Why the higher death rate?

Racism and Covid-19

Capitalism itself is the cause of structural social inequality, writes James Linney

On June 2 Public Health England (PHE) published its much anticipated report regarding disparities in the risk and outcomes of the Covid-19 infection.1 The government had promised there would be an investigation into why a disproportional number of black, Asian and minority ethnic (Bame) people have been affected by the pandemic and would set out recommendations for correcting this increased risk.

Unsurprisingly, the final report did neither of these things; instead it largely reproduced data confirming what was already well known: increasing age, obesity, geographical area and being male are risk factors for death from Covid-19. The small section on Bame and risk also revealed nothing not already well established: namely, that if you are from the Bame community then Covid-19 is a significantly more serious threat to your health than if you are white. To be fair to PHE, these disparities are so striking that it was data worth repeating, yet it leaves the most anticipated question unanswered: are the disparities due to institutional racism within the national health service?

The PHE report shows us that being black makes you much more likely to be diagnosed with Covid-19: 486 per 100,000 of the population in females and 649 in males, compared to the much lower rate in people of white ethnic groups (220 in females and 224 in males). It also confirms that being Bame results in much worse outcomes in those who are more seriously affected and need hospitalisation:

After accounting for the effect of sex, age, deprivation and region, people of Bangladeshi ethnicity had around twice the risk of death, when compared to people of white British ethnicity. People of Chinese, Indian, Pakistani, other Asian, Caribbean and other black ethnicity had between 10% and 50% higher risk of death when compared to white British.

Further, all-cause mortality was four times higher for black males during the pandemic, compared to the same time last year.

These shocking statistics join a growing body of evidence documenting the disproportional burden that Covid-19 is having on Bame people. For example, the Office of National Statistics (ONS) published data last month revealing that black men and women are four times more likely to die from the virus,2 while another recent study published in the BMJ found that 56% of all pregnant women admitted to hospital with Covid-19 have been Bame.3 This disproportionality is seen even more acutely in healthworker deaths, where 61% of Covid-19’s victims are from a Bame background.4

Despite the PHE report confirming these horrendous disparities, it drew controversy more for what was excluded: an early draft had included an additional 64-page section, dealing with the causes of Bame Covid-19 deaths and presenting some suggestions for remedying the problem. According to a Health Service Journal article, the chapters ultimately removed from the final publication

included responses from the 1,000-plus organisations and individuals who supplied evidence to the review. Many of these suggested that discrimination and poorer life chances were playing a part in the increased risk of Covid-19 to those with Bame backgrounds.5

The government has been accused of whitewashing the PHE report, apparently due to fears that the redacted sections would ignite more protests in the light of the Black Lives Matter movement. Initially the government denied this section ever existed - strange then that it was leaked and is now due to be belatedly published. At the time of writing, this still has not happened, but it reportedly includes some recommendations for reducing future Covid-19 Bame deaths. These include Bame NHS staff having individual stratified risk assessments, ethnicity data collection and recording, funding for “culturally competent” Covid-19 education campaigns and shielding Bame workers from jobs with the highest risk of Covid-19 transmission.


Hardly riot-inducing, but it is the accusations contained in these pages that the health service is institutionally racist that spooked the government. This was an echo of the Macpherson inquiry into the Stephen Lawrence murder, which found institutional racism in the police force, and perhaps too risky a reminder that in the 21 years since this inquiry very little has changed.

There have been some erroneous suggestions that there is an underlying biological explanation for the Bame Covid-19 deaths - genetic reasons that predispose some to more serious illness. One such theory has been that vitamin D deficiency has a role in infection susceptibility and results in poorer outcomes. Vitamin D deficiency is more common in darker-skinned people because larger amounts of the pigment, melanin, in the epidermal layer of skin reduces the ability to absorb vitamin D from sunlight. There is, however, very little evidence supporting the idea that vitamin D plays a significant role in the deaths, and what evidence there is suggests only a small benefit in correcting a vitamin D deficiency.6

Another attempt to explain the disparities are that Bame people have more underlying co-morbidities, due to genetic predispositions to certain ailments, such as diabetes and cardiovascular disease. Although some single gene conditions, such as sickle cell disease (a gene mutation which causes red blood cells to become less efficient at carrying oxygen), are more prevalent in people of African, African-Caribbean or south Asian origin, these are still very rare and do not have a major impact on Covid-19 death rates. Diabetes and cardiovascular disease, in contrast, are far more complex, but the role of genes in these illnesses is poorly understood and there is again very little evidence that they are able to explain the high Covid-19 death rates. For one thing, there are variations within different ethnicities, where the diabetes and cardiovascular risk factors should be the same, but the deaths from Covid-19 are very different. For example, the risk of dying from Covid-19 for people originating from Bangladesh and Pakistan is nearly twice that of those from India, according to the ONS data.7

What then does it mean to claim that the health service is institutionally racist? It implies more than just individual discrimination on the behalf of doctors, nurses or health workers towards non-white patients. Proportionally Bame people are more highly represented in the NHS than in the UK population as a whole (21% versus 19%); and, although individual racism is inevitably present in the NHS, the nature and experiences of the job - ie, caring for sick people - is more promoting of empathetic, less discriminatory attitudes, compared to, say, the police force, where (aside from naive fantasies of protecting the public from ‘bad people’) part of the job is overtly protecting the privileged position and property of the ruling class, at the expense of the least privileged in society, who are disproportionally Bame.

