Addressing racial inequalities in a pandemic: data limitations and a call for critical analyses
Authors: Flávia B Pilecco, Luciana Leite, Emanuelle F Góes, Luisa Maria Diele-Viegas, Estela M L Aquino
Journal: The Lancet Global Health (2020)

Racial inequality has risen to prominence with the emergence of the Black Lives Matter protests. Although the protests were sparked by police brutality, they also fuelled discussion of racial injustice during the COVID-19 pandemic.1Laurencin CT McClinton A The COVID-19 pandemic: a call to action to identify and address racial and ethnic disparities.J Racial Ethn Health Disparities. 2020; 7: 398-402Crossref PubMed Scopus (526) Google Scholar Pedro Baqui and colleagues' Article (July, 2020)2Baqui P Bica I Marra V Ercole A van der Schaar M Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study.Lancet Glob Health. 2020; 8: e1018-e1026Summary Full Text Full Text PDF PubMed Scopus (361) Google Scholar was the first nationwide study to show that mortality rates from COVID-19 vary with race in Brazil. Here, we elaborate on points that influence how this finding should be interpreted and understood. Scientific associations and the media have discussed the disproportionate health impacts of COVID-19 on communities of colour since the early days of the pandemic.3Garcia R Em um mês e meio, número de infectados por COVID-19 dobra no país; adesão à quarentena cai. J. O Globo.https://oglobo.globo.com/sociedade/coronavirus/em-um-mes-meio-numero-de-infectados-por-covid-19-dobra-no-pais-adesao-quarentena-cai-24512139Date: June 2, 2020Date accessed: July 9, 2020Google Scholar, 4Borjas GJ Demographic determinants of testing incidence and COVID-19 infections in new york city neighborhoods.SSRN Electron J. 2020; (published online April.)https://doi.org/10.2139/ssrn.3572329Crossref Google Scholar, 5Aldridge RW Lewer D Katikireddi SV et al.Black, Asian and minority ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data.Wellcome Open Res. 2020; 5: 88Crossref PubMed Scopus (219) Google Scholar However, few studies have been published from Brazil. A search of LitCovid (a COVID-19 literature hub connected to PubMed) produced only three articles on racial inequality and COVID-19 in Brazil (our search, done on July 12, included the terms [race/ethnicity OR ethnicity OR "minority populations" OR "Black people" OR Indigenous] AND Brazil. Next, we repeated the same search without including Brazil, which produced 302 results). Until July 12, globally, less than 0·01% of the 30 599 scientific papers on COVID-19 referenced racial inequality. We posit that one reason for this sparse literature is the scarcity of data collected and shared by public health agencies. With few published studies, researchers might be reluctant to publish analyses of incomplete data; the issue might be perceived as unimportant, so collection of these data is not prioritised, resulting in a negative feedback loop. Baqui and colleagues' study excluded 38·7% of patients with SARS-CoV-2 because of missing data,2Baqui P Bica I Marra V Ercole A van der Schaar M Ethnic and regional variations in hospital mortality from COVID-19 in Brazil: a cross-sectional observational study.Lancet Glob Health. 2020; 8: e1018-e1026Summary Full Text Full Text PDF PubMed Scopus (361) Google Scholar even though collection of such data in Brazil is required by law,6Ministério da SaúdeOrdinance 344, of February 1, 2017.https://bvsms.saude.gov.br/bvs/saudelegis/gm/2017/prt0344_01_02_2017.htmlDate: 2017Date accessed: July 9, 2020Google Scholar indicating that a legal requirement is being routinely ignored. Furthermore, data that are collected appear to be undervalued. Municipal and state governments rarely report statistics by race or colour, and the epidemiological panel from the Ministry of Health fails to provide information on race or colour. Use of the correct terminology is essential for understanding racial inequalities in health. The discussion about race in Brazil is operationalised through skin colour markers. Baqui and colleagues refer to race and skin colour, hereafter referred to as race, as "ethnicity". These terms carry different meanings in Brazil. Race is an important determinant of social relationships and access to health care, which is not necessarily congruent with ethnicity. Unlike other countries where race is defined as ancestry, in Brazil a phenotypic classification prevails and the darker the skin, the greater the incidence of racism and the worse the health indicators. Skin colour is, therefore, the variable used for the analysis of structural racism and for designing and implementing health policies that address the issue. Mistranslations and misapplications of these terms can hinder the development of solutions to racial inequalities. Studies show how the Black community faces barriers to accessing health services and achieving better living conditions, which ultimately result in worse health outcomes.7IBGESocial inequalities by color or race in Brazil. Rio de Janeiro.https://biblioteca.ibge.gov.br/visualizacao/livros/liv101681_informativo.pdfDate: 2019Date accessed: July 12, 2020Google Scholar, 8IBGESynthesis of social indicators: an analysis of the living conditions of the Brazilian population: 2019. IBGE, Coordenação de Populaçãoe Indicadores Sociais, Rio de Janeiro, Brazil2019https://biblioteca.ibge.gov.br/visualizacao/livros/liv101678.pdfDate accessed: July 12, 2020Google Scholar Finally, for an analysis of racial inequality to result in change, it must be accompanied by a deeper critique of structural racism and recommendations to address the issue.9Iacobucci G COVID-19: review of ethnic disparities is labelled "whitewash" for lack of recommendations.BMJ. 2020; 369m2208Crossref PubMed Scopus (11) Google Scholar Racial inequality in health outcomes is a consequence of structural racism which, in a pandemic, results disproportionately in illness and deaths in Black people. The policies that perpetuate these inequalities have been described as necropolitics: the use of social and political power to dictate who should live and who should die.10Mbembe A Necropolitics.in: Morton S Bygrave S Foucault in an age of terror. Palgrave Macmillan, London, UK2008: 152-182Crossref Google Scholar The COVID-19 pandemic adds one more burden to be shouldered by Black communities, alongside genocide of Black youth, incarceration, poverty, and other forms of systemic oppression. On top of these burdens, one must also ask: what might be the consequences on individual mental health and community organisation of knowing that you have a higher risk of dying from COVID-19 because of the colour of your skin? Missing data not only hinders the analysis of racial inequality during the pandemic but also makes it more difficult to develop solutions. We propose that federal, state, and municipal authorities: (1) ensure that data for race are collected, (2) make data available to scientists and the wider public, (3) develop data-informed policies to tackle racial inequalities, as foreseen in the national integrated health policy for the Black population, and (4) implement these policies with urgency, ensuring that vulnerable communities have access to clean water, sanitation, and masks, and extending access to emergency funds to enable social isolation. This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 25, 2020 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on September 25, 2020 We declare no competing interests.