The health of people from ethnic minority groups in England

This content relates to the following topics:

This explainer examines the differences in health outcomes for ethnic minority groups, highlighting the variation across groups and conditions, and considers what’s needed to reduce health inequalities.

Key messages

  • In England, there are health inequalities between ethnic minority and white groups, and between different ethnic minority groups. The picture is complex, both between different ethnic groups and across different conditions, and understanding is limited by a lack of good quality data.
  • Access to primary care health services is generally equitable for ethnic minority groups, but this is less consistently so across other health services. However, people from ethnic minority groups are more likely to report being in poorer health and to report poorer experiences of using health services than their white counterparts.
  • Despite this, before the Covid-19 pandemic, life expectancy at birth was higher among most ethnic minority groups than the white population. This underlines the complexity of the picture and the importance of distinguishing between the inequalities experienced by different ethnic groups.
    • People from the Gypsy or Irish Traveller, Bangladeshi and Pakistani communities have the poorest health outcomes across a range of indicators.
    • Compared with the white population, disability-free life expectancy is estimated to be lower among several ethnic minority groups.
    • While the incidence of cancer is highest in the white population, rates of infant mortality, cardiovascular disease (CVD) and diabetes are higher among Black and South Asian groups. CVD and diabetes cause significant morbidity among these groups, much of which can be prevented by public health measures aimed at tackling risk factors such as obesity, poor diet, inadequate physical activity and smoking.
  • The Covid-19 pandemic has had a disproportionate impact on ethnic minority communities, who have experienced higher infection and mortality rates than the white population. The reasons for this are multi-factorial and not fully understood, but there is overwhelming evidence that existing socio-economic inequalities and co-morbidities such as CVD and diabetes have played a key role. The impact of Covid-19 has been so significant that it has reversed the previous picture and many ethnic minority groups now have higher overall mortality than the white population. 
  • Unpicking the causes of ethnic inequalities in health is difficult. Available evidence suggests a complex interplay of deprivation, environmental, physiological, behavioural and cultural factors.
  • Ethnic minority groups are disproportionately affected by socio-economic deprivation, a key determinant of health status. This is driven by a wider social context in which structural racism can reinforce inequalities among ethnic groups, for example in housing, employment and the criminal justice system, which in turn can have a negative impact on their health. Evidence shows that racism and discrimination can also have a negative impact on the physical and mental health of people from ethnic minority groups.
  • Covid-19 has shone a light on inequalities and highlighted the urgent need to strengthen action to prevent and manage ill health in ethnic minority communities. A cross-government strategy for reducing health inequalities, and the wider socio-economic and structural inequalities that drive them, should be an urgent priority. 
  • Comprehensive, good-quality data is essential for enabling policy-makers and health care professionals to identify the specific needs of different ethnic minority communities, respond with tailored strategies for addressing inequalities, and track the impact of these strategies. 

Introduction

In the 2011 census, 15 per cent of people in England identified themselves as belonging to an ethnic minority group (see Table 1)1. Office for National Statistics (ONS) estimates of population by ethnic group show the per cent non-White in England in 2018 was 16 per cent. Ethnicity is a complex, multidimensional concept, defined by features such as a shared history, origins, language, and cultural traditions. Although it is a social construct often used to describe distinct populations, it is a subjective identity based on how individuals define themselves.

Health patterns differ significantly between ethnic minority groups and the white population, and between minority groups, reflecting the diversity of demographic, socio-economic, behavioural, cultural and other characteristics between ethnic groups.

This explainer provides an overview of health outcomes and their determinants among ethnic minority groups. It focuses on selected topics where ethnic differences are significant and affect large numbers.

This is not a comprehensive review of all aspects of ethnic minority health. In particular, it does not cover mental health because of the challenges in summarising ethnic differences across diverse forms of mental illness in a short report.

Ethnic groupNumberPer cent
All53,012,456100
   
White45,281,14285.4
White British42,279,23679.8
White Irish517,0011.0
White Gypsy/Traveller54,8950.1
White other2,430,0104.6
   
Asian4,143,4037.8
Indian1,395,7022.6
Pakistani1,112,2822.1
Bangladeshi436,5140.8
Chinese379,5030.7
Other Asian819,4021.5
   
Black1,846,6143.5
African977,7411.8
Caribbean591,0161.1
Other Black277,8570.5
   
Mixed1,192,8792.3
White and Black Caribbean415,6160.8
White and Black African161,5500.3
White and Asian332,7080.6
Other Mixed283,0050.5
   
Other548,4181.0
Arab220,9850.4
Any other ethnic group327,4430.6

Source: Office for National Statistics (2011)

Notes:

1. ONS estimates of population by ethnic group show the per cent non-White in England in 2018 was 16 per cent.

References:

Office for National Statistics (2018). ‘Population denominators by ethnic group, regions and countries: England and Wales, 2011 to 2018’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/adhocs/008780populationdenominatorsbyethnicgroupregionsandcountriesenglandandwales2011to2017 (accessed on 28 January 2021).

Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).

Data on the health of ethnic minority groups

This explainer focuses on the health of ethnic minorities in England. Where articles and data sources refer to different geographies, eg, England and Wales or the UK, this is stated in the text.

The 2011 census ethnic categories are used, although sometimes data sources refer to aggregated ethnic groups when numbers are small. The categories used here are those used in the original data sources. The South Asian group refers to people from India, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan. The Asian group generally also includes people from South East Asia. The Black group includes people of African and/or Caribbean origin.

Much of the data for examining ethnic differences in health comes from health records. However, its coverage and quality are imperfect. National data on mortality by ethnic group has not been available routinely because ethnicity is not recorded at death registration (although Scotland introduced this in 2012). Earlier analyses of mortality therefore used country of birth of migrants as a proxy for ethnicity, but this excludes second-generation migrants. Ad hoc analyses of mortality have been undertaken, for example by the ONS and Public Health England, by linking death records to secondary sources from which ethnicity is derived, eg, the 2011 Census and hospital records. These data limitations present barriers to understanding health issues among ethnic minority groups.

