Laia Bécares, epidemiologist and James Nazroo, sociologist
Ethnic minority people in the UK are at increased risk related to the Covid-19 outbreak, resulting from the underlying social and economic inequalities, which are intertwined with structural racism. There is an urgent need to consider the impact of racial discrimination in scientific and policy discussions.
There is now convincing evidence that marked ethnic inequalities in COVID-19 related complications and deaths exist in the UK, as well as elsewhere. In the UK, initial evidence came from growing public and media recognition that a large proportion of the NHS and care staff who were dying were not white. Then a report by The Intensive Care National Audit and Research Centre showed that 35% of COVID-19 related admissions to intensive care were of ethnic minority people, and that 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). While more recent analysis of 106 healthcare workers who have died from covid-19 showed that 63% were from an ethnic minority background, and just over half were not born in the UK.
In the context of an estimated non-white ethnic minority UK population of 14% at the 2011 Census, this seemed like a large over-representation. This impression was reinforced by analysis of data released by the NHS, which suggested meaningful increases in death rates for ethnic minority people after taking into account differences in age structures and place of residence, and in data showing that geographical variations in risk of COVID-19 related mortality are strongly associated with the proportion of the population who are from an ethnic minority group. Importantly, although the evidence suggests that there may be some variation in the size of the risk across specific ethnic minority groups, it also suggests that this risk is higher for each of them, including White minority people. That is, the increased risk of COVID-19 related mortality is present across all groups whose identities are subject to racialisation.
Precarious employment and vulnerable health conditions
There has been much public debate about what might be driving these ethnic inequalities in risk of COVID-19 related complications and death. Perhaps not surprisingly, central to these debates has been the likelihood that the increased risk results from the underlying social and economic inequalities that are faced by ethnic minority people. That is, most ethnic minority groups are more vulnerable to, and have poorer prognosis from, COVID-19 infection, because they are more likely to : have poorly paid and insecure employment ; live in over-crowded, multi-generational housing ; and live in deprived neighbourhoods with high rates of concentrated poverty and increased pollution levels (Byrne et al. 2020).
Ethnic minority people are also more likely to be employed in sectors that increase their risk of exposure to the COVID-19 virus. An over-representation of ethnic minority people can be found working in transport and delivery jobs, in security guard jobs, as 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 the personal protective equipment that is intended to reduce the risk of transmission of the COVID-19 virus. It is of note that people in these occupations have now been deemed key workers, but for decades ethnic minority people working in these jobs have endured job insecurity, low pay, and discrimination.
The negative consequences related to COVID-19 [that are faced by ethnic minority people] are amplified by long established pre-existing ethnic inequalities in health, both of which are driven by social and economic inequalities.
In addition to increased exposure to infection because of their over-representation as key workers, and increased vulnerability to COVID-19 because of social and economic inequalities, ethnic minority people are also more likely to have the underlying health conditions that have been linked to increased risk of COVID-19 complications and mortality, such as asthma, diabetes, high blood pressure, and coronary heart disease. These health conditions are socially-patterned, so the social and economic inequalities faced by ethnic minority people described above, lead to an increased risk of developing these health conditions. As a result, it is apparent that the increased risks associated with COVID-19 infection that are faced by ethnic minority people are now a core component of wider ethnic inequalities in health, and that the negative consequences related to COVID-19 are amplified by long established pre-existing ethnic inequalities in health, both of which are driven by social and economic inequalities.
Underpinning racial discrimination
Behind this complexity, however, is a key consideration that is typically absent from investigations into ethnic inequalities in health. The social and economic inequalities that are faced by ethnic minority people are driven by entrenched structural and institutional racism and racial discrimination. An explanation of ethnic inequalities in health that stops at social and economic inequalities and doesn’t acknowledge how these inequalities have been, and continue to be, shaped by historical and current processes of colonisation underpinned by racism, is limited in its ability to generate an understanding of, and solutions to, ethnic inequalities. A myriad of studies in the UK and elsewhere have now documented the role of racism in patterning inequalities in education, employment and income, housing, and proximity to pollution. In addition, experiences of racial discrimination have been linked to a numerous mental and physical health outcomes, including asthma and hypertension (Nazroo 2003, Wallace et al. 2016, Williams et al. 2019). 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 inequalities in COVID-19 infections and related 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 that question whether ethnic inequalities in COVID-19 might be due to biological/genetic or cultural differences, a line of thinking that risks taking us back into a time of scientific racism, but which is, for example, reflected in a recent call for research on this issue.
