How do we understand health?
Updated on 10 June 2024
Health is not just limited to the physical and mental wellbeing of an individual, but is influenced by wider structural forces (economic, social, political, environmental) that shape the conditions in which we are born, live, work and age. Researchers refer to these conditions as the social determinants of health inequalities, which include, but are not limited to: income, access to education, housing and living conditions, racism and discrimination, unemployment and job insecurity.
Determinants of health are driven by wider structural inequalities. Over a decade of austerity (reduced social spending and increased taxation) has resulted in cuts to healthcare services, as well as increased poverty, homelessness and unemployment, which can cause and exacerbate physical and mental health issues. Immigration policies and enforcement can restrict access to healthcare, deter communities from seeking care, and exacerbate physical and mental health conditions through practices of detention and deportation (see the asylum statistics). Structural racism can result in premature death for marginalised communities through the entrenchment of exclusionary frameworks across society, and its interaction with state violence (see the criminal justice and deaths in custody statistics pages). The role of marketisation is important, especially as the inverse care law – the principle that the availability of good medical care varies inversely with the need for it in the population served – is more pronounced where medical care is most exposed to market forces.
All of this requires us to view health and mental health in a holistic way – we can’t look at health inequalities in isolation from wider structural inequalities, as otherwise this will only give a partial picture. Intersectionality, which recognises that we are all shaped by the interaction of overlapping power structures, social identities and inequities is an important tool for researchers to get to the root of how and why health inequalities persist, in order to move towards meaningful health justice. When reading the statistics, it’s worth asking, what other factors are at play here? What information is side-lined or omitted through the specific lens chosen?
How to read the statistics
In medical science and much of health research, all too often researchers turn to biology to answer questions that are often better explained by social inequality (this was seen particularly during the covid-19 pandemic, when comorbidities were used as the sole explanations of disproportionate BME deaths). Locating health inequalities in genetics, whilst ignoring the wider structural issues that impact a person’s health, can lead to racial stereotypes that suggest minoritised groups are innately more vulnerable to certain health risks, which does not get to the heart of why inequalities persist. At its most dangerous, it can uphold scientific racism – a tradition which divides humankind into a hierarchy of races, using biology to prove the existence of race and to maintain existing social hierarchies.
Rather than assume health inequalities have a genetic basis (and are therefore inevitable and unchangeable), more attention needs to be placed on biological responses to racism and discrimination. There are increasing calls for racism, discrimination and xenophobia to be recognised as a public health issue. Structural racism corrals minorities into unhealthy environments, such as in poor housing or in polluted areas, which increase ill-health and restricts access to healthcare. Repeated exposure to racism has a bodily impact – the repeated or sustained over-activation of stress response pathways can wear out the physical and mental health of marginalised communities (termed ‘weathering’ by public health expert Arline T. Geronimus) resulting in epigenetic ageing and premature death. However, this is often not captured in the data.
Therefore, researchers must look beyond the statistics to draw out the wider forces at play, and at times look beyond the disparities framework – we have to work harder, to understand what creates the material conditions that lead to the disparities in the first place, and ask ourselves, which variables are not captured in the data. We also must be attuned to the ways in which data, particularly on ethnic inequality, can homogenise experiences without looking closer at variation within a community, as well as consider issues of class, racism or other structural factors that make up social reality.
-
-
-
-
- Health outcomes
- Access to healthcare
- Experiences of healthcare
- Maternal healthcare
- Stillbirth and neonatal and child mortality
- Barriers to accessing maternity care for migrant women
- Healthcare in prisons
- Physical health
- Mental health
- Pregnancy in prisons
- Health and mental health in immigration detention
- Health in immigration removal centres (IRCs)
- Health in institutional accommodation
- Housing
- Disability
- Environmental racism
- Mental health (please note that the mental health section is currently being updated)
-
-
-
Health outcomes
Deprivation and life expectancy
Inequality in health between richer and poorer communities across the UK is marked. A 2020 study by the Nuffield Trust and the Health Foundation showed across a wide range of indicators that people who live in the most deprived areas in England have worse access to, experiences of, and outcomes in their healthcare. For example, in 2017/18 in the most deprived areas there were three times as many hospital admissions for conditions usually dealt with by primary care compared to the least deprived. Data published by the Office for National Statistics has shown that in England, the gap in life expectancy between the least and most deprived areas was 9.4 years for males and 7.4 years for females. These differences in health outcomes are related to the overlapping, interrelated effects of long-term inequality and poverty. Research published in 2024 by the Institute of Health Equity found that between 2011– 2019, over a million (1,062,334) people died earlier than they otherwise would have, had they lived in areas where the richest 10% of the population reside. Of these excess deaths, the author attributed 148,000 to austerity measures implemented from 2010.
