Rageshri Dhairyawan and Darren Chetty
Racism has accompanied the COVID-19 pandemic from its early stages with reports of East Asian people experiencing racist attacks on the streets of Britain. In the United States (US) President Trump has repeatedly chosen to refer to the ‘Chinese virus’ in his official briefings from the White House. Whilst all of these actions have been widely condemned, they are merely the most overt expressions of racism in connection with the virus. Less overt racism may well cost numerous lives.
Early reports suggest that people from racially minoritised groups are being disproportionately affected by COVID-19 in the UK and US. In the UK, a national critical care audit has shown that despite making up 18% of the general population, people from Black, Asian and minority ethnic (BAME) groups represent 32% of critical care patients. In the US, several states report that racially minoritised groups are also bearing the brunt of the disease. In Michigan for example, African Americans make up 14% of the state’s population, but 40% of its deaths.
To those that study health disparities, these differences may come as no surprise. Racial disparities in other health conditions are common. But how we account for these disparities informs the action we take in response to them. So what may be the causes for these racial differences with COVID-19?
In the UK, people from BAME groups are, on average, more likely to live in deprived, densely populated urban areas, where smaller living space is more common. Thus they are more likely to be exposed to the virus due to socioeconomic factors that mean that they cannot socially distance as advised. They are more likely to be persistently poor with higher rates of unemployment or in low-skilled, low-paid occupations. They may be less able to work from home. BAME groups may also be more likely to have poor outcomes once infected. The Marmot Review Ten Years On examines health equity in England and shows that people living in economically deprived areas have a lower life expectancy and increased risk of chronic health conditions such as cardiovascular disease, type 2 diabetes mellitus and hypertension. These chronic health conditions are associated with poorer outcomes with COVID-19. All of this points to socioeconomic factors having a great impact on health disparities.
Despite this evidence, when racial disparities are observed in health outcomes biological explanations are often proposed by commentators and indeed clinicians, and unfortunately COVID-19 is no different. The UK critical care audit cited at the start of this piece has provoked discussion about possible causes for the disparities, including biological differences. This is not surprising, as it remains common practice for doctors to use ‘race’ as a marker for ancestry and to believe that human bodies have innate differences that can be determined by physical appearance. But ‘race’ is a poor marker of ancestry – the Human Genome Project demonstrated that there is more genetic diversity within racialised groups than between them. Categorising people into races by their appearance or cultural practices is also done with great variability amongst clinicians and researchers. Most doctors are not taught about the historical context for now discredited scientific theories of distinct races.
Notions of ‘race’ developed by European scientists and philosophers during the period of European colonial expansion ascribed different traits, and crucially, value to different bodies. These theories helped facilitate the subjugation, enslavement and genocide of peoples thought to be of lower human worth than Europeans. This thinking was also used to justify unethical medical experimentation on subjects. Doctors continue to use knowledge gained from these experiments, but are rarely taught about the origins of this knowledge. This is significant, as echoes of this thinking can still be heard in current medical discussions. For example, in early April 2020 French television showed doctors suggesting that COVID-19 vaccine trials should be carried out in Africa, not Europe or Australia, as there were less healthcare facilities and protective equipment there. This suggests that unequal value is still ascribed to different bodies.
COVID-19 is far from unusual in being a disease that some parts of the population are affected by, at a higher rate. Attempting to explain this by defaulting to theories of racial difference is, to put it mildly, not good science. Professor of Public Health and Policy, Margaret Whitehead, described health inequities as resulting from the “systematic and unjust distribution of economic, political and environmental resources needed for health” (1). If we continue to misattribute racialised health disparities to innate biological causes, we ignore the socioeconomic determinants of health that contribute to these health inequities.
With our current limitations on critical care capacity, decisions are being made rapidly about who will be most likely to survive and therefore who should have access to critical care resources. Doctors are advised to consider underlying health conditions (2). It is highly likely that the underlying health conditions will include those that BAME groups are disproportionately affected by, which suggests that racial inequalities may indirectly factor in determining who gets critical care. We risk removing health resources from those who are already socially disadvantaged, thus compounding health inequities. In such a situation, there is a serious risk that racial inequality, social in origin, might implicitly be used as a justification for further racial inequality. To prepare for future pandemics, clinicians and researchers must recognise how racial pseudo-science still manifests in subtle, but potentially deadly ways in our decision-making.
(An earlier version of the article was submitted as a blog to one of the most-read medical journals in the UK. We received two messages informing us that the editors would respond quickly to our submission. However, after 8 days we were unable to secure either a decision, or a clear response as to when we could expect a decision. Given the rapidly developing situation, we have chosen to publish it here.)
(1) WHO Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on social determinants of health. Geneva, WHO, 2008.
(2) NICE guidelines [NG159]. COVID-19 rapid guidelines: critical care in adults. Last updated 31/3/20.
Dr Rageshri Dhairyawan, Consultant Physician in HIV Medicine, Barts Health NHS Trust. @crageshri Darren Chetty, Teaching Fellow, UCL. @rapclassroom