Coronavirus: ‘Structural racism not to blame’ for higher death rates among minorities, says No 10’s ethnicity adviser

New government report on Covid-19 disparities shows socioeconomic and geographic factors contribute to high mortality rates among ethnic groups, says Dr Raghib Ali

Samuel Lovett
Thursday 22 October 2020 00:57 BST
Coronavirus in numbers

The government’s new adviser on Covid-19 and ethnicity has denied that structural racism within the UK health system is responsible for the higher coronavirus death rates reported among ethnic minorities.

A Public Health England (PHE) analysis in June showed that people of certain ethnicities were at greater risk, with black men and women nearly twice as likely to die from Covid-19 than white ethnic groups.

The PHE report said that "historic racism and poorer experiences of healthcare" meant individuals from black, Asian and minority ethnic (Bame) communities were less likely to seek care, or speak out about personal protective equipment (PPE) and Covid-related health risks.

Individuals and organisations who were consulted for the review “pointed to racism and discrimination experienced by communities and more specifically by Bame key workers as a root cause affecting health, and exposure risk and disease progression risk”.

Dr Raghib Ali, a senior clinical research associate at Cambridge University’s MRC Epidemiology Unit, has challenged such findings as he moves into his new role as an ethnicities and Covid-19 adviser to No 10.

Ahead of his unveiling, Dr Ali told a media briefing that “he was not convinced” by the mainstream narrative that suggested racism within the health care system contributed to the higher death rates seen among certain ethnic groups.

“The second Public Health England report didn't say that it was due to racism but said that racism may contribute to some of these disparities,” he said. “But they didn't put up any objective evidence for this. It was based on the views of 4,000 stakeholders.

“If structural racism was an important problem — I'm not saying it doesn't exist — but if it was an important problem in health outcomes, then you'd expect that to be reflected not just in Covid but in other outcomes as well.”

He said the latest data show that many ethnic minority groups in England and Scotland enjoy better overall health and have lower rates of morality than their white counterparts.

Dr Ali pointed to research compiled by OpenSAFELY, a health analytics platform established by the University of Oxford and others on behalf of the NHS, which “showed that overall mortality in ethnic minorities was not higher than whites this year”.

He added: “Although they had higher mortality from Covid-19, they had lower mortality from other causes and the two balanced out. So I don't think structural racism is a reasonable explanation.”

Dr Ali was briefing journalists on the government’s first report on health inequalities related to Covid-19 and ethnicity.

The review has been led by equalities minister Kemi Badenoch, who will present the findings to the House of Commons today. 

It was commissioned after an earlier PHE report was criticised for failing to outline any recommendations to address Covid disparities among ethnic minorities.

The report concluded that there is an “increased risk for Black and south Asian ethnic groups”, which is “readily explained” by a number of socioeconomic and geographical factors.

“Where people live, particularly in London and other cities, has had a large effect on the risk of individuals catching Covid-19,” the report said.

It said that occupational exposure, population density, household composition and pre-existing health conditions all contribute to the higher infection and mortality rates seen among ethnic minority groups “rather than genetic differences”. It added: “Deprivation is a good marker of many of these factors.”

The data show a higher prevalence of antibodies in households with seven or more occupants, the report said, adding that people from ethnic minorities are more likely to live in large or overcrowded houses.

It also said that certain occupations carry an increased risk of getting infected from Covid-19, highlighting that ethnic minorities make up 20 per cent of all high-risk jobs — despite accounting for 11 per cent of the total national workforce.

The report “confirms that ethnic groups … were more likely to be infected in the first place”, but disproved the theory that people from these backgrounds faced a higher risk of death once admitted to intensive care, said Dr Ali.

“Although the relative risk of intensive care admission was much higher in Asian and blacks — so between two and four times higher — it was not as high for death,” he said.

“There is certainly no evidence … that blacks and south Asians were treated any differently once they reached hospital. If anything, the opposite is true.

“That their death rates did not match the intensive care admission [rate] is suggestive again that the disease was not as severe.”

The research acknowledges “part of the excess risk” from Covid-19 “remains unexplained for some groups”, and says that ethnic differences still persist even after after accounting for certain factors, such as socioeconomics and comorbidities.

“More evidence and data are needed in order to investigate in detail whether a range of other factors account for differences in infection, hospitalisation or mortality rates,” the review said.

The report made 13 recommendations to prime minister Boris Johnson, all of which have been accepted. These include:

  • The mandatory recording of ethnicity as part of the death certification process
  • Increased public health communication with minorities to raise awareness, build confidence and dispel myths surrounding Covid-19
  • The shielded patient list must be updated in line with the improved knowledge of the factors that put people at greatest clinical risk
  • Equalities minister to work with ministerial colleagues to establish metrics for assessing the impact of their policies to tackle Covid-19 disparities
  • A rapid review of action taken by local authorities to support people from ethnic minority backgrounds

In light of the findings, Dr Ali said it was not equitable to “exclude whites or other ethnic groups who are also at increased risk” from Covid-19.

“It was reasonable to target minorities [in the first stages of the pandemic], but now we have more information to explain that increased risk.

“There's no reason why a white bus driver should be treated differently from an Asian bus driver, or a white doctor should be treated differently from an Asian doctor — they should have the same risk assessment done.”

He said that ethnicity was a “proxy” for the most high-risk factors, and that it was vital to tackle UK-wide issues of deprivation, crowded accommodation and occupational exposure to help the most vulnerable groups in the months to come.

“My suggestion going forward is that instead of using ethnicity as a criteria by which you see whether someone needs extra testing or attention is look at the actual risk factor that is causing that — look at their overcrowded housing, their deprivation, their occupation. Then you'll capture everybody, whether white, black, brown or any other colour. I think that's more equitable.”

Dr Hajira Dambha-Miller, a clinical lecturer in general practice at the University of Southampton, said the government’s report was “comprehensive” and a “welcome first step”.

“Further detail is still needed in explaining why Bame groups are more susceptible to worse outcomes,” she added. “I don't think the report goes far enough in exploring the wider social factors that may contribute to viral transmission and death.”

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