Racism: The riskiest pre-existing condition for COVID-19 in the UK

In the 24th post in our series #NSUNCovidLife,  Jayasree Kalathil responds to the publication of the recent Public Health England review: “the biggest pre-existing risk factor for the health of people from racialised communities in the UK is the systemic and structural racism that is the direct result of white supremacy and privilege.”

When the Conservative-Liberal Democrat coalition government came into power and released a white paper on public health, I was a policy consultant for The Afiya Trust, a national charity working to reduce inequalities in health and social care provision for racialised communities. In association with ROTA and various other organisations and individuals from racialised communities, I helped produce our response to the white paper and a ‘Framework for Action’ on achieving equality in health and social care.

We analysed ‘ethnic disparities’ in health outcomes, in treatment within health, mental health and social care services, in awareness of and influence over policy and practice within health and social care services. We offered solutions and a road map for action. The single most important lesson was that the biggest public health problem faced by racialised communities in the UK is systemic and structural racism.

That was in the spring of 2010.

A decade later, in 2020, springtime has been engulfed by a new global pandemic. The USA is reeling with anger and sorrow at the murder of yet another of our brothers, and COVID-19 is wreaking havoc through our communities in the UK, even as both our governments are blithely mouthing banalities. The old pandemic of racism is alive and well, but one would not suspect that when one reads the review published by Public Health England (PHE) yesterday about the ‘disparities’ in the risks and outcomes of COVID-19.

The review reinforces information we already have from other sources such as the ONS: that death rates from COVID-19 were highest among people of Black and Asian ethnic groups; that after accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death than people of White British ethnicity, and people of Chinese, Indian, Pakistani, Other Asian, Caribbean and Other Black ethnicity had between 10 and 50 per cent higher risk of death when compared to White British.

Responses to the review from the establishment have been predictable. Health Secretary Matt Hancock said that he felt a “deep responsibility because this pandemic has exposed huge disparities in the health of our nation.” And he assured us that the government is “absolutely determined to get to the bottom of this and find ways of closing this gap.” BBC’s Michelle Roberts said in her analysis that the findings reinforce what we already know – that “belonging to an ethnic minority group is a major risk factor.” The review itself proclaims that the disparities are a result of ‘complex’ factors.

I’m not entirely sure how the man responsible for the health of this nation can think COVID-19 is the first time the disparities in the health have been exposed. No wonder he thinks we need more efforts to ‘get to the bottom of this’. Because, otherwise, we would have to accept what we know, what we have known for decades – that the single biggest public health crisis affecting racialised communities is structural and systemic racism. A similar distortion of narrative is at play in Michelle Roberts’ comment as well. Is belonging to an ethnic minority community in contemporary UK the risk factor? Or is it racism – a product of white supremacy and privilege that affects every aspect of our lives on an everyday basis – that puts us at risk? 

The review is notably silent on this issue. It has been reported that a section in an earlier draft circulated within the government has been removed from the final published version. This section, significantly, contained responses from 1000+ organisations and individuals who supplied evidence to the review, and suggested the role of discrimination and poorer life chances in being at risk of COVID-19.

Much has been made of ‘pre-existing conditions’ that increase the risk of COVID-19. These are often talked about in terms of health conditions, as though health conditions are not connected to social, economic, political and material conditions. This also helps blame the communities for ‘getting’ more COVID-19.

So it is time we considered the deadliest pre-existing conditions of them all – structural racism and white privilege. I’ll give you just two examples.

We’ve all been told about the need for social distancing, for shielding vulnerable people, for ensuring that we stayed home where it was supposedly safe in order to minimise the risk of COVID-19. How does that work when people from Black, Asian and mixed backgrounds are significantly more likely to live in the most deprived 10% of neighbourhoods?  When, according to the English Housing Survey (2014-17), 30% of Bangladeshi households, 16% of Pakistani households and 12% of Black households experienced overcrowding, compared to just 2% of white British households?
Don’t deprivation and over-crowding count as pre-existing risk conditions? What measures were put in place to protect people living in these conditions? What measures are put in place now when the lock-down is eased, when we are sending our children back to school and our workers back to their workplaces, and they come back to multi-generational households in over-crowded spaces?

All of us are aware of the brilliant work our tired yet determined NHS has been doing during this pandemic. We’ve all (well, most of us at least) displayed our pasty skins and wild hair on our doorsteps and balconies on Thursday evenings to clap for the NHS. And yet nothing much has been said about the fact that being a key worker or working on zero-hour contracts that lands you in vulnerable jobs such as frontline NHS staff, care home workers, drivers, cleaners, food preparation and sales, delivery staff and so on are pre-existing risk factors for COVID-19.

Are we going to address that fact that millennials from racialised groups are 47 per cent more likely to be in zero-hour contracts, 5 per cent more likely to be doing shift work, and 4 per cent less likely to have permanent contracts than their white counterparts? Are we going to acknowledge that Black and Asian workers make up a disproportionately large section of the key worker sectors, especially in London?

Are we going to acknowledge that 61 per cent of the 200 healthcare workers who have died of COVID-19 were from racialised communities at risk from pre-existing conditions such as key working and zero-hour contracts?

Black and Asian nurses have reported feeling that they were targeted for working in COVID wards, that “they are being taken from the wards that they usually work on and put on the COVID wards and they feel that there is a bias – the same bias that existed before they are feeling is now influencing their being appointed and they are terrified…” Medics and healthcare workers from racialised communities have said that “systemic discrimination on the frontline of the coronavirus outbreak may be a factor in the disproportionate number of their colleagues who have died after contracting the virus.”

Could we pause for a minute and think whether institutional racism within the NHS is a pre-existing condition that puts the lives of people from racialised communities at risk? We know from history that it has fatal consequences for patients from our communities. COVID-19 has exposed how fatal it is for staff from our communities.
The PHE review is significant in that it makes no recommendations for action. There will now be calls, as is usual whenever the spectre of ‘ethnic inequalities’ raises its head, for race equality training, ‘nudge’ theories placing the blame on individual behaviours, for setting up equality panels and advisory groups (most of which, one might add, were dismantled by this government over the last ten years).

None of which will make any real difference. So let’s say it once again:

The biggest pre-existing risk factor for the health of people from racialised communities in the UK is the systemic and structural racism that is the direct result of white supremacy and privilege.

Owning up to it is the fundamental, most crucial, step towards solving this problem. The rest is much easier because there is no scarcity of knowledge about how to practice anti-racism in institutional, societal as well as personal spaces. What is scarce, though, is the political will. Can we expect it of this government, or of the one that is waiting in line? That is the maddening – and saddening – question.

Many of my colleagues from a decade ago who worked to achieve equality in health and social care are still working to challenge racism and discrimination.  This work is even harder now because much of the infrastructure painstakingly built up by people from racialised communities over many years to support this work – voluntary organisations, community support services, user-led organisations, campaign groups, advocacy services, self-help groups, refuges – have been systematically dismantled by a government that sees some lives as disposable. I know, for a fact, that we are tired, and we are angry.