It is not possible to know the exact number of people belonging to minority groups worldwide, due to the lack of a widely accepted definition for minorities. However, commonly ‘minority groups’ are understood to be people who have characteristics that are different to the majority of the population in the place where they live. This could include being part of religious, linguistic, national, or ethnic minorities or other characteristics. Examples include groups living in well-defined areas, such as the Niuenans and Tongan ethnic groups who live on islands in the Pacific. There are also relatively large religious minority groups, including Rohingya Muslims in Myanmar and Christians in Sri Lanka.
Disease outbreaks affect minority groups disproportionately, on a number of different levels. In this resource, we explore the different factors using COVID-19 for the majority of examples, however, many principles and activities can be applied to other disease responses, to ensure religious, ethnic and national minority groups are involved in programming. In addition to these minorities, the Hygiene Hub also offers guidance on the following groups for creating an inclusive COVID-19 response: indigenous populations, older people and people with disabilities and gender.
Are those who are part of minority groups particularly vulnerable to infectious diseases?
Minority groups have a higher risk of contracting COVID-19 and an increased risk for severe outcomes if infected.
Historically, we have witnessed minority groups being disproportionately vulnerable to infectious diseases. This is partially due to the entrenched exclusion, discrimination and lower socio-economic status of many people belonging to minority groups. Historically, long-standing social and health inequities are principal causes for the disproportionate effects that are frequently seen. Furthermore, stigma, fear, discrimination and racism have been highlighted as root causes for many minority groups’ increased exposure and severe health outcomes from infectious diseases. This has certainly been evident during the COVID-19 crisis, with increased vulnerability among minorities to COVID-19 being witnessed across high, middle and low-income countries. In the United Kingdom, people of Pakistani origin are 2.9 times more likely to die due to COVID-19 and black Africans are 3.7 times more likely to die from COVID-19, compared to white British people. People of Bangladeshi origin face an even higher risk, being 4.4 and 5.2 times more likely to die compared to White British males and females, respectively. In Norway, citizens of Somali ethnicity were more than 10 times more likely than the general population to contract COVID-19.
Cumulative COVID-19 Age-Adjusted Mortality Rates by Race/Ethnicity for the years 2020-2022. Data is from the CDC. AIAN: American Indian or Alaska Native; NHOPI: Native Hawaiian or Other Pacific Islander. Source: KFF
Why are minority groups at increased risk of infectious diseases?
Discrimination, or fear of discrimination, can act as a barrier to inclusion and participation in infectious disease responses. Discrimination forms as a part of social stigma that may arise in disease outbreaks and can often lead to minorities being branded as scapegoats who are perceived to ‘endanger’ the rest of the population. Such stigma can have detrimental effects on slowing the spread of infectious disease outbreaks and people’s access to information and treatment.
If we take COVID-19 as an example, in Mozambique, migrants returning from South Africa to their home country were met with suspicion and stigma in their home communities, due to a fear that they would bring COVID-19 with them across the border. In South Korea, members of Shincheonji Church of Jesus were concerned about the pandemic and rising cases of COVID-19 in their country. Although the church itself implemented measures to keep its congregation safe from COVID-19, its members avoided getting COVID-19 tests in fear of discrimination by the public. In February, the Shincheonji Church of Jesus became the centre of the largest outbreak of COVID-19 in South Korea, showing how fear and discrimination can lead to devastating consequences.
In India, 3000 members of the Islamic missionary movement Tablighi Jamaat, were forced to spend more than 40 days in quarantine after seven Indonesians visited their mosque. Scientific evidence suggests that such an extended quarantine period is not necessary, but irrespective of this, the Tablighi Jamaat members were not discharged until the government approved of their release. Similar discriminatory actions against ethnic minorities have been seen in Pakistan, Cambodia, South Korea and Israel.
Lacking identification documents or having a vulnerable legal status are challenges that minority groups may face in accessing information, testing and treatment for infectious diseases. In Lebanon, migrant domestic workers from Ethiopia were denied COVID-19 testing at a hospital in Beirut, as they did not have identification documents. Secondary impacts of not having proper identification documents include not being able to access COVID-19 relief measures, such as in Pakistan, where undocumented migrants are ineligible for financial assistance.
These forms of discrimination and prejudicial behaviour towards minority groups have been witnessed in many health crises, such as the HIV/AIDs crisis and the current mpox outbreak, with sexual minorities bearing the brunt in both cases. For further information on sexual and gender minorities and WASH, see this resource page from Water for Women.
Exclusion from response efforts
Many minority groups experience long-term social injustice and discrimination which often leads to exclusion and marginalisation. Institutional and structural racism determine these disparities, and consequently, minority groups are often excluded from health policies. Within the COVID-19 response, calls have been made to make special considerations to mitigate the impact on minority groups, but despite those efforts, minority groups have been disproportionately impacted by COVID-19.
Discrimination can be a barrier to accessing testing and treatment. The Taureg and Tabu minority groups in Libya have limited access to health care, due to years of conflict, neglect and insecurities. Without appropriate health services, Southern Libyan minorities were left unprepared to tackle the COVID-19 pandemic.
