One of the last things I did before lockdown began was to speak at the Royal College of Obstetricians and Gynaecologists at an event on race and maternal mortality. It has been known for a few years now that – incredibly – black women in the UK are five times more likely to die in pregnancy than white women, while Asian women are twice as likely to die. The atmosphere in the room was heavy with anger and disappointment. Black doctors, nurses and midwives were exasperated by the failure to protect women.
In the United States, too, black and Native American women suffer greater rates of maternal mortality than white women. This is just one of many examples of racial inequality in health. A US study found last year that black patients were 40% less likely than white patients to get the medication they needed to relieve acute pain. A UK study published in January showed that Asian patients with dementia were 14% less likely to be prescribed beneficial anti-dementia drugs than white patients were.
It isn’t as though nobody has spoken out about this before. Many of us have been shouting for years into what has felt like the void, trying to get professional health bodies and politicians to act on what has always been apparent in the data: that to be black or brown is to see your body suffer disproportionately and you may even die sooner than average. The problem is particularly pronounced in the US. According to research from the Centers for Disease Control and Prevention, the life expectancy gap between black and white Americans has narrowed over time, but still sits at more than three years.
Little did we know that it would take a pandemic to finally put the issue of minority-ethnic health at the top of the agenda. Within weeks, data began to show that ethnic minorities in both the US and the UK were clearly bearing the brunt of the virus. As we began clapping for NHS workers, stories emerged in the press of Asian and black doctors dying in surprisingly high numbers. Ate Wilma Banaag, a nurse at Watford general hospital, died in early April. Krishan Arora, a GP in Croydon, died later that month. Cecilia Fashanu, a nurse at Cumberland infirmary, died at the end of it.
The UK’s Intensive Care National Audit and Research Centre found that a third of patients needing breathing support in intensive care who had tested positive for the virus were non-white. Data published by the Office for National Statistics (ONS) in early May suggested that black people in England and Wales at that time were around four times more likely than white people to die from Covid-19.
The media attention on coronavirus meant these figures couldn’t easily be ignored. But neither should we have been all that surprised. All the factors that have long impacted the health of minorities were inevitably going to play out in the event of a pandemic. When you factor in that London – which has a minority white British population – was hit first, and that many high-risk frontline jobs, particularly in hospitals, are held by BAME people, then the data pretty well matched what anyone should expect. We could have predicted this. There was no great riddle here, no scientific puzzle to be solved.
What was really odd was all the head-scratching in the press, even in major scientific journals. “Mystery over high risk to black and Asian Britons”, ran an online Daily Mail headline. It was as though people had forgotten that racial disparities in health have always existed. A hasty government review into minority-ethnic deaths due to Covid-19, published last week, scrambled to explain in a few weeks what researchers have been documenting for decades. The Public Health England report not only failed to tell us anything we didn’t already know, but even fell short of telling us everything we did, including the considerable health impacts of structural discrimination.
Meanwhile, in their desperation to solve the race puzzle they had invented for themselves, scientists have continued to ask whether there might be deeper genetic factors at play. Could it be possible that BAME people have innate qualities that make them more likely to get sick? You know, those horribly faulty black and brown genes? The UK Biobank, a repository of public DNA, is being mined for correlations as I write. Some medical researchers appear to have forgotten that the racial categories we use every day are socially, not genetically, defined. In the US, for instance, a person can have just one ancestor of African origin and still be categorised as black based on their appearance and society’s perception of them.
But then, this is what the medical community has always done: pathologise blackness. In the US in the 19th century, as Harvard historian Evelynn Hammonds has documented, a medical condition known as “drapetomania” was invented by white physician Samuel Cartwright to describe the phenomenon of black slaves running away from their owners. Because how else to explain the errant behaviour of the naturally enslaved? From bone density and skin thickness to susceptibility to pain, doctors have long sought to isolate what is tangibly different about those who society has already oppressed. Despite their persistent failure to find any meaningful differences, they still do it now.
As the pandemic has rolled on, many experts have wondered whether vitamin D might be responsible for the gaps we’ve seen. After all, we know that it’s linked to immunity and that it’s harder to get enough of it when you’ve got darker skin and you’re living in a colder climate. Voila! It’s one of those neat explanations that immediately absolves society of all blame for social disparities in health. The reason those with darker skins are dying is that they’ve simply forgotten to take their supplements!
A more likely explanation for some of the disparities we see, as people are slowly beginning to acknowledge following the killing of George Floyd in Minneapolis, lies not in race, but in racism.
Racial health inequality has its roots in the same neck-crushing racism as a bigoted thug with a police badge, but it plays out in more subtle ways: in the white flight that created ethnic ghettos, in the inhumanity shown to migrants and refugees, in the difficulties black and Asian people face in getting good jobs, in ethnicity pay gaps, in all the little bullets that society fires at you if your skin colour happens to be different. If you want to know how early these bullets begin to be fired, even infant mortality rates are higher in the US among black Americans.
Being poor is a crucial social factor when it comes to bad health. The life expectancy of women living in the most deprived areas of England is more than seven years lower than that of women living in the least deprived, according to the most recent data published by the ONS. For men, the gap is more than nine years. And it has got worse over the last decade.
Poverty overlaps with race, but not entirely. And this means that, as more data comes in, we must also acknowledge that some of the factors that make ethnic minorities more vulnerable also make certain white Britons and Americans more vulnerable, too. As of June, the region in England with the highest death rates from Covid-19, overtaking London, is the north-east, which suffers terrible levels of deprivation and child poverty – and also has among the whitest towns in the country.
Individual disadvantage, as much as we may want to view it as a simple formula, operates in complicated ways. An affluent black Briton may well have better living conditions and diet than a working-class white person living in a former mining town, but then they are also more likely to face racial discrimination when they go to a hospital. There are layers of complexity here, each of which has to be unpicked. Going forward, what we need is fewer knee-jerk official reports and more slow, careful research on the many and varied social determinants of health.
In the end, as the data shows, this is also about power. The levers of capitalism have widened inequality between the rich and poor; funds drained from the NHS and local communities have left them less resilient; and populist politics have pitted people against each other when we should be united. The issue is not just racism, but how racism plays out in a society that is already brutalising its citizens. Tackling racism is just one crucial part of the enormous task of making life fairer for everyone – but it is a necessary one, because a nation that is able to view some of its people as less human than others will never have the moral strength to resolve its other problems.
Angela Saini is the author of Superior: The Return of Race Science, out in paperback on 25 June.