Following the Covid-19 pandemic, national agencies are moving to improve ethnicity recording in health records and the government has said it will introduce ethnicity recording in death certificates. These data developments should facilitate a better understanding of ethnic differences in health.

NHS Digital (2020). ‘Detentions under the Mental Health Act’. GOV.UK website. Available at:
https://www.ethnicity-facts-figures.service.gov.uk/health/mental-health/detentions-under-the-mental-health-act/latest#:~:text=Black%20people%20were%20most%20likely%20to%20be%20detained,ethnic%20group%20%E2%80%93%20232.8%20detentions%20per%20100%2C000%20people (accessed on 29 January 2021).

Mathur R, Bhaskaran K, Chaturvedi N, Leon DA, van Staa T, Grundy E, Smeeth L (2013). ‘Completeness and usability of ethnicity data in UK-based primary care and hospital databases’. Journal of Public Health, vol 36, no 4, pp 684–92. Available at: https://pubmed.ncbi.nlm.nih.gov/24323951 (accessed on 11 February 2021).

NHS England (2020). Implementing phase 3 of the NHS response to the Covid-19 pandemic [online]. NHS England and NHS Improvement website. Available at: ww.england.nhs.uk/publication/implementing-phase-3-of-the-nhs-response-to-the-covid-19-pandemic (accessed on 29 January 2021).

Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).

Public Health England (2020). Beyond the data: understanding the impact of Covid-19 on BAME groups [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (accessed on 29 January 2021).

Race Disparity Unit, Cabinet Office (2017). Race disparity audit summary findings from the Ethnicity Facts and Figures website [online]. GOV.UK website. Available at: www.gov.uk/government/publications/race-disparity-audit (accessed on 29 January 2021).

Race Disparity Unit, Cabinet Office (2020). Quarterly report on progress to address COVID-19 health inequalities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/quarterly-report-on-progress-to-address-covid-19-health-inequalities (accessed on 29 January 2021).

Saunders CL, Abel GA, El Turabi A, Ahmad F, Lyratzopoulos (2013). ‘Accuracy of routinely recorded ethnic group information compared with self-reported ethnicity: evidence from the English Cancer Patient Experience survey’. BMJ Open, art no: e002882. Available at: https://bmjopen.bmj.com/content/3/6/e002882 (accessed on 29 January 2021).

Overall health

General health can be measured by self-reported outcomes, such as how people perceive their health, and observed outcomes such as mortality. There are differences in health between ethnic minority groups, and between ethnic minority groups and the white group; the patterns vary depending on the aspect of health being measured.

People from ethnic minority groups (especially Pakistani and Bangladeshi groups) are more likely than those from the White British group to report limiting long-term illness and poor health, with those identifying as White Gypsy and Irish Traveller reporting the poorest health. Health-related quality of life scores at older ages, based on responses to the GP patient survey, are lower than average among most ethnic minority groups, especially the White Gypsy and Irish Traveller, Bangladeshi and Pakistani groups, but not among some others (Black Caribbean, Black African and Mixed groups). Ethnic minority groups also have an increased prevalence of some long-term conditions (eg, diabetes), but not of some other common conditions (eg, arthritis).

Compared with the White British group, disability-free life expectancy is estimated to be higher among the Other White, Chinese and Black African groups, lower among Black Caribbean, Other Black, Indian, Other Asian and some Mixed groups, and lowest among the Pakistani and Bangladeshi groups.

Analyses show most ethnic minority groups in England and Scotland have lower overall mortality than white counterparts but also that this mortality advantage is reduced in their UK-born descendants – possibly because cultural assimilation over time leads to lifestyle changes, eg, in diet and smoking. Public Health England’s analysis showed that in 2014–18 all-cause mortality rates in England were up to 20 per cent lower among Asian and Black groups than the national average. Analyses by country of birth for years back to 1971, when data by ethnicity was unavailable, also showed a general pattern of lower overall mortality rates among migrants born in South and East Asia, Africa, the Caribbean and the Middle East compared with the national average.

However, the Covid-19 pandemic has reversed the mortality advantage in some ethnic minority groups. Between March and July 2020 overall mortality was higher in Black Caribbean males and females, and Black African and Bangladeshi males, than in the white group; it was lower in Chinese, Indian and Other ethnic groups.

The ONS is due to publish a comprehensive analysis of ethnic differences in overall and cause-specific mortality in spring 2021 .

Bhopal RS, Gruer L, Cezard G, Douglas A, Steiner MFC, Millard A, Buchanan D, Katikireddi SV, Sheikh A (2018). ‘Mortality, ethnicity, and country of birth on a national scale, 2001–2013: a retrospective cohort’. PLoS Med, vol 15, no 3, art no: e1002515. Available at: https://doi.org/10.1371/journal.pmed.1002515 (accessed on 29 January 2021).

Britton M, Balarajan R, Bulusu L (1990). ‘Mortality among immigrants in England and Wales, 1979-83’. In Britton M, ed. Mortality and Geography. A review in the mid 1980s. England and Wales. OPCS series DS No 9. London: HMSO.

Evandrou M, Falkingham J, Feng Z, Vlachantoni A (2016). ‘Ethnic inequalities in limiting health and self-reported health in later life revisited’. Journal of Epidemiology and Community Health, vol 70, no 7, pp 653–62. Available at: https://jech.bmj.com/content/70/7/653 (accessed on 29 January 2021).

Fischbacher CM, Steiner M, Bhopal R, Chalmers J, Jamieson J, Knowles D, Povey C (2007). ‘Variations in all cause and cardiovascular mortality by country of birth in Scotland, 1997–2003’. Scottish Medical Journal, vol 52, no 4, pp 5–10. Available at: https://pubmed.ncbi.nlm.nih.gov/18092629/ (accessed on 29 January 2021).

Gruer L, Cézard G, Clark E, Douglas A, Steiner M, Millard A, Buchanan D, Katikireddi SV, Sheikh A, Bhopal R (2016). ‘Life expectancy of different ethnic groups using death records linked to population census data for 4.62 million people in Scotland’. Journal of Epidemiology and Community Health, vol 70, no 12, pp 1251–4. Available at: https://jech.bmj.com/content/70/12/1251 (accessed on 10 February 2021).