A clue as to how institutional racism manifests itself was given to us in another report, which was coincidentally published in February - around the time Covid-19 was spreading to the UK. Health equity in England: the Marmot review 10 years on8 was an update on the original Michael Marmot-authored report, which 10 years ago found social inequality to be the biggest single factor in health disparities in the UK. The updated report found that, rather than the government attempting to implement any of the original recommendations, it had instead opted for 10 years of ruthless cuts to welfare, social and healthcare funding. This left the NHS on its knees and for the first time since the 19th century we saw a stalling, and in some areas a fall, in life expectancy. Life expectancy follows a social gradient: the more deprived, the shorter life expectancy. The Marmot reports documented a carefully developed attack on the working class as a whole, but this has been accompanied by a vicious state-sponsored racist campaign, known as the ‘hostile environment’. Bame people have not only been vilified by the government, but they have more acutely felt the burden of the cuts.

Currently two-fifths of people from ethnic minorities live in low-income households - twice the rate for white people.9 About 70% of Bangladeshi, 60% of Pakistani and 50% of African-Caribbean households are within the lowest income - not surprising then that these are the worst hit by Covid-19. The reality of inequality for these communities means poorer-quality housing, more people per household, a greater rate of unemployment or less secure jobs, less money for healthy food, less leisure time, less availability of green spaces - the list goes on. In other words, it is a system designed to leave them in poorer health and predictably the worst hit when a lethal pandemic comes around. These conditions afflict the non-Bame community too - in greater numbers, but proportionally less. of course. Hence living in the more deprived areas of the UK means you are more than twice as likely to die from Covid-19.10

The very high proportion of Bame healthworker deaths can be explained by the fact that more Bame doctors tend to work in more deprived, urban areas, such as London, serving communities where the virus is more prevalent and resources stretched more thinly. Hence it has been reported that Bame doctors are more likely to work where there are shortages in personal protective equipment (PPE).11 Add to this the fact that Bame doctors face more insecurity in their work, feel less able to raise safety issues, have less opportunities for career progression, earn less on average12 for the same roles and are more likely to be in jobs on the front line of the NHS, where there is more Covid-19 exposure.

All of these are good reasons to support the publication and recommendations of the missing part form the PHE report, joining the call for better PPE for Bame workers, safe working conditions and for equal pay and opportunities with their co-workers. At the same time, we must be clear that we hold no illusions that government reports or inquiries will improve the situation for Bame people in the UK as a whole.

Attempts have always been and are currently still being made (even by those campaigning against it) to depoliticise racism. These people would have the working class struggle against racism, such as the Black Lives Matter protests, reduced to tokenistic displays. Before long the main issue has become the removal of statues or politicians proving their worth by ‘taking the knee’.

The point is to make these campaigns and the issue of Bame deaths due to Covid-19 more political, not less. The data from the PHE report is not just evidence of institutional racism: it provides objective evidence of the violent reality of capitalism. As we have seen, racism thrives because of inequality - social, economic and political inequality. The only cure for this virulent disease is through working class solidarity and organisation.

  1. assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/891116/disparities_review.pdf.↩︎

  2. ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/methodologies/coronavirusrelateddeathsbyethnicgroupengland

  3. bmj.com/content/369/bmj.m2107.↩︎

  4. theguardian.com/world/2020/may/25/six-in-10-uk-health-workers-killed-by-covid-19-are-bame.↩︎

  5. hsj.co.uk/coronavirus/exclusive-government-censored-bame-covid-risk-review/7027761.article.↩︎

  6. patient.info/news-and-features/vitamin-d-and-coronavirus-is-there-evidence-it-can-help.↩︎

  7. ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/methodologies/coronavirusrelateddeathsbyethnicgroupengland

  8. instituteofhealthequity.org/resources-reports/marmot-review-10-years-on/the-marmot-review-10-years-on-executive-summary.pdf.↩︎

  9. poverty.org.uk/low-income-and-ethnicity.↩︎

  10. bmj.com/content/369/bmj.m2389.↩︎

  11. bma.org.uk/news-and-opinion/bame-doctors-hit-worse-by-lack-of-ppe.↩︎

  12. bmj.com/racism-in-medicine.↩︎