RACISM AND HEALTH
The real reason COVID-19 has had a disproportionate impact on the BAME population
At the height of the pandemic, black men were three times more likely to die of COVID-19 than white men. But this disparity has nothing to do with genetics and everything to do with societal inequalities, argues this month’s guest speaker, Dr Winston Morgan. Race is a cultural concept, not a scientific one.
The question is what we can do about it
Early on in the COVID-19 pandemic, it emerged that certain factors – particularly older age, male sex and geographical area – correlated with greater infection and death rates. But it was the suggestion that race or ethnicity could affect your chances of being infected that really exercised the media. As the pandemic developed, some used race as the principal explanation for the coronavirus’s disproportionate impact on society. Such was the focus on this that other factors – like having a compromised immune system and various co-morbidities, including diabetes and obesity – were almost seen as trivial by comparison.
Increasingly, susceptibility to COVID-19 was being used to redefine what we understand as “race”, effectively giving the concept a new scientific credibility. What’s more, the frantic efforts to find scientific explanations linking race to the medical outcomes of COVID-19 were suffocating any substantive discussions around the possibility that structural racism could be a more likely explanation for what we were observing.
As the pandemic took hold, people “racialised” as black were being forced to accept the extra burden of death from COVID-19 as a consequence of something inherent in them: the burden of genetics. At one point, it appeared as if it was only a matter of time before scientists discovered a single COVID-19 susceptibility gene, one that was found
exclusively in black, Asian and other minority ethnic (BAME) populations.
Among the unforeseen consequences of the speculation around race is that susceptibility to the virus could be used as a cover for both direct and indirect racial discrimination. For example, if it was accepted that certain groups are more susceptible to viruses, then employers could use it as a pretext to restrict what these people can do in the workplace. This is not hypothetical. Such is the power of race and ethnicity in our society today that, at the height of the pandemic, some NHS managers were seriously contemplating removing
BAME staff from certain roles.
In the end, the government launched a review of the evidence that the virus was disproportionately affecting BAME communities. The review concluded that people from certain groups (black and Bangladeshi) were most likely to be exposed to COVID-19 and consequently die from the virus. Unsurprisingly, it also found that among many BAME groups, especially in poor areas, there are higher incidences of chronic diseases and multiple long-term conditions occurring at younger ages. These co-morbidities and other factors contributed to the increased risk from the virus.
The review avoided the potentially controversial topic of genetic factors and barely mentioned race, preferring to use the term “ethnicity”. It defined ethnicity as a shared culture, with distinctive traditions that are maintained between generations, fostering a sense of shared identity. The reluctance of the review to discuss race and genetics is in contrast to the widespread speculation in the media, which is what prompted the call for a review in the first place.
Identity Crisis
In multiracial and multi-ethnic societies, we are frequently identified by race, or are required to identify ourselves in such terms. In many cases, both those demanding the information and those providing it have little understanding of what the different racial identifiers actually mean, or the history behind them. The result is that, today, we view the world through the prism of race, and society looks back at us through the same prism.
The racial categories we know now were constructed many years ago and have never had any scientific foundations. The idea of separating humans into distinct groups or races was primarily popularised to justify colonialism. Today, the most ardent advocates of theories about racial differences tend to be those with a white supremacist agenda.
Despite these questionable origins, a person’s race is largely treated with unquestioning social and medical certainty. Race is used alongside age, gender and social class to describe most societal outcomes, from employment to criminal justice, and even to inform medical decision-making processes. This acceptance of race as a reliable descriptor can also be seen on government-sponsored medical websites, where certain racialised groups are described as being more susceptible to conditions such as diabetes and heart disease.
This creeping acceptance of race as a scientific category with medical relevance has generally not been interrogated. This may be because of the wide acceptance of the role that genetics plays in so many aspects of our lives.
The dramatic and devastating impact of the coronavirus pandemic might represent the moment when we, as a society, were forced openly to examine the role that race and ethnicity play in medical and societal outcomes.
For the first time, government data was suggesting that a person’s race was the key determinant of their chances of surviving a pandemic – or, at least, that was how it was portrayed in the media. More worrying was the fact that neither the scientists nor the medical professionals were able to provide any alternative explanations. But how accurate are claims that it is your race that decides whether you are more likely to die from COVID-19? And if race is merely a social construct with no scientific basis, why are BAME populations worse affected?
The Race Fallacy
To understand how structural racism drives health inequalities – and ultimately deaths from COVID-19 – we must remember that race comes out of racism, and not the other way around.
