What race and deprivation tell us about the pandemic

'Inequality' is an insurgent word pervading popular and policy discourse since the 2008 financial crisis. From discussions surrounding Occupy Wall Street to Thomas Piketty’s widely acclaimed book ‘Capital’ (centered around income inequality), the concept of social, economic and political inequality rears its head in several contexts. 

While some British politicians have implied – and the New York governor has referred to – the virus as ‘the great equaliser’, others have called it the inequality virus revealing the sharp equity gradient in societies globally. 

While income inequality alone is a definite fault-line through which the coronavirus is expressing its devastation, a nuanced narrative is emerging through the statistics coming out of countries with marginalised ‘ethnic minorities’ like the United Kingdom and the United States. 

These stories are diverse but share some core themes which point to disparities in survival which follow ‘racial’ or ethnic lines. 

Available statistics are often rudimentary but aggregated data from some US states which have accounted for race and ethnicity are gradually emerging. These (as of April 30th) reveal a disturbing picture that black Americans across most states are experiencing coronavirus related deaths at  ‘elevated rates, relative to their population, in 31 of the 39 jurisdictions’ as analysed by the APM research lab.

Interestingly, a similar trend is noted in the UK. A recent analysis of four datasets reveal that the black, Asian and Minority Ethnic (BAME) communities have experienced disproportionately higher deaths among NHS staff as well as hospital and community deaths from the coronavirus. 

Remarkably, the first 10 doctors to die from the coronavirus in the UK were all from minority communities. 

These statistics are jarring, but come as no surprise. Racial and ethnic minority groupings face increased risk from coronavirus related death and illness (morbidity and mortality) through three major downstream pathways: increased direct exposure to the virus, poorer baseline health status including increased chronic conditions and finally through less accessible and lower quality healthcare. 

As decontextualised risk factors it may seem logical that interventions at these levels would lead to health improvements and hopefully lower overall risk when faced with a future pandemic.

The problem though, is that these ‘risks’, like the coronavirus, are not neutral functions of nature or inevitable biology. They are a consequence of upstream determinants which are very much influenced by human intent.

It could be argued that these poor health outcomes in ‘ethnic minority’ groupings could be accounted for by a lower socioeconomic status - since a poorer health status and lower income levels have well established associations. 

However, US studies around the ‘racial opportunity gap’ show us that when each income level is analysed, health disparities between black Americans and white racial groupings persist. Many of the upstream factors accounting for this are related to spatial issues linked to segregation.  

Health inequalities have been proven to follow ‘racial’ lines through various, and often interlinked pathways both at an individual level - through the individual experience of racial discrimination having a proven direct effect on health - as well as at the structural level. 

Structural rot

Structural racism that perpetuates health inequalities have some similarities when looking at the US and the UK. These root issues include “education, employment, income, housing, and  proximity to pollution.” 

These factors place disadvantaged populations at greater risk of chronic and underlying health conditions which may allow for greater morbidity and mortality from the coronavirus.

BAME groupings, both in the US and the UK face increased exposure to the coronavirus as a result of the areas in which they live. In urban areas, these are often densely populated spaces with overcrowded housing which may face multiple environmental risks. 

These areas face chronic underinvestment from both government and the private sector leading to poorer educational opportunities and weaker health systems, especially in the US where citizens don’t have the benefit of an National Health Service like the UK. 

We see that black Americans and BAME populations in the UK are more likely to hold jobs which put them at greater risk to coronavirus exposure. 

In the UK, "Pakistanis, black Africans and black Caribbeans are overrepresented among key workers overall," placing them at greater risk of "contact with contagious individuals." 

Intriguingly, trends in the US are comparable to the UK where, "Black workers are about 50% more likely to work in the healthcare and social assistance industry and 40% more likely to work in hospitals, compared with white workers." 

In the US, where income is tied to access to healthcare and health outcomes, there is still a wide household income differential between black American and white households. 

Individual income is also linked to food security and safe housing which  are some of the underlying determinants of chronic conditions which then prove to be risk factors for coronavirus related morbidity and mortality. 

As of 2018 (even after the Affordable Care Act), African Americans had an uninsured rate of 9.7 percent compared to 5.4 percent among whites. This translates to less health-seeking behaviour and less control of chronic conditions which may predispose these individuals to severe illness as a result of the coronavirus infection. 

Among the uninsured, there may also be a reluctance to seek treatment for symptoms of the coronavirus infection because of the threat of out of pocket payments. These payments impact already-strained household budgets with resultant secondary adverse health impacts from decreased household financial reserves. 

It's not theory

How we chose to explain these factors which place ethnic minorities at greater risk matters, because it has a bearing on outcomes. 

Failing to recognise the root causes of health inequalities which follow ethnic lines means that interventions aimed at secondary measures will simply allow inequalities to persevere through other pathways. 

Tying factors like education, occupation and housing to individual effort and choice erroneously misses the root cause of these issues. 

The reality is that these inequalities need to be considered through the paradigm of structural, cultural and individual-level racism.

The individual experience of racism is well known to have direct effects on health, with emotional distress leading to physiological consequences including hypertension. 

Centering risk factors for morbidity and mortality from the coronavirus around discussions of Vitamin D deficiency or explaining that unhealthy lifestyle choices places ‘blame’ at the level of the individual.

By holding individual choice and cultural factors responsible for health differentials, broader entrenched prejudices and discrimination are obfuscated. 

Here, the legacy of federal policies which have entrenched segregation or redlining and mortgage discrimination can be overlooked becuse inequalities in death and illness from the coronavirus are then tied to and bound within the bodies of ethnic minorities. 

In the US, the argument around innate biological differences being responsible for health differentials dates back to slavery where there was a need to justify enslavement of Africans.

We see this same pattern playing out with some ‘science’ attempting to sidestep issues of socioeconomic stratification along racial and ethnic lines with the vitamin D discussion as well as the provision of culturally bound reasons for certain groupings having a greater prevalence of chronic health conditions. 

Are African Americans and BAME groupings destined to be low wage, ‘front-line’, high exposure jobs because of biological ‘predisposition’ or would the legacy of racial segregation, redlining and chronic underinvestment in health, environmental and educational services be a more plausible rationale for higher coronavirus related mortality rates within certain communities?

These questions require evidence-based, theoretical probing and morally driven answers. As society conducts a collective post-mortem, an honest body of evidence needs to emerge so that the tragedy unfolding before us is not repeated.