Marmot MG, Adelstein AM, Bulusu L (1984). Immigrant mortality in England and Wales 1970–78: causes of death by country of birth. London: HMSO.

Office for National Statistics (2020). Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020 [online]. ONS website. Available at: www.ons.gov.uk/releases/explainingethnicbackgroundcontrastsindeathsinvolvingcovid19england2ndmarchto3rdjuly2020 (accessed on 29 January 2021).

Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).

Public Health England (2019). Health-related quality of life for people aged 65 and over. Available at: www.ethnicity-facts-figures.service.gov.uk/health/physical-health/health-related-quality-of-life-for-people-aged-65-and-over/latest#data-sources (accessed on 29 January 2021).

Public Health England (2018). A review of recent trends in mortality in England [online]. GOV.UK website. Available at: www.gov.uk/government/publications/recent-trends-in-mortality-in-england-review-and-data-packs (accessed on 29 January 2021).

Public Health England (2018). Local action on health inequalities: understanding and reducing ethnic inequalities in health [online]. GOV.UK website. Available at: www.gov.uk/government/publications/health-inequalities-reducing-ethnic-inequalities (accessed on 29 January 2021).

Scott AP, Timæus IM (2013). ‘Mortality differentials 1991-2005 by self-reported ethnicity: findings from the ONS Longitudinal Study. Journal of Epidemiology and Community Health, vol 67, no 9, pp 743–50. Available at: https://pubmed.ncbi.nlm.nih.gov/23740930/ (accessed on 29 January 2021).

Wallace M (2016). ‘Adult mortality among the descendants of immigrants in England and Wales: does a migrant mortality advantage persist beyond the first generation’? Journal of Ethnic and Migration Studies, vol 42, no 9, pp 1–19. Available at: www.researchgate.net/publication/292946924_Adult_mortality_among_the_descendants_of_immigrants_in_England_and_Wales_does_a_migrant_mortality_advantage_persist_beyond_the_first_generation (accessed on 29 January 2021).

Watkinson RE, Sutton M, Turner, AJ ((2021). ‘Ethnic inequalities in health-related quality of life among older adults in England: secondary analysis of a national cross-sectional survey’. The Lancet Public Health. Available at: www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30287-5/fulltext (accessed on 1 February 2021).

Wild S, Mckeigue P (1997). ’Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92’. BMJ, vol 314, pp 705. Available at: www.bmj.com/content/314/7082/705 (accessed on 29 January 2021).

Wild SH, Fischbacher C, Brock A, Griffiths C, Bhopal R (2007). ‘Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003’. Journal of Public Health, vol 29, no 2, pp 191–8. Available at: https://academic.oup.com/jpubhealth/article/29/2/191/1505208 (accessed on 29 January 2021).

Wohland P, Rees P, Nazroo J, Jagger C (2015). ‘Inequalities in healthy life expectancy between ethnic groups in England and Wales in 2001’. Ethnicity and Health, vol 20, no 4, pp 341–53. Available at: https://doi.org/10.1080/13557858.2014.921892 (accessed on 29 January 2021).

Maternal and infant mortality, and child health

Maternal mortality

More than one-quarter of the 600,000 babies born annually in England and Wales are to mothers of ethnic minority origin (see Table 2). Compared with the white group, the rate of women dying in the UK in 2016–18 during or up to one year after pregnancy is more than four times higher in the Black group, and almost double in the Asian group (although the number of such deaths is relatively low – under 10 a year in both the Black group and also the Asian group).

Infant mortality

Infant mortality rates are generally higher among ethnic minority groups. Infant mortality in 2015 –17 was highest among babies of Pakistani origin, followed by Black African and Black Caribbean groups (see Table 2).

The causes of infant mortality differ between ethnic groups. South Asian and Black mothers have higher proportions of premature and low birthweight babies than white mothers (see Table 2). Although immaturity-related conditions, such as respiratory and cardiovascular disorders, contribute most to infant mortality in most ethnic groups, in the Pakistani and Bangladeshi groups more infant deaths are caused by congenital anomalies. However, ethnic minority women are less likely to smoke and the risk of sudden infant death syndrome is lower in South Asian babies. Explanations for variations in infant mortality between ethnic groups are complex, involving the interplay of deprivation, environmental, physiological, behavioural and cultural factors. Research suggests quality of care is equitable.

Table 2 Live births, low birthweight and infant mortality by ethnic group, England and Wales

Ethnic groupTotal live births (term) 2018Per cent of live births 2018Low birthweight (term) 2018Per cent of low birthweight 2018Infant deaths per 1,000 live births 2015-17
White British353,41859.48,9972.53.2
White other71,38312.01,5412.22.6
Bangladeshi8,6961.55616.54.8
Indian18,1323.01,0665.94.1
Pakistani24,5034.11,1724.86.8
Black African19,6613.36123.16.3
Black Caribbean4,9460.82154.35.6
Other69,96811.82,1553.14.1
Not stated24,2674.16972.9-
Total594,97410017,2862.93.8

Source: Office for National Statistics (2020a, b)

Child health

Health and wellbeing in the early years have a significant bearing on future health. Childhood obesity rates are higher among Black and Asian children (see Table 3). Some of these differences may be associated with higher levels of deprivation among ethnic minority groups, as children in deprived areas are twice as likely to be obese than those in less-deprived areas. Children in Asian (37 per cent) and Black (37 per cent) households are twice as likely to live in persistent low-income households than children from White households (18 per cent).

South Asian children also have lower levels of physical fitness than children in white European and Black groups, and physical activity levels are lower among children from Bangladeshi and Pakistani groups.

Table 3 Prevalence of obesity by ethnic group, England, 2018/19

Ethnic groupAges 4-5 years per centAges 10-11 years per cent
White9.318.4
Asian9.825.2
Black 15.228.9
Chinese6.418.7
Mixed10.122.4
England9.720.2

Source: NHS Digital

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Department for Work and Pensions (2020). ‘Persistent low income’. GOV.UK website. Available at: www.ethnicity-facts-figures.service.gov.uk/work-pay-and-benefits/pay-and-income/low-income/latest (accessed on 29 January 2021).

