Hot on the heels of The BMJ’s special edition on Racism in Medicine, the covid-19 pandemic has produced a “stress test” for everyone concerned about structural racism in healthcare. The higher mortality rates from covid-19 for people from ethnic minority backgrounds across the general population and in health and social care roles has been widely documented. Scrutinising the causes of health and social inequality is critical to mitigating risk and preventing further deaths. It is 20 years since the Macpherson inquiry into the racially motivated death of Stephen Lawrence, which brought attention to the problem of institutional racism. Our confidence to identify, name, and act on racism appears to be dwindling. Public Health England’s recent inquiry into the disproportionate impact of covid- 19 on ethnic minority communities served to confirm data, but was a missed opportunity. Unless we overcome the persistent fragility and discomfort surrounding discussions of discrimination at institutional and individual levels, findings, recommendations, and actions will be limited.

We must avoid inquiries based solely on biological determinism. Race is a social, not biological construct.  While biological factors may in part contribute to the disproportionate burden of covid- 19 mortality in people from ethnic minorities, we must recognise many underlying factors are linked to social determinants that in turn are directly influenced by racism. If we regard race as a social construct, we will move away from reductionist assumptions, to ways of reasoning which account for historical and contextual legacies of power, privilege, discrimination and oppression in UK society as well as in our healthcare and social systems. 

Macpherson defined institutional racism as “The collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people.” 

There is well documented evidence of racism in healthcare, the NHS, and medical education. Within the population there is inequitable access to healthcare, provision, treatment and outcomes across a number of areas by ethnicity. Healthcare workers from ethnic minority backgrounds face differential training and career progression, pay levels and complaints processes, as well as bullying and harassment at work. There is also differential attainment between students from ethnic minorities and white medical students, with questions raised whether some medical schools are “turning a blind eye to racism”. Chaand Nagpaul, chair of BMA Council, highlighted data that show “doctors from an ethnic minority are nearly twice as likely to say that they would not feel confident in raising workplace safety concerns, and fear being unfairly blamed or suffering adverse consequences if they did so.” Many healthcare workers from ethnic minorities are operating in a culture of fear.

The current protests in the US, and across the world, and the focus on “Black Lives Matter” after the tragic death of George Floyd more than ever demands that we look beyond inadequate specious responses when structural racism is laid bare. To be successful we need to name racism as a determinant of health and invest significant effort to identify and dismantle bias and discrimination in our health systems and institutions, as well as at an individual level. Racism has and continues to drive health and social inequality in the UK and is, we believe, a likely co-factor contributing to deaths in ethnic minority communities in this crisis. We must widen our investigative frameworks beyond biological determinism, and avoid unintended scientific racism. We should not let the covid-19 “stress test” pass without action on racism and inequality.

Christine Douglass has a background in social accountability in medical education. 

Molly Fyfe is a senior academic fellow in the Medical Education Research and Innovation Centre, Department of Public Health and Primary Care at Imperial College, London.

Amali U. Lokugamage is a consultant in obstetrics and gynaecology at Whittington Health NHS Trust, London, UK and Honorary Associate Professor and Deputy Lead of Clinical and Professional Practice at UCL Medical School, London.

Competing interests:

CD is member of the Patient Liaison Group, British Medical Association. 

MF no competing interest. 

AUL is on the Board of Directors of the International MotherBaby Childbirth organisation and a Trustee for the Birthlight Charitable Trust. She is a company director of a small publishing company called Docamali Ltd.