The EconomistNovember 21st 2020 International 552 someBrazilianhospitals black and brown
women are treated as though they are of
lesser value, says Dr Marinho.
Many indigenous people in Brazil are
reluctant to go to hospital at all. Previous
interactions and “years of delays [in getting
hospital appointments] generated a lack of
trust, a lack of hope,” explains Elivar Kari-
tiana, of the Karitiana tribe, who works for
the indigenous health-care system in the
Amazonian state of Rondônia. When his
uncle, a healthy 56-year-old, became very
ill with covid-19, he ended up in hospital in
Porto Velho, the state capital and died. Vil-
lagers insisted “the doctors killed him” by
putting in a breathing tube, says Mr Kari-
tiana. He now worries about a second wave
in the village. Since his uncle’s ordeal the
tribe has become even more sceptical.
A problem everywhere
Even Britain, where health care is free, has
disparities. Some groups make less use of
programmes meant to catch health pro-
blems before they become more serious.
Several studies have shown that women
from ethnic minorities in Britain make less
use of cervical screening than white wom-
en. They were more likely than white wom-
en to say (wrongly) that they were not at
risk or to say they were scared of what
might be found, or embarrassed or fearful
of being seen by a male doctor.
Governments are belatedly working to
ensure that efforts to stop covid-19 reach all
people: putting testing centres in places
particular groups will visit, for example,
such as churches. At the start of the pan-
demic Latinos in Chicago, many undocu-
mented migrants, made less use of testing
centres than others because they were
afraid of the authorities who ran them.
Awareness of cultural barriers will be
crucial when rolling out covid-19 vaccines.Culture Care, in California, matches black
patients with black medics. An nberstudy
in 2018 found that black men seen by black
doctors consented to more invasive pre-
ventive screening procedures (blood tests,
for example, and injections), and more of
them, than those seen by non-black ones.
But there is also evidence, mostly from
America (which has good data), that people
of colour simply receive worse medical
care. When a black man enters a hospital
with a heart attack he is about a third less
likely than a white man entering a similar
hospital with similar symptoms to receive
a treatment called balloon angioplasty
within 90 minutes (this timing is a key
quality indicator). Studies show that black
patients get less pain medication too (so
much so that it is thought to have helped
keep opioid addiction rates among black
Americans well below those of whites).
Pain in black people is underestimated
compared with pain in white people. An
experiment by the University of Virginia
found that around half of a sample of white
medical students held some false beliefs
about biological differences (that black
people have thicker skin, for example).
Such views were associated with underes-
timating and undertreating black pain.
New research looks at the health effects
of chronic exposure to discrimination. The
idea is that living in a racist society in-
creases stress hormones for minorities and
damages their health. Living in a racist en-
vironment can harm the health of all black
people, even those who do not directly ex-
perience racism, says Delan Devakumar, at
the Institute of Global Health at University
College London. “This is akin to other envi-
ronmental risk factors for health, such as
high levels of air pollution,” he adds.
And yet all this does not fully explain
the racial disparities seen with covid-19.This is apparent from work done using the
Biobank data set, an exceptionally detailed
medical database of the lives and health of
hundreds of thousands of British people.
When using these data to account for so-
cioeconomic status, lifestyle, vitamin D
levels and pre-existing health disparities,
they still do not explain all the differences.Known unknowns
Some are now calling for a deeper look into
the possible genetic contributions to co-
vid-19-related health disparities. Naomi Al-
len, Biobank’s chief scientist, says popula-
tion-level differences in the genetics of the
immune response to sars-cov-2 might in-
crease the risk of hospitalisation and
death. Asking questions about genetic fac-
tors, though, is tricky. Some fear they will
distract from the big and important socio-
economic factors. Others think they are a
red herring because the races that humans
recognise are socially determined, rather
than having real genetic underpinnings.
And yet it is true that different popula-
tions from different environments and
places can have different variants of the
same genes. In malaria-ridden parts of the
world, natural selection has led to an in-
creased prevalence of a gene that causes
blood cells to form an odd sickle shape
(which helps explain why over 90% of suf-
ferers of sickle-cell disease in America are
black). This protects against malaria.
Evolution has also tinkered with immu-
nity. In some areas, presumably where an-
cestral levels of pathogens were higher, the
immune system is more reactive. That is
useful when fighting off illness, but having
an overactive inflammatory system can
also trigger chronic troubles such as diabe-
tes and cardiovascular disease. These then
put people at greater risk for other health
conditions. There is evidence that those of
African ancestry have a stronger inflam-
matory response than Europeans.
A set of genes inherited from Neander-
thals influences which patients get severe
covid-19. They are found throughout Euro-
pean populations at a low frequency. They
are, though, particularly prevalent in South
Asia. Bangladeshis carry the highest fre-
quencies of these genes, a factor worth ex-
ploring when considering why Britons of
Bangladeshi origin have had such high
death rates of covid-19. These genes are ab-
sent in black people—who have a high in-
fection risk, too. This demonstrates just
how multifactorial disease can be.
According to research conducted by Raj
Chetty, an economist, and others, the life-
expectancy gap between rich and poor
Americans has been rising even as the ra-
cial one has been declining. This suggests
that in America race is becoming a poorer
predictor of health outcomes than income
or deprivation. The disparities change. But
the world cannot stop counting. 7A dismal picture