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Cardiovascular disease

Cardiovascular disease(CVD) is a leading cause of death nationally, and in ethnic minority groups, causing 24 per cent of all deaths in England and Wales in 2019. It is a significant contributor to inequalities in life expectancy and a risk factor for poor outcomes from Covid-19. Up to 80 per cent of premature deaths from CVD are preventable through better public health. Diabetes increases the risk of CVD almost two-fold.

Prevalence of CVD

Studies in the UK and across the Indian diaspora (eg, Europe, Fiji, Singapore, South Africa, the US and Canada) consistently show a higher incidence, prevalence and mortality from CVD in South Asian groups compared with the white group or national average. South Asian groups also develop heart disease at a younger age. As with heart disease, stroke incidence and mortality are also higher in the South Asian population. CVD mortality is high and rising in South Asia, in contrast to the declining trend elsewhere.

These patterns are associated with a higher clustering in South Asians of risk factors3 that increase the risk of heart disease, stroke and diabetes. Although body mass index (BMI) levels are lower among South Asian groups compared with normal ranges, rates of excess abdominal fat and insulin resistance are higher. Hence National Institute for Health and Care Excellence (NICE) guidelines specify lower BMI thresholds for use by health care professionals for introducing preventive interventions in these groups. In terms of other risk factors, although smoking prevalence is lower among South Asian groups, they have low physical activity rates, especially among women. The causes of increased CVD risk among South Asian groups are multifactorial and include physiological susceptibility, environmental determinants such as deprivation, and adverse changes to lifestyle and diet following migration.

In contrast to South Asian groups, Black groups in the UK have a significantly lower risk of heart disease compared to the majority of the population, despite having a high prevalence of hypertension and diabetes (risk factors for heart disease and stroke). Lower cholesterol levels among people of African Caribbean heritage than white Europeans may protect them against heart disease. Heart disease rates are low in sub-Saharan Africa and the Caribbean.

However, Black groups have a higher than average incidence of and mortality from stroke, and they have strokes at a younger age. The prevalence of hypertension, a risk factor for stroke, is reported to be high in the West Indies. Obesity levels are also higher in Black groups, with NICE guidelines specifying lower BMI thresholds for them.

Care for CVD

Recent evidence suggests that greater awareness among health care providers of the CVD risk in South Asian populations, earlier diagnosis and improved management of diabetes and CVD, together with second-generation adopting healthier lifestyles than first-generation migrants, have reduced CVD mortality risks relative to white Europeans. Research also indicates that South Asian groups have equitable access to care for heart disease and better survival rates from it.

In contrast, Black groups have lower than expected rates of access to and use of cardiovascular care.

Notes:

2. Cardiovascular disease (CVD) is the collective term for diseases affecting the circulatory system, ie, heart, arteries, blood vessels. The main forms of CVD are heart disease and stroke.

3. This clustering of risk factors is called the metabolic syndrome and includes abdominal obesity, high blood pressure, high blood sugar levels, high triglyceride (fat in the blood) levels and low HDL (the ‘good’ cholesterol) levels. It is associated with obesity, physical inactivity and insulin resistance (inability to control blood sugar levels because the body doesn’t respond properly to insulin).

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Gunarathne A, Patel JV, Potluri R, Gammon B, Jessani S, Hughes EA, Lip GY (2008). ‘Increased 5-year mortality in the migrant South Asian stroke patients with diabetes mellitus in the United Kingdom: the West Birmingham Stroke Project’. International Journal of Clinical Practice, vol 62, no 2, pp 197–201. Available at: https://pubmed.ncbi.nlm.nih.gov/18036165/ (accessed on 29 January 2021).

Gunarathne A, Patel JV, Gammon B, Gill PS, Hughes EA, Lip GYH (2009). ‘Ischemic stroke in South Asians: a review of the epidemiology, pathophysiology, and ethnicity-related clinical features’. Stroke, vol 40, no 6, pp e415-23. Available at: www.ahajournals.org/doi/epub/10.1161/STROKEAHA.108.535724 (accessed on 29 January 2021). 

Hanif W, Susarla R (2018). ‘Diabetes and cardiovascular risk in UK South Asians: an overview’. British Journal of Cardiology, vol 25, suppl 2, pp S8–13. Available at: 
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Office for National Statistics (2020). ‘Deaths registered in England and Wales: 2019’. ONS website. Available at: www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2019 (accessed on 29 January 2021).

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Rana A, de Souza RJ, Kandasamy S, Lear SA, Anand SS (2014). ‘Cardiovascular risk among South Asians living in Canada: a systematic review and meta-analysis’. CMAJ Open, vol 2, no 3, pp E183–91. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC4183167/ (accessed on 29 January 2021).

Singh V, Prabhakaran S, Chaturvedi S, Singhal A, Pandian J (2017). ‘An examination of stroke risk and burden in South Asians’. Journal of Stroke and Cerebrovascular Diseases, vol 26, no 10, pp 2145–53. 

Stroke Association (undated). Stroke and South Asian people. Stroke Association website. Available at:
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Stroke Association (2018). State of the nation: stroke statistics [online]. Stroke Association website. Available at: www.stroke.org.uk/sites/default/files/state_of_the_nation_2018.pdf (accessed on 1 February 2021).

Volgman AS, Palaniappan LS, Aggarwal NT, Gupta M, Khandelwal A, Krishnan AV, Lichtman JH, Mehta LS, Patel HN, Shah KS, SH Shah, Watson KE (2018). ‘Atherosclerotic cardiovascular disease in South Asians in the United States: epidemiology, risk factors, and treatments: a scientific statement from the American Heart Association’. Circulation, vol 138, no 1, pp e1-e34. Available at: www.ahajournals.org/doi/full/10.1161/cir.0000000000000580 (accessed on 1 February 2021).

Wild S, Mckeigue P (1997). ’Cross sectional analysis of mortality by country of birth in England and Wales, 1970-92’. BMJ, vol 314, pp 705. Available at: www.bmj.com/content/314/7082/705 (accessed on 1 February 2021).