Minority groups can also be excluded from response efforts if information about the disease is shared in a language they do not speak fluently, or through media they do not have equal access to. For example, in Norway, the lack of information about the COVID-19 pandemic reaching the Somali community was believed to be one of the reasons for the disproportionate number of confirmed COVID-19 cases among this community.
Exclusion from reporting
When collecting and disseminating socio-demographic data, there are often limited options available for reporting ethnicity, religion, languages and other categories related to social identity. The absence of such options results in artificial data sets that do not represent the true composition of the population and blinds authorities to the effect of disparities between communities. For instance, in a 2020 review of publications and national reports on COVID-19 outcomes in the UK, only 2 of 29 reports shared results disaggregated by ethnicity.
Source: Mona Chabli
Minority groups are disproportionately represented within the world’s poorest populations. In Latin America, Afro-Descendants are 2.5 times more likely to be chronically poor and earn less for the same job as other Latin Americans. Poverty itself is a barrier to accessing information about public health risks through technology, such as mobile phones, televisions and computers. It is also a barrier to maintaining preventative behaviours, such as self-isolation, shielding and staying at home as much as possible, as this might lead to a loss of income. The COVID-19 crisis has demonstrated that minority groups are vulnerable to the health impacts and even more vulnerable to the economic fallout. Businesses going bankrupt and mandated lockdown orders by authorities due to the pandemic, have led to a loss of livelihood and income, further driving poverty. Poverty can also act as a barrier to testing and treatment if there are any costs associated with accessing health care services.
Many minorities live in overcrowded housing and densely populated areas, due to poverty. This makes preventative actions such as self-isolation or physical distancing challenging. Furthermore, many minority groups lack access to essential services such as water, sanitation and hygiene (WASH). This applies to many minority groups in high-income countries, such as the Roma in Europe and African Americans in the United States, as well as those in low- and middle-income countries. Inadequate access to improved WASH poses a significant challenge for preventing the transmission of infectious diseases among minority households and communities.
The type of work a person engages in has a significant impact on the risk of contracting infectious diseases. For instance, whilst some people are able to conduct their work from home or carry out their jobs in a safe place during disease outbreaks , essential workers (also known as frontline, critical or key workers) and informal workers are forced to risk their own health by going to work and coming in contact with other people. Essential workers include, but are not limited to, those who work in health care (such as nurses and social workers), food service industry, public transportation, hospitality and retail. In many countries, racial/ethnic minorities and migrants are overrepresented in the “essential workers” category. Women also make up some 85% of the informal sector in low and middle income countries and account for 70% of the health and social care workforce globally.
Frontline workers are at a higher risk of acquiring infectious diseases at work, which leads to further risk for their families. Despite there being a high risk of contracting the disease at work, there is a pattern of employers failing to protect minority workers from diseases and to provide adequate support for employees who have been exposed to the pathogen or fallen ill. There are often minimal or no laws and policies in place to protect informal workers, and this undermines their access to health services, disease prevention, testing and treatment services and equipment.
Taking the example of COVID-19, one occupational group which has been particularly affected is sex workers; lockdown measures have adversely impacted the industry, whilst increasing associated risk. Moreover, this group has been largely excluded from government-led support schemes, culminating in financial challenges. A UNFPA study on the impact of COVID-19 on sex workers in Eastern and Southern Africa reported that food and housing crises were faced by 50% of participants.
Frontline workers experience worse job security, mental and physical health and experience a greater risk of contracting COVID-19. Source: OECD
Those living with underlying medical problems such as diabetes, respiratory conditions, hypertension and cardiovascular diseases are typically at a higher risk of experiencing severe health outcomes due to infectious diseases.
For instance, it is known that the risk of complications and death from COVID-19 is higher in people with existing health conditions. Some minority groups experience disproportionate levels of comorbidities, putting them at increased risk if infected with COVID-19. For instance, in the UK, ethnic minorities are 2 to 4 times more likely to have type 2 diabetes. Immunocompromised individuals are also at greater risk; for instance, the risk of severe or fatal COVID-19 is 38% greater in people living with HIV.
Around the world, minority groups are at increased risk of systematic violent repression, mass killing and genocide. Many minorities have fled from countries where they were a part of the majority until conflict forced them to flee their homes. Those who are living as refugees in a foreign country, such as Syrians in Turkey and South Sudanese refugees in Uganda, face unique challenges that require a context-adapted response. Minority groups living in camps and camp-like settings may also require special considerations when responding to infectious diseases. Read our guidance for camp settings here.
What measures can responders take to reduce the disproportionate effect of the focal disease on minority groups?
Identify minority groups in your target area
Explore datasets with a critical eye for ethnicity and religion, and take time to look up the regions where you are working in directories of minority groups, such as Minority Rights Group International. This will help identify minority groups in your country and access information regarding current issues and relevant history that may affect your response programme. As a part of the programme design phase and formative assessment, make sure that all minority groups are identified in your target area so that no one is excluded. Do not group minorities together because it may miss important differences between groups (e.g. a religious minority group may have different needs than an ethnic minority group, despite living in the same area).
