A reparatory account of health inequities

Abstract

I. INTRODUCTION

Calls for reparations for historic abuses have grown globally over the last two decades as the need to come to terms with the past and address its enduring legacies has become more urgent.¹ This renewed interest has been strengthened by the unmet promise of racial and gender equality,² as well as the success of key interventions by academics and activists.³ The UK has a long and particular history of reparatory discourses, particularly in the context of slavery, the paradigm issue within reparation debates. Here reparations were first considered at a national level in the 1820s when the British Parliament debated and rejected a proposal calling for Caribbean colonies to receive compensation for the enslavement of their peoples.⁴ A decade later, however, reparations were a successful part of the Slavery Abolition Act 1833, although it was slave owners who were compensated. Payments were made according to the productivity and perceived value of enslaved people.⁵ This was combined with ‘apprenticeships’ that tied freed men and women to work unpaid for their former owners for between 4 and 6 years.⁶ The final cost of the compensation was £20 million—equivalent to approximately £16 billion in 2024—and was an estimated 40 per cent of the national budget at the time.⁷ It was only repaid in full by the UK government in 2015.⁸

Modern Britain is founded upon, and shaped by, slave ownership.⁹ This is through the wealth accumulated by virtue of slave labour, as well as the reparations paid under Lord Wilberforce’s Act.¹⁰ This compensation was dispersed by its many recipients across economic, political, and cultural activities.¹¹ It was also deployed in the colonization of new territories,¹² deepening the relationship between slavery and the wider projects of colonialism and Empire. In tracing the monies paid, the Centre for the Study of the Legacies of British Slavery has created a contemporary census of approximately 61,000 individuals whose financial legacies can be traced throughout Britain’s modern history.¹³ This work to make visible again slave ownership attempts to address the erasure of Britain’s historical—and modern—reliance on slavery.¹⁴ Importantly, uncovering the contemporary legacies of wealth generated by slave ownership directs attention to the very different legacies experienced by the descendants of those who experienced enslavement and other practices of colonialism. In contrast to the immediate payments to slave owners, the question of reparations for the harms caused and entrenched by these historic abuses has been less easily resolved.¹⁵ Indeed, state-based reparations continue to be fiercely contested, even as the idea of what reparations might look like in the twenty-first century evolves. This article responds to the need for reparations and argues for action to address racialized health inequities, which are identified as an enduring legacy of British colonial history and one of the means by which the UK may start to address the past.

Chattel slavery was a distinct economic and political practice and has been recognized as a crime against humanity.¹⁶ While it is essential to acknowledge this, slavery was a stage of colonialism, allowing colonizers to address labour shortages as well as simultaneously extending markets for products.¹⁷ Western Europe’s historically unprecedented growth between 1500 and 1800 can be ‘almost entirely’ explained by access to the Atlantic economy, which was enabled by both the trafficking of enslaved Africans and participation in markets sustained by colonial conquest.¹⁸ These economic and political processes cannot be separated from each other or divorced from the present. As Olúfẹ’mi Táíwò notes, ‘slavery and colonialism built the world we live in’,¹⁹ and ‘the patterns in how advantage and disadvantage flow have changed very little’.²⁰ This understanding has seen calls for reparatory action increasingly bring together slavery and colonialism. This responds not just to their interrelationship, shared logics, and how capital, people, and technologies moved across the geographies of colonialism,²¹ but also how they have been instrumental in the formation of the modern world order,²² and, to return to Táíwò, the ‘global racial empire’.²³ As he writes, this is a ‘system of distribution, explaining where social advantages and disadvantages are made and how much of those social advantages and disadvantages different people and places get’.²⁴ In the UK, as elsewhere, this has created enduring racially codified economic and social inequalities.²⁵ These, in turn, have resulted in enduring racialized health inequities. While our knowledge of such inequities is longstanding, COVID-19 brought them to the fore and into wider public knowledge. As Yaya and others observe, the pandemic has ‘illuminated a disturbing and inconvenient truth: the “colour of health” and how ethnoracialized differences in health outcomes have become the new normal across the world’.²⁶ It is addressing the ‘colour of health’ inequities in the UK as part of a process of reparation for colonialism that is the focus of this article.

While calls for state-based reparations grow, reparatory discourses have—for some—moved from a focus on a singular payment in compensation for a past wrong to the need for a more sustained and expansive politics of repair. Acknowledging this, I argue that addressing racialized health inequities can be an important element of the work to repair past wrongs. Early abolitionists focused on undoing the harms inflicted on the bodies of enslaved people.²⁷ Prefiguring embodied accounts of justice that emerged towards the end of the twentieth century,²⁸ many abolitionists articulated and campaigned for liberty in embodied terms.²⁹ Contemporary racialized health inequities demonstrate both the importance of this focus and how the need to repair the body endures. It is argued that this reparatory work can be done by mobilizing social determinants of health (SDH) research, which has long linked social disadvantage to poor health and other outcomes.³⁰ As the World Health Organisation (WHO) explains, health is determined by ‘the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life’.³¹ The conditions of daily life create a health gradient that tracks improving health outcomes on a consistent and predictable slope, from those who have the least to those who have the most.³² This gradient is raced, and an increasing body of work addresses the role of racism in driving inequalities in determinants of health.³³ Indeed, structural racism has been identified as a ‘long-standing public health emergency’,³⁴ and as the United Nations Secretary-General restated in 2023, slavery and colonialism ‘are among the major sources of contemporary racism, racial discrimination, xenophobia and related intolerances’.³⁵

