25th August 2020 marks the 40th anniversary of the Black Report. Intended as a celebration of the NHS, the report instead revealed stark, widening class divisions in terms of health and illness. These were tied not to healthcare failures but to wider social inequalities in income, housing, education, employment and working conditions. Despite the incoming Conservative government’s attempted to bury it—the report was released over the August Bank Holiday—its conclusions prompted decades of community interest and epidemiological research into ‘health inequalities’, most notably the Whitehall studies. Remarkably for a government document, a paperback version was published by Penguin in 1982; it went through multiple print runs and revised editions. But even though a battered copy of the paperback was a staple on many NHS doctors’ bookshelves, health inequalities have widened ever since its publication.
In 2020, in the midst of a global pandemic, the Black Report is not just an indictment of the state of the nation in the late 1970s, but also a grim prophecy that poverty is the most significant comorbidity of all. As a radical, progressive object, it should be commemorated. But as with every historical artefact, it also had its blind spots. As a member of the all-white committee later recalled, the ‘ethnic’ dimension ‘never occurred’ to him and the report did not do it justice. Indeed, ‘race’ is only discussed on a couple of the report’s 400+ pages. The authors acknowledged skin colour as a significant factor in ‘social and economic disabilities’, but in the absence of health data they speculated that male migrants from the ‘New Commonwealth’ self-selected for better health and fitness than their British-born counterparts who seemed to die younger. And they attributed poor child health in immigrant communities to ‘cultural factors such as diet’ or lack of natural immunity to endemic infectious diseases.
But, while the Black Report was sanguine on ‘race’, the 1980s saw a flush of health activism among Black and Asian community workers and patient organisations, working on the impact of ‘race’ and racism on the health of racialized people. Where the Black Report indicted not the NHS but wider inequality that led to class health divides, these activists identified key interventions the NHS could make. Crucially, they argued that in terms of housing and work conditions, Black and Asian people were more likely to be disadvantaged—and that their poor health outcomes were then blamed by the medical community not on racism or even class but on ‘culture’ (just as the Black Report had done).
In 1981, for example, the Brent Community Health Council noted that the NHS attitude towards early infant mortality in their London borough focused on Black and Asian women failing to attend perinatal appointments, rates of illegitimacy, and better contraceptive education programmes, ignoring the fact that rates of infant mortality were worse in areas with poorer housing. ‘In a few deft logical steps,’ the CHC noted, ‘any collective responsibility for the suffering which results from class exploitation – babies dying because of poverty – has been absolved, and the problem ascribed to cultural inferiority.’
The authors of The Heart of the Race: Black Women’s Lives in Britain (1985) took doctors to task for blaming differential maternity outcomes on ‘the “irresponsibility” of Black mothers’, without considering how the ‘kind of work we can or cannot do, the housing we have, the amount of rest we can get and the quality of food we can eat all have a decisive effect on our babies’ chances at birth.’ And the Liverpool-based Race and Health Project (1986-88) investigated ‘class and racial inequalities’, including under the Mental Health Act, and called for ‘radical changes in policy formulation and implementation, which would benefit all, irrespective of race, class, age or gender.’
Today, the flourishing of Black and Asian health activism in the 1980s is less well commemorated even than the Black Report. Tragically, it took COVID-19 to bring the ethnic dimension of health and healthcare back into focus. This is because, even when class and income are taken into account, Black and Asian people are 10-50% more likely to die from the virus than white people, rising to twice as likely in the Bangladeshi community. They also find themselves once again having to counter old arguments about genetics, culture and health—this time regarding the high death rate from COVID-19. Interventions pioneered four decades ago by Black and Asian health activists, such as the translation of public health pamphlets into languages other than English, have not been implemented by the government during the COVID-19 crisis.
Why are we having these same conversations again, forty years after this debate began, and after so much important work was done? The cultural symbolism of the NHS for a national commitment to fairness, equality and harmonious diversity, exemplified in the diversity of its workforce, has shielded it from critiques of health inequality and racism. But the staggering statistic that 94% of doctors who have died from COVID-19 have been BAME, combined with a recent BMA survey showed that 64 per cent of BAME doctors have felt pressurised to work with inadequate PPE, explodes this myth. In the wake of the protests about the death of George Floyd and the unfolding impact of COVID-19, have come calls to decolonise the NHS and to develop an explicitly anti-racist agenda within health research. A new project at the University of Bristol will ‘explore how research in Black humanities might intervene in the current racialized landscape of medicine and health.’ Historians, too, have begun to reckon with the intertwined legacies of the welfare state and empire, and how these have shaped the present health environment in Britain for racialized people.
The 70th anniversary of the NHS passed with much fanfare and commemoration two years ago; even the service’s 72nd birthday was feted around the country. And yet the 40th anniversary of the Black Report—a rare attempt to hold the state accountable for the promises of 1948—is passing mostly unacknowledged. As we commemorate it, we must also recognise those who were left out, and remember the efforts of grassroots activists and healthcare workers who championed the rights and entitlements of the most under-served people in our society.