Intended for healthcare professionals


Playing hide and seek with structural racism

BMJ 2021; 373 doi: (Published 21 April 2021) Cite this as: BMJ 2021;373:n988
  1. Dipesh P Gopal, NIHR in-practice fellow in primary care1,
  2. Mala Rao, director2
  1. 1Institute of Population Health Sciences, Queen Mary University of London, London, UK
  2. 2Ethnicity and Health Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
  3. Correspondence to: D P Gopal d.gopal{at}

A key contributor to ethnic disparities in health

The much anticipated report from the Commission on Race and Ethnic Disparities1 has generated controversy. The commission was established by the UK government after the Black Lives Matter protests in 2020 to explore the “state of race relations today” and “why so many disparities persist.” In particular, the commission was to investigate ethnic differences in education, employment, crime and policing, and health.

Despite confirming that racism “is a real force in the UK,” the report’s overall findings were widely condemned, with leaders and experts united in their concern that the report minimises and sometimes even rejects the key role of structural racism in theinequalities endured by ethnic minority people in the UK.

The 34 page chapter on health compares ethnic minority and white people on a wide range of outcomes. It examines differences in life expectancy, behavioural risk factors, genetics, and access to health. It rightly identifies that risk factors for health outcomes may include behaviours that in theory are modifiable by individuals but are also influenced by “socio-economic factors which can be changed, but often require government or societal action to facilitate that change.” However, it is deeply troubling that the report concludes that “communities can take steps to improve their own health outcomes and should be helped to do so” while failing to acknowledge the need to also tackle socioeconomic inequalities, with government leading that action.

The spotlight on higher maternal mortality rates among ethnic minority women and the recommendation that this should be prioritised for research is welcome. But in its response, the Royal College of Obstetricians and Gynaecologists highlights the racial bias towards poorer outcomes which permeates all aspects of women’s health and the need for more ambitious government targets to address this.2

Other commentators challenge the report’s conclusion that deprivation, family structures, and geography, not ethnicity, are key risk factors for health inequalities.3 The Royal College of Psychiatrists’ rebuttal goes further,4 warning that denying the effect of structurally determined social factors on racial disparities in mental health5 and blaming individuals and families instead is “dangerous to communities.”

Nothing has exposed the role of structural and institutional racism as starkly as the disproportionate effects of covid-19 on ethnic minority communities. Public Health England’s report identifies racism and discrimination as key contributors to infection risk, outcomes, and life chances.6 This is further reinforced by the covid-19 Marmot review Build Back Fairer,7 which attributes excess mortality in ethnic minority people to longstanding inequalities and structural racism.

Superficial and misleading

The commission’s analysis of access to healthcare is brief and concludes that racism and discrimination are not widespread. Yet there is substantial evidence of racial inequalities in areas as diverse as myocardial infarction,8 diabetes care,9 cancer,10 sickle cell disease,11 and genetic services.12 All of this has been overlooked, along with any consideration of the adverse effects of racism on cardiovascular health19 and signs of early aging.20

The scientific basis of medicine also offers well documented examples of racial bias, including a lack of appropriate dermatology teaching on brown and black skin,13 pulse oximeters that underestimate oxygen saturation in people with darker skin,14 and erroneous race based adjustments in measures of renal function.1516 All have persisted unnoticed for years and continue to risk misdiagnosis and the perpetuation of ethnic inequalities.17

The commission’s analysis of ethnic disparities in the NHS workforce is also superficial and misleading. It acknowledges the importance of the Workforce Race Equality Standard18 but makes no further mention of the many dimensions of racism experienced by ethnic minority staff. Discussion of the NHS ethnicity pay gap uses a 2019 mean basic pay for all staff to show that Asian men and women earn more than their white counterparts. Yet NHS Digital’s data from 2020 show that the pay gap favours white staff and has increased since 2017.21

Disappointingly, this report offers few innovative suggestions for tackling ethnic health inequalities. Nevertheless, some recommendations are worth considering such as a review of the ethnic pay gap, adding measures of ethnic inequality to Care Quality Commission inspections, and enhancing shared learning on the causes of, and solutions for, ethnic health disparities.

Working towards race equality is not new in the NHS, which embarked on an ambitious strategy seven years ago, initially limited to the workforce. The effect of covid-19 on ethnic minority staff and the Black Lives Matter movement have triggered many antiracist actions in healthcare. Medical curriculums are being decolonised, race based medical guidelines are being reviewed, and equal opportunity measures for career progression and a zero tolerance approach to racist abuse are being implemented in many institutions. In academia, centres for ethnic minority research are strengthening their engagement with communities. The scale of these activities is unprecedented and unstoppable.

Now, the proposed Office for Health Disparities, recommended by the report, needs to acknowledge its cross-cutting government role in removing structural barriers to change. Only then will it have the credibility to harness academia, the NHS, and minority communities to play their part in the journey towards a post-racial society.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: MR is medical adviser for NHS England’s workforce race equality strategy. The views expressed are those of the authors,and not necessarily those of their employers or funders.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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