This article provides a reparatory account of racialized health inequities in the UK in order to help ‘address the ways in which injustices may be acknowledged and put right’.³⁶ SDH research highlights how addressing the conditions and inequalities of daily life promotes greater health and social justice. Universally available improvements in the determinants of health (in education, housing, nutrition, income, and so forth) acknowledge the complex histories and patterning of abuse, disadvantage, and need across different communities. It also recognizes the wider demands of reparation: ‘If slavery and colonialism built the world and its current basic scheme of social injustice, the proper task of social justice is no smaller: it is, quite literally, to remake the world’.³⁷ In making the case for addressing health inequities as part of a reparatory programme, this article provides a framework for understanding and responding to racialized health inequities, creating a research agenda for public health disciplines in terms of designing effective and equitable implementation. Law is a key public health discipline, although it remains ‘underutilised and poorly understood’.³⁸ This article joins a growing body of literature that responds to this, drawing law into the SDH framework. ³⁹ In doing so, it clarifies our understanding of law as a determinant of health.

This reparatory account starts by providing a brief history of reparations, acknowledging that this is, in general, a history of failure.⁴⁰ It then addresses how reparations have come to be articulated differently, with the debate moving from a narrow focus on compensation to questions of repair and a broader reparatory politics.⁴¹ Acknowledging early abolitionists’ focus on the body and emergent ideas of embodied justice, the concept of health equity and the SDH research that links disadvantages experienced by different racial and ethnic populations to poor health outcomes are then introduced. This includes groups that have experienced different colonial practices, but where enduring poor health is a common legacy. The final section considers law and the work of repair. It addresses how a focus on racialized health inequities can add to conceptualizations of reparatory justice, as well as to our understanding of what is demanded when we articulate law as a determinant of health.

II. A HISTORY OF REPARATIONS

The question of reparations in the UK has been obscured by the Abolition of the Slave Trade Act 1807 and the Slavery Abolition Act 1833, which have allowed the country to focus on its role in ending slavery.⁴² This has deflected attention from the nation’s 250 years of slaving, its position as the largest slaving nation during this time, and the fact that it was responsible for the introduction of chattel slavery; that is, the denial of humanity to enslaved Black people.⁴³ While the focus of this article is the UK, this section—and indeed the argument more generally—draws on the development of calls for reparations and understandings of reparatory justice from across jurisdictions, most notably the USA. This recognizes not only the historical particularity of the UK and how this has limited engagement with reparatory discourses, but also the fact that ‘slavery, colonialism, and the political structures they produced were and are global phenomena’.⁴⁴ As such, while jurisdictional particularities are important, they do not negate the relevance of reparatory work from elsewhere. Indeed, the interconnected global legacies of disadvantage have rightly provoked global visions of repair.⁴⁵

In jurisdictions around the world, reparation campaigns have emerged within a variety of contexts, including slavery,⁴⁶ mistreatment of people with disabilities,⁴⁷ land rights,⁴⁸ wage control,⁴⁹ genocide,⁵⁰ sexual enslavement,⁵¹ and acts of war.⁵² In Europe, reparations are most commonly associated with the financial settlements paid by Germany, first in 1921 following World War I, and then the sum Germany agreed to pay at the World Jewish Congress in Israel in 1952. Successful examples have also arisen in postcolonial contexts. Reparations were made by the UK government in 2011, for example, to the families of individuals who had been murdered or detained following accusations of membership in the Mau Mau resistance in Kenya between 1952 and 1960.⁵³ While these provide examples of successful claims, they are far outweighed by those that have failed. In this vein, the attitude of successive UK governments towards the question of reparations for slavery has been characterized as dismissive.⁵⁴ As already noted, the earliest unsuccessful attempt at national-level reparations was in the 1820s.⁵⁵ The UK also debated and rejected various calls for reparations that formed part of the wave of independence campaigns from former colonized nations that marked the mid-twentieth century.⁵⁶

In the last decade, calls for reparations have been buttressed by unrest and condemnation following a number of high-profile police killings of Black people in the USA, mobilization of publics around the world by the Black Lives Matter movement, and the racialized impacts of COVID-19⁵⁷—that is, the ‘color of COVID’.⁵⁸ The effects have been felt globally, including the UK. In July 2020, Lambeth Council in London passed the first successful motion of its kind to formally demand reparations for slavery, calling on the UK government ‘to establish a commission to study the impact of UK involvement in the transatlantic trafficking of enslaved Africans and to make reparations’.⁵⁹ This commission would be an All-Party Parliamentary Commission of Inquiry for Truth and Reparatory Justice.⁶⁰ In March 2021, Bristol Council supported establishing such a commission, as well as advocating for the development of a reparations plan.⁶¹

While reparations for slavery have not been forthcoming at national level, some indirect and local initiatives can be identified. For instance, calls for the British Government to pay reparations to Caribbean countries have recirculated since 2002.⁶² While the payment of formal reparations continues to be rejected, UK investment in many Caribbean countries has increased, helping to improve infrastructure including, health care.⁶³ The legacies of slavery are also increasingly acknowledged by institutions, including companies, banks, and universities. Some organizations who received compensation for their historic ownership of enslaved people, or who otherwise benefitted from wealth generated from slave labour, are now undertaking to make payments to Black communities.⁶⁴ Individuals are also coming together to consider their obligations.⁶⁵ While these and other initiatives—or micro-reparations⁶⁶—are welcome, they fall short of the coordinated national approaches needed. At the same time, such national approaches have provoked a number of objections.