BME groups are disproportionately affected by health inequalities. Census data has shown, for example, that people from ethnic minority groups are far more likely than white British people to live in the most deprived 10% of neighbourhoods in England. Pakistani and Bangladeshi people, for example, are over three times more likely than white British people to live in these deprived neighbourhoods, and Black African and Caribbean people were more than twice as likely to live in these areas.
The follow-up to the Marmot Review, published in 2020, tracks the widening of health inequalities since the introduction of austerity in 2010, when the initial review was published. The review showed how poor health outcomes are pronounced for BME people, highlighting recent work on mortality in the UK which has demonstrated the projected lower life expectancy among Pakistani and Bangladeshi people in particular.
Roma, Gypsy and Traveller communities face some of the starkest health inequalities in terms of outcomes. A 2022 Friends Family & Travellers briefing found that Roma, Gypsy and Traveller communities face life expectancies between 10 and 25 years shorter than the general population and experience significantly higher prevalence of long-term illness, health problems and disabilities. A University of Manchester study showed that the average health of a Romany or Traveller person in their 60s is comparable to that of a White British person in their 80s.
Burden of conditions
Moreover, evidence has shown that certain minority groups experience a higher burden of some conditions that are potentially preventable. Bangladeshis and Pakistanis, for instance, have much higher rates of heart disease compared to their white British counterparts. Black African and African Caribbean people have higher rates of hypertension compared to other ethnic groups. Further, BME groups overall are six times more likely to develop diabetes compared to white British people.
Cancer treatment
Cancers are the leading cause of death in England. BME groups have poorer outcomes for some cancers and report worse experiences of healthcare. For instance, Asian and Black women with breast cancer, and Black men with prostate cancer have poorer survival rates than their British White counterparts. Black and Asian people in England have to wait longer for a cancer diagnosis, with a review showing that the median time between first presenting symptoms to a GP and getting a diagnosis is 55 days for a white person, whereas for Asian people it is 60 days (9% longer) and for black people it is 61 days (11%). Diagnosis delays can mean fewer treatment options, while starting treatment later may mean it is less effective, thereby reducing the odds of survival.
Screening rates for breast and cervical cancer are lower among women from ethnic minority groups, particularly South Asians. South Asians also have lower rates of bowel cancer screening.
Later life care
Health inequalities have been shown to continue into later life. A 2021 study looking into health inequalities in later life found that people from Pakistani backgrounds are twice as likely to report poor health than White people; for people from Bangladeshi backgrounds, the odds are 1.64 times higher, and for the Black Caribbean group the chances of reporting poor health are 1.5 times higher than for White British people. A study by University College London and the London School of Hygiene and Tropical Medicine found that Britons of black and south Asian origin with dementia die 2.66 and 2.976 years younger, and sooner after being diagnosed, than white people.
Access to healthcare
Access to primary care is particularly important for addressing population health inequalities, as it often acts as the first point of contact in the healthcare system. However, a 2024 analysis has shown that ethnic minorities has systematically poorer access to general practitioners (GPs). As of October 2023, there were 34 GPs per 100,000 patients in the areas with the highest proportion of people from ethnic minority backgrounds, which is 29% lower than the 48 GPs per 100,000 people in neighbourhoods with the highest proportion of white British people.
Accessing healthcare for certain ethnic minority groups can be difficult. Doctors of the World reports that the most often cited barriers to accessing healthcare in London include: administrative and legal barriers (29%), lack of knowledge or understanding of the healthcare system and of their rights (17%), language barriers (14%), and fear of being arrested (11%). As Healthwatch UK’s 2022 report demonstrates, language barriers and a lack of interpreters can make it difficult to register with a GP, access urgent care, explain their problems or understand what the doctor says, resulting in not accessing the healthcare needed. Government statistics show that between 2011/12 and 2017/18, the ‘Any other’, ‘Black African’ and ‘Gypsy or Irish Traveller’ ethnic groups were consistently among the least likely to report success in getting an NHS dental appointment.
