Racism Hurts Health, Fuels Inequality in London

Structural Racism, Ethnicity and Health Inequalities in London reviews both published and unpublished reports, materials and research, as well as health and social determinants data. The review was informed by an advisory board and through consultation and collaboration with community groups. It was funded by the Greater London Authority.

The review's findings highlight how people who are repeatedly exposed to racism during their daily lives, or when using essential services, experience worse physical and mental health.

The report also acknowledges the many new and outstanding efforts to reduce structural and institutional racism in London, but found the impacts of racism remain starkly evident, manifesting, particularly, in ethnic inequalities in poverty, housing, employment, pay and career progression.

IHE researchers also highlighted the known and marked inequalities among ethnic groups in maternal and child health and mental illness, alongside experiences with the criminal justice system and healthcare services more widely.

As a result of the findings, the IHE is calling for greater accountability, particularly from leaders, institutions and employers to prevent racism from continuing unchecked and to improve the lives of people who experience it. The review's approach and recommendations are also relevant to other places across the UK and globally.

Professor Sir Michael Marmot, UCL Institute of Health Equity Director and co-chair of the review's advisory board said: "Racism is a scar on society. Social justice requires that we take the action necessary to deal with it. It is a profound injustice if the conditions for good health are unequally distributed, depending on ethnicity. Especially so, where that unequal distribution results from the evils of racism. Inequalities in the social determinants of health are storing up health problems for the future."

Key findings from the review showed that:

• Nearly 70% of Bangladeshi and Pakistani and 52% of Black children are growing up in relative poverty (after housing costs) in London, compared to 26% of children in White households. One of the most important drivers of health and wellbeing is income - children who grow up in poverty are less likely to live in decent housing, be able to eat nutritious food, or have places to play or sleep. As a result, their educational attainment and prospects throughout life (such as income and employment) are negatively affected (Department of Work and Pensions, 2019).
• Progress in education does not translate into good employment or income due to workplace racism: while many young Londoners from ethnic minority groups are reaching high levels of educational attainment (a result of their own efforts and progress by London schools and staff) this does not translate into good employment or income, manifesting in disturbingly high rates of poverty among many minority ethic groups - 59% of Bangladeshi, 53% of Pakistani and 42% of Black households in London are living in poverty after housing costs (compared to 20% of White households) (GLA, 2020; DWP, 2019).
• Ethnic inequalities are most apparent in employment opportunities and levels of pay: unemployment among young people who identified as Black (aged 16-24) are more than double the rate of those who identified as White. Meanwhile, White Gypsy and Travellers have the highest rate of unemployment of any ethnic minority group. Additionally, in London 40% of ethnic minority group workers had reported racism at work in the last five years, and nationwide one third of employers were found to lack Equality, Diversity and Inclusion (EDI) strategies.

Professor Habib Naqvi, co-chair of the advisory board and Chief Executive of the NHS Race and Health Observatory, said: "We know that racism is a challenge that transcends boundaries and borders, and whilst this report is for London, we hope it will have wider impact across the UK. Racism has deep historical roots; it is pervasive, and it is embedded in the structure of our society. We find ourselves at a pertinent time in history; now is the time to wake up to the scale of inequality and remove the scourge of racism from our society and improve health for all."

As health is largely shaped outside the health care system, the recommendations that improve living and working conditions, and the distribution of power, money and resources that shape daily life (the social determinants of health) will therefore have a greater effect on promoting health equity than just focusing on healthcare services.

Sir Michael Marmot added: "Focusing on disease and healthcare services fails to address three impacts of racism on health. First, how racism directly damages health and wellbeing.

"Second, the reasons why some ethnic groups are more likely to be in poverty, experience poor housing, suffer in the educational and criminal justice system, and experience low pay, racism and poor employment prospects - all of which harm health.

"Third, it does not deal with racism that leads to worse experiences of healthcare and other services and worse outcomes as a result.

"Then there are impacts of other dimensions of inequality. Being poor, disabled and from an ethnic minority group is much worse for health than being only one of those alone."

As a result, the review includes the following recommendations:

• Ensure all employers pay the London Living Wage and eliminate inequalities in pay by ethnicity.
• Greater London Authority to develop and lead on anti-racism approach for all employers in London.
• Strengthen enforcement of legal requirements for non-discriminatory recruitment and support people into work and training by building co-designed programmes with affected groups.
• Reports on racism to be investigated by independent bodies not by employers.

Dr Cordelle Ofori, advisory board member and Manchester City Council's Director of Public Health, explained the review is particularly important to cities like Manchester, where communities impacted by racial inequalities form more than 50% of the population.

Dr Ofori said: "The time is now, to build trust with communities, to ensure services are anti-racist and culturally competent, and to dismantle policies and process that ensure that a significant group of Britain's population continue to be underserved. This is why Manchester's five-year action plan, Making Manchester Fairer, is so important as it aims to address health inequalities and other forms of inequity that impact people's lives and the communities they live in."

The review's recommendations build on many ongoing and developing programmes, which have been set up to tackle racism in London. They include strong antiracism leadership from City Hall in London, the Greater London Authority, London Boroughs, health and care organisations, public health, some employers, service providers and community organisations and leaders.

The report also sets out how legal and regulatory mechanisms can strengthen approaches to tackling racism. The new Government has committed to greater action. For example, the 2024 King's Speech proposed new legislation covering the right to equal pay and requirements for ethnic pay gap reporting, in addition to reform of mental health services.

Study limitations

There is insufficient data and evidence about ethnicity in many important areas which limits the ability to report on ethnic inequalities in health and the social determinants of health and more broadly has hampered efforts to recognise and challenge racism. The review therefore makes recommendations for further research and information and to ensure communities with lived experience are at the heart of decision making and policy development and implementation