In the context of the paradigm question of reparations for slavery, objections have included: ‘that the victims of the direct harm are dead, that the perpetrators are diffuse, and that some of the actual harms were legal at the time they were committed’.⁶⁷ Such identified difficulties generally have a legalistic hue, with law painted as natural or apolitical,⁶⁸ and a transhistorical determinant of the possible. Having said that, current legal rules do create significant obstacles for those seeking reparations through the courts in advance of any legislative intervention.⁶⁹ As Johnstone and Quirk note: ‘[i]n the absence of a clear-cut legal relationship between a set of identifiable plaintiffs and identifiable defendants, existing laws frequently have little to offer reparations campaigners’.⁷⁰ At the same time, as these obstacles have been acknowledged, the nature of the reparation debates has shifted. Calls for reparations have moved to include more than financial compensation and an admission of past wrongs. They now often seek to address the trauma that has folded out from these past wrongs to create centuries of social injustice.⁷¹ This requires reparations to include not only compensatory and restitutionary purposes, but also the aim of building a more just future.⁷² These purposes and ambitions inform articulations of reparatory justice.

A. Reparatory justice

A distinction is increasingly made between reparations—generally denoting compensation—and reparation, which has come to mean repair and engages a broader reparatory politics directed at justice.⁷³ It moves the debate beyond a narrow focus on the payment of a compensatory sum and invokes the need for a broader response to obligations owed. This follows, in part, from a more appropriate temporal frame: looking beyond an act to which compensation attaches, to the wider context, history, and legacies of harm. Thus, it acknowledges the ‘government policies and decades of indifference’ that followed the legal end of slavery and processes of decolonization to produce ongoing ‘racial disparities in wealth, health and criminal justice’.⁷⁴ In terms of the temporal frame, it is also forward-oriented, aiming ‘to achieve cultural changes that diminish the likelihood that these things will take place again’.⁷⁵

Different approaches to reparatory justice have evolved. These recognize the need not just for material restitution, but also apology, public memorialization, and accurate historical education.⁷⁶ As Rhoda Howard-Hassmann states: ‘Accurate acknowledgement would be a first step in reparations. Apology is a second step.’⁷⁷ Memorials and financial reparations then follow.⁷⁸ These elements are essential, yet they must be joined by interventions that address the material conditions of communities living with the legacies of colonial abuses. This is addressed, for example, with the CARICOM Ten Point Plan for Reparatory Justice, which addresses both slavery and the related colonial abuses of indigenous Caribbean peoples. The plan demands: (i) Full Formal Apology, (ii) An Indigenous Peoples Development Programme; (iii) Repatriation for those who desire it; (iv) Cultural Institutions; (v) Attention to the Public Health Crisis in the Caribbean; (vi) Illiteracy Eradication; (vii) African Knowledge Programme to rebuild ruptured relationships; (viii) Psychological Rehabilitation; (ix) Technological Transfer, and (x) Debt Cancellation.⁷⁹ The CARICOM Plan aligns with Táíwò’s model of reparation, which demands not only compensation, but also the structural change necessary for social justice⁸⁰:

This is the constructive view of reparation: a historically informed view of distributive justice, serving a larger and broader worldmaking project. Reparation, like the broader struggle for social justice, is concerned with building the just world to come.⁸¹

Focusing on reparation as repair, the argument developed here centres the ongoing need to repair the body as an essential element of reparatory justice and the worldmaking Táíwò envisages. This directs attention not to the ‘racial wealth gap’ but the ‘health gap’ with which it correlates. This health gap is a social injustice arising from the disadvantages that historic wrongs have caused and entrenched. The argument draws on SDH research to link contemporary health inequities to the historic and ongoing disadvantages experienced by racial and ethnic minorities. This research also provides a solution: mandating investment in social determinants to address health and other inequities. The next section outlines the health equity concept. It then illustrates how racism intersects with social determinants before the health impacts of this are then addressed in the section that follows it.

III. HEALTH EQUITY, SOCIAL DETERMINANTS, AND RACE

In Undoing Slavery: Bodies, Race, and Rights in the Age of Abolition, Kathleen Brown reveals an ‘abolitionist body politics’ whereby early abolitionists centred the body in the pursuit of liberty for the enslaved.⁸² Dominant historical accounts argue that abolitionists campaigned for recognition of the human rights of enslaved peoples as a means of securing a future free from harm. Contrary to this, Brown argues that these abolitionists understood that bodily integrity—and a body free from the brutal bodily harms of slavery—was a necessary precondition for achieving rights and liberty. As she notes, this focus on bodily or embodied integrity as necessary for the realization of human rights and flourishing had to wait until the twentieth century to be engaged by human rights academics, activists, and others.⁸³ In this, the abolitionists foreshadow work that has come to identify bodily integrity as the fundamental value and a cornerstone of all other rights.⁸⁴ They also prefigure the embodied theories of justice that have featured prominently in feminist and other critical fields in the last 30 years.⁸⁵

Contemporary work on health equity centres the body in an echo of this abolitionist body politics, providing an account of why health should be the focus of our ethical and political concerns, as well as our legal action. Health equity has its foundations in the special status of health,⁸⁶ which is necessary not just for well-being, but also for social and political existence.⁸⁷ Inequities in health are therefore inequities in opportunity and the freedoms this creates. In other words, health inequities can significantly diminish the life choices of different groups within a population and are therefore a profound social injustice.⁸⁸ In response, health equity has come to mean a state where everyone has a fair and just opportunity to be as healthy as possible.⁸⁹