Gypsies and Travellers face long-standing barriers to primary healthcare services. A 2019 study found that almost half of participants from Gypsy and Traveller communities reported difficulties in registering with a GP, over one third reported difficulties in getting an appointment and over one third found information from their GP difficult to understand. Between 2018 and 2019, Friends, Families and Travellers (FFT) found that, despite no regulatory requirement to provide proof of address or identification in order to register, out of 50 GP practices, nearly half refused registration on this basis. This issue similarly impacts other communities experiencing high levels of inequality, such as migrants in vulnerable circumstances and those experiencing homelessness.
For migrants and asylum seekers, accessing healthcare can also be very difficult. A 2018 comprehensive review from Imperial College London and Doctors of the World UK found that there are clear barriers to accessing healthcare for people seeking and refused asylum both at systemic policy level and in implementation and practice. A study by Doctors of the World UK in 2018 found that one fifth of attempts to register Doctors of the World patients (typically people experiencing homelessness, sex workers, migrants with insecure immigration status, asylum seekers, refugees and Roma communities) with GP practices were refused.
Qualitative research has shown that NHS charges and ‘hostile environment’ policy deters and restricts migrants from seeking care or attending screenings. This has been documented amongst migrants living with HIV, for example, despite the fact that HIV treatment is exempt from charging. Moreover, evidence has shown that during the COVID-19 pandemic, hostile environment policies and charges on healthcare has deterred migrants and asylum seekers from accessing healthcare. See our COVID-19 page and see below for barriers for pregnant migrant women and health in immigration detention centres.
Experiences of healthcare
Once BME people manage to access the healthcare they need, their experiences of care can be poor.
Analysis of the 2017 GP Experience Survey has shown that on almost every index ethnic minority people reported less good experiences than White British people.[1][1] This experience is particularly marked for Bangladeshi, Pakistani and Chinese groups; for example the proportion of overall positive experiences was 77% for Bangladeshi, 75% for Pakistani and 72% for Chinese groups, while white British people’s experiences were 84% positive. The 2017 Race Disparity Audit also found that most Asian groups generally express lower levels of satisfaction and less positive experiences of NHS General Practice services than other ethnic groups.
Moreover, in 2019 the Care Quality Commission found that almost half of BME people with a previous mental health problem wanted to raise concerns about mental health services, compared to just 13% of non-BME people with a mental health problem. Also, 84% of BME people with a mental health problem wanted to raise concerns or make complaints about the standard of their care generally, as compared to 63% of non-BME people.
Maternal healthcare
Maternal health refers to the health of women during pregnancy, childbirth and the postnatal period.
There is a growing body of research showing that women facing severe and multiple disadvantages (unstable housing, experiences of trauma and abuse, poverty, physical and mental health conditions, insecure immigration status, unemployment) experience poorer maternity care and are more likely to die during pregnancy or after childbirth. MBRRACE-UK’s 2022 report found that:
- Black women were 3.7 times more likely to die than White women, and Asian women were 1.8 times as likely to die in pregnancy or childbirth as White women.
- 1 in 9 of the women who died during or up to a year after pregnancy in the UK faced severe and multiple disadvantages.
- Women living in deprived areas have the highest maternal mortality rates and are two and a half times more likely to die than their counterparts living in the least deprived
areas.
The UK’s first inquiry into birth trauma found a ‘postcode lottery’ for the quality of maternity care that women receive. Gypsy, Roma and Traveller women are not included in MBRRACE’s statistics, but a 2024 review suggests they have worse maternal outcomes than other groups. Black women are more likely to suffer from severe birth complications, with a 2024 analysis showing that black women are 1.5 times more likely to develop pre-eclampsia than white women, and six times more likely to develop pre-eclampsia superimposed on chronic hypertension.
A 2022 rapid review of ethnic inequalities in maternal healthcare highlighted a lack of adequate interpreting services and resultant communication barriers, as well as disrespect, stereotyping and discrimination within maternity services. Qualitative studies published in 2022 by Five X More and Birthrights have shown the role of structural racism and discrimination in driving inequalities in maternity outcomes.