Wild SH, Fischbacher C, Brock A, Griffiths C, Bhopal R (2007). ‘Mortality from all causes and circulatory disease by country of birth in England and Wales 2001–2003’. Journal of Public Health, vol 29, no 2, pp 191–8. Available at: https://academic.oup.com/jpubhealth/article/29/2/191/1505208 (accessed on 1 February 2021).

Yusuf S, Reddy S, Ôunpuu S, Anand S (2001). ‘Global burden of cardiovascular diseases, part II: variations in cardiovascular disease by specific ethnic groups and geographic regions and prevention strategies’. Circulation, vol 104, no 23, pp 2855–64. Available at: www.ahajournals.org/doi/epub/10.1161/hc4701.099488 (accessed on 1 February 2021).

Zaman MJS, Philipson P, Chen R, Farag A, Shipley M, Marmot MG, Timmis AD, Hemingway H (2013). ‘South Asians and coronary disease: is there discordance between effects on incidence and prognosis?' Heart, vol 99, pp 729–36. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC3960593/ (accessed on 1 February 2021).

Diabetes

Diabetes4 is a chronic condition that can cause serious secondary complications and premature death if it is not well managed. This explainer considers type-2 diabetes. Being overweight, abdominal obesity and physical inactivity are risk factors for diabetes. The prevalence of diabetes is higher among South Asian and Black groups than in the white population and people in these groups develop the condition at a younger age.

Prevalence of diabetes

The risk of developing diabetes is up to six times higher in South Asian than white groups. About 400,000 people of South Asian ethnicity in the UK have diabetes, one-fifth of the UK diabetes population. High diabetes prevalence is seen also in their countries of origin and across the South Asian diaspora worldwide, eg, in Europe, the US, Canada, the Caribbean, South Africa, Fiji. South Asians with diabetes have a higher risk of developing secondary complications of cardiovascular and end-stage renal disease. However, recent studies show that excess CVD mortality in South Asians with diabetes has reduced and overall mortality is lower than in the white group.

Explanations for the high prevalence of diabetes among South Asian groups include a mix of biological, lifestyle and socio-economic factors. As with CVD, these patterns are associated with a clustering in South Asians of risk factors (see footnote 3) that increase the risk of diabetes, exacerbated by socio-economic disadvantage and changing lifestyles after migration. Even though South Asians typically have a low BMI, excess abdominal fat increases the risk of diabetes and CVD. Accordingly, NICE, the World Health Organisation and several national diabetes associations recommend lower BMI thresholds for introducing preventive measures in South Asians with diabetes.

Diabetes prevalence in Black groups is up to three times higher than in the white population; they also have a higher risk of hypertension and stroke but, unlike South Asians, are less prone to heart disease. The physiological pathways and impacts of diabetes therefore differ between ethnic minority groups. Diabetes-related co-morbidities in Black groups are similar to or lower than those in white groups, except for higher rates of end-stage renal disease. Like South Asians, excess mortality associated with diabetes is lower in Blacks groups than in the white population.

Care for diabetes

A recent study found improved diabetes outcomes in South Asians are attributable in part to earlier diagnosis and risk factor management, indicating increased awareness among health care providers, equity of access and standardisation of care for chronic conditions incentivised in the Quality and Outcomes Framework for GPs. It also found little evidence of inequalities in the management of diabetes among Black patients at initial diagnosis, indicative of a wider trend of shrinking inequalities in diabetes care.

Notes:

4. Diabetes is a lifelong condition that causes a person’s blood sugar level to become too high. It can lead to serious secondary complications. There are two types of diabetes: type-1 diabetes when the body makes no insulin at all, and type-2 diabetes when the body doesn’t produce enough insulin or when it doesn’t react to the insulin. Some women can develop gestational diabetes during pregnancy. About 90 per cent of people with diabetes have type-2 diabetes, which is potentially preventable.

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Cancer

Cancer incidence

The incidence of cancer overall is generally lower among ethnic minority groups in England. Asian, Chinese and Mixed groups have a significantly lower risk (of 20–60 per cent) of getting cancer than the white group; smoking rates are generally lower in these groups. Cancer incidence is also lower among Black women but similar in Black and white men.

In terms of specific cancers, Asians have a higher incidence than the white group of cancer of the liver and mouth (females only), and a lower risk of the four major cancers (breast, prostate, lung, colorectal) and several less common cancers.

Black groups have a significantly lower incidence of three major cancers (breast, lung and colorectal) and several less-common cancers. However, the incidence of and mortality from prostate cancer is significantly higher among Black males than white males. Black men in Africa, the Caribbean and the US are also at greater risk of prostate cancer for reasons that are unclear.

Although lower breast cancer incidence in Asian and Black women is associated with a lower risk profile (such as lower alcohol consumption, breastfeeding, childbearing), cultural assimilation over time can lead to changes in health behaviours. Some evidence suggests cancer rates in South Asian groups are converging towards those in the white population.

Cancer screening

Screening is an important part of efforts to reduce cancer mortality. Screening rates for breast and cervical cancer are lower among ethnic minority women, particularly South Asians. South Asians also have lower rates of bowel cancer screening.

Poorer awareness of risk factors for cancer and symptoms, and socio-cultural and practical barriers such as language, contribute to lower cancer screening rates among ethnic minority groups.

Stage at diagnosis

The stage at which cancer is diagnosed can have an impact on treatment outcomes and mortality. It may be related to a patient’s route to diagnosis, including through screening. Although data for 2012–13 showed the Black Caribbean group was more likely than the White British group to be diagnosed late for some cancers, 2017 data shows the proportion of early-stage cancer diagnoses among Asian and Black groups (55 per cent) was similar to the white group (52 per cent). Research has also found weak evidence of ethnic inequalities in times to cancer diagnosis and staging.

Cancer mortality

Cancer mortality rates measure cancer deaths in relation to population size, and reflect both cancer incidence (ie, the numbers who develop cancer) and the deaths from it. Overall cancer mortality rates by country of birth are lower than the national average among migrants born in Asia, Africa and the Caribbean. However, prostate cancer mortality is higher among male migrants born in West Africa or the West Indies.