While this understanding of health and health inequity mandates that improving population-level health should be a primary goal of states,⁹⁰ governments nevertheless often accept or promote situations that create or exacerbate health inequities. As the WHO asserts, the conditions that determine the unequal distribution of poor health are not natural, rather they are ‘the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics’.⁹¹ Importantly, inequalities in social determinants—that is, inequalities in the distribution of power, income, goods, and services, and the conditions of work, leisure, and home life—are ‘responsible for a major part of health inequities between and within countries’.⁹² Given this relationship between social and health inequities, health disparities demand our attention not just because of the direct and indirect harms they cause, but also because they highlight structural inequalities. Social and economic inequalities correlate to inequities in health. Conversely, when societies are fairer, a population’s health outcomes are better.⁹³ Health inequities therefore highlight fault lines of inequality, discrimination, and deprivation. Without concerted global action, it has been observed that health inequity may become the ‘defining narrative of the 21st century’.⁹⁴

In the UK, a growing body of work focuses on the impact of racism on the distribution of social determinants and identifies racism as a legacy of colonialism.⁹⁵ As Nazroo and Williams write: ‘the socio-economic disadvantage faced by ethnic minority migrants in the UK, was, and continues to be, structured by racism that has its roots in colonial history’.⁹⁶ Colonialism created ‘race’,⁹⁷ a socially constructed taxonomy reflecting the ‘intersection of particular historical conditions with economic, political, legal, social, and cultural factors, as well as racism’.⁹⁸ Racist scientific and political theories then emerged to justify colonialism, with these becoming embedded in the social, political, and legal structures of slaving nations.⁹⁹ The end of slavery and the processes of decolonization did not challenge these embedded values. Rather, notions of racial hierarchy were amplified and have endured.¹⁰⁰ As the United Nations Secretary General recently reported:

United Nations experts have documented the linkages between the past and the present, shedding light on the economic, psychological, social, political, cultural, educational and intergenerational dimensions of the lasting and structuring impact of past tragedies and crimes in past societies. They have shown that the formal abolition of enslavement and colonialism was insufficient to dismantle the racially discriminatory structures built by those practices. Instead, it often gave way to racially discriminatory policies and systems, including segregation… that perpetuated racial discrimination, oppression and inequalities.¹⁰¹

This captures the experience of racial and ethnic minorities in the UK, seen particularly graphically with mass migration from colonial territories in the Caribbean, Africa, and the Indian subcontinent following the end of World War II. These migrants travelled to escape poverty and economic decline in the colonies and to address labour shortages in the UK.¹⁰² Nevertheless, they were met with ‘hostility bred from the attitudes of racial supremacy fostered by centuries of imperial power’.¹⁰³ This was witnessed at every level of society, from the actions of the British state and its elites, to interpersonal racism and violence on the streets.¹⁰⁴ Such racism has been a ‘defining feature’ of post-war Britain,¹⁰⁵ where it is ‘deeply sedimented’ in all layers of society.¹⁰⁶ This has resulted in social and economic segregation and the consequent uneven distribution of the determinants of health:

Shaped by ideas of Empire and Britain’s colonial history,…discriminatory practices in areas such as housing, employment and criminal justice produced a deeply unequal society, in which black and minority communities have been disproportionately concentrated in more deprived areas, in poorer quality housing, and within low-wage and insecure employment.¹⁰⁷

While discriminatory practices happened across sectors or determinants—such as education and employment—housing has a particular importance in terms of its place within the dynamics and longevity of segregation and stratification. Racism shaped access to private and public housing for migrants.¹⁰⁸ In the public sector, racism by local authorities saw racial and ethnic minorities allocated the least desirable housing in the least favourable estates.¹⁰⁹ Susan Smith identifies housing as a lynchpin, whereby it is fundamental in constituting citizenship, and creating and sustaining racial inequalities:

As a residential pattern…, racial segregation reflects and structures enduring inequalities in access to employment opportunities, wealth, services and amenities, and to the package of civil and political rights associated with citizenship. As an ideology…, segregation builds from the objective deprivation of black people to a subjective acceptance that racial differentiation has a logic of its own; it provides a reservoir of common sense justifications for discriminatory policy and separatist practice.¹¹⁰

Housing disadvantage became entrenched in the decades that followed post-war migration and has been exacerbated by changes in the housing landscape in more recent decades. The UK now experiences ‘stark and persistent ethnic inequalities in housing’, with at least a third of Bangladeshi, Pakistani, and Black African people living in overcrowded conditions. This compares to 1 in 20 white households.¹¹¹ Housing for racial and ethnic minorities is also more precarious, with these households significantly over-represented as statutory homeless.¹¹² Within this context of entrenched and intergenerational housing inequality, and echoing Smith’s earlier observations, housing retains its influence on experiences of other determinants of health.

The next section addresses how inequalities in access to social determinants translate to health inequities experienced by racial and ethnic minorities in the UK. Findings across different populations are provided, acknowledging that contemporary experiences of health inequities are raced, with their origins in the complex and interrelated histories of colonialism. In this, racism is revisited and acknowledged as a complex and ‘fundamental’ determinant of health.¹¹³