Without racism, race has no significance and cannot exist in any meaningful way. The artificiality of race and ethnicity, particularly as they apply to biological outcomes, often leads to confusion and contradictions. Race is defined by a limited number of physical characteristics, primarily skin colour, hair texture and facial features. Ethnicity can be linked to language, culture and religion.
To complicate matters, many of these determinants transcend race and ethnicity.
For example, groups who are categorised as
Asian possess the full range of human skin colours; they also belong to the historical racial category of Caucasians, which includes white Europeans. Similarly, language, culture and religion may be observed across different ethnic and racial groups.
In the UK, the picture is further confused by data from the Office for National Statistics (ONS) of England and Wales. It categorises death rates from COVID-19 using a combination of race, religion and ethnicity, and this reveals differences that undermine the notion that infection rates are dependent on genetic factors linked to race. For example, people identified as being Indian, Pakistani, or Bangladeshi – who are normally all categorised under the same racial “group” – have very different outcomes from COVID-19. Look at the ONS data for males, who are more affected by the virus for reasons we do not yet fully understand, and you will see that those categorised as black are over 4.5 times more likely to die than their white counterparts, followed by Pakistanis and Bangladeshis (4.03), with Chinese and Indian males just over 2.5 times more likely to die. Even when the data is controlled for age, a range of socioeconomic factors and health, black males are still around
1.9 times more likely to die, with Pakistanis and Bangladeshis 1.8 times more likely.
An Unequal Playing Field
It is now widely accepted that those with conditions such as type 2 diabetes, obesity and cardiovascular disease are more likely to suffer adverse effects and even death following infection. There is also strong evidence that these conditions are found at higher levels in some black and Asian groups, contributing to the fact that they are disproportionately affected.
Though there is a genetic element to all of these conditions, the majority of the genes responsible are found in most human groups, and are not linked
“If race is a social construct, why are BAME people suffering more from COVID-19?”
to the socially constructed characteristics of a person’s race. In the absence of any genetic rationale, then, we are left with the more difficult-to-accept reality that these groups must be suffering more from the coronavirus because of how our society is organised.
The COVID-19 review makes numerous references to the importance of racism. The central tenet of racism is the belief that certain human phenotypic characteristics (in other words, observable genetic traits) allow us to place individuals in distinct groups or races, whose members have similar abilities and qualities. Such groups are then considered either “superior” or “inferior” to other groups and are treated accordingly.
Racism can be evidenced by poorer societal outcomes for those racialised as “inferior”.
Such groups are also less likely to have significant economic or political power. Racism can be seen at the individual, organisational or societal and structural level. Evidence for structural racism is everywhere, from poorer educational outcomes in children to criminal justice, housing and employment in adults. It drives conditions such as type 2 diabetes in several ways: cheaper foods tend to contain higher levels of fast-releasing carbohydrates and be more caloriedense, which, over a long period, are contributors to the condition. Structural racism is also a major cause of stress, which leads to a greater and more prolonged release of hormones such as epinephrine (adrenalin) and cortisol, adversely affecting blood sugar levels.
Taking Responsibility
The overwhelming message from the COVID-19 review was the need to address the cumulative effects of racism on BAME groups. The review made several recommendations that could be interpreted as follows: that there should be better data collection at all stages of health and social care based on individuals’ race and ethnicity, and that this data should be publicly available. That there should be better participatory research, so more BAME researchers can be involved in the process of data collection and analysis. That in order to improve outcomes for BAME patients, we need to increase the presence of
BAME staff at all levels of the health and social-care systems.
It also advised that risk assessments be conducted with greater cultural competency. Public health messaging, too, should be crafted with improved cultural awareness. Any post-COVID-19 recovery strategies must be aimed at specifically reducing racial and ethnic inequalities and should be sustainable, with adequate funding.
The inequalities that this pandemic has laid bare in places like the UK and the US are revealing particularly because these are multiracial, multi-ethnic societies and also putative liberal democracies, with everyone having collective responsibility for how all in society are treated. Such societies rely heavily on institutions such as the NHS to ensure fairness, and generally ignore the fact that such institutions have failed to prevent inequalities linked to race and ethnicity.
With these inequalities exposed, society needs credible explanations. However, our instinctive response has been to persuade ourselves that the inequalities are themselves the result of a natural phenomenon, and therefore outside the remit of our democracy and the control of our institutions. Rather than accept that racism is driving these inequalities, which would leave society at fault, we search for inherent deficits, including in the genes of those suffering. But there is overwhelming evidence that conditions such as type 2 diabetes and cardiovascular disease are rife in disadvantaged communities not because of any inherent genetic predispositions, but as a result of structural racism. And for that, we are culpable.