Excess COVID-19-related mortality in France’s Seine-Saint-Denis département:Minorities are invisible in the figures

The department of Seine-Saint-Denis saw particularly high rates of excess mortality due or related to COVID-19 compared to the rest of metropolitan France. Ethnic statistics in the United States and the United Kingdom have unambiguously shown that some ethnic-racial minorities are overrepresented among COVID-19 victims. In France, however, the question is seldom discussed in research or the media, one reason being that health data seldom identify patients’ or deceased persons’ origins. Solène Brun, post-doctoral fellow at the Institut Convergences Migrations, and Patrick Simon, senior researcher at INED, have turned to available figures that help explain the situation. 
INSEE has since published mortality figures by country of origin that show particularly heavy overexposure for people born in North Africa and sub-Saharan Africa. While poverty is an obvious factor, ethno-racial discrimination also seems to have an impact on exposure to the virus.

According to data published by INSEE (Institut National de la Statistique et des Études Economiques) and based on civil registry-recorded deaths, from March 1 and April 19, 2020, Seine-Saint-Denis had the highest excess mortality rate of all départements making up the Île-de-France region: approximately 130%, as against 74% in Paris and 122% in the Hauts-de-Seine. These excess mortality rates take into account place of death but not deceased’s place of residence. In fact, from 2018 to 2020, over one quarter (27%) of deceased Seine-Saint-Denis residents died outside the département. And for the March 1 to April 19 period, the figure was 24%, half of whom died in Paris. If mortality rates by place of residence are taken into account, excess mortality for the period rises to 134%, as opposed to 114% for the Hauts-de-Seine and 99% for Paris—figures much higher than for other départements in the région.

The Seine-Saint-Denis population’s heavy exposure to the virus is due to several factors. With 6,802 inhabitants per square kilometer (more than 64 times the average population density in France), Seine-Saint-Denis is the country’s third-most densely populated département, behind Paris and Hauts-de-Seine. Housing conditions are also a virus transmission factor, as the département has the highest over-occupancy rate in the Île-de-France région (20.6% of housing units, as against a regional average of 12.7%). And multigenerational cohabitation is more frequent there than average, increasing the exposure of older family members. Last, the département has the highest number migrant worker hostels (35 sites).

Seine-Saint-Denis is the French département with the highest number of immigrant residents (excepting Mayotte). In 2016, 30% of département residents were immigrants, as against 9% on average for France as a whole. Moreover, 28% of adults aged 18 to 50 and 50% of under-18s are descendants of immigrants, as against, respectively, 18% and 33% in Île-de-France. The health disadvantages in these groups are now beginning to be studied in greater detail, but we still have relatively little knowledge on the subject. Immigrants’ self-reported health is worse overall than that of French-born persons of the same age, a finding that seems closely linked not only to the precarious living conditions many have to cope with but also their experience of discrimination and racism, a factor that helps explain health inequalities. A recent study (2019, SSM-Population Health) has shown that at comparable social milieus and education levels, mortality among male descendants of North African immigrants is higher than majority population mortality and mortality among descendants of immigrants from Southern Europe. And studies have shown that some comorbidity factors associated with COVID-19, such as diabetes (2011,InVS) are closely linked not only to socio-economic conditions but also country of origin.

Immigrants are heavily overrepresented among the département’s manual and lower-level office workers (57% and 39%, respectively, compared to 2016 national averages of 20% and 27%), meaning they work in high-exposure “frontline” occupations. We do not have département-level statistics by occupation and origin, but we do know that 35% of domestic employees, 25% of security guards, and 14% of cleaning workers and related service employees in France are immigrants.

It is also residents of this département that make the greatest use of public transport to get to work (53%, as against an average of 43% in Île-de-France), also an important infection risk factor.

The indicators on health care supply in Seine-Saint-Denis compiled by the Observatoire Régional de Santé regional health observatory point to deficits for all concerned structures. The département has the lowest density of non-hospital doctors, both GPs and specialists. Hospital bed numbers for all types of hospitals are also the lowest in the région (2 full beds per 1,000 residents as against 3.3 in Île-de-France and 7.7 in neighboring Paris). While the population’s health indicators are also worse than the regional average, particularly for the comorbidities associated with COVID-19 (diabetes, asthma, cardio-vascular disease, respiratory ailments, and tuberculosis), the départment’s limited health care supply and the fact that people in precarious economic situations in general and immigrants in particular seek health care less often than others are very likely to worsen the health crisis and its effects.

The authors call for making more detailed information available on the people who account for the excess mortality observed, data that would enable researchers to better grasp the effects of ethno-racial discrimination on exposure to the virus in France. Ethnic statistics in the United States and the United Kingdom unambiguously show overrepresentation of that certain ethno-racial groups are overrepresented among COVID-19 victims. British researchers have recently shown that with other factors kept equal, Black and Southeast Asian minorities are more at risk of dying from COVID-19 than others. In France, published health data very seldom identify patients’ or deceased persons’ origins. And France has a deficit of statistics on immigrants’ descendants. All those data, if we had them, would improve our knowledge of the epidemic and its effects, and of ethno-racial health inequalities generally.