Cancer survival measures the proportion of people with cancer who survive, and reflects many factors including deprivation, stage at diagnosis and quality of care. Cancer survival in minority ethnic groups is reported to be similar to the white population.

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Covid-19

The Covid-19 pandemic is having a disproportionate effect on ethnic minority groups, with Black, Asian and most other minority groups more likely to be diagnosed with Covid-19, get severely ill and die compared to the white population. Several factors contribute to these patterns.

Outcomes of Covid-19

Exposure to infection is higher among ethnic minority groups because, for example, they are more likely to work in public-facing jobs such as transport and health and social care, use public transport, and live in high-density housing, multi-generation households and urban areas where transmission is higher.

Once infected, the risk of severe disease and death from Covid-19 is also higher in South Asian and Black groups, in part due to a higher prevalence of obesity and chronic conditions such as CVD, hypertension and diabetes, which increase the risk of adverse outcomes.

In the first Covid-19 wave5, ethnic minority groups other than Chinese had higher Covid-19 mortality rates than the white group, rates being about double in Black groups. In the second wave, Pakistani and Bangladeshi groups continued to have higher Covid-19 mortality, but Black groups did not. Lockdown measures introduced in March 2020 were associated with significant reductions in ethnic inequalities in Covid-19 mortality. The findings suggest these inequalities are largely due to an increased risk of infection rather than a worse prognosis, and can be addressed.

Higher mortality is also reported for NHS and social care staff from Black, Asian and other ethnic minority groups.

Covid-19 and inequalities

Several reviews have examined the impact of Covid-19 on ethnic minority groups and the contributory factors, including the role of racism and discrimination, noting how Covid-19 has amplified health and socio-economic inequalities in UK and elsewhere. Demographic, geographical, socio-economic and household characteristics, and co-morbidities, contribute significantly to ethnic differences in Covid-19 outcomes, but they do not explain all the variation. The reasons for ethnic differences in Covid-19 outcomes are not yet fully understood, and the government has funded research on this.

Notes:

5. The first wave is defined as the period from 24 January 2020 to 31 August 2020, and the second wave is defined as the period from 1 September to 28 December 2020.

References:

Amnesty International (2020). Exposed, silenced, attacked: failures to protect health and essential workers during the COVID-19 pandemic [online]. Amnesty International website. Available at: www.amnesty.org/en/documents/pol40/2572/2020/en/ (Accessed on 1 February 2021).

Ayoubkhani D, Nafilyan V, White C, Goldblatt P, Gaughan C, Blackwell L, Rogers N, Banerjee A. Khunti K, Glickman M, Humberstone B, Diamond I (2021). ‘Ethnic minority groups in England and Wales - factors affecting the size and timing of elevated Covid-19 mortality: a retrospective cohort study linking Census and death records’. International Journal of Epidemiology, vol 49, no 6, pp 1951–62. Available at: https://doi.org/10.1093/ije/dyaa208 (accessed on 11 February 2020).

Cook T, Kursumovic E, Lennane S (2020). ‘Exclusive: deaths of NHS staff from covid-19 analysed’. HSJ website, 22 April. Available at: www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article (accessed on 1 February 2021).

Ghosh P (2020). ‘Covid studies to examine virus link with ethnicity’. BBC News website. Available at: www.bbc.co.uk/news/health-53565655?fbclid=IwAR1XXN3qBO2hoHiehjrMnuURrHwtN8gpMoD4QHXkmJ3aHqbWGMw3kxcUKss (accessed on 1 February 2021).

Haque Z, Becares L, Treloar N (2020). Over-exposed and under-protected the devastating impact of COVID-19 on black and minority ethnic communities in Great Britain [online]. Runnymede Trust website. Available at: www.runnymedetrust.org/projects-and-publications/employment-3/overexposed-and-underprotected-covid-19s-impact-on-bme-communities.html (accessed on 1 February 2021).

House of Commons Women’s and Equalities Committee (2020). Third report: Unequal impact? coronavirus and BAME people [online]. UK parliament website. Available at:
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Independent Scientific Advisory Group on Emergencies (2020). Disparities in the impact of Covid-19 in black and minority ethnic populations: review of the evidence and recommendations for action [online]. Indie_SAGE website. Available at:
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Intensive Care National Audit and Research Centre (2020). ICNARC report on COVID-19 in critical care England, Wales and Northern Ireland [online]. ICNARC website. Available at: www.icnarc.org/Our-Audit/Audits/Cmp/Reports (accessed on 1 February 20211). 

ISARIC (2020). Ethnicity and outcomes from COVID-19: the ISARIC CCP-UK prospective observational cohort study of hospitalised patients [online]. ISARIC website. Available at: https://isaric.tghn.org/articles/ethnicity-and-outcomes-covid-19-isaric-ccp-uk-prospective-observational-cohort-study-hospitalised-patients/ (accessed on 1 February 2021).

Khunti K, Platt L, Routen A, Abbas K (2020). ‘Covid-19 and ethnic minorities: an urgent agenda for overdue action’. BMJ, vol 369, art no: m2503. Available at: http://dx.doi.org/10.1136/bmj.m2503 (accessed on 1 February 2021).

Lassale C, Gaye B, Hamer M, Gale CR, Batty GD (2020). ‘Ethnic disparities in hospitalisation for Covid-19 in England: the role of socioeconomic factors, mental health, and inflammatory and pro-inflammatory factors in a community-based cohort study’. Brain, Behavior, and Immunity, vol 88, pp 44 –9. Available at: https://pubmed.ncbi.nlm.nih.gov/32497776/ (accessed on 1 February 2021).

Lawrence D (2020). An avoidable crisis: the disproportionate impact of Covid-19 on Black, Asian and minority ethnic communities: a review [online]. Lawrence Review website. Available at: www.lawrencereview.co.uk/ (accessed on 1 February 2021).

Lewis K (2020). ‘What do we know about Covid-19 inequalities among people from minority ethnic groups?’ Full fact website. Available at: https://fullfact.org/health/Covid-19-inequalities-minority-ethnicities/ (accessed on 1 February 2021).

