The Sewell report cited my work – just not the parts highlighting structural racism

If the authors had referred to my latest research, they would not have been so quick to dismiss this crucial factor

Illustration by Sébastien Thibault
Illustration: Sébastien Thibault/The Hlcarpenter.com
Illustration: Sébastien Thibault/The Hlcarpenter.com

Last modified on Wed 7 Apr 2021 12.49 EDT

There has been a great deal of interest in the report of the Commission on Race and Ethnic Disparities (Cred), which reviewed pertinent evidence on discrimination in education, the labour market and elsewhere. My focus, unapologetically, is on the health chapter, which prominently cites my own work. Unfortunately, the authors of the report quote my views from the 2010 Marmot Review produced by the UCL Institute of Health Equity (IHE) – but they do not mention the explicit reference to race/inequality in two reports from our institute last year, Health Equity in England: The Marmot Review 10 Years On and Build Back Fairer: The Covid-19 Marmot Review.

I focus on health, not only because that is where Cred cites my work but because my longstanding worldview is that the level of health of the population tells us a great deal about how well a society is meeting the needs of its citizens. Inequalities in health tell us about inequalities in society. The health lens gives me a way of evaluating which inequalities in society are most salient. For example, should we care if one family lives in a bigger house than another? My approach to that difficult question is: no, we should not care, if those differences in housing do not lead to inequalities in health. But if living in an overcrowded, underheated, unaffordable dwelling leads to worse health, then we should indeed care. It means the way I evaluate the Cred report’s conclusion on the existence or otherwise of racism is whether it provides an adequate explanation of racial/ethnic health inequalities. (The report’s heading is “disparities”, but in the health chapter it sometimes lapses into the more familiar language of “inequalities”.)

Its chapter on health has much that is good in it. It states clearly that health inequalities are not primarily owing to inequalities in access to healthcare but to inequalities in the social determinants of health and in behaviours. It draws attention to the problems of the term Black, Asian and minority ethnic (BAME) – there are important differences in health among ethnic groups. I can, though, illustrate Cred’s shortcomings in its approach to racism by its shortcomings in the way it handles my reports on health inequalities. In reference to the IHE’s 2010 Marmot Review, the Cred report states: “The Marmot Review did find variations by ethnic minorities, however, it did not answer why the social determinants of health are unequally distributed between different racial and ethnic groups. This question was beyond the remit of the review but was also affected by the lack of consistent data collection on ethnicity in health.”

That is an accurate version of our thinking in 2010. Our charge then was to examine inequalities in health between social groups defined on the basis of socio-economic characteristics. Indeed, in 2010, I thought that most of the ethnic differences in health could be accounted for by various socio-economic characteristics. My change in view was very much influenced by the experience of chairing the Commission of the Pan American Health Organisation (Paho) on Equity and Health Inequalities in the Americas. The report, published in 2019 concluded that throughout the Americas – from North America to Latin America and the Caribbean – Indigenous peoples have worse health than non-Indigenous; and people of African descent consistently suffer disadvantage in health and in the social determinants of health. It highlighted the effects of colonialism and structural racism, and emphasised the overwhelming need to deal with such racism in combating the social determinants of health inequalities.

This thinking on structural racism informed our interpretation of evidence on health in the UK, and we cited the work of Paho in Build Back Fairer. Had the Cred commissioners consulted the executive summary of our 2020 report reflecting the first months of the Covid pandemic, they would have found a more pertinent insight: “The links between ill health, including Covid-19, and deprivation are all too familiar. Less so have been the findings of shockingly high Covid-19 mortality rates among British people who self-identify as Black, Bangladeshi, Pakistani and Indian. Much, but not all, of this excess can be attributed to living in deprived areas, crowded housing, and being more exposed to the virus at work and at home – these conditions are themselves the result of longstanding inequalities and structural racism.”

I think about these ethnic inequalities in two ways. The first perspective considers what causes the causes of ill health. Smoking, poor diet and obesity are causes of ill health, but the “causes of the causes” are the social determinants of health – the conditions in which people are born, grow, live, work and age. Structural racism can be one cause of the social determinants of health – the causes of the “causes of the causes”.

For example, we quote in Build Back Fairer the finding that, for 17 occupations, the higher the proportion of workers that come from BAME groups, the higher the Covid-19 mortality rates. The “causes of the causes of the causes” means that some ethnic groups are more likely to have adverse social conditions, in this case working in high-risk occupations.

The second way to think about ethnic health inequalities flows from the intersection between ethnic patterns of disease and socio-economic position. There are health differences between races that are not fully explained by class; it is likely that racism plays an important role. To put it simply, these two issues may overlap, but they are not the same thing. The report notes that some ethnic groups have better health than others, but this simply reveals the limitations of the BAME classification; it does not disprove the role of racism.

It is surprising that the Cred report’s authors are so ready to dismiss structural racism when they quote “experts advise us that mental ill health has little to do with genetic predisposition but rather is to do with adverse social circumstances, including racism and hardship”. The debate is more than semantic. The report’s authors recognise the importance of social determinants of health but want to look downstream at what individuals and communities can do for themselves. What? If you find yourself in unaffordable housing or in-work poverty, do what you can to get out of it? Those of us who recognise that the nature of society is vital want to look upstream to the social structures that have such powerful influences on health and wellbeing. Achieving a fair distribution of health among social and ethnic groups will be a sign that we have changed society for the better.

  • Michael Marmot is professor of epidemiology at University College London, director of the UCL Institute of Health Equity, and past president of the World Medical Association