With mounting evidence of disproportionate Covid-19 mortality among ethnic minority groups, in April 2020 Public Health England undertook a review of ethnic inequalities in relation to this evidence. The terms of reference were subsequently broadened to include other axes of social inequality – age, gender, geography, and deprivation – thus diluting the original focus on ethnic inequalities. When, after some delay, the review was published on June 2, entitled ‘Disparities in the risk and outcomes of COVID-19’, it was widely criticised for failing to propose specific action to redress these inequalities. After initially claiming that it had insufficient data to make recommendations, the government changed course and on 16 June published a second review, ‘COVID-19: understanding the impact on BAME communities’, based on extensive meetings with stakeholders from Black, Asian and minority ethnic groups. This review acknowledged both the disproportionate impact of Covid-19 on these communities, and the central role of racism in creating the inequalities that account for this impact, and it did contain recommendations. But the narrow biomedical focus of many of its headline messages, its many references to clinical and behavioural factors such as ‘diet’, or ‘vitamin D’, and its repeated disclaimers that ‘genetics’ may account for part of the problem , detract from what might otherwise have provided a coherent review of the deep-seated social and structural determinants involved in the disproportionate impact of Covid-19 on ethnic minorities.
The second review recognises the relevance of ‘the social and structural determinants of health’, and how social inequalities shape racial inequalities in health. Yet it ignores the extensive evidence that underlying these inequalities is historical and institutional racism, which explains why ethnic minorities are more likely to live in deprived circumstances in the first place. This follows the approach adopted in the earlier disparities review, which statistically portioned out some of the excess mortality to deprivation, as opposed to ‘ethnicity’, thus masking the role of racism in undergirding these inequalities.
The reality is that racism heightens vulnerability to Covid-19 at all levels of society, not only among deprived social groups but also among high-income professionals. To understand why BAME doctors have died from Covid-19 in such large numbers, for example, we need to ask why BAME doctors may have ended up in roles involving particularly extensive contact with patients with very high viral loads – including how it happened that South Asian-origin doctors have been shunted towards the comparatively under-valued specialism of geriatric medicine, where they have found themselves caring for so many of the sickest Covid-19 patients. A senior Indian geriatrician interviewed by Parvati Raghuram and colleagues explained that ‘if you applied for popular jobs – if you applied for obstetrics, gynaecology, being an Indian you hardly ever got it’, adding that ‘there were instances where the consultants said “this is my shortlist, I have included all the names I could pronounce and spell”’. This is systemic racism at its most explicit: the normalisation and institutionalisation of racial discrimination, such that – throughout UK society – organisational priorities, policies and practices privilege the dominant group. The PHE review shows a reticence to recognize the multiple forms of racism, which is not limited to prejudiced interpersonal encounters but is also structural, lacking a single identifiable perpetrator, resulting in taken-for-granted inherent disadvantage. This is precisely how the MacPherson inquiry understood institutional racism as key to the improper investigation of the killing of Stephen Lawrence and the ‘unwitting racism’ that ran through the Metropolitan Police Force.
While the report includes some useful recommendations – mandating the recording of ethnicity on death certificates, for example – Public Health England has not captured the most important points that were raised by the BAME communities themselves. Three of the seven recommendations focus on ‘cultural competency’ – efforts to make public health information and messaging, and prevention interventions, more culturally and linguistically appropriate for BAME groups. Certainly, public health interventions need to be culturally competent, but the space given to these recommendations risks the impression that the inequalities suffered by BAME groups are due to factors internal to them, rather than to the wide-spread institutional discrimination that lies at the root of the inequalities they experience.
So Public Health England has still to offer a coherent set of concrete recommendations addressing both the direct and indirect ways in which racial discrimination has resulted in a disproportionate impact of the pandemic on BAME groups. The second review has been followed by the announcement of a new commission on racial inequalities. While this creates the impression of action, a further commission is not what is needed. Why so many low-paid jobs involving extra exposure to COVID-19 are disproportionately filled by BAME people who are endowed with the same range of innate ability as anyone else is not a mystery, and practical measures to deal with the problem in a wide range of fields are not hard to specify. They would directly address the culture and institutions that normalise racial prejudice, such as reforms to school curricula that would reverse the message that a sizeable part of the British population is not valued.
In short, health inequalities policy in the UK has looked at deprivation and socio-economic inequalities, but COVID-19 makes it clear that race/ethnicity also needs to be a distinct focus – as has been recognised in other countries, such as Australia. The key point is that as Phelan and Link observe, ‘if racism is a fundamental cause of health inequalities, then ‘the fundamental cause must be addressed directly’.