If we do not address structural racism, then more black and minority ethnic lives will be lost 

Covid-19 brings into stark view how racial inequalities within the health sector have been damaging, detrimental, and deadly

The UK Government has finally published its report into how ethnicity, obesity, and gender can affect vulnerability to covid-19. The report was controversial because of its delay, suspected censorship, and confirmation of what many already suspected: “Death rates from covid-19 were highest among people of Black and Asian ethnic groups” and “after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity,” says the report.

However, the most alarming and controversial part of the report is that despite this finding, there is not a single recommendation in the report for how to mitigate against these statistics and save the lives of black and minority ethnic groups: the UK government has effectively discovered who is dying from covid-19, with no strategy or recommendations as to what to do about it. With the backdrop of widespread protests against racial inequalities and racism following the murder of George Floyd in the US, there is a need to confront how racism in the UK pertains to every sector of society, including the NHS. 

We know from previous public health emergencies that migrant, black and ethnic minority groups show disproportionate levels of mortality. For example, during H1N1, hospitalisation and mortality were substantially higher for indigenous groups in Australia and Canada. With regard to covid-19 in the UK, we knew from an ONS report that the death rate of black and ethnic minority people in hospitals was more than twice that of white ethnic groups, mirrored by data from USA. 

Explanations as to risk factors tend to focus on exposure: geographical areas where people live, where people work, and how they are treated at work. For example, an IFS report highlighted that black and minority ethnic communities are more likely to live in areas with high incidence of covid-19. Given black and minority ethnic people make up two thirds of covid-19 related deaths among the health workforce, there could be a suggestion that it was their work that put them at risk. This may partly be the case, and is an acute issue to consider when reviewing the government’s inadequate or lack of timely provision of personal protective equipment (PPE), however it is important to remember that while accounting for two-thirds of covid-19 deaths, black and minority ethnic people only make up 20% of the health care workforce. Moreover, while these geographical and labour variables are vital, we must not lose sight of the fact that the black and minority ethnic population tend to be younger, a protective characteristic for covid-19. Importantly, those black and minority ethnic individuals who have died from covid-19 have been younger than white counterparts. 

Exposure therefore only goes part of the way to explaining the problem. We know that co-morbidities, such as hypertension and diabetes, play a part in explaining why black and minority ethnic groups are more likely to be at risk and warrants further investigation. The shift to “biology” as explanation will no doubt come from parts of the medical world, however we would advise strong caution as such calls rapidly descend into racism’s greatest science ally: eugenics. Ethnicity is a wholly inadequate explainer: there is no gene for being a minority ethnic group, and ethnicity and race are complex socio-cultural concepts. Grasping biological explanations allows public authorities to abdicate responsibility and ignore the role of systemic racism and socio-economic inequalities which are driving the serious illness and death associated with covid-19 in black and minority ethnic communities. Clinical research is vitally important to the covid-19 response and this must involve diverse members of society, but more often than not it is racial and social inequalities that drive disease and unequal mortalities. We need to look at wider society as much as virology.

In collaboration with the Fawcett Society and Women’s Budget Group, we conducted a UK-wide survey into how covid-19 and the response to it had affected the UK population. From this, we are able to begin to disentangle the impact of the government’s response to the virus on black and minority ethnic people and how this may begin to contribute to pioneering work in this field. Our data show a number of alarming trends: black and minority ethnic women were more likely to say they were struggling with the competing demands on their time than white counterparts, showed greater concern over debt as a consequence of the outbreak, and significant numbers indicated that they had lost support systems during the pandemic. Anxiety is also higher amongst individuals who identify as black and minority ethnic.

Of particular interest was that black and asian respondents were significantly more concerned about being able to access medication and NHS treatment for non-covid related health needs, than white counterparts. Black parents were more concerned about accessing treatment than other minority ethnic groups. 

Why would black and asian respondents, particularly black parents be most concerned about access to treatment? The answer could be self-evident, respondents were responding to the key government message—stay home, protect the NHS, save lives—and thus interpreted the message to stay home at all costs. Given the vagueness of access to treatment in the initial stages of the outbreak, part of the explanation could be about where to seek care and when seeking care is considered appropriate. Previous research has demonstrated lack of awareness in how to seek care being an issue in health-seeking behaviours among black and minority ethnic groups. In addition, these groups may see the high numbers of covid-19 related deaths among black and minority ethnic groups in the media and national statistics, particularly in the healthcare sector, and calculate that health centres are risky and thus best avoided. The PHE report identified black and minority ethnic people worked predominantly in care, security services and transport, and employment factors partially account for increased incidence. People from black and ethnic minorities know they are at risk and may not want to exacerbate such risk by seeking treatment for non-covid-19 related health issues. 

More substantively, concern over access to treatment is not just about covid-19, it could also be drawn from experience of wider discrimination and racism in the health sector. Existing research suggests black and minority ethnic patients can be subject to a variety of forms of racial discrimination and inequality in healthcare settings: poor standards of care, mis-diagnosis of symptoms, dismissing concerns of pain or false assumptions with regard to ability to withstand high pain thresholds, association of ill health with ‘“lifestyle” such as poor diet or drug use. Prior to covid-19 one of the starkest indications of racial inequality within the health sector was with regard to maternal mortality, where according to the MMBRACE study black women in the UK were five times more likely to die during pregnancy, childbirth and post-partum periods than white women. The racism linked to these pathological racial stereotypes are detrimental for black and minority ethnic people’s health and wellbeing, diminish their humanity, and shorten their lives.  

These issues are compounded with the health sector being dragged into the murky world of the UK government’s hostile environment policies (now re-branded as compliant environment policies), where trusted professionals and public authorities are now being asked to act as border agents, instead of providing services which should not distinguish between who you are and where you come from. Thus, beyond the systemic racism and racial discrimination, migrants can be subject to further barriers to access through NHS charges. This has significant effects; migrants are not seeking care during covid-19, as migrants know that the NHS is required to share data with home office. This sends a strong signal that for the UK government, policing borders is more important than protecting people’s lives.

Talking about racism in a health service that is beleaguered, traumatised, and celebrated from a global pandemic is absolutely necessary. Racism does not just influence black and minority ethnic group’s livelihood and life chances, it is a matter of life and death. Covid-19 brings into stark view how racial inequalities within the health sector have been damaging, detrimental, and deadly to the lives of black and minority ethnic people. Unless systemic racism and racial inequalities are identified as risk factors in health emergencies and pandemics, a greater number of black and minority ethnic lives will continue to be lost, even beyond covid-19.  

Zubaida Haque is Interim Director of the Runnymede Trust and a member of Independent Sage. Twitter: @Zubhaque

Sophie Harman is professor of International politics at Queen Mary University London. Twitter: @DrSophieHarman

Clare Wenham is Assistant Professor of Global Health Policy at London School of Economics. Twitter @clarewenham

Competing interests: None declared.