All the doctors dying are Asian - what’s going on?

[MMXVi]

And why is nobody asking questions about this?

I’m over-invested in the answer because my sister is a doctor very much on the frontline, and we’re of Indian ethnicity. I want her to be protected and if she’s facing some sort of additional genetic, behavioural or dietary risk I want that flagged up to her and other doctors PDQ, not to mention their patients of the same ethnicity.

If I see another glib and possibly slightly racist response about BAME people being poorer and therefore more prone to underlying conditions I’ll flip my lid totally by the way. There’s a world of difference between an Asian hospital consultant on £150k in stockbrokerville and someone Asian on the breadline in an overcrowded council flat, and it isn’t helpful to lump them together in this instance.

So far, I’ve seen a thread about Vitamin D3 deficiency making darker-skinned people more susceptible to respiratory illness. That makes sense to me, and I’ve already ordered some from Amazon for my sister as well as the rest of our family.

My mother (not medically qualified) has a touching belief in the anti-inflammatory and anti-carcinogenic powers of turmeric so I’m making daal as we speak.

My dad (retired very senior doctor and the veteran of more than one pandemic) says probably multi-factorial, but as he’s currently recovering from cancer and therefore very high risk, I’m not going to make him elaborate.

Any other ideas and theories?

Anyone else concerned about why the press have neglected to mention this glaringly obvious information?

Interesting about the "white man's plague" thing... I remember reading that being heterozygous for cystic fibrosis (ie having 1 single copy of the gene as opposed to a double copy which leads to the full disease) provides protection against lung infections like TB. These are more prevalent in northern regions due to long periods with insufficient sun for many months of the year and hence low vitamin D. CF gene is therefore a protective mechanism for the genome at a population level in those countries, though obviously deleterious for individuals with the double copy.

Same goes for sickle cell anaemia and thalassemia in african and mediterranean populations for malaria, a parasite that destroys red blood cells. Heterozygous genes confer protection, but homozygous people get the full genetic condition.

I find it very intriguing that Covid19 affects the interface between these physiologies, ie lungs and red blood cells... part of its process is to affect red blood cells' ability to interchange O2/CO2 at the alveoli and transport around the body... hence the shortness of breath, but not lack of lung pumping ability as you'd expect in typical presentations of pneumonia. It's more like hypoxia from malaria or mountain sickness. As the heme molecules are depleted of ability to carry oxygen by the virus, this is why initial studies of long forgotten anti-malaria drugs like HCQ are showing promise with treatment. And vitamin D is so important for all ethnicities for preventing and mitigating infectious diseases, but peoples with darker skins living in northern latitudes (or who are covered for cultural reasons) should be recommended a higher RDA. Equity is not the same as equality, and BAME individuals should be recommended a higher dose in order for them to achieve parity of optimal vitamin D levels as their white fellows.

"1 in 5 nhs employees is BAME. 4 in 5 NHS deaths are BAME."

But about 45% of doctors according to a pp and an article linked. Is the 1 in 5 including non-medical staff?

Xenia - fair enough you wanted it for your kids, but I lived in a continental European country with better healthcare than us and they didn't have it - I think because it doesn't protect much against different strains - and as I said, having had it has only been a disadvantage for me so far so I don't think it's black and white. I do hope it will prove to have been worth having.

"most of us here are not privy to a breakdown of death rates"

We're talking about deaths of doctors mainly and those are published so we are privy to the death rates.

Gwen - I mean the breakdown WITHIN BAME.

Gwen we also don't know whether they're male/female, age, health conditions etc.

I just caught something on the news, only the tail end of it, but they said that the vast majority of people (all people) who have died have had underlying health conditions of some description and then listed all the usual suspects that we all know about; diabetes, hypertension etc. Within that is the elderly, who have underlying health conditions are an unavoidable part of being elderly, rather than for any other reason I suppose.

So it looks like it may be really that simple and that many more BAME people have these specific comorbidities than white people do, proportionally speaking. I am sure there are other more subtle factors at play too, but on the face it, it would appear to be the main reason.

Of course this still doesn't make any sense that all BAME groups Even those who have white or whitish skin) would have all these things in common, but without a breakdown of the specific ethnicities of those who have died, it's hard to be any clearer on that.

