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Determinants of Health Update August 2021

Welcome to this month’s policy update from HLA:THINK

Through these regular updates we will share with you some of the key developments in different areas of health and care policy, all through publicly available resources.

If you are interested in the work of HLA:Think and would like to get involved, feel free to contact us on

Coding determinants of health

In a recent correspondence in Lancet Psychiatry, researchers from Universities in Manchester and Liverpool highlight the underappreciated importance of appropriately coding determinants of health. Codes for social determinants of health have been introduced in ICD-9, but their implementation remains incomplete in the latest edition of the International Statistical Classification of Diseases and Related Health Problems, ICD-11. Related, a report from the Nuffield trust on ethnicity coding in English health service datasets found that understanding the full impact of COVID-19 on ethnic disparities in health is made more difficult in part by a lack of recording of ethnicity in death registration, limited recording in primary health records, the inconsistent use of ethnicity codes, and the use of outdated codes (full report). These data are critical if the UK government is to successfully pursue the recommendations put forward by the report from the Commission on Race and Ethnic Disparities (full report), particularly recommendation 23 aiming to “Develop and publish a set of ethnicity data standards to improve understanding and information gathering, reducing the opportunity for misunderstanding and misuse.”

Ethnic disparities in health

The coding issues form a backdrop for two recent studies on ethnic disparities in health in England and the United States of America. A report from the King’s fund on health of people from ethnic minority groups in England found that life expectancy at birth – a key summary indicator of population health – was actually higher among most ethnic minority groups compared to the white population before the COVID-19 pandemic. However, disability-free life expectancy, which measures the expected lifespan in good health, is estimated to be lower among several ethnic minority groups in England, possibly due to the relatively higher prevalence of cardiovascular disease and diabetes in some minority populations. In addition, the pandemic is thought to have reversed the previous life expectancy advantage. Similarly, a simulation study of the US and 16 other high income countries found that the US suffered larger losses to life expectancy compared to other high income countries primarily due to an exacerbation of ethnic disparities in mortality. Life expectancy between 2018 and 2020 declined by 3.88 and 3.25 years for the Hispanic and non-Hispanic Black populations, compared to 1.36 years lost for the non-Hispanic White population.Structural inequalities have been cited by the Scientific Advisory Group for Emergencies as the cause for the differential infection rates and mortality rates between ethnicities. For example in the United Kingdom (UK), the Ministry of Housing, Communities, and Local Government (MHCG) report that 24% of individuals of Bangladeshi ethnicity reside in overcrowded households compared to 2% of persons of White British ethnicity. The MHCG also reports that almost double the proportion of the minority ethnic population compared to the White population live in the most deprived neighbourhoods of the country.


Ethnicity is also reported to play a part in conflict. The annual USA report on genocide and atrocities prevention highlighted ethnicity as a prevailing issue for the genocides in China, Myanmar, and Ethiopia. Conflict has direct effects on health. For example, the ongoing fulfilment of the Doha Agreement – otherwise known as the Agreement for Bringing Peace to Afghanistan – by the USA and its allies has trigerred widespread bombings and killings in Afghanistan. The Uppsala Conflict Data Program has found an increasing number of battle-related deaths occurring year on year over the last decade. This is despite the number of wars decreasing. This paradox is explained in this educational video.

Produced by Rok Hrzic and Soham Bandyopadhyay



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