Racism, ethnicity, and COVID-19 related inequalities in the UK

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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.

A woman, protected by a mask, in front of a mural in central London depicting a National Health Service woman carer – Source : unknown (help us find her : defacto@​icmigrations.​fr)

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.

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Authors

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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