IV. THE COLOUR OF HEALTH INEQUITIES IN THE UK

Racialized inequities in health outcomes are substantial and have generally not changed over time.¹¹⁴ Within this overall context, health inequities are uneven across racial and ethnic minorities and health conditions. As the UK Parliamentary Office of Science and Technology summarized, racial and ethnic minorities ‘generally have worse health than the overall population, although some … groups fare worse than others, and patterns vary from one health condition to the next’.¹¹⁵ Thus, it should be noted that while some groups have the poorest health outcomes across a range of indicators,¹¹⁶ it is more common to see high levels of variance across indicators. To provide a brief and incomplete illustration of the complexity of the patterning and experience of racialized health inequities in the UK, it can be noted that there are higher rates of heart disease among ‘South Asian’ people, but particularly among Bangladeshi and Pakistani people.¹¹⁷ Hypertension and stroke are experienced more frequently by Caribbean and African people than other groups, and these populations also experience higher rates of admission to psychiatric hospitals with a diagnosis of psychotic illness.¹¹⁸ While rates of maternal mortality are generally low in the UK, poor outcomes are higher for mothers and babies from Black and Asian groups.¹¹⁹ Compared to white groups, the rate of women dying in the UK in 2016–2018 during and up to 1 year after pregnancy was more than four times higher in the Black group.¹²⁰ Obesity is also experienced by a significantly higher number of Black adults,¹²¹ and childhood obesity has a higher prevalence among Black and Asian children.¹²² It is associated with higher levels of deprivation and has a significant bearing on immediate and future health. Children in Asian and Black households are twice as likely to live in persistent low-income households than children from white households.¹²³ Such deprivation is a risk factor in infant mortality, which is experienced at higher levels in racial and ethnic minorities.¹²⁴ Thus, while for many conditions and outcomes, there are differences between groups, infant mortality is a health inequity shared across all racial and ethnic minorities. This is also seen with Type 2 Diabetes and associated complications.¹²⁵

The picture is therefore complex and identifying causation is difficult. It is suggested that the experience of health inequities is driven by the interplay of deprivation, environmental factors, and health-related behaviours.¹²⁶ The Parliamentary Office of Science and Technology concluded: ‘Ethnic health inequalities result from many inter-linking factors, of which the relative poverty of [racial and ethnic minorities] is probably the most important’.¹²⁷ Returning to the importance and influence of housing, Public Health England have stated that ‘ethnic minority people reside disproportionately in areas of high deprivation with poor environmental conditions, with concomitant negative impacts on health’.¹²⁸ Importantly, racism is increasingly identified as a significant contributor to these socio-economic factors and therefore to the health disparities that follow. Public Health England, for example, go on to highlight the role of racial discrimination in housing, education, employment, and other determinants.¹²⁹ Increasingly, work on racialized health inequities has developed to identify the importance and interaction of structural, institutional, and interpersonal forms of racism.¹³⁰ As Gee and Ford argue, to understand racism as a ‘fundamental determinant of health disparities requires attending to the multiple manifestations of racism’.¹³¹

This can be illustrated through the example of racialized inequities in severe mental health, which have been reported consistently for more than 60 years.¹³² At the macro level, structural racism leading to socio-economic disadvantage creates an increased risk of severe mental illness.¹³³ At the same time, such socio-economic disadvantage increases the likelihood of interactions in health and criminal justice domains where institutional racism can lead to unequal health outcomes.¹³⁴ Black Caribbean and Black African patients, for example, are at least three times more likely than white patients to experience compulsory admission under the powers of the Mental Health Act.¹³⁵ This follows similar disparities in police contact before admission, where Black Caribbean patients are at least 2.5 times more likely, and Black African patients are at least 3.5 times more likely, than white patients to have had contact with the police prior to admission.¹³⁶ At the same time, Black Caribbean and Black African patients are almost half as likely to have seen a general practitioner before admission compared to white patients.¹³⁷ Once admitted, these groups are more likely to be in psychiatric intensive care units and medium secure units, more likely to be secluded or physically restrained, spend longer in acute hospital care, and subsequently experience more frequent compulsory readmissions.¹³⁸ During this time, they can receive non-standard pharmacological treatment.¹³⁹ This reflects the broader picture whereby racial and ethnic minorities are more likely to experience negative pathways through care, poorer access to effective interventions, and poorer outcomes.¹⁴⁰ Finally, it should be noted that the incidence of severe mental illness is significantly increased for people reporting verbal or physical racist abuse.¹⁴¹

The data on mental health disparities demonstrate how structural, institutional, and interpersonal racism across domains can compound disadvantage. Stressing the interaction of different forms of racism, Nazroo and colleagues nevertheless single out the importance of institutional racism:

Institutions are sites crucially situated in and shaped by both wider forms of structural racism and inequality, and spaces within which forms of interpersonal racism and micro-forms of racialisation operate, and can sediment and acquire greater salience through their institutionalisation.¹⁴²

It is against this backdrop of health inequities shaped by interrelated racism that the COVID-19 pandemic unfolded. As Yaya and colleagues note, it aggravated ‘an already very fragile situation’ characterized by ‘grave inequalities’.¹⁴³ The statistics detailing ethnic disparities in the impact of the pandemic in the UK are stark. Racial and ethnic minorities together are 13 per cent of the UK population and yet accounted for one-third of those with the virus who were admitted to intensive care units in the first months of the pandemic.¹⁴⁴ A review of National Health Service (NHS) data found that people identifying as South Asian and Black African had positive test rates, respectively, at 2 and 1.7 times the rates of white British.¹⁴⁵ The Office of National Statistics (ONS) found that in the early months of the pandemic, the rate of death for Black males was 3.8 times greater than that for white males, while the rate for Black females was 2.9 times greater than for white females.¹⁴⁶ Statistics to 31 March 2021 confirmed that mortality rates remained higher for Black Caribbean males and Bangladeshi and Pakistani males and females.¹⁴⁷

