This blog post was written by Dr Saffron Karlsen, (Senior Lecturer in Social Research, University of Bristol)
On the last weekend of May 2020, much of the world watched with horror scenes of US urban disturbances in response to the death of George Floyd – another Black person killed in police custody. On the other side of the pond, many in the UK also awaited the release of an official report into the higher rates of infection and death of Black and other ethnic minority people from COVID-19.
Delays and disappointment
This Public Health England (PHE) report was heralded as an opportunity to finally provide answers to questions we’d had since evidence of these inequalities first emerged. The inquiry’s lead, Professor Kevin Fenton, described the pressing need for open discussion, to listen to the views of people from Black communities and those who worked with them to find out what was producing these inequalities.
Unfortunately, the report which was finally released is very far from fulfilling these ambitions. It does not provide a detailed investigation of the drivers of these ethnic inequalities and includes very little new information from which to make sense of these patterns.
More questions than answers
The report documents the higher rates of COVID-19 diagnosis among Black ethnic groups and higher rates of death among those with Black and Asian ethnicities. After adjusting for the effects of differences in sex, age, area deprivation and region of residence between the groups, people of Bangladeshi ethnicity were found to have around twice the risk of death of those with white British ethnicities. Those with Chinese, Indian, Pakistani, ‘other Asian’, Caribbean and ‘other Black’ ethnicities also have significantly higher risks of death. But this is evidence we already have.
What the report can say is greatly overshadowed by what it can’t. There are problems with the analyses. For example, the ethnicity measure used in most of the tables – which groups people considered to have ‘white’, ‘Asian’, ‘Black’, ‘Mixed’ and ‘other’ ethnicities separately – is extremely crude. Given that the authors themselves single out the particular disadvantage of Bangladeshi people (including compared with Indian and Pakistani people, also in this ‘Asian’ group), it’s easy to see how such an approach will conceal important differences. The report’s comparison of changing mortality patterns raises more questions than it answers, including the value of comparing COVID-19 deaths to those from all causes, despite their obvious differences.
Socioeconomic position is a key driver in health inequalities
Most disappointing is the complete lack of any attempt to properly investigate what might be driving these inequalities. We already know that socioeconomic position is an important part of the explanation for ethnic inequalities in experiences of COVID-19, while co-morbidities appear less so. Such findings concur with a wealth of existing evidence regarding explanations for ethnic inequalities in other health conditions. This existing research consistently shows that what explains ethnic health inequalities are societal, not genetic or cultural, in origin. But the PHE report barely touches on this.
Rather than detailed analysis, we are presented with a selection of results from other research which describes lives lived in urban, overcrowded and deprived dwellings, funded by jobs which expose them to higher risks. The higher death rates among those with minority ethnicities infected with COVID-19 are explained with reference to the higher rates of cardiovascular disease and diabetes in some groups. But the possible reasons for these poor living conditions, higher-risk jobs and co-morbidities are not discussed. We are left to assume that this concentration of people in poorer environments and worse health is to be expected. That they are caused by natural or cultural differences, inherent to these ethnic minority groups. Likewise, we are told that there may be ‘additional barriers in accessing [health] services that are created by, for example, cultural and language differences’, but seemingly nothing else.
This is a continuation of a story we’ve heard repeatedly since the beginning of this pandemic. That while we know that differences exist, they should not concern the public, or policy-makers, because they are caused by problems within the people who suffer them. We are not told about the wealth of evidence documenting the ways in which those with minority ethnicities are persistently excluded from the education, employment and other opportunities which will enable them to attain good jobs or decent housing. Or the prejudice which prevents them from acquiring those lower risk jobs, that better housing, or high-quality health care which comes so easily to others, even when they have the skills and the rights to have them. Or the ways in which these negative experiences produce the stress that drives these ‘co-morbidities’.
We knew that the inquiry had engaged with people who didn’t support these views. Thousands of stakeholders and third-sector organisations had directly contributed evidence of lived experiences and recommendations to the review. Where was this evidence?
As the day closed, a story began to circulate. That a far more extensive version of the report had been submitted to Matt Hancock’s office. One that had included details of all these discussions, and drawn attention to the role of structural discrimination in disadvantaging those with minority ethnicities, in relation to COVID-19 and more generally. Over the following days, there was also Government backtracking regarding Prof Fenton’s involvement and further speculation regarding whether this additional data would ever be released. It is unclear where this evidence went, or why. But given the previous reluctance to consider the effects of racism, it is difficult not to assume a whitewash.1
Another way: local leadership
There is another way. Local political leaders are approaching this pandemic differently, in a way which acknowledges the urgent need for action and for that to be deep-rooted, widespread and long-term. The first response of Bristol City Council, under the leadership of Mayor Marvin Rees and Cllr Asher Craig, was to commission a comprehensive report from University of Bristol academics into the drivers of these ethnic inequalities. This makes useful reading for anyone who didn’t get what they wanted from the PHE report. They have also established an ethnic minority-led, global network of stakeholders to identify and respond to the impact of COVID-19 on the lives of those with minority ethnicities, now but also into the future. At the second of these summits, on 29 May, discussions ranged from supporting communities managing the long-term traumas of the pandemic to establishing better ways of working which acknowledge the impact of racism and colonialism on our practices. On the understanding that, as one delegate commented, “relying on a capitalist system to address exploitation is madness”. The day after the PHE report was released, the Council announced that Professor Olivette Otele, Bristol University’s first Professor of the History of Slavery will take over as the new independent Chair of their Commission for Race Equality. This is the sort of political leadership we have been crying out for. It is the best hope we have to resolve these issues once and for all. It shows that things can be done differently.
We cannot distance the experiences of those with minority ethnicities with COVID-19 in the UK, or the US, from the deaths of George Floyd and others. It is the same institutional and individual racism, repeated and reinforced throughout history and across contemporary society, which explains them both. Until we acknowledge it, we cannot hope to address it.
1 After considerable pressure from the public, a report focusing on over 4000 stakeholder contributions was finally published by PHE on 16 June 2020. This 69-page report contains a series of recommendations which specific draw attention to the role of societal factors and racism in the generation of ethnic inequalities in coronavirus.
This blog post was original published on 5 June 2020 and updated with a footnote on 12 August 2020.