Before we respond to such an agenda we should ask ourselves the simple question : ‘what could possibly be the biological or cultural similarities between an ethnic minority family living in Tower Hamlets, London and another living in Detroit, Michigan, both of whom face an increased risk of COVID-19 related complications and mortality?’. More likely than having shared genetic and cultural risks, 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 that 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. Given this, the increased risks faced by ethnic minority people from COVID-19 should not have been unexpected, as appears to have been the case, they could and should have been anticipated.
Excluding racism – the root of ethnic inequalities in COVID-19 infections and related 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.
That Public Health England has been tasked by the UK Government to review ethnic inequalities in COVID-19 related outcomes could be a significant and important shift of focus, especially when contemporary policy work around inequalities in health have largely ignored the question of ethnicity. However, in its implementation it is crucial that this review 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 review 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.
The justification for these measures is that their estimated effect on reducing the impact of the COVID-19 pandemic on the NHS, by protecting its capacity to provide care for people who become seriously ill as a result of a COVID-19 infection, would offset their acknowledged extremely negative economic, social, health and psychological impacts. That is, the negative is on average judged to be worth the estimated direct health benefits. However, the situation facing ethnic minority people is far more precarious than ‘the average’, as detailed above, meaning that these measures are certainly having a more negative effect on ethnic minority people in both the short and the long term. In addition, some of the more punitive dimensions of ‘lockdown’, such as changes in the Mental Health Act, police surveillance, and discontinuity in the clinical management of pre-existing conditions are also going to more adversely impact on those with racialised identities.
Unless racism is named and discussed as a system of oppression that patterns the chances of exposure to and mortality from COVID-19, 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.
One step further
- Bridget Byrne et al. (eds.), Ethnicity, Race and Inequality in the UK : State of the Nation, Policy Press, 2020. [available online]
- James Y. Nazroo, Ethnicity, class and health, Londres, Policy Studies Institute, 2001, 196 p.
- James Y. Nazroo, « The structuring of ethnic inequalities in health : economic position, racial discrimination, and racism », American Journal of Public Health, vol. 93, n° 2, 2003, p. 277–284. [available online]
- James Y. Nazroo & Laia Bécares, « Evidence for ethnic inequalities in mortality related to COVID-19 infections : Findings from an ecological analysis of England and Wales », 2020. [Under Review]
- James Y. Nazroo, Kamaldeep S. Bhui, & James Rhodes, « Where next for understanding race/ethnic inequalities in severe mental illness ? Structural, interpersonal and institutional racism », Sociology of Health and Illness, vol. 42, n°2, 2020, p. 262–276. [available online]
- Stephanie Wallace, James Y. Nazroo & Laia Bécares, « Cumulative exposure to racial discrimination across time and domains : exploring racism’s long term impact on the mental health of ethnic minority people in the UK », American Journal of Public Health, vol. 106, n° 7, 2016, p. 1294–1300. [available online]
- Davis, Williams, Jourdyn A. Lawrence & Brigette Davis, « Racism and health : Evidence and needed research », Annual Review of Public Health, vol. 40, n°1, 2019, p. 105–125. [available online]
Laia Bécares is a Senior Lecturer in Applied Social Science (Social Work and Social Care) at the University of Sussex.
James Nazroo is Professor of Sociology at the University of Manchester, Deputy Director of the Centre on Dynamics of Ethnicity (CoDE).
To cite this article
Laia Bécares and James Nazroo, « Racism, ethnicity, and COVID-19 related inequalities in the UK », in : Solène Brun et Patrick Simon (eds.), Issue « Inégalités ethno-raciales et pandémie de coronavirus », De facto [Online], 19 | May 2020, online since 15 May 2020. URL : https://www.icmigrations.cnrs.fr/2020/05/13/defacto-019–02/?lang=en
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