COVID-19 has shone a light on the relationship between race and ethnicity, deprivation, and poor health. The ONS found that people from racial and ethnic minorities were more vulnerable to COVID-19 because of pre-existing socio-economic inequalities.¹⁴⁸ As already noted, minoritized ethnic populations in the UK experience higher levels of material deprivation and are more likely than white British residents to live in larger, overcrowded households, with multiple generations, in rental properties, and in deprived areas. The Institute for Fiscal Studies argued that some of the disproportionate impact was likely to be due to greater exposure in employment, given that people in these groups are more likely to be key workers.¹⁴⁹ All of these factors add to the likelihood of contracting the virus, as does the dependency on public transport and the reduced capacity to work from home. This increased risk of exposure is coupled with a higher likelihood of underlying health conditions that exacerbate the impact of infection.¹⁵⁰

Structural racism leading to inequalities in social determinants therefore amplified the effects of COVID-19 amongst racial and ethnic minorities in two ways that compound each other. First, key determinants (including poverty, housing, and employment) increased the risk of contracting the virus. Secondly, longstanding inequalities led to higher levels of pre-existing co-morbidities, increasing the impact of the virus in its severity and mortality. Returning to institutional racism, the pandemic exposed racism in the healthcare system. At its starkest, Black women reported receiving substandard care and being sent home after presenting to hospital with COVID-19.¹⁵¹ Public Health England also reported that institutional racism within the workplace may have made it less likely that minority ethnic staff raised concerns about risk levels or lack of personal protective equipment.¹⁵² As Marmot and colleagues concluded: ‘The implication is clear: dealing with this higher risk entails not just healthy practices, handwashing and social distancing, but also recognizing and dealing with structural racism.’¹⁵³

It is important to note that the disproportionate impact of the pandemic was as sharply experienced by racial and ethnic minorities in many jurisdictions. The racial impact in the USA is well known. States with larger African American communities demonstrated pronounced inequalities in the impact of the pandemic. In Illinois in 2020, for example, while African Americans constitute 16 per cent of the State’s population, 37 per cent of the total confirmed cases and 45 per cent of COVID-19 deaths were amongst the Black population. Similar statistics are available for Michigan, Missouri, North, and South Carolina.¹⁵⁴ To give a very different example, these inequities were also evident in Scandinavian countries. Somalians in both Sweden and Norway, for example, had higher infection rates than the white populations. In Norway, Somalians had an infection rate 10 times higher than the national average.¹⁵⁵ As Priest and Williams note, ‘Since colonization, racism has been deeply embedded in the structures, systems and institutions of society… with vast and severe consequences for health and health disparities.’¹⁵⁶

Returning to the special status of health, contemporary racialized health inequities can be understood as continuing the injustices of historic colonial abuses as these pasts shape inequities in the present. These continuities give added weight to arguments that the failure to meet rectificatory duties and the subsequent passing of time does not nullify obligations to make reparation. Indeed, as Daniel Butt has argued, such ‘failure to rectify injustice counts as an act of injustice. The passage of time does not mean that a particular set of reparative obligations … lapses’.¹⁵⁷ This argument has increased significance when a failure to meet an initial obligation can lead to a compounding of harm. This is illustrated with health inequities, with COVID-19 providing a particularly stark example of this effect.¹⁵⁸ The issue of racialized health inequities also illustrates how reparations in the form of a single compensatory payment are likely to be inadequate:

[I]nstead, what is indicated is the need for an on-going commitment on the part of the advantaged community to correct the distributive distortion caused by both the initial wrongdoing and the subsequent failure to fulfil rectificatory obligations.¹⁵⁹

V. LAW AND THE WORK OF REPAIR

It has been noted that the history of reparation campaigns is, in general, a history of failure.¹⁶⁰ In response, some have argued that advocates must expand the concept of reparations, whereby any legal steps that address the legacies of slavery and colonialism (including racism, disadvantage, or health inequities) can be understood as a type of reparatory action.¹⁶¹ This can allow majority citizens to identify with and support reparatory interventions, potentially countering low public support for more traditionally articulated programmes.¹⁶² This can strengthen attempts at building shared, or at least overlapping, interests. Derek Bell famously argued that reparations would fail because of white self-interest.¹⁶³ Nevertheless, he noted that advances—like desegregation—happen when interests converged; specifically, when white political elites believed they were necessary to achieve economic and political advances.¹⁶⁴ Bell argued that distinct but overlapping interests can enable change. A focus on achieving health equity through improved social determinants—that is, greater fairness in social arrangements and the distribution of resources¹⁶⁵—has the potential to generate some degree of convergence in both political and public realms.

The need to build alliances draws attention to the precarity of the politics of repair. While some document a changing appetite to repair the injustices of the past, others caution that significant state-based responses remain unlikely. This has provoked warnings that energy expended on such campaigns is misdirected. Johnson and Quirk, for example, observe that, if ‘claims for historical restitution are likely to have limited political prospects, then perhaps other forms of political argument might be more successful in achieving comparable or equivalent goals?’¹⁶⁶ Such arguments can direct us to consider the effects of historic injustices on contemporary lives and rights. Torpey makes such a point, arguing that the new ‘forward-looking’ reparations seek to ‘harness the prevalence of “human rights” to political projects oriented both to coming to terms with brutal pasts and to equalizing the imbalance between rich and poor’.¹⁶⁷ Torpey’s characterization supports bringing together reparatory justice and health equity. Addressing the ‘imbalances between rich and poor’ means addressing not just the ‘wealth gap’ but also the ‘health gap’. This also aligns with Táíwò’s capabilities-informed account of the worldbuilding needed for repair. As he argues: ‘Everyone in the world order should have capabilities that grant effective access to the means of maintaining their biological existence, economic power, and political agency.’¹⁶⁸

Reference to human rights raises questions about the role of law in this context. The primary focus of this analysis has been racialized health inequities in the UK and their origins in colonialism. Focusing on UK domestic law, health inequities engage existing legal obligations. So, for example, racialized health inequities breach duties that exist under UK equality legislation. As Public Health England has acknowledged, action on such inequities is needed to meet the legal duty on the Secretary of State for Health, NHS England, and Clinical Commissioning Groups to have regard to the need to reduce health inequities and to comply with the Equality Act 2010.¹⁶⁹ There are also domestic obligations created by international law in the context of the right to health, particularly when read together with non-discrimination obligations.

