What do we know about health inequalities of older BAME groups?

In March of this year when we were still learning about COVID-19 in the UK, I remember listening to a journalist on the telly saying the coronavirus does not discriminate – it infects and kills everyone, rich or poor, young or old. But as more news started filtering in, a pattern of who the virus infected the most began emerging. Even while scientists and public health personnel were grappling with this new virus and how it spreads, one of the earliest news trends of the pandemic is that the virus seemed to affect particular groups, such as older people, those with underlying health conditions, those living in deprived areas, lower-skilled workers, those working in social care, those living in care homes and BAME (Black, Asian and Minority Ethnic) groups more than any other group.

The COVID-19 pandemic has shone a light on health inequalities that disproportionately affect older people and BAME people, also confirmed by the recent PHE report published in June 2020.

This blog looks at what we know about health inequalities of older BAME groups, what we need to know more about and what are some key recommendations to promote healthy ageing that is inclusive for all.

In the UK, BAME groups tend to have a ‘health disadvantage’ than White groups. In England, data shows that the proportion of people aged 61-70 reporting poor health is much higher for BAME groups (86% for Bangladeshi people, 69% for Pakistani people, 63% for Indian people, and 67% for black Caribbean) than for white English groups (34%). A 2020 BMJ editorial reports that the health of white English people aged 61-70 is equivalent to that for Caribbean people in their late 40s or early 50s, Indian people in their early 40s, Pakistani people in their late 30s, and Bangladeshi people in their late 20s or early 30s.

BAME groups also tend to have lower life expectancies and even lower disability-free life expectancy (DFLE) than White groups in England and Wales. Compared to White British men (61.7 years) and women (64.1 years), the lowest DFLE observed was for Bangladeshi men (54.3 years) and Pakistani women (55.1 years). A surprising finding was that Indian women had similar life expectancies as White British women but had 4.3 years less disability-free. This shows that BAME groups may not be homogeneous, which need to be taken into account in future research and policy.

These existing health inequalities were replicated and exacerbated with COVID-19. During the coronavirus pandemic, people of BAME ethnicities had “between 10 and 50% higher risk of death” compared to white British people.

We need better data to understand the issues affecting older BAME people. The UK’s largest survey of ageing, the English Longitudinal Study of Ageing (ELSA), running since 2002, included less than 5% ethnic minority sampling at its most recent data release, in a country with 13% BAME population. A BMJ editorial has termed the exclusion of adequate BAME representation from population studies as a ‘form of institutional racism’.

The PHE report acknowledges that we do not fully understand the relationships between comorbidities and the risk of COVID-19 diagnosis and death. Intersecting disparities of age, ethnicity, sex, occupation or deprivation and the drivers behind these inequalities, are topics that deserve greater attention. For instance, what is the cumulative health effect on BAME groups due to a lifetime of inequalities in income, education levels or deprivation? How much more likely is it that an older BAME person belonging to a certain ethnicity, age segment, or pre-existing health condition will die due to COVID-19?

The PHE report is a timely reminder of the health inequalities in society that have been further exacerbated during the COVID-19 pandemic. The BMJ has published a list of ten recommendations to address these inequalities. Some of these recommendations include practical measures such as redeploying BAME staff away from high risk clinical areas in hospitals.

In the longer term, we need a fundamental shift in attitudes, culture, activities and in resource allocation to promote healthy ageing and life expectancy for all:

• There must be a focus on healthy ageing across the life course as a key population health outcome for all groups. Newly integrated care systems and partnerships should include healthy ageing indicators as part of their framework for measuring outcomes.
• Take a bolder approach to regulatory prevention measures and promote healthy behaviours through multi-behaviour change models. The targeting of areas with the greatest level of need will be critical to reduce the stark health inequalities across England. We also need to ensure that more communities and groups are reached and that barriers are overcome with effective communication.
• Take action to promote healthy behaviours through multi-behaviour change models. We need to close ethnic minority data gaps in large population studies, and develop evidence-based policies relevant for all groups. The NHS should promote more consistent commissioning of evidence-based strength and balance programmes, as recommended by NICE, which have been demonstrated to be particularly effective at maintaining and improving functional ability in middle and older age.

The risk of dying from COVID-19 is not the same for all of us. We need further investigation into the lived realities of those most at risk, the drivers behind these health inequalities among the population and what action can be taken to reduce them.

First published on NIHR Health & Social Care Workforce Research Unit at King's College London.