Stillbirth, neonatal health, infant mortality
The 2022 MBRRACE-UK report showed that:
- Women living in the most deprived areas are at 80% additional risk of stillbirth and neonatal death compared to women living in the least deprived areas.
- Babies of Black and Black British ethnicity remain at over twice the risk of stillbirth and 45% increased risk of neonatal mortality compared to babies of White ethnicity.
- Stillbirth and neonatal mortality rates for babies of Asian and Asian British ethnicity are both around 60% higher than for babies of White ethnicity.
A study using data from 2015–2018 suggests that thousands of babies in England are being born prematurely, smaller than expected or stillborn because of gross socioeconomic and racial inequalities across the country. Figures from the National Child Mortality Database showed that, from 2022 to 2023, the estimated infant death rate per 1,000 live births for Black or Black British babies increased by 28% and for Asian or Asian British increased by 17%.
Barriers to accessing maternity care for migrant women
Migrant, refugee and asylum-seeking women have some of the worst pregnancy outcomes, with access to care obstructed by structural, social and cultural barriers, and negative experiences of clinical intervention.
Maternity services, including antenatal appointments, scans, and postnatal care are included in the scope of the NHS charging regulations meaning that many migrant women face bills for maternity care. Maternity Action has documented the detrimental effects of charging on mothers and children,[2] with the Royal College of Obstetricians and Gynaecologists calling for its immediate suspension.
MBRRACE-UK’s 2019 report into maternal deaths reported that three of the women who died between 2015–2017 may have been reluctant to access maternity care due to fears about NHS charging and the impact on their immigration status. This detrimental impact, particularly for undocumented migrant women, was explored in a 2021 qualitative study.
Delayed access to maternity care can increase health risks and lead to long-term complications. Doctors of the World’s 2022 study showed that 81% of pregnant migrant women who accessed its London drop-in clinic had their first antenatal care appointment beyond the recommended 10 weeks of pregnancy. 45% of the women did not have any antenatal care until after 16 weeks of pregnancy, compared to just one in ten women nationally. Within this group, more than six in ten women from Sub-Saharan Africa (62%) accessed care after 16 weeks. Mental health issues occurred in over a third of women, potentially exacerbated by the fact that over a third also received a bill of up to £14,000 for their maternity care.
Healthcare in prisons (see our criminal justice page for more information)
Physical health
Since, April 2006, the NHS is responsible for commissioning healthcare for people in prisons in England (previously it was the Home Office’s responsibility). Prison healthcare is based on the principles of ‘equivalence’, meaning that those detained should receive at least equivalent standards of care and health outcomes as the general population. Despite this, health inequalities of those in prison are stark – the average age of death in prison is 56, compared with 81 in the general population.
People in prison have significantly poorer health than the general population. The Prison Reform Trust has shown how those in prison are more likely to have been taken into care or have experienced abuse as a child, been homeless, been excluded from school or been unemployed, resulting in complex health needs that are compounded by the prison environment. A number of organisations including INQUEST, Medical Justice, the British Medical Association and Medact have reported on concerns about healthcare provision in prisons.
Despite a lack of data on how a prisoner’s ethnicity affects their access to health services, we know BME prisoners are significantly overrepresented in the prison system with approximately 28% of the overall prison population from a BME background in 2022 (see our criminal justice page). Nuffield Trust’s 2020 study on how prisoners’ health needs revealed that those in prisons had 24% fewer inpatient admissions and outpatient attendances than the wider population and 40% of outpatient appointments for prisoners were not attended (32,987 appointments) – double the proportion of non-attended appointments in the general population.
Mental health in prisons
The HM Inspectorate of Prisons reports 71% of women and 47% of men in prison as having mental health problems. The Justice Committee on mental health reported a high unmet need for mental health care in prisons, with around 10% of prisoners recorded as receiving mental health care, with a suggestion that as many as 70% may have some form of mental health need at any one time. The Lammy Review reported that BME individuals, in both adult and youth estates, are less likely to be identified with problems such as learning difficulties or mental health concerns on reception at prison than other prisoners.
Self-harm data is often used as an indicator of mental health care needs in prison. In the 12 months to September 2021, there were more than 52,726 self-harm incidents recorded in prison. Of the 371 deaths of people in prison in the 12 months to December 2021, 86 were self-inflicted, an increase of 28% on the previous 12 months.
