Laia Bécares and James Nazroo
Recent headlines have identified alarming ethnic inequities in COVID19 infections and related deaths. UK data come from a report by The Intensive Care National Audit and Research Centre, which showed that 35% of COVID19 related admissions to intensive care were of ethnic minority people, and ethnic minority admissions were slightly more like to die in critical care (for example, 48.4% of White patients died in critical care compared with 55.3% of ethnic minority patients) [updated 30/4/20].
Given that people who self-identify as Asian, Black, mixed, or other, make up 13% of the population in England and Wales, this is a gross over-representation. A similar ethnic inequity has been reported in the US, where Black people are disproportionately represented in COVID19-related deaths. For example, in Michigan, a state where 15% of the population is Black, 40% of deaths are of Black people. The UK Government have recently announced that they will hold an ‘inquiry’ into this, but what might underlie these inequalities?
Reasons behind ethnic inequities in COVID19 have been discussed across blogs and news outlets, and mostly point towards the increased risk being a result of the underlying social and economic inequalities faced by ethnic minority people. That is, most ethnic minority groups are more vulnerable to infection and poorer prognosis from COVID19 because they are more likely to have poorly paid, insecure employment; live in over-crowded, multi-generational housing; and live in deprived neighbourhoods with high rates of concentrated poverty and increased pollution levels.
They are also more likely to be employed in sectors that increase their risk of exposure to COVID19. An over-representation of ethnic minority key workers can be found in the transport and delivery jobs, health care assistants, hospital cleaners, social care workers, and in nursing and medical jobs. Not only do these occupations increase risk of infection, some of these are also occupations that have been the last to receive supplies of personal protective equipment.
In addition to increased vulnerability because of social and economic inequalities and increased exposure to the COVID19 virus, ethnic minority people are more likely to have underlying health conditions such as asthma, diabetes, high blood pressure, and coronary heart disease. These health conditions are socially-patterned, so that the social and economic inequalities faced by ethnic minority people, briefly described above, lead to an increased risk of developing these health conditions, which have now been linked to increased risk of COVID19 infection and mortality. So the increased risks associated with COVID19 infection are now a core component of wider ethnic inequalities in health, and its negative consequences are amplified by long established pre-existing ethnic inequalities in health.
Behind this complexity there is one underlying cause to all the factors leading to increased exposure and vulnerability to infection and mortality from COVID19 – entrenched structural and institutional racism and associated racial discrimination. A myriad of studies in the UK and elsewhere have now documented the role of racism in patterning inequalities in education, employment, income, housing, and proximity to pollution (including toxic, hazardous and dangerous waste facilities). In addition, experiences of racial discrimination have been linked to a numerous mental and physical health outcomes, including asthma and hypertension. Importantly, these processes do not operate in isolation, they co-occur and sequentially lead to deepening inequalities in many domains across a person’s life course, and are transmitted from one generation to the next.
Excluding racism – the root of ethnic inequities in COVID19 infections and mortality – from scientific and policy discussions around the determinants and implications of the coronavirus pandemic can lead to dangerous and ineffective investigations and policy interventions. These include un-evidenced reductionist approaches which question whether ethnic inequalities in COVID19 may be due to biological/genetic or cultural differences. Hypotheses of biological and cultural and religious differences have already been proposed, and these lines of thinking risk taking us back into a time of eugenics and scientific racism.
What could possibly be the biological or cultural similarities between two ethnic minority families – one living in Tower Hamlets, London, and the other in Detroit, Michigan – who have been impacted by the coronavirus pandemic? And would any tenuous similarities in such factors be driving their vulnerability to COVID19?
More likely the similarity is that they will both live in disinvested neighbourhoods with high levels of pollution and concentrated poverty, with insecure and underpaid employment, and in overcrowded conditions with substandard levels of housing. Chances are they have had their lives shaped by institutional and structural racism, and have experiences of racial discrimination deeply embedded in their lives. These are the similarities that policy and research efforts should be paying attention to. And these are all caused by systemic racism.
Since 16th March 2020, the UK government has introduced a series of social distancing, social isolation and ‘lockdown’ measures intended to reduce the impact of the COVID19 pandemic on the NHS by protecting its capacity to provide care for people who become seriously ill as a result of a COVID19 infection. These measures have been supported by new legislation, the Coronavirus Act 2020, that received Royal Assent on 25th March 2020. The measures are acknowledged to have extremely negative economic, social and psychological impacts that, on average, are judged to be worth the estimated direct health benefits.
However, the situation facing ethnic minority people is on average far more precarious than ‘the average’, as detailed above and here. And some of the more punitive dimensions of ‘lockdown’, such as changes in the Mental Health Act and police surveillance, are also going to more adversely impact on those with racialised identities. These factors should be urgently considered in the implementation of policies in response to the coronavirus pandemic if we are to mitigate, rather than aggravate, existing ethnic inequalities.
Unless racism is named and discussed as a system of oppression that patterns the chances of exposure and infection to, and mortality from COVID19, and ethnic inequality is considered in the response to the coronavirus pandemic, the Government risks further increasing ethnic inequities in social and health outcomes in the UK. In this context it is welcome that the Government is considering an inquiry into the ethnic inequalities resulting from COVID-19. This is a significant and important shift of focus when contemporary policy work around inequalities in health have largely ignored the question of ethnicity.
However, in its implementation it is crucial that the inquiry considers how current inequalities relate to longstanding ethnic inequalities in health and in doing so the question of racism as an underlying driver of these inequalities must not be side-stepped. Similarly, the inquiry must also focus on the greater harm done to ethnic minority people as a result of Government responses to the coronavirus pandemic and move quickly to consider how these greater harms might be mitigated.