South Asians are Uniquely At-Risk from COVID-19
A look at how South Asians are uniquely affected by the COVID-19 pandemic
Summary
Nearly 19 million people have tested positive for contracting the coronavirus worldwide, which represents about 0.25% of the global population. Nearly 5 million of these cases have arisen in the United States, which represents approximately 1.5% of the US population.
And while this disease does not discriminate as to who it devastates, it appears to pose a unique problem for the South Asian community.
South Asians represent a disproportionately large percentage of the healthcare work force in the United States, which means they and their families are disproportionately exposed to the virus - and at heavier viral loads as well in light of their service on the frontlines.
Unfortunately, according to a study out of the UK, South Asians also are the most at-risk population for the most severe outcomes of COVID-19.
This is likely because South Asian's are disproportionately at risk for obesity, diabetes, and heart disease. This is a phenomenon I previously detailed in a 2017 piece entitled "Skinny Fat."
This piece will further explore the unique threat that COVID-19 poses to the South Asian community in their roles as frontline healthcare providers as well as a result of their status as an at-risk population at large.
On the Frontlines
Since the beginning of the pandemic, news channels have featured medical experts to help the general public better understand the health risks COVID-19 presents.
If you've watched the coverage from a few different channels, as I have, you may have noticed one fairly consistent trend - by and large the experts tend to be of South Asian heritage.
This includes (not an exhaustive list):
Dr. Vin Gupta
Dr. Alok Patel
Dr. Vivek Murthy (former Surgeon General)
Dr. Sanjay Gupta (CNN Anchor)
Dr. Kavita Patel
Dr. Lipi Roy
Dr. Murtaza Akhter
Dr. Jay Bhatt
Dr. Prakash Gatta
Dr. Bela Patel
Dr. Shilpa Patel
Dr. Purvi Parikh
Seema Verma (Administrator for CMS)
Dr. Ashish Jha
Dr. Manisha Juthani-Mehta
In fact, even Rachel Maddow commented on the trend as far back as April 8, 2020 where she stated, "Here`s another you should see. By coincidence, it is another doctor (of) Indian descent. Like I believe Dr. Gatta and like the Irish prime minister, this is Dr. Ajit Rai, who is an anesthesiologist who works in California but he is in New York now because he volunteered to come do time in a front line New York City hospital."
One reason for this abundance of South Asian voices in the public health conversation is because over 14% of all physicians in the US are of Indian heritage - the % increases when you add in other South Asian nations.
2019-2020 American Physicians of Indian-Origin (AAPI) President Dr Suresh Reddy, applauded the hundreds of thousands of Indian-origin medical personnel bravely fighting against the virus, "every 7th doctor in the US is an Indian and they are at the frontlines, working as soldiers and fighting the virus. The entire medical fraternity has become the Army right now, fighting the coronavirus." Reddy told PTI in an interview here.
As you can imagine, this represents a serious exposure risk to the South Asian community given their disproportionate exposure to higher than normal viral loads of COVID-19.
For context, South Asians make up 1.9% of the U.S. population but Indians alone comprise more than 14% of the physicians across the country. This increased exposure filters through to their families and respective communities. The magnitude of the exposure risk increases when you factor in the rest of the South Asian diaspora as well as all the other healthcare workers and frontline jobs that come into play in treating COVID-19 beyond physicians.
At Risk Health Factors
Compounding the increased exposure risk detailed above is the fact that South Asians tend to be disproportionately affected by obesity, diabetes, and heart disease - each of which elevates the risk factors for COVID-19 according to the CDC.
A case study in China showed that from the beginning of the outbreak through Feb. 11, 2020, the death rate among patients with COVID-19 who had diabetes was 7.3% compared with 0.9% in those without comorbid conditions.
In multivariable logistic regression adjusted for age and sex, the prevalence of obesity remained higher in patients with critical COVID-19 than in those with non-critical COVID-19.
Among the 1210 patients in an ICU non-COVID-19 comparison group, 314 (26%) patients had obesity. The prevalence of obesity was numerically higher in patients with critical COVID-19 than in ICU patients without COVID-19. After adjustment for age and sex, odds of obesity were significantly higher in patients with critical COVID-19.
According to the Mayo Clinic, the risk of developing dangerous symptoms of COVID-19 may be increased in people who are older and also in people of any age who have other serious health problems — such as heart or lung conditions, weakened immune systems, severe obesity, or diabetes
South Asians are susceptible to many of the aforementioned risk factors, because they disproportionately exhibit what is often referred to as “skinny fat.” What that means is that we may appear to have an outwardly healthy physique, but we are actually medically at risk for diseases associated with obesity. It is also referred to as (MONW) Metabolically Obese Normal Weight.
