This explainer is part of a Local Democracy Research Centre paper on global health inequalities. Read Still unequal: dealing with health inequalities through the pandemic and beyond
The pandemic has highlighted the structural disadvantage and systemic discrimination faced by Black, Asian and minority ethnic communities groups in the UK and globally. The reasons for this are due to a complex interplay of factors rather than a single cause.
The King’s Fund published The health of people from ethnic minority groups in England in September 2021. It examines ethnic differences in health outcomes, highlighting the variation across ethnic groups and health conditions, and considers what is needed to reduce health inequalities. They point out that the picture is complex, both between different ethnic groups and across different conditions, and understanding is limited by a lack of good quality data.
The Covid-19 pandemic has had a disproportionate impact on ethnic minority communities who have experienced higher infection and mortality rates than the white population. Geography, deprivation, occupation, living arrangements and health conditions such as CVD and diabetes accounted for a large proportion, but not all, of the excess mortality risk of Covid-19 in ethnic minority groups. Covid-19 has reversed the previous picture for some ethnic minority groups which now have higher overall mortality than the white population.
An essay published in the BMJ Journal of Epidemiology and Community Health, Unequal impact of the Covid-19 crisis on minority ethnic groups: a framework for understanding and addressing inequalities suggests that differences in health outcomes due to the pandemic could arise through six pathways: differential exposure to the virus; differential vulnerability to infection/disease; differential health consequences of the disease; differential social consequences of the disease; differential effectiveness of pandemic control measures and differential adverse consequences of control measures. (Srinivasa Vittal Katikiredd, Enitan D Carrol, Claire L Niedzwiedz, Kamlesh Khunti, Ruth Dundas, Finn Didenrichsen, Ben Parr).
The authors conclude that ethnicity is a complex, multi-dimensional social construct and health differences between some ethnic groups largely reflect social pathways, embedded within the unequal power relationships that propagate inequalities.
There is growing evidence from the US of the unequal impact of the pandemic on Black Americans, resulting from existing inequalities in their working lives, access to healthcare, and income. Black Americans are more likely to have jobs involving close contact with people, including care support roles, personal services such as hair salons and in food preparation and hospitality.
Ichiro Kawachi in an article in the International Journal of Epidemiology refers to
the persistent residential segregation of neighbourhoods, where ‘unequal exposure to air pollution and over-crowded housing conditions amplify the spread of infection’. He also notes that besides residential neighbourhoods and workplaces, some of the biggest outbreaks have been recorded in prisons, where some 2.3 million Americans are incarcerated, half of whom are Black or Hispanic.
(Kawachi, October 2020, International Journal of Epidemiology)
The experience of ethnic minority groups in the UK mirrors that in the US.
An article in the LSE website British Politics and Policy in May 2021 (Lucinda Platt) considered the complex background to the impact of Covid-19 on people of different ethnicities in England that may influence both infection and severity. She notes that once the fatality rates are adjusted for age, the death rate for minority groups has been disproportionately higher, albeit with some variation by specific group. This was the case for people in Black and Asian minority groups living in care homes, as well as for those in the rest of the population.
Although deaths have been highest among older (predominantly White British) people, once the fatality rates are adjusted for age, the death rate for minority groups has been disproportionately higher, albeit with some variation by specific group. This higher rate was the same for ethnic groups living in care homes as for the rest of the population.
The article examines the complex links between different risk factors. The link between deprivation and enhanced risks from Covid-19 are now well researched in terms of area deprivation, socio-economic position, census-based measures of deprivation, and overcrowding:
Since ethnic minorities are more likely to be living in poor families and deprived areas, a counting for these levels of deprivation has mediated some, though not all, of the excess risks faced by specific minority ethnic groups.
Given how particular health conditions increase the severity of the impact of Covid-19, analysis was adjusted for relevant health conditions and hospitalisations, which again explain an additional share of the disparities but still leave unexplained gaps. A further disparity relates to rates of survival among those admitted to hospital, which showed ethnic group differences that were particularly severe for Bangladeshis. Again, adjusting for pre-existing health conditions (and for other factors) reduces but does not close this gap.
Platt points out both the presence of relevant health conditions and their severity may be linked to prior patterns of persistent disadvantage and discrimination, complicating the relationship between prior health, deprivation, and Covid-19 mortality.
In addition, those health conditions that are linked to high risks of mortality from Covid-19 may also be more or less severe and more or less well managed across ethnic groups. Bangladeshi men and women and Pakistani women of this age are more likely to have a longstanding health problem and multi-morbidities than the White British, while those from the Other White and Black African ethnic groups in this age range are rather less likely to.
The fact that ethnic minorities may be disproportionately employed in roles that carry elevated risk of exposure to Covid-19 has also been identified as a possible contributing factor to their elevated mortality risk.
Note: The above is an edited extract from the author’s published work in the LSE Public Policy Review (available open access here).
A joint report by the House of Commons health and social care and science and technology committees on lessons learnt from Covid-19 included comment on the disproportionate impact of covid-19 of people of people of Black, Asian and minority ethnic communities:
In October 2020, the ethnicity sub-group of SAGE concluded with high confidence that genetic differences between ethnic groups “cannot explain the higher number of severe cases and deaths since ethnic minorities are very genetically diverse”. Written evidence submitted to our inquiry suggested that differences in covid-19 outcomes among different ethnic groups were instead more likely to reflect underlying social, structural and economic inequalities.
During the initial phase of the pandemic Black, Asian and minority ethnic people experienced significantly higher levels of severe illness and death from covid than was typical the population as a whole. Research conducted so far suggests that the drivers of these elevated levels of impact among Black, Asian and minority ethnic people arise from greater likelihood of jobs that come with higher exposure to covid infection; more challenging social and economic circumstances; more densely occupied housing; and comorbidities from different health conditions. These are classic features of inequality in society and in the economy.
See LGIU briefing Covid-19: Britain’s alarming public health failure