So it looks like it may be really that simple and that many more BAME people have these specific comorbidities than white people do, proportionally speaking. I am sure there are other more subtle factors at play too, but on the face it, it would appear to be the main reason.

Thus exposing existing health inequality which we know to be a compound effect of a number of issues relating to cultural lifestyles (includes diet and religion relating to background), social interactions (including racism), geographic (where you live in the country) economic (class and occupation as well as living conditions and how that affects diet), educational (includes educational barriers such as lack of english) and pure genetic risk.

Not one singular cause which many people on this thread seem desparate to find.

The problem is that structural issues like this are much harder to solve because they are so multi faceted. And it also means that its hard - if not impossible - to put in measure in the middle of a crisis to protect BAME healthcare workers from the increased risk that this combination of factors create.

It doesn't mean that people pointing this out are callous and don't care and therefore racist. Its an acknowledgement that changes are so wide and so expansive that we need to properly unpick them and challenge them over a long period of time by issue (as some of these issues also affect those who don't fall into the BAME catergory).

Totally agree Redtoothbrush

Recent, but very small study from China on a possible latent (or active) TB connection here:

"To determine if latent or active TB increase susceptibility to SARS-COV-19 infection and disease severity, and lead to more rapid development of COVID-19 pneumonia." ...

"This observational study of the relationship between MTB infection and COVID-19 pneumonia suggests that individuals with latent or active TB may be more susceptible to SARS-CoV-2 infection, and that COVID-19 disease progression may be more rapid and severe."

"Given that TB causes more deaths than any other infectious disease (1.45 million deaths and 10 million new cases in 2018), and that global rates of LTBI are estimated to be as high as 25%, these findings are a cautionary reminder to clinicians that MTB infection status should be considered when treating COVID-19 patients in order to prevent rapid deterioration in patient health."

"Our data suggest that MTB infection could be a more important risk factor than the comorbidities commonly reported in epidemiological studies such as diabetes and hypertension12."

"COVID-19 and TB are both respiratory diseases. It is perhaps not surprising that chronic respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD), and indeed active TB, could predispose susceptibility to SARS-CoV-2."

"The strength of this finding, however, is limited by the relatively low number of cases involved in this study and requires further validation.
Based on our findings, we make the following recommendations for the management and treatment of patients with a history of MTB infection (LTBI or active TB) and possible SARS-CoV-2 coinfection" ...

"This is the first study to date to consider MTB infection as a comorbidity for COVID-19.Going forward, it will be important to validate the relationship uncovered here among these 36 COVID-19 cases in a larger study."

www.medrxiv.org/content/10.1101/2020.03.10.20033795v1

"Latent tuberculosis infection (LTBI) is a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens without evidence of clinically manifested active TB. Someone has latent TB if they are infected with the TB bacteria but do not have signs of active TB disease and do not feel ill. However, they can develop active TB disease in the future."

Screening for latent tuberculosis in UK health care workers 2017.

Background:

"Active tuberculosis (TB) infection was diagnosed in two health care workers (HCWs) originally from high-incidence countries at a National Health Service (NHS) hospital trust in Northern England. In response, the trust screened current clinical employees from countries with a high TB prevalence for active and latent TB infection (LTBI)."

Aims:

"To identify the number of HCWs, within the organization, who are at risk of TB infection."

Methods:

"Clinical employees from countries with a high TB prevalence (those described by the World Health Organization as having an incidence of >40 cases per 100000 populations) were reviewed. Employees were identified via human resource systems and occupational health records, from which nationality or country of birth was identified. A letter was sent to identified employees advising of the rationale for a reviewed screening process and inviting them to attend for an interferon-gamma release assay (IGRA) blood test."

Results:

"A total of 587 clinical staff were identified as fitting the criteria of clinical HCWs from high-incidence countries. Of 469 HCWs screened, 27% screened positive using IGRA. This represented 4% of the total clinical workforce for the organization."

Conclusions:

"A considerable proportion of the workforce at this NHS hospital trust had previously undiagnosed LTBI, carrying a risk of conversion to active disease."

www.ncbi.nlm.nih.gov/pubmed/29016903

Apprently only 10% of deaths have been people with no known underlying health condition.

this link here (sorry it's the DM but it's a useful article with charts) shows the comorbidities of CV deaths broken down by age, and between men and women. No breakdowns are given for ethnicity. After heart disease, the biggest one is dementia, especially for women. Then lung disease and at the bottom is diabetes.