Marmot M, Allen J, Goldblatt P, Herd E, Morrison J (2020). Build back fairer: the Covid-19 Marmot review. London: The Health Foundation and Institute of Health Equity. Available at:
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Nafilyan V, Islam N, Mathur R, Ayoubkhani D, Banerjee A, Glickman M, Humberstone B, Diamond I, Khunti K (2021). ‘Ethnic differences in Covid-19 mortality during the first two waves of the coronavirus pandemic: a nationwide cohort study of 29 million adults in England’. medRxiv website. Available at: https://www.medrxiv.org/content/10.1101/2021.02.03.21251004v1 (accessed on 11 February 2021).

Office for National Statistics (2020). ‘Coronavirus (Covid-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 15 May 2020’. ONS website. Available at:
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Office for National Statistics (2020). ‘Updating ethnic contrasts in deaths involving the coronavirus (COVID-19), England and Wales: deaths occurring 2 March to 28 July 2020’. ONS website. Available at: www.ons.gov.uk/releases/explainingethnicbackgroundcontrastsindeathsinvolvingcovid19england2ndmarchto3rdjuly2020 (accessed on 1 February 2021).

Pan D, Szec S, Minhas JS, Bangash MN, Pareek N, Divall P, Williams CML, Oggioni MR, Squire IB, Nellums LB, Hanif W, Khunti K, Pareek M. ‘The impact of ethnicity on clinical outcomes in COVID-19: a systematic review’. Lancet EClinical Medicine, vol 23, art no: 100404. Available at: www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30148-6/fulltext (accessed on 1 February 2021).

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Public Health England (2020). Beyond the data: understanding the impact of COVID-19 on BAME groups [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-understanding-the-impact-on-bame-communities (accessed on 29 January 2021).

Public Health England (2020). Disparities in the risks and outcomes of Covid-19 [online]. GOV.UK website. Available at: www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes (accessed on 29 January 2021).

Race Disparity Unit, Cabinet Office (2020). Quarterly report on progress to address COVID-19 health inequalities [online]. GOV.UK website. Available at: www.gov.uk/government/publications/quarterly-report-on-progress-to-address-covid-19-health-inequalities (accessed on 29 January 2021).

Raisi-Estabragh Z, McCracken C, Bethell MS, Cooper J, Cooper C, Caulfield MJ, Munroe PB, Harvey NC, Petersen SE (2020). ‘Greater risk of severe Covid-19 in Black, Asian and minority ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank’. Journal of Public Health, vol 2, no 3, pp 451–60. Available at: https://pubmed.ncbi.nlm.nih.gov/32556213/ (accessed on 1 February 2021).

Scientific Advisory Group for Emergencies – Ethnicity Sub-Group (SAGE) (2020). Drivers of the higher Covid-19 incidence, morbidity and mortality among minority ethnic groups, 23 September 2020 [online]. Available at: www.gov.uk/government/publications/drivers-of-the-higher-covid-19-incidence-morbidity-and-mortality-among-minority-ethnic-groups-23-september-2020 (accessed on 1 February 2021).

Vepa A, Bae JP, Ahmed F, Pareek M, Khunti K (2020). ‘Covid-19 and ethnicity: a novel pathophysiological role for inflammation’. Diabetes and Metabolic Syndrome, vol 14, no 5, pp 1043 –51. Available at: https://pubmed.ncbi.nlm.nih.gov/32640416/ (accessed on 1 February 2021).

Determinants of health

Here we examine ethnic differences in some key determinants of health, namely behavioural risk factors, access to health care services, and socio-economic factors.

Selected behavioural risk factors

Smoking, high alcohol consumption, physical inactivity and a poor diet are four principal behavioural risks to health; the latter two also cause obesity. Their prevalence varies across the population, although they tend to cluster in more deprived communities.

Smoking

Smoking prevalence is lower in most ethnic minority groups than in the white group, and highest in the Mixed group (see Figure 1).

Alcohol consumption

Adults in ethnic minority groups are less likely to drink alcohol at a hazardous, harmful or dependent level compared to white groups (see Figure 2).

Physical activity

Physical activity levels differ between ethnic groups and genders. People from Asian and Black groups, and women in particular, are most likely to report being physically inactive and least likely to report being active (see Figures 3a and b).

 

Healthy eating

The proportion of people eating recommended portions of fruit or vegetables per day is lower in ethnic minority groups than in white groups (see Figure 4).

Obesity

Compared with the White British group, obesity prevalence is higher in Black adults and lower among other minority groups (see Figure 5).

Access to services and patient experience

Free, universal access to health care and standardised treatment protocols have resulted in greater equality of access and outcomes across ethnic groups, especially in primary care, but less consistently across other health services. However, patients from ethnic minority groups report a poorer experience than the White British group of using a range of health care services, for example: GP, GP out-of-hours, inpatient, maternity, and cancer services. Patient-reported experiences differ between ethnic groups, with South Asian and Chinese groups generally responding more negatively than the white group, and Black groups less so or not at all.

As we have shown, there are different patterns of health across different ethnic groups. Moreover, ethnic minority communities experience a higher burden of some conditions that are potentially preventable. For example, much of the excess morbidity and mortality from CVD and diabetes among some ethnic minority groups is associated with modifiable risk factors. Prevention should therefore be a priority for public health and health care services.

Low health literacy, potentially exacerbated by language barriers, can lead to unhealthy behaviours and poorer uptake of preventive services. Modes of disease presentation and therapeutic needs may also differ by ethnicity.

Health care services therefore need to be aware of the specific health care needs, risk factors and treatment requirements in different communities and ensure services are culturally tailored to promote adherence. For example, the incidence of diabetes among ethnic minority groups can be moderated through dietary and physical activity modifications, and culturally tailored diabetes programmes are effective at improving outcomes. Research shows that culturally adapted interventions can improve participation in cancer screening.

