Dr Raghib Ali is an Honorary Consultant in Acute Medicine at the Oxford University Hospitals NHS Trust, and a Visiting Research Fellow of the Department of Population Health, University of Oxford.
Last month, it was widely reported that Public Health England’s report, ‘Beyond the Data: Understanding the Impact of COVID-19 on BAME Communities’, proved that systemic racism had contributed to their increased COVID-19 death rate.
The report itself was more nuanced, saying: “racism, discrimination and social inequalities…may have contributed to the disproportionate impact of Covid-19 on people from black, Asian and minority ethnic (BAME) backgrounds.”
While it is true that the death rate for Covid-19 is higher in non-whites, the analyses presented did not account for the effect of occupation or comorbidities. The current evidence is inconclusive and most of the increased risk can be accounted for by known risk factors, including co-morbidities, deprivation, higher risk occupations, living in densely-populated urban centers, air pollution and multi-generational households.
In fact, the claims about racism were based on the subjective views of 4000 ‘stakeholders’ – not on objective evidence – as the report itself acknowledged. Although it is possible that racism contributed to some of the risk factors, this certainly does not prove that racism caused Covid-19 deaths, and such inflammatory claims should not be made without solid evidence.
Also, if it were true that non-whites suffer from systemic racism throughout their lives – adversely affecting their health, education, income, housing, employment (the key determinants of health) – this would be reflected in life expectancy/overall mortality figures which are the best measures of overall health.
However, (in contrast to the situation in the US, where Blacks do have lower life expectancy) non-whites in the UK actually have higher life expectancy / lower overall mortality than Whites. In Scotland life expectancy (LE) is higher in Indians, Pakistanis and Chinese than Whites, and in England and Wales, both Blacks and Asians have slightly lower death rates than Whites, with those born in Africa, the Caribbean, and South Asia all having lower overall and premature mortality than those born in the UK.
This finding is surprising as some ethnic minorities are much poorer than Whites – with over 30% of Pakistanis & Bangladeshis and 20 per cent of Blacks living in the most deprived 10 per cent of areas (versus 10 per cent for Whites & Indians) and deprivation is the main factor associated with lower LE. Those who live in the most deprived areas of England (predominantly in the North) live on average 10 years less compared to the least deprived (25 years between Blackpool and Westminster) – the gap is even worse for healthy life expectancy where the difference is 20 years on average (33 years between Blackpool and Westminster) and this gap or social gradient in health is seen within all major ethnic groups.
This gradient was also seen for Covid-19 where, amongst non-whites, the most deprived were four times more likely than the least deprived to require intensive care, again illustrating the need to focus on deprivation.
We see a similar picture when it comes to education – which is both a key determinant of health and hugely affected by deprivation. The Race disparity Audit showed that, when looking at outcomes by ethnic group alone, Indians & Chinese outperform other ethnic groups, including Whites, at every level of education while Black Caribbean children perform worst – and significantly worse than Black Africans – except for university entry where Whites have the lowest rate (although they then do go on to have the best degree and employment outcomes.)
Once deprivation is taken into account – by comparing only those on Free School Meals (FSM) – White and Black Caribbean children have the worst outcomes on almost every measure and especially university entry. (Although there are again huge regional variations – 48 per cent of inner London FSM children v 18 per cent in the South West.)
Children from ethnic minorities are now also more likely than Whites to attend grammar schools whereas just 2.6 per cent of their students are on FSM (compared to 14 per cent of the population.) Even for Oxbridge entry, non-white students are now as likely as Whites to gain entry whereas those on free school meals have almost zero chance.
This was also my experience as a student at Cambridge where it was not my ethnicity which made me stand out as much as the fact I had been on FSMs. There were many non-White students – but invariably from middle-class, private or grammar school backgrounds – whereas there were barely any deprived students of any colour.
Deprivation, therefore, is the key factor driving educational inequalities with children of all ethnicities on FSMs doing much worse than those who are not.. But again, we see that some groups (Pakistanis, Bangladeshis and Black Africans) – despite being more deprived than Whites and Black Caribbeans – have better educational outcomes.
Based on this data, I draw three broad conclusions.
Firstly, the primary factor in health and educational inequalities is deprivation, not race.
Secondly, there is now no overall ‘White privilege’ in health or education (and especially not for deprived Whites) – or overall ‘BAME disadvantage’ – and these categories are now outdated and unhelpful. There are large differences in both health and educational outcomes between & within ‘Blacks’ and ‘Asians’ – with the biggest differences seen within Whites. Deprived Whites actually have more in common with deprived non-whites in terms of the challenges they face in education, employment, housing and health.
Thirdly, where ethnic disparities do exist (e.g. employment, promotion, criminal justice, etc.) we must take deprivation into account (i.e. compare deprived minorities to deprived Whites) – otherwise it is easy for some to blame racism when poverty may be the main factor. This also applies to those who, while rightly highlighting the plight of the white working class, blame ‘positive action’ towards ethnic minorities without presenting any evidence.
While I fully support the objective (if not always the means) of the young people demonstrating to eradicate racism, I have found that many of them are neither aware of these facts nor of the massive progress that has been made. Growing up in a white working class neighbourhood in the early 80s, we suffered racist abuse and attacks – with one of my earliest memories being of a brick being thrown through our front window. (But I knew they only represented a small minority and all my friends were also white).
My father had also faced open racial discrimination from the time he arrived in the early 1960s, but my parents never encouraged us to view ourselves as victims and stressed that education and hard work were the keys to a better future, with my mother – who enrolled in evening classes to gain additional qualifications while working full-time – as our inspiration.
Racism still blights too many lives today and we must we must continue to work towards a colour-blind society but Britain is not a racist country and what has been achieved in my lifetime is remarkable with my children growing up in a country transformed. Enoch Powell has been proven wrong – the UK is one of the most successful, multi-ethnic nations in the world, with huge, positive changes in social attitudes. Ethnic minorities are now well-represented – and successful – in almost every walk of life including medicine, business, sport, culture and politics. And this has been achieved without positive discrimination or quotas which ignore root causes and can be counter-productive – patronizing minorities and leading to resentment.
Unfortunately, there has been far less progress for the poorest in society – of all ethnicities – with evidence that gaps in life expectancy are worsening and social mobility is actually going backwards.
I therefore welcome the government’s ‘Levelling-up’ agenda to address the huge geographical variations in deprivation, health and education. These inequalities are longstanding and will require long-term solutions with better educational opportunities – particularly in the early years – being the key to breaking the cycle of deprivation and ensuring that everyone has the best possible start in life.
We can learn from those inner-city schools in London, which despite serving highly deprived (mostly non-white) populations, are producing outstanding results. And we should investigate why these deprived groups are doing better than others – including exploring the difficult terrain of whether cultural values, higher marriage rates and more stable homes are contributing to better outcomes.
In conclusion, we need geographically-targeted policies and interventions based on need, not ethnicity (but which will actually help those ethnic groups who have the highest levels of poverty the most – including deprived Whites.) Because the greatest determinant of your life chances today is not the colour of your skin but the circumstances into which you are born – and we must tackle this enduring injustice of ‘systemic classism’ to create a fairer Britain for all.