We suggest you take the following steps when communicating with minority groups about the disease outbreak:
Raise awareness in minority communities: Take particular care to ensure minorities are included in your community outreach, and share information on disease symptoms and transmission, prevention, treatment and vaccinations, where applicable.
Promote respect for human dignity and diversity: Speak out against misinformation, rumours, stigma and discriminatory stereotyping targeted at minority groups. Governments and public health officials may need to address their historical tendencies of linking the spread of disease to minority groups.
Communicate in the language that minority groups speak: Access to accurate, reliable and timely information that minority groups understand is key to having a successful disease response. For example, the international non-governmental organisation, Translators Without Borders (TWB), have developed resources for how to communicate with the general population, minority groups and response staff during COVID-19 responses. For example, TWB describes how in northeast Nigeria, the term “corona” or “korona” is more widely used to describe both the virus and the disease. The term “COVID-19” is used mostly for administrative communication. TWB also has an online glossary of terms relating to the COVID-19 pandemic in 46 languages.
Bridge the digital divide: In an era where information is being spread nearly solely on electronic devices, steps must be taken to ensure information reaches both users and non-users of digital devices. In areas where coverage of smartphones is high but not everybody has access to the internet, one option could be to provide free internet to users. In Peru, the government made public internet access free during the countrywide State of Emergency issued due to the COVID-19 pandemic.
Create an inclusive dialogue: Two-way communication with minorities should be at the core of COVID-19 response programming and may have a direct impact on the acceptance of and adherence to control efforts. For instance, in refugee camps in Cox’s Bazar, Bangladesh, Rohingya women and girls self-mobilized and formed groups to inform neighbours, families and peers about COVID-19 prevention measures in the camp. Faith communities have also played a vital role in COVID-19 responses worldwide.
Rohingya women keeping the community informed on how to prevent the spread of COVID-19 in Cox’s Bazar refugee camp in Bangladesh. Source: UN Women.
A priority for disease response programming in minority communities should be ensuring access to food and other critical services during outbreaks. Minority groups living in poverty may have little to no access to food stocks and may not have enough cash savings to cover any loss of income associated with the outbreak. In Tunisia, the Amazigh minority group implemented measures to prevent COVID-19 from spreading in their town amidst growing rates in the country. With help from the National Army, they managed to close the borders of the small town they live in and restrict any movement in and out. Food solidarity measures were then implemented by the National Army and the Regional Office of Commerce, allowing the community to protect themselves from COVID-19 safely.
Emergency financial aid for minority groups working in informal economies should also be a priority, particularly for groups facing heightened discrimination, such as sex workers. Cash assistance will enable minorities to carry out economic activities (including accessing health care) as usual throughout the outbreaks. Keep in mind that such assistance should be available to all, including those who may not be able to provide identification or proof of residence, due to vulnerable legal status.
Address barriers to testing, treatment and vaccines
Inequitable access to healthcare for ethnic minorities is a key issue which must be addressed, as illustrated by the COVID-19 vaccination gap. As of 2022, just 38% of Black Africans living in the UK had received all three doses, compared to 68% of the White British population. Health care services should be available to everyone, including those who lack identification documents. Understanding health-seeking behaviour prior to the outbreak and understanding levels of trust that minorities have in public health services should be explored as a part of formative assessments, prior to starting your response. Assessing the effects of stigma and discrimination of minorities in your target area can help explore if this has an impact on health service access. The costs of healthcare are a well-documented barrier to accessing services by minorities experiencing poverty. Ensuring that care is available and free to all can help address this barrier.
Work with employers to ensure minority workers are protected
Including workers, employers and workplaces as your target population and/or setting could be an effective way of reaching minorities. When working with employers during outbreaks, adequate responses should promote and implement preventive behaviours at the work place. For instance, during a COVID-19 response, employers should promote: hand hygiene, respiratory hygiene, physical distancing, reducing and managing work-related travels, regular environmental cleaning and disinfection, risk communication, training and education. Identifying where support for minority workers is needed can be done by conducting work risk assessments. These should take into account underlying health conditions and the employee’s age and ethnicity – these are crucial factors that have an impact on the level of risk the individual employee is experiencing, and often put minorities at increased risk of getting diseases. To reduce the severity of secondary impacts of the disease outbreak, such as loss of employment or income, responders should work with employers and authorities to ensure that financial aid schemes are available to minority workers.
Monitoring and evaluation
Ensure data collected is disaggregated, to reflect different ethnicities, religions, sex and age. Data on testing confirmed cases and fatalities related to COVID-19 should be monitored and disseminated regularly in a transparent manner. It is important to make sure that all reports are available to minority communities in a language they speak.
For more information on monitoring and evaluation, please access our resources on:
Written by: Astrid Hasund Thorseth
Reviewed by: Christopher Bachtrog, Sheillah N. Simiyu, Eva Niederberger
Version date: 01.03.2023