Socio-economic inequalities

There is a strong, systemic relationship between health and deprivation, with more deprived communities experiencing worse health and a shorter life-expectancy than more affluent groups. Deprivation levels are higher among ethnic minority groups and they are over-represented in deprived communities. People from minority ethnic groups make up 15 per cent of the total population, but account for 22 per cent of the population in the most deprived areas (see Figure 6).

If you are on a mobile device, please rotate your screen to landscape in order to view the full detail of this chart.

Socio-economic inequalities experienced by ethnic minority groups also include the following examples.

  • Income: Asian (26 per cent ), Mixed (26 per cent) and Black (29 per cent) groups are more than twice as likely to live in households with persistent low income (after housing costs) than the white group (12 per cent).
  • Housing: rates of overcrowding are higher in ethnic minority households than White British households (2 per cent), and highest in Bangladeshi (24 per cent), Pakistani (18 per cent), Black African (16 per cent) and Arab (15 per cent) households.
  • Unemployment: unemployment rates in Black, Pakistani and Bangladeshi communities are approximately double the national average of 4 per cent.

However, on children’s education the white group compares unfavourably:

  • the White British group has the worst educational attainment rates at Key Stage 4 (ages 14–16 including GCSEs) and the biggest ‘attainment gap’ between children from low income families and others.

Structural racism and marginalisation

There is the wider social context that drives ethnic and other social inequalities. Evidence documents the prevalence of racism and discrimination in the UK, and the negative effects they can have on the physical and mental health of people from ethnic minority groups. They can also create barriers to accessing health information and health care services. Structural racism can also have an impact on health outcomes, operating via exclusionary frameworks that marginalise minority groups in, for example, the housing, employment and criminal justice systems.

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Conclusion

This explainer has highlighted inequalities in health among ethnic minority groups, such as higher mortality among infants and higher mortality from Covid-19, and a greater disease burden from diabetes and CVD. Strategies for improving the health of England’s ethnic minority communities need to address the multiple factors that have an impact on their health.

Comments

iford

Position
Digital Manager,
Organisation
The King's Fund
Comment date
07 April 2021

Hi Leila,

Thanks for your post. We don't have any immediate plans to write something specifically focused on mental health inequalities by ethnicity but I've passed your suggestion on to colleagues.

Thanks,

Ian

Leila Reyburn

Comment date
07 April 2021

Would you consider doing a piece focused on mental health inequalities by ethnicity?

Jonathon Holmes

Comment date
01 April 2021

Hi Michael, in a manner of speaking. Existing analysis suggests that historically the mortality rate for non-white groups in the UK is lower than in white groups. This advantage is most associated with first generation migrants and the advantage decreases in subsequent generations. The causes of this are really complicated, one suggestion is the "healthy migrant" effect, i.e. that people who migrate tend to be in good health. The effects of assimilation are seen in subsequent generations.
Covid-19 has impacted ethnic minority mortality rates hugely and has reversed the mortality advantage in some ethnic minority groups.
Overall minority ethnic groups do have lower mortality rates, but it's a very complicated and changing picture.

Michael Maggiore

Position
Accountant,
Comment date
29 March 2021

Am I correct in saying that a white person will die earlier than any other race?

Candy Ballantyne

Comment date
15 March 2021

Brilliant article, thank you Veena! All those years of working on the NHS Outcomes Framework and it had somehow escaped me that UK Life Expectancy at birth was lower for white people than for many other ethnic groups, but that the longer they live here the worse it gets.
Hope you are well.

Roger Bysouth

Position
various,
Organisation
various voluntary organisations in Manchester
Comment date
04 March 2021

(Thanks for the report. It's undoubtedly useful.) Yes you are constrained by the fields in the Census. The same scheme that lumps disparate people together is about to be used in the 2021 Census, unfortunately. What I can see in the explainer is your point that "good-quality data is essential", not that BETTER quality data is essential. Nor in what way it should be better. It's up to the ONS but presumably they will carry on doing what they do unless reputable health statisticians tell them what they produce is not adequate. If it is really impossible (or is it?) to ask people to tick a box to indicate they are say Kashmiri or Somali etc., then maybe other sorts of data should be taken into account e.g. refugee or migrant status, and overlaid with income, economic activity etc.

Veena Raleigh

Position
Senior Fellow,
Organisation
The King's Fund
Comment date
25 February 2021

Mr Khan thank you for your helpful observation. Unfortunately our analysis is constrained by the ethnic categories used in national data sets, which largely reflect those used in the 2011 population census. And these data sets don't identify British Kashmiris as a distinct ethnic category. However, we do note the diversity of health patterns between ethnic minority communities, and the need for better data on ethnicity to be able to monitor health patterns across all communities.

Sardar Aftab Khan

Comment date
24 February 2021

The health of people from ethnic minority groups in England. Unfortunately, this report doesn't recognise & identify the differences in health outcomes for one of the largest Ethnic minority community - #BritishKashmiris, Why?

iford

Position
Digital Manager,
Organisation
The King's Fund
Comment date
21 February 2021

Hi Pat,

Thanks for getting in touch. As you've noted, the report doesn't go into much detail on mental health. The introduction gives our reason for this: 'This is not a comprehensive review of all aspects of ethnic minority health. In particular, it does not cover mental health because of the challenges in summarising ethnic differences across diverse forms of mental illness in a short report.'

In case helpful, we published a blog on mental health in the time of Covid-19: https://www.kingsfund.org.uk/blog/2020/07/mental-health-care-time-covid…

We also published a podcast on Covid-19, racism and the roots of health inequality which has some overlap too: https://www.kingsfund.org.uk/audio-video/podcast/covid-19-racism-health…

Thanks,

Ian Ford

Angelina Geoge

Position
Executive Assistant to CEO,
Organisation
Londonwide LMCs
Comment date
19 February 2021

Good article with comprehensive examination of the facts. I felt that the importance of diet on health could have been explored in greater depth. Many illnesses, including the ones in the article, can be prevented with and counteracted by good nutrition. I have read many articles such as this, and think that authors need to be careful not to inadvertently indicate that it is ethnicity per se which leads to poor health. There is a reference [in the article] to 'biological' indicators which comes close to suggesting that the differences may be down to genetic differences; this is an erroneous and dangerous road down which to travel.

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