The dementia being so high especially for women is explained by the fact that women live longer than men on average and if you are 90 plus then the chances of having dementia are high anyway.

I saw those new figures today and they do not include a category of obesity. I wonder if almost 100% of the 10% are obese? or hardly any? In their 20s many very over weight people have no medical conditions yet (those come in their 30s) so they may well be a lot of the 10% who have no underlying condition.

www.dailymail.co.uk/news/article-8225245/What-coronavirus-death-figures-REALLY-show.html

Sorry, forgot to post the link!

www.latimes.com/science/story/2020-04-15/coronavirus-risk-higher-for-obese-people

"In one of two new studies released this week, COVID-19 patients who were younger than 60 and had a BMI between 30 and 34 were twice as likely as their non-obese peers to be admitted to the hospital for acute care instead of being sent home from the ER. They were also 1.8 times more likely to require critical care in a hospital’s intensive care unit.
More severe obesity posed an even greater risk to COVID-19 patients in this under-60 age group. When these patients had a BMI of 35 or higher, they were 2.2 times more likely than their non-obese peers to need standard hospital care and 3.6 times more likely to end up in the ICU.

Obesity appears to be a previously unrecognized risk factor for hospital admission and need for critical care,” wrote the authors of the study published this month in the journal Clinical Infectious Diseases. But that only applies to relatively younger patients; among those ages 65 and older, there was no link between obesity status and hospital care."

Redtoothbrush
Thus exposing existing health inequality which we know to be a compound effect of a number of issues relating to cultural lifestyles (includes diet and religion relating to background), social interactions (including racism), geographic (where you live in the country) economic (class and occupation as well as living conditions and how that affects diet), educational (includes educational barriers such as lack of english) and pure genetic risk.

Given that these are all a specific career we're talking about i.e. doctors, you can discount a lot of the above as being factors.

www.theguardian.com/world/2020/apr/15/role-of-vitamin-d-deficiency-in-bame-medic-deaths

Today's Guardian

Sorry, yesterday's. I don't even know what day of the week it is anymore.

Im not sure you can though Balmy with the exception of possibly competency in English, income and education level, all of those other things can affect people of different ethnicities and have related cultural factors. You don't stop wearing hijab and covering all of your skin just because you are a doctor. You don't stop living in a multi generational household just because you are a doctor. You don't stop being a vegetarian or being the product of a first cousin marriage (thereby being potentially more vulnerable due to inherited genetic factors) just because you are a doctor.

If indeed any of those things have any bearing on it at all.

Although you would hope that any dark skinned doctor (especially a woman who covered) would know to take a high level Vit D supplement.

What's the thing with being vegetarian? It's not particularly associated with vit D deficiency is it? Veganism maybe, but vegetarian?

And Ann, yes, I don't see how a dark skinned doctor wouldn't know this. I also don't see how wearing a head scarf and long clothes make that much difference. We live in a place that is cold most of the year - most of us cover up.

Given that these are all a specific career we're talking about i.e. doctors, you can discount a lot of the above as being factors.

No you can't

The following still apply

Religion / Ethnic background and how this affects diet
Culturally living in multi generational households
Racism in the workplace meaning different specialities putting a heirachy on certain roles (so BAME staff may be in higher risk roles rather than prestigious ones)
Geographic living in cities which have been affected more than provinicial towns and rural areas economic
Genetic Risk

I think the only one you can eliminate is education with real certainity.

You might also need to add in the possible BCG factor if you grew up somewhere it wasn't routine - and this being particularly important if you work in healthcare compared with the general population

And potential cultural / religious beliefs about duty which might mean BAME doctors more likely to work longer or come out of retirement for the crisis than their white counter parts.

@Gwenhwyfar being vegetarian is used as shorthand for risk of vitamin d deficiency in lots of epidemiological studies . Based on other studies often showing vegetarians have lower blood levels. Let alone vegans.

They are discussing this very topic on Sky News right now.

I was going to say it’s in the Mail now that Downing Street is going to launch an investigation into why BAME medical staff have been disproportionately affected by Covid-19.