Pregnant women and babies in prisons
The NHS classifies all pregnancies in detained settings as high risk. The experiences of BME pregnant women and babies in prison has been highlighted following the death of a full-term baby, Aisha Clearly, in HMP Bronzefield whose mother, a vulnerable 18-year-old black care leaver, was left alone to give birth with no medical assistance in a prison cell at HMP Bronzefield in September 2019. The coroner was strongly critical of the midwifery care provided by Ashford and St Peter’s Hospital Trust, prison and healthcare staff and Camden social services, concluding that serious operational and systemic failings contributed to the death of Aisha.
There were 196 pregnant women in prison during the 12-month period from April 2022 to March 2023, with campaigners calling for the end of the imprisonment of all pregnant women. Data shows that pregnant women in prison are five times more likely to have a stillbirth and twice as likely to give birth to a premature baby than women in the community, although this data has not been broken down by ethnicity.
Health and mental health in immigration detention
This section includes information on health issues faced by those in immigration removal centres (also known as detention centres) as well as institutional asylum accommodation (including former military bases, barges, hostels, hotels and initial accommodation sites). See the immigration statistics page for further information.
Health in immigration removal centres (IRCs)
Since September 2014, NHS England is responsible for commissioning health services for people detained in IRCs and short-term holding facilities (prior to this, it was the responsibility of the Home Office). However, as Medical Justice notes, ‘healthcare delivery is still contracted to a small pool of private companies’ and is largely inadequate with no access to specialist services. Home Office policy is that people in detention receive healthcare equivalent to NHS services that the general public receives in the community – however this is often not the case.
Detention in and of itself can exacerbate health conditions and cause mental illness. A 2021 systematic review found that three quarters of people in immigration detention experienced depression, more than half experienced anxiety and almost half experienced post-traumatic stress disorder. The prevalence of all three disorders was around twice as high in detained refugees and migrants compared to non-detained refugees and migrants.
According to an FOI response, from June 2022 to March 2023 there were 255 documented incidents of self-harm across the Immigration Removal Centres. A 2023 Medical Justice analysis of the medical assessments of 66 people held in immigration removal centres found that detention had already caused the mental state of 64 (97%) people to deteriorate and had caused harm to all. 63 (95%) had a diagnosis of at least one mental health condition and 49 (74%) people were recorded as having self-harmed, suicidal thoughts and/or attempted suicide. See medical justice.
In 2015 an NHS Health and Wellbeing Needs Assessment Programme report on the immigration detention estate in the UK noted that detainees exhibited raised prevalence of certain forms of disease and chronic il-l health such as diabetes and tuberculosis. Health issues can last after detention, with Medical Justice’s 2022 report showing that Home Office failings have led to the unsafe release of extremely vulnerable and unwell people into the community, without adequate support, care plans or referral to community healthcare.
Health in institutional accommodation
Since 2019 there has been a vast increase in the use of temporary asylum accommodation, including hotels and military barracks (see asylum and immigration page). Conditions in institutional asylum accommodation are known to exacerbate existing traumas, resulting in a deterioration of physical and mental health conditions. Human Rights Watch and Just Fair’s 2023 report outlines ‘serious deficiencies’ with temporary asylum accommodation, including a lack of healthy food, damp, mould, overcrowding and pest infestation, leading to serious health challenges.
The use of former barracks at Manston and Napier has caused serious health risks and clinical harm, including the breakout of diseases including diphtheria, norovirus and scabies, as well as incidents of suicidal thoughts and self-harm attempts. There has been 73 known cases of diphtheria amongst asylum seekers in England in 2022, and an additional 13 cases in England in 2023. An outbreak of diphtheria, as well as scabies, occurred in Manston in October 2022, where a 31-year-old Iraqi man who tested positive for diphtheria died.
A number of outbreaks of infectious diseases associated with accommodation for asylum seekers have taken place across the country from 2020–2023, presenting a risk to public health, including cases of:
- Diphtheria (a potentially fatal bacterial infection)
- Shigella (an intestinal infection)
- group A Streptococcus (can cause infections such as scarlet fever and strep throat)
- MRSA (a bacteria that can cause serious infection)
- varicella zoster virus (chickenpox)
- coronavirus
- flu
- scabies
- tuberculosis
- legionella (a bacteria that can cause to a deadly lung infection)
Doctors of the World’s 2021 assessment found that people housed in the Napier and Penally sites reported bad or very bad health, 68% had a psychological condition and 36% reported suicidal ideation or attempted suicide whilst being accommodated at the barracks. The All-Party Parliamentary Group on Immigration Detention concluded, large-scale institutional settings such as military barracks and barges ‘jeopardise the mental health and wider well-being’ of those held, finding them ‘fundamentally unsuitable’.
