Structural racism is a fundamental cause and driver of ethnic disparities in health

The UK government report on race disparities is a missed opportunity and will lead to a worsening of systemic inequalities, say these authors

That structural racism is an important factor in ethnic disparities in health will not come as a surprise to anyone who has looked at the evidence. Several decades of research clearly shows that racism in all its forms—in particular structural racism—is a fundamental cause of ethnic differences in socioeconomic status, adverse health outcomes, and ethnic inequities in health. [1] 

The much-delayed UK government report on race disparities has devoted 30 pages to disparities in health. The report claims that “for many key health outcomes including life expectancy and overall mortality… ethnic minority groups have better outcomes than the White population.” It further claims that “genetic risk factors” along with “cultural” and “behavioural” factors have led to the disparities seen in covid-19. 

The 30 page section on health in the report claims to undo several decades of irrefutable peer reviewed research evidence on ethnic disparities, previous governments’ reports, and independent reviews all reaching similar conclusions: ethnic minorities have the worst health outcomes on almost all health parameters. [1] The report’s conclusions, recommendations, and cherry-picked data to support a particular narrative shows why it should have been externally peer reviewed by independent health experts and scientists. Furthermore, we would expect that a report with such lofty ambitions of presenting a “new race agenda” would have at least one health expert or a biomedical scientist on the commission. It included a space scientist, a retired diplomat, a politics graduate, a TV presenter and an English literature graduate, but no one with an academic background in health inequalities. 

The report also concludes that deprivation, “family structures,” and geography—not ethnicity, are key risk factors for health inequalities. However, it ignores the overwhelming evidence that systemic racism, in particular residential segregation, which is rising in the UK, is a major driver of ethnic differences in socioeconomic status. [2,3] There is a wealth of evidence that segregation also affects health due to poorer quality education, employment opportunities, and poorer access to resources to enhance health. The concentration of poverty in these areas leads to exposure to higher levels of multiple chronic and acute psychosocial stressors, greater clustering of these stressors, and greater exposure to undesirable social and environmental conditions. [3-5] Previous research also shows that segregation is independently associated with late diagnosis and inferior survival rates in lung or breast cancer. [6]

The report says that health data are inconsistent and incomplete, but still concludes that life expectancy is improving for ethnic minorities. This is not true. It cites two reports on life expectancy in Scotland where only 3% of UK ethnic minorities live. The Marmot Review in England shows that health inequalities have widened overall, life expectancy has stalled, and the amount of time people spend in poor health has increased over the past decade. The situation is much worse for ethnic minority groups, who have higher rates of deprivation and poorer health outcomes. [7-12] The report’s data, which shows lower life expectancy in Black and South Asian people compared to people with White ethnicities, does not support its own conclusions. 

The devastating effects of covid-19 on ethnic minorities have exposed and aggravated the structural socioeconomic disadvantages experienced by ethnic minority communities. There is no evidence of “genetic risk factors” for covid-19 as the report claims. There is now sufficient evidence that ethnic disparities in covid-19 are partly due to high risk public facing jobs, living conditions such as multigenerational households, poverty, chronic comorbidities, as well as racial discrimination and the effects of structural racism such as residential segregation. [1,13] 

Black and South Asian men are 4.2 times and 3.6 times as likely to die from covid-19 compared to their White counterparts, respectively. A similar trend is seen for other covid-19 measures, with higher rates of infection, hospitalisation, and intensive care admissions for these groups. Ethnic minorities also continue to experience wider adverse consequences of the pandemic including mental health issues, unemployment, financial insecurities, and housing evictions. [13]

Ethnic disparities in covid-19 are part of the historical trend of poorer health outcomes in marginalised ethnic groups with higher rates and earlier onset of disease, more aggressive progression of disease, and premature death. [1] Empirical analyses show that ethnic differences in health persist even after adjustment for socioeconomic status. In the UK, for example, Black women are five times more likely to die during pregnancy than White women and Black people have a greater risk of detention under the Mental Health Act than White people. [14,15]

This report is a missed opportunity. It lacks the scientific credibility and authority to be used for major policy decisions. Its methodology and language, its lack of scientific expertise, and the well known opinions of its authors make it more suitable as a political manifesto rather than an authoritative expert report. The new government approach on race, divorced from reality, fails to provide any solutions to ethnic disparities in health. Its attempts to undermine the well established and evidence based role of ethnicity on health outcomes will lead to a worsening of systemic inequalities, putting more ethnic minority lives at risk. 

Mohammad S Razai, academic clinical fellow in primary care, St George’s University of London. Twitter: @mohammadrazai

Azeem Majeed, Professor of Primary Care & Public Health, Department of Primary Care & Public Health, Imperial College London @Azeem_Majeed

Aneez Esmail, Professor of general practice, Division of Population Health, Health Services Research & Primary Care, University of Manchester. Twitter @aneezesmail


  1. Razai MS, Kankam HKN, Majeed A, Esmail A, Williams DR. Mitigating ethnic disparities in covid-19 and beyond. BMJ. 2021 Jan 14;372:m4921. doi: 10.1136/bmj.m4921.
  2. Brady D, Burton L. Oxford handbook of the social science of poverty. Oxford University Press, 2016.
  3. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health2019;40:105-25. doi:10.1146/annurev-publhealth-040218-043750 pmid:30601726
  4. UK Government. Ethnicity facts and figures. 30 Oct 2020.
  5. Office for National Statistics. 2011 census.
  6. Landrine H, Corral I, Lee JGL, Efird JT, Hall MB, Bess JJ. Residential segregation and racial cancer disparities: a systematic review. J Racial Ethn Health Disparities2017;4:1195-205. doi:10.1007/s40615-016-0326-9 pmid:28039602
  7. Social Metrics Commision. Measuring poverty 2020: a report of the Social Metrics Commission. 2020.
  8. Department for Work and Pensions. Statistics on the number and percentage of people living in low income households for financial years 1994/95 to 2018/19. DWP, 2020.
  9. UK Government. Race in the workplace: The McGregor-Smith review. UK Government, 2017.
  10. UK Government. The Lammy Review: An independent review into the treatment of, and outcomes for, black, Asian and minority ethnic individuals in the criminal justice system. UK Government, 2017.
  11. Cabinet Office. Race disparity audit: summary findings from the ethnicity facts and figures. Cabinet Office, 2017.
  12. Institute of Health Equity. Health equity in England: the Marmot Review 10 years on. IHE, 2020.
  13. Osama T, Razai MS, Majeed A. COVID-19 vaccine allocation: addressing the United Kingdom’s colour-blind strategy. J R Soc Med. 2021 Mar 9:1410768211001581. doi: 10.1177/01410768211001581. 
  14. MBRRACE-UK. Saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. MBBRACE, 2019.
  15. Modernising the Mental Health Act: Increasing choice, reducing compulsion; final report of the Independent Review of the Mental Health Act 1983. 2018.

Editor’s note: This piece was edited on 1 April 2021 to take out a parenthesis in the fifth paragraph.