Visually, this “skinny fat” may present as central obesity, where an individual will appear to have a normal, even skinny upper body and lower body, but has an accumulation of fat around their mid-section. I sometimes refer to this as malnourishment fat since the two situations visually appear to have a similar “spare tire” appearance on a “skinny” frame.
This is a very serious issue because our apparent “normal” physical appearance makes us less vigilant than we should be about our health. As a community, we are disproportionately susceptible to diabetes and cardiovascular disease, which makes our false sense of security that much more dangerous.
Here are some shocking stats:
The World Health Organization (WHO) has concluded that South Asians have a higher percentage of body fat than Caucasian people of the same age, sex and BMI.
When compared to white Europeans of the same BMI, South Asians have 3 to 5 percent higher total body fat.
South Asians have higher weight-related disease risks at lower BMI
Even the occurrence of type 2 diabetes is more in lower BMI than the WHO cut-off limit of 25 kg/m2.
Thus, WHO recommended that for many South Asians the limits for public health action should be 23 kg/m2. The categories suggested for Asians are: less than 18.5 kg/m2 (underweight); 18.5–23 kg/m2 (normal); 23–27.5 kg/m2 (overweight) and 27.5 kg/m2 or higher (obesity).
The South Asian cutoffs for overweight and obesity are nearly 10% lower than the BMIs for the same categories for non-South Asians
Almost 90% of people living with type 2 diabetes are overweight or have obesity. Currently 60% of the world's diabetic population is Asian. This higher risk may be because Asians, especially South Asians, are more likely to have less muscle and more abdominal fat, which increases insulin resistance. For example, even though Indian newborns have a lower average body weight compared to white newborns, Indian newborns have higher levels of body fat and insulin.
Imaging technology that measures fat in humans has shown that Asians of a healthy BMI have more fat around organs and in the belly area than Europeans with the same BMI. In short, being “skinny fat” makes one more susceptible / at risk of diabetes and all the maladies that come along with it.
Obesity is a major risk factor for cardiovascular disease and has been strongly associated with insulin resistance. South Asians account for nearly 25% of the global population, yet we as a community bear over 60% of the world’s heart disease burden. South Asians in the United States have been found to have a near-50% greater mortality rate from cardiovascular disease in comparison to other ethnic communities.
South Asian women have a near one-third greater risk of heart disease related death than their Caucasian counterparts. Studies suggest that nearly one in four incidents of heart attacks among East Indian men occur under the age of 40. Studies suggest that 50% of the incidents of heart attacks among East Indian men occur under the age of 50. Nearly one third of cardiac deaths within the community occur in individuals under the age of 65..
The UK Study
A UK study shows that South Asian people are the most likely to die from coronavirus after being admitted to hospital in Great Britain. They are the only ethnic group to have a raised risk of death in hospital and is partly due to high levels of diabetes.
The study, the largest of its type in the world, reported that South Asians were 20% more likely to die than white people:
290 die out of every 1,000 white people needing hospital treatment for COVID-19
350 die out of every 1,000 South Asian people needing hospital treatment for COVID-19
South Asians needing hospital care were 12 years younger on average than their white counterparts (a significant difference) and they were less likely to have dementia, obesity or lung disease. They did show that they had very high levels of diabetes, however. 40% of South Asian patients had either type 1 or type 2 diabetes compared with 25% of white groups.
Diabetes has a dual effect of increasing the risk of infection and damaging the body's organs, which may affect the ability to survive a coronavirus infection.
This is thought to be a major factor in increasing the death rate in people of South Asian ethnicity, but the full picture has not yet been uncovered. Other explanations could include poverty or subtle genetic differences that increase the risk of serious infection, the researchers say.
Conclusion
South Asians are disproportionately on the frontlines of the COVID-19 fight as they represent a significant portion of the healthcare worker labor force in the United States. This means that they, their families, and their respective communities have a greater likelihood of exposure to COVID-19 than the average American.
Additionally, South Asians are disproportionately affected by obesity, diabetes, and cardiovascular disease - likely as a result of genetic and/or cultural factors, which is why the South Asian BMI cutoffs for "overweight" and "obesity" are nearly 10% lower than the BMIs for the same categories for non-South Asians.
With this in mind, a large UK study has found that South Asians are far more at risk of the worst outcomes from COVID-19 than any other ethnicity, once hospitalized.
These results have many implications, including begging the question: should there be a different set of public health policies for South Asians? For example should there be different hospital policies for a frontline South Asian physician or nurse as compared to a white physician or nurse?
One thing is certain - COVID-19 presents a wholly unique threat to the South Asian community. It remains to be seen how we respond to it.