Disability
Learning difficulties
BAME communities are disproportionately likely to have profound and multiple learning disabilities and to die in childhood or early adulthood. Of those who died in childhood (ages 4-17 years), 43% were from BAME groups. There is a 26-year difference in life expectancy between white people and BAME people with profound and multiple learning disabilities.
A systematic review found that those with learning disabilities from BME communities are more likely to face barriers in accessing services, less likely to receive specialist services, and more likely to have poor knowledge about those services available to them.
Race Equality Foundation’s report showed that people with a learning disability were six times more likely to die from COVID – and 40% of the deaths were of people from Black and Pakistani communities. People of Bangladeshi origin were twice as likely to die from COVID, even before having a learning disability is taken into account.
Physical function and disability
In one of the few UK investigations into physical functioning in BME communities, a 2020 study found that at every stage of adulthood, those from a South Asian background were more likely to experience poor physical functioning and had an increased risk of developing a physical disability than their White counterparts. African Caribbean women had elevated odds of poor physical functioning compared with White British women from middle age onwards.
Asylum seekers with disabilities are often overlooked in receiving basic services, with reports of being trapped in unsuitable housing. 55 asylum seekers with a range of severe disabilities and life-limiting conditions were placed in a former care home in Essex, opened in November 2022, with no trained care workers or nurses present. On 18 June 2023 an Iranian asylum seeker living in the property died after a stroke – doctors repeatedly said he needed a wheelchair but he never received one.
Environmental racism
Environmental racism encompasses all the ways in which BME communities are exposed to environmental hazards, which can include living in areas in close proximity to toxic waste sites and in homes containing toxic substances such as mould, asbestos and lead paint.
Air pollution plays a significant role in worsening health inequalities. BME communities are three times more likely to live in areas with high air population than their white counterparts, which can put them at disproportionate risk of heart attacks, cancer and strokes. Air pollution disproportionately affects lower-income areas, with half of neighbourhoods with high air pollution in the bottom 30% of the most deprived neighbourhoods.
As well as being more exposed, a 2023 report shows that BME communities are particularly vulnerable to air pollution, with those of Black/African Caribbean and Indian, Pakistani/Bangladeshi descent consistently reporting poorer health outcomes when exposed to heightened levels of air pollution than their white counterparts.
The impact of pollution on the health of BME communities was highlighted following the death of 9-year-old Ella Kissi-Debrah in 2013, who was the first person to have air pollution given as a cause of death following a landmark coroner’s report.
An investigation by Greenpeace UK in 2020 found that waste incinerators – that burn rubbish into ash, flue gas and heat, can cause significant health impacts – are three times as likely to be situated in the most deprived and ethnically diverse areas, reporting that areas in the top 20 per cent for deprivation host one-third of the waste incinerators.
Roma and Traveller communities experience significant negative environmental impacts, with many encampments and housing sites located in polluted environments. In 2004, seventy percent of local authority Irish Traveller sites in England were identified as having at least two or more environmental hazards, while twenty-three percent of such sites were identified as being subject to four or more environmental hazards.
For more information see:
‘The Lancet Series on racism, xenophobia, discrimination, and health’, The Lancet, 8 December 2022, https://www.thelancet.com/series/racism-xenophobia-discrimination-health.
Wayne Farah, ‘Institutional racism in the NHS intensifies in times of crisis, IRR News, 23 April 2020.
Wayne Farah, ‘New Right, Old racism’, IRR News, 20 May 2020.
Wayne Farah, ‘Racial Democracy?’, IRR News, 5 August 2021.
References
[1] Byrne, Bridget et al., Ethnicity, Race and Inequality in the UK: State of the Nation (Bristol, Policy Press, 2020).
[2] See Rayah Feldman, ‘NHS charging for maternity care in England: its impact on migrant women’, Critical Social Policy 41, no. 3 (2021).