Ethnicity, Race & Health

1. Ethnicity, Race & Health By Dr Yoga Nathan

2. Learning objectives You should be able to: • Critically assess social and theoretical assumptions underpinning the concepts of `race' and ethnicity. • Explore the meaning of institutionalised racism in relation to health care. • Explore the theory and practice of ethnic monitoring within the Health Service

3. Lecture contents • Migration • Human species • Definitions of race and ethnicity • Assessing ethnicity and race • Census and ethnicity in UK & Ireland • Relative and absolute approaches in interpreting variations, examples in practice and research • Ethnicity, clinical medicine and genetics • Challenges • Conclusions

4. Migration-key to understanding • The driving force creating multi-ethnic societies • Fundamental human behaviour • Reasons – trade and commerce, demand for work, demand for workers, education, personal aspirations, political refugecuriosity • All are worthy and important

5. Human species • What is a species? • Were there several human species on Earth at any point? • How many human species are there on the earth today?

6. All humans on the earth now are Homo sapiens: race and ethnicity define subgroups.

7. Race • The group a person belongs to, or is perceived to belong to because of- physical features reflecting ancestry • Increasingly concept emphasises a common social, religious and political heritage • The concept is largely discredited in Europe, where it is displaced by ethnicity

8. Ethnicity • The group a person belongs to, or is perceived to belong to, because of- • culture, • language, • diet, • religion, • Ancestry and • physical textures • Ethnicity subsumes race

9. Assessing ethnicity: three approaches • 3 main approaches i.e. self-assessment assessment by another using data assessment by another by observation. • However you do it, you need to create a classification-difficult • UK has taken the task seriously only in the last 20 years or so

10. England: Comparison of the 1991 and 2001 Census ethnic groupings

11. Census in Ireland in 2006 and classification of ethnicity

12. Census in Ireland in 2006 and classification of ethnicity excluding White Irish

13. Assessing variations by ethnic group • Absolute risk approach: examine patterns within each group (primary). • Then compare with other ethnic groups-the relative risk approach (secondary). • The interpretation will be different. • Maximise value by doing both. • Absolute risk is your risk of developing a disease over a time-period. We all have absolute risks of developing various diseases such as heart disease, cancer, stroke, etc. The same absolute risk can be expressed in different ways. For example, say you have a 1 in 10 risk of developing a certain disease in your life. This can also be said a 10% risk, or a 0.1 risk - depending if you use percentages or decimals. • Relative risk is used to compare the risk in two different groups of people. For example, the groups could be 'smokers' and 'non-smokers'. All sorts of groups are compared to others in medical research to see if belonging to that group increases or decreases your risk of developing certain diseases. For example, research has shown that smokers have a higher risk of developing certain diseases compared to (relative to) non-smokers.

14. Figure 1. Death rates from infection for Aboriginal and non-Aboriginal infants born in Western Australia according to geographical area of mother's residence at time of infant's birth, 1980–2001. (from the Lancet, 2006)

15. Newcastle Heart Project: Smoking prevalence (%) This heterogeneity of South Asians matters in public health

16. NHP- Prevalence (%) of diabetes 25-74 years)

17. Mortality for stroke given as standardized mortality ratios (95% confidence interval) in Bangladeshi born men in England and Wales, around 2001 census SMR = (Observed no. of deaths per year)/(Expected no. of deaths per year).

18. Reported fair or bad health Health Survey for England 1999

19. Reported fair or bad health by age Health Survey for England 1999

20. GP consultation rate Health Survey for England 1999

21. Treated among those with hypertension Health Survey for England 1999

22. Ever visits the dentist Health Survey for England 1999

23. Latest explanation for CVD/Diabetes excess in South Asians: The Adipose Tissue Compartment Overflow Hypothesis “.. the superficial subcutaneous adipose tissue compartment is larger in whites than in South Asians. … South Asians exhaust the storage capacity of their superficial subcutaneous adipose tissue compartment before whites do and .. develop the metabolic complications of upper body obesity at lower absolute masses of adipose tissue than white people.”Sniderman et al (IJE February 2007)

24. Forces generating ethnic health inequalities • Culture and lifestyle • Social, educational and economic status • Environment before and after migration • Early life development • Generational effects • Genetics • Access to and concordance with health care advice • Question: Are ethnic inequalities inequities i.e. injustices?

25. Inequalities & Inequities? • Healthcare inequality (also called health disparities in some countries) refers to the disparities in the access to adequate healthcare between different gender, race and socioeconomic groups. • Definition of inequity is when an individual considers that he/she is treated unfairly if he/she perceives the ratio of his/her inputs to his/her outcomes to be inequivalent to those around him/her.

26. Equity and inequality • Consider whether the following are inequities: • The lower prevalence of smoking in Chinese women compared to White women • The higher rate of colo-rectal cancer in White people compared to S. Asians • The lower life expectancy of African Americans compared to White Americans • What do you think? • One deep problem is racism?.

27. Humans and genetics of race “The genetic differences between the snail populations of two Pyrenean valleys are much greater than those between Australian aboriginals and ourselves. If you were a snail it would make good biological sense to be a racist: but you have to accept that humans are tediously uniform animals.” Dr Steve Jones, The Independent. The 1991 Reith lectures.

28. Race and genetics • “Genetic explanations are … likely where differences … persist … in migrants who have been settled outside the home country for several generations and where .. differences are .. found in all countries where the migrant group has settled e.g. Scots (Mac) have higher incidence of Multiple Sclerosis… genetic factors are likely to underlie the high rates of coronary heart disease and non-insulin-dependent diabetes … in people of South Asian .. descent settled overseas.” Paul M McKeigue AM J Hum Genet 1997; 60:189

29. Pharmacological variations by ethnic group: BiDil • Finding of the efficacy of isosorbide dinitrate plus hydralazine (BiDil) in black patients (Taylor, N Engl J Med 2004, 351 p 2055) • FDA approval for populations describing themselves as black (unique and controversial decision) • The race, medicine and genetics debate is wide open

30. Health-care challenges for a multi-ethnic world Responding to • varying health behaviours, beliefs and attitudes • differences in the pattern of diseases • language and cultural barriers • calls for a service sensitive to cultural differences • personal biases, stereotyped views, individual racism, and institutional racism • laws requiring equal opportunities in employment and promotion

31. Medicine and diversity • In an increasingly diverse society, which serves to enrich our lives and experiences, doctors must learn to value ethnic diversity to deliver effective health care. In doing so, they will bring mutual benefits for their patients and themselves. J Kai et al. Medical Education 1999 p622

32. Conclusions • International migration and exchange are creating multi-ethnic global societies. • The concept of ethnicity can improve public health, health care, and clinical care, and advance science • The greatest goal is that people should be long-lived, free of disease and disability, brimming with energy, creative and full of ideas. • Ethnicity can contribute to this goal. • The multiplicity of challenges in research and health care in multi-ethnic societies are surmountable.

34. Web links http://www.hse.ie/eng/staff/FactFile/Census_2006/Census_2006_LHO_by_Ethnicity/ http://www.hse.ie/eng/services/Publications/services/SocialInclusion/InterculturalGuide/Terminology.html

35. Ethnicity In An Irish Context • Ethnic Minority Groups within Ireland • Travellers • Asylum seekers, refugees, low income migrant workers Issues that might exacerbate : • Homeless • People with disabilities • Mental health

36. Ethnicity In An Irish Context • Recommendations For Public Policy • Addressing social exclusion, promoting inclusion and respecting diversity • Data collection strategies • Equitable and culturally sensitive public service delivery • Promoting mental health and improving access to quality mental health services