Dr Shahzaib Ahmad
As soon as the first wave of patients with Covid-19 started coming into my hospital, it soon became apparent that, in a significant proportion who were critically ill, there were some common features; a very high proportion of critically ill patients with Covid-19 were:
1. Of Asian or African origin
3. Had either diabetes or high blood pressure or both
4. A degree of obesity ranging from overweight to morbidly obese
It is said medicine is the art of observation. Diagnosing a disease is all about pattern recognition. There are no medals for recognising the typical Covid-19 patient. It was immediately discernible and recognised by all. So much so that when we would hand over the care of patients from the day team to the night team, we would not tell them about the patient’s history, co-morbidities or social circumstances as we normally would during handover, we would just say, “it’s your typical Covid-19 patient”. They would immediately understand what that meant. That the patient was Asian, male, diabetic, probably hypertensive and likely overweight.
Then, it soon became apparent that this wasn’t a South London phenomenon. No, this was a countrywide problem. Luckily, we could identify how big a problem this really was because this is the type of data that is collected by the Intensive Care National Audit and Research Centre (ICNARC).
What did the ICNARC data show?
The latest ICNARC data was published on the 30th April 2020 and reported on the first 7542 patients critically ill from covid-19. It reported:
1. 71.5% of patients were male
2. >70% were overweight or obese
3. Risk of dying was highest for people of Asian ethnicity – 54.4% of patients who were Asian and were admitted to intensive care died. This includes those Asian patients who were admitted to intensive care but not ventilated. Therefore, the risk of dying if you are ventilated and Asian is likely to be even higher.
4. As advertised by the scientists on TV, the mortality for the elderly was the highest. If you were above 60, your chance of dying was 55.7% if you became critically ill. For those above 70, this figure was 67.1%.
Just pause here for a moment and think about this. The chance of surviving this is 50/50. Whether you survive or not, you might as well flip a coin. Me being an Asian myself, looking after these patients was close to home. I had patients with surnames that included Ahmad, Khan, Siddiqui etc. Had I not looked carefully, I could have mistaken them for friends or family.
What made it worse was that there was a similarly disproportionate number of healthcare workers dying from Covid-19 who were of Asian or African ethnicity. 63% of all healthcare workers dying from Covid-19 were Asian or African. 71% of nurses or midwives and a staggering 94% of doctors dying from Covid-19 were Asian or African.
Such pronounced is this disproportionality that a government enquiry has been launched in to why this effect is observed. So pronounced is the risk to Asian and African doctors that the NHS is making plans to give these staff roles that remove them from the front line.
The important question of disproportionality
There are a few reasons why this might be happening. These can be divided into medical, socio-economic and cultural.
The medical reasons were obvious. The common co-morbidities were diabetes and hypertension. The receptor for Covid-19 is a protein in the lung cells called ACE2. ACE2 is part of a hormonal feedback loop that regulates blood pressure aiming to keep it within normal parameters. A common factor seemed to be that a lot of these patients were on a blood pressure tablet that interfered with this receptor. A lot of diabetic patients are also put on this tablet even if they do not have blood pressure as these tablets protect the kidneys from the deleterious effect of diabetes. But recent research has shown this tablet does not have a deleterious effect on patients with Covid-19.
In addition, diabetes is known to be immunosuppressant. This is one reason why the seasonal flu vaccination is advised for all diabetics. Or is it immunogenetic factors? Each individual has a unique set of genes that determine all the proteins in our body. Maybe Asians and Africans have genes that predispose them to becoming critically ill with Covid-19. As far as medical factors go, the jury is out. No one knows and there is intense research investigating this.
An important question about this disproportionality is whether it can be due to sociological and economical reasons. Is it because Asians and Africans, as a community, are usually less well off, living in more cramped conditions, working in less flexible jobs and less well educated than their white counterparts?
If you are less well off, you are more likely to live in smaller accommodation meaning self-isolation is near impossible. If you are less well off and working in an inflexible job, you might not be able to take time off work or even survive on a furlough salary. If you are less well off, you might not have an office based job, rather jobs like a cab driver or delivery driver and this means you cannot work from home. If you are less well educated, you may not understand the science and rationale for the poorly imposed lockdown.
Is it that ignorance is giving a false sense of security casting aside the advice to self-isolate and stay at home. These are the most crucial reasons why the enquiry into this disproportionality is important.
Finally, an important question is, does this disproportionality have anything to do with cultural reasons? Is it simply that coronavirus is spreading like wildfire because Asians and often Africans live in joint family systems with continuous mingling. It’s also part of the Asian culture to have at least weekly family reunions – thus the virus is thoroughly blended in, from toddler to grandparent. Culturally, Asians have a habit of greatly exhibiting affection so that the vulnerable octogenarian comprehensively hugs and kisses the asymptomatic grandchild transmitting coronavirus. When informed of this risk, often the answer is “I just can’t resist”.
It is most likely that genetic factors play the most important role in this disproportionality. The reason for this is the excessive number of people dying are male. Yes, diabetes, hypertension and being overweight are important factors but being male seems to be the strongest factor. However, there is no doubt that sociological and economical and cultural factors are also important and an investigation into their role is underway.
As the number of deaths from Covid-19 start to decline, and the government’s stance on the lockdown softens, our urge to go out and socialise will overcome us. I beseech you to be careful. The burden of Covid-19 on the NHS is declining which means there is space in the system. Soon, there may even be space in ICUs around the country. Do not utilise that space!
May Allah protect us from the illnesses of our bodies and souls and rid the world of Covid-19. Amin