest difference can be seen between white women and black men where the risk for black men is about five times greater than for white women:
The Intensive Care National Audit and Research Centre’s (ICNARC) analysis of people admitted to critical care in the UK with Covid-19 shows ethnic inequalities in health outcomes: 34% of those admitted to critical care were from BAME communities, substantially higher than the 22% which would have been expected if BAME and white people were at similar risk.[5] The ICNARC found that 39.3% of white people admitted died in critical care compared to 45.1% of Asian people and 42.4% of black people.[6] This analysis doesn’t take into account other differences between the patients, but the study shows that BAME people admitted to critical care with Covid-19 had fewer risk factors than white people admitted: BAME patients were younger, less likely to be obese and less likely to have most comorbidities.
There are many reasons that contribute to these differences, which several organisations in the UK have and continue to investigate. However, these reasons can broadly be grouped into two types: risk of exposure to the virus, and risk of poor outcomes once exposure has taken place. This paper will aim to summarise the key points for older people.
Risk of greater exposure to COVID-19
A person’s risk of severe illness and mortality from COVID-19 is shaped by a number of factors (including age and pre-existing comorbidities) which will be discussed below. However, the risk of severe illness and death can be cut if the risk of exposure to the virus is reduced or eliminated.
Older people from BAME communities are at increased risk of acquiring COVID-19 because they are more likely to live in densely populated and urban areas, in overcrowded households, and have jobs, or live with people that have frontline jobs, that expose them to higher risk.[7]
We know that larger cities have been hit harder by COVID-19 than other areas and that higher proportions of people from BAME communities live in cities that are more densely populated.[8] Older people from BAME communities are more likely to be residing in overcrowded and multigenerational households.[9] For example, older Indian, Pakistani, Bangladeshi and Black African people live in larger households for longer than other White ethnic groups, either because they choose to live with extended families or because the cost of housing leads people to live with extended family.[10] There is evidence to suggest that infection rates are lower in one- and two-person households than in larger households.[11]
People from BAME communities are also more likely to live in the private rented sector and to experience higher levels of housing deprivation: lower rates of home ownership for BAME groups aged 50-64 compared to those aged 65 and over suggest that levels of housing deprivation increase as people get older.[12]
2.4 We also know that people from BAME communities are more likely to work in front line sectors that increase their exposure to COVID-19 such as transport and delivery jobs, healthcare and social care.[13] This is both a direct risk to those older BAME people working in these sectors as well as those people living with relatives who work in these sectors.
2.5 All these factors increase the risk of coming into contact with other people who have the virus for older BAME people in the community.
Care home residents
2.6 There has been a significant loss of life for care home residents. As of 12 June 2020, the number of care home residents who were confirmed or suspected of dying of COVID-19 was 19,394.[14]
2.7 In a report published on 17 June 2020, the Care Quality Commission (CQC) found that BAME care home residents in the UK were more likely to die from COVID-19.[15] Higher proportions of deaths among Black (54%), Asian (49%) and other (53%) than White (44%) people in care homes were attributed to COVID-19 in the month mid-April to mid-May.[16]
2.8 However, due to poor availability of data on care home residents, the CQC’s investigation is unable to answer some important questions. For instance, whether there are ethnic differences in:
- Proportions of recipients of adult social care who died in general;
- Background characteristics of recipients of adult social care (age, background health etc.);
- Access to testing for COVID-19; and
- Infection with COVID-19.
It is therefore not possible to get a full picture of the true ethnic inequalities in risk of death from COVID-19 for care home residents. The true effect may be larger than that estimated by the CQC.
Risk of poor outcomes for older BAME communities
There is also a body of academic research that indicates that because of social and economic inequalities, people from BAME communities are more likely to experience those underlying health conditions including asthma, diabetes, and coronary heart disease that are linked to increased risk of COVID-19.[17] For example, in 2019, 62% of adults (people aged 18 and over) in England were overweight or obese; 74% of Black adults were overweight or obese, the highest percentage out of all ethnic groups.[18]
2.9 There is a paucity of research on health inequalities for older BAME people. However, using data from a nationally representative sample for 2009-2011, Evandrou et al., 2016 report that as a result of lifetime exposure to social and economic disadvantages, older people from most ethnic minority groups are more likely to report poor self-rated health than White British older people.[19]
3 COVID-19 and race inequality
3.1 To what extent has structural racism and inequality impacted on the health and wellbeing and socio-economic status of older people from BAME communities and how in turn has this affected their risk of contracting and of experiencing COVID-19?
3.2 Older people are not a homogenous group whose experiences are only shaped by one factor: age. Their experiences will be shaped by ethnicity, gender, socio-economic status, disability, and sexuality. Despite the societal, political, and legislative measures enacted to address inequality in the UK, structural inequality, and prejudice in its many forms, still exist. Racism against ethnic minority communities has long existed in the UK. For example, since their arrival on the Windrush in the 1950s, the British Afro-Caribbean community has faced ongoing racism evident by attacks on residents in Notting Hill in the 1950s, to the murder of Stephen Lawrence, and most recently the Windrush scandal. The fact that older BAME people were at the heart of this scandal highlights the way in which racial inequality prevented this particular group of older people from accessing the government support and services they were entitled to, in particular, healthcare. This had and continues to have a devastating impact on the lives of those affected.
3.3 The COVID-19 pandemic has revealed the systemic health inequalities facing older people from BAME communities. In response, it is imperative that the impact of COVID-19 on the population be analysed through an equalities framework, which necessitates the collection of good quality data about its effect on people with protected characteristics, especially people from BAME backgrounds.
3.4 Everyone who is at high risk of contracting COVID-19 and at risk of severe illness, should have access to the right information and advice in order to make decisions about their health and lives, and the support they need to live safely and well for the duration of the pandemic and beyond.
July 2020
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