The relationship between law and health is, however, more complex, and this article contributes to the developing literature that locates law within the social determinants framework, where health outcomes and inequities are understood as determined by the ‘conditions in which people are born, grow, live, work, and age, and the inequities in power, money, and resources’.¹⁷⁰ This requires that we address the different ways in which law shapes health, where it can be helpful to think of this in terms of scale—working from the highest level of governance to the most individualized. At a macro level, law impacts health through the organization of political and economic systems that can result in greater or lesser inequality within a population.¹⁷¹ Again, the more equal a society is, the better its overall health outcomes. In other words, justice is good for health.¹⁷² At the intermediate scale, law works at a structural level within SDH,¹⁷³ influencing equity and justice within the distribution of determinants such as education, housing, transport, and income.¹⁷⁴ Finally, specific laws and their enforcement act to ‘sort’ individual people—and populations when the effect is aggregated—into more or less healthy environments.¹⁷⁵

These elements are not neatly disaggregated, but approached in this way we may better understand the relationship between law and health, and what is demanded as we address racialized health inequities as an act of reparatory justice. In terms of the macro level, slavery and other colonial practices were economic and political projects enabled and secured by law.¹⁷⁶ Colonialism relied on administrative provisions that determined the shape and governance of Empire. This authorized systems that damaged the health of millions, with harms experienced intergenerationally.¹⁷⁷ In turn, the economic and political relations instantiated under colonial governance continue to shape contemporary global economic and political systems to the detriment of the Global South, including the health of its populations.¹⁷⁸ This is a foundation of Táíwò’s global racial empire, the global system that continues to distribute advantage and disadvantage.¹⁷⁹

In terms of the intermediate scale, and as already noted, colonialism has resulted in ongoing social and economic stratification. One result of this, is that in the UK some racial and ethnic minorities experience disadvantage in each of the social determinants.¹⁸⁰ This is an issue for law. As McGowan and colleagues note, ‘many structural and social factors that negatively influence health and well-being are not “natural” - they are human made, often through the creation, revision, repeal, or lack of law and legal policy’.¹⁸¹ Here, it is argued that failure to meet reparatory obligations and to introduce laws that effectively address social inequalities is a cause of ongoing racialized health inequities. This can be illustrated with COVID-19. As the Institute for Fiscal Studies noted, racial and ethnic minorities had a disproportionate experience of the worst outcomes because of inequalities that increased the risk of transmission and the incidence of pre-existing comorbidities that amplified the chances of a poor outcome.¹⁸² Both are the product of social inequalities that law has failed to remedy. This argument is supported by a study that examined the impact of COVID-19 on African Americans, comparing data from Louisiana to that of South Korea, a more ‘egalitarian polity’.¹⁸³ The authors’ analysis demonstrates how a programme of reparations would have potentially reduced several variables that determined the reproductive ratio of the virus.¹⁸⁴ Provided prior to the pandemic, reparations may have suppressed the negative effects of COVID-19 on African Americans by narrowing the racial wealth divide, creating changes in the built environment, fostering the ability to social distance, ensuring that frontline work was spread across racial and ethnic groups, and decreasing race-based allostatic load; that is, the cumulative burden of chronic stress and adverse life events on the body. While the study focuses on the USA, the lessons are applicable to the UK.

Finally, the impact on health outcomes through law’s more individualized work of ‘sorting’ people into more or less healthy environments is seen in the long history of racially discriminatory legislation after the abolition of slavery. While legislation that is directly discriminatory has disappeared, indirect forms of discrimination persist. Furthermore, the discriminatory implementation or enforcement of laws can also ‘sort’ people into health-damaging environments, such as prisons.¹⁸⁵ This is seen with the racially discriminatory implementation of drug and stop-and-search laws, for example.¹⁸⁶ This discriminatory enforcement is a product of the racism and racial hierarchy that was created and embedded by colonialism and survived its end.

Repair will require work at each of these scales. The argument developed in this article has focused on the intermediate scale; that is, the distribution of social determinants. Here, law has a key role in securing the equitable distribution of determinants of health. As already noted, health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires ‘removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care’.¹⁸⁷ Law can effect change in each of these areas, ensuring, for example, basic income and minimum wages, housing standards, and environmental safety. In this, law must work with other public health disciplines to ensure that improvements are applied universally ‘but with a scale/intensity proportionate to the level of disadvantage’.¹⁸⁸

A necessary part of the work towards health equity is addressing racism. In 2018, the United Nations Special Rapporteur on Contemporary Forms of Racism visited the UK in order to ‘assess the situation of racism, racial discrimination, xenophobia, and related intolerance’.¹⁸⁹ In her End of Mission Statement, Tendayi Achiume highlighted the pervasiveness of racism in contemporary Britain. The Report identifies the ‘striking’ levels of ‘structural socio-economic exclusion of racial and ethnic communities in the UK’ in areas such as housing, employment, policing, and health. She concluded that race and ethnicity, ‘continue to determine life chances in ways that are unacceptable, and in many cases, unlawful’.¹⁹⁰ Achiume’s report provides an important account of the prevalence of structural racism in the UK. While structural racism is frequently identified as the ‘root cause’ of racialized health disparities,¹⁹¹ the examples of inequities in severe mental health and the impacts of COVID-19 illustrate the complex ways in which structural, institutional, and interpersonal racism interrelate. As Nazroo and colleagues write, an integrated account of racism working at these different levels ‘provides a more comprehensive identification of how racisms operate to shape opportunities, and a powerful and fundamental framework for understanding race/ethnic inequalities more generally’.¹⁹²

Emphasizing the role of law in promoting equality and non-discrimination is important as increasing attention is paid to law as a determinant of health. As already noted, the role of law in public health is ‘underutilised and poorly understood’,¹⁹³ and there can be a tendency to focus on the role of law in building and regulating healthcare systems and interventions. In other words, as we continue to develop an understanding of law as a determinant of health, we should not lose sight of the key lessons from SDH research that health inequities are driven by inequalities in the conditions of everyday life.¹⁹⁴ Returning to race, Zinzi Bailey, Justin Feldman, and Mary Bassett argue that combatting racialized health inequities will ‘require policies that restructure the chances for a healthy life for people of color, righting the wrongs of everyday life’.¹⁹⁵ This includes the need for law to articulate and develop the instruments through which it can better address the racisms that drive racialized health inequities.¹⁹⁶ This work can also help to strengthen the understanding of law as an essential public health discipline and a mechanism to achieve justice.

VI. CONCLUSIONS

Social stratification is intimately linked to ethnic and racial diversity and, in particular, histories of large-scale migration, oppression of indigenous groups by settlers, and slavery. In each instance, colonialism shapes the contemporary social inequalities that drive persistent racialized health inequities.¹⁹⁷ In this regard, and as Táíwò notes, ‘[h]istory is not merely an interesting point of comparison for our contemporary problems. Everything we experience happens in the flow of time from past to present to future.’¹⁹⁸ This stratification and social inequality cannot, however, be addressed without confronting racism, and this must be engaged in SDH research.¹⁹⁹ As Williams and Cooper acknowledge, in determining unequal access to resources and opportunity, racism is a ‘fundamental cause’ of racialized health inequities. As they conclude: ‘The bottom-line is that the system of racism has created reduced access for stigmatized groups to the many opportunities that facilitate socio-economic attainment, quality of life and health.’²⁰⁰

The global pandemic brought many of these issues to wider attention. It highlighted how historically determined racism, segregation, and inequality have a direct impact on the health outcomes and lifespan of racial and ethnic minorities today. In this, COVID-19 has underscored the importance of Daniel Butt’s pre-pandemic assertion that, in a world where the distribution of resources is ‘literally of vital importance, the failure of colonial powers to fulfil their reparative duties to the people they have wronged is a continuing injustice, which cries out for rectification’.²⁰¹ Butt’s reference to vitality highlights the importance of health equity as a focus for reparatory action. Addressing the need to repair the body that continues to be harmed by the legacies of colonialism engages the changing nature of reparatory discourses and the need for a broader politics of repair. This articulation of reparation through health equity is also a means of addressing the frequently cited objections to the way reparations are traditionally framed. As Kevin Outterson states: ‘Disparities in Black health may provide a better foundation for successful [reparations] litigation, resolving major issues in standing, statutes of limitations, and sovereign immunity’.²⁰² Perhaps most importantly, in the face of entrenched and life-limiting inequalities, new ways to articulate and achieve repair are essential. As Johnson and Quirk write, in these circumstances ‘it becomes necessary to find a way of combining both ethical ideals and practical calculations’.²⁰³

While this article argues for a focus on health inequities—that is, the ongoing embodied effects of the structural disadvantages wrought by colonialism—this strategy is not without risks. In this regard, it is important to state that centring the body and health is not a proxy or substitute for the other essential reparative acts which must happen alongside. It is notable that in some contexts health has become a substitute for such action. As already noted, while the UK Government has continued to refuse to apologize for slavery in the Caribbean, or directly address reparatory claims, it has increased its investment in Caribbean nations, including in healthcare infrastructure.²⁰⁴ While such investment is important and can address the lived legacies of slavery and colonization, it leaves central reparative obligations unmet. A similar picture is seen in Australia. Closing the Gap is a longstanding national initiative to address the significant inequities in health and life expectancy that are experienced by Australia’s First Nations people.²⁰⁵ While the programme is important and aims to address the intergenerational harms experienced by many communities, it has had a limited impact and has, for some, replaced the national action that is still needed to address Australia’s brutal past and the unmet obligations of repair.²⁰⁶

The abolition of slavery through legislation in 1807 and 1833 has shaped the UK’s collective memory of slavery and the wider histories of colonialism and Empire. This has left the country’s colonial pasts unresolved, both in terms of the need to make reparation and the wider accounting for the harms caused. Contemporary racialized health inequities are a legacy that continues to re-enact the harms and injuries of the past. Directing reparatory attention towards health inequities should not distract from the wider demands of reparatory justice. Rather, this account of the ongoing embodied legacies experienced by racial and ethnic minority populations should act to underscore the issue of our unresolved past and the continuing need for repair.

Footnotes

Acknowledgements

I would like to thank David Carter, Beth Goldblatt, Sheelagh McGuinness, and Carl Stychin for their thoughtful and encouraging comments and conversations on earlier versions of this article. I am also grateful for research assistance from Althea Gibson, Evelyn Rose, and Jaden Ametson.

Conflict of interest

None declared.

Funding

None declared.