By Dr Yoga Nathan

04/18/23 1

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

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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

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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

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What is a species?

Were there several human species on Earth at any point?

How many human species are there on the earth today?

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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

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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

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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

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1991 Census 2001 Census

White British, Irish, Any other white background

Black Caribbean, Black African, Black other

Caribbean, African, Any other Black background

Indian, Pakistani, Bangladeshi Indian, Pakistani, Bangladeshi any other Asian background

Chinese Chinese

Any other ethnic group Any other ethnic group

No ‘Mixed’ category White and Black Caribbean, White and Black African, White and Asian, Any other mixed background

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0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

Irish Irish Traveller Any otherWhite

background

African Any otherBlack

background

Chinese Any otherAsian

background

Otherincluding

mixedbackground

Not stated

L eins ter Muns ter C onnac ht Uls ter (part of)

Census in Ireland in 2006 and classification of ethnicity

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0

20000

40000

60000

80000

100000

120000

140000

IrishTraveller

Any otherWhite

background

African Any otherBlack

background

Chinese Any otherAsian

background

Otherincluding

mixedbackground

Not stated

L eins ter Muns ter C onnac ht Uls ter (part of)

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

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.

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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)

Indian Pakistani Bangladeshi European

Men

(S. Asian combined, 33%)

14 32 57 33

Women

(S. Asian combined, 3%)

1 5 2 31

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This heterogeneity of South Asians matters in public health

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

0

5

10

15

20

25

Men Women

European

Indian

Pakistani

Bangladeshi

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Standardpopulation

Bangladeshi men

SMR for stroke(ICD 10 I60-69)

100 249

(213-292)

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SMR = (Observed no. of deaths per year)/(Expected no. of deaths per year).

Age adjusted odds ratio compared with white English

0.5

1

1.5

2

2.5

3

3.5

4

Caribbean Indian Pakistani Bangladeshi Chinese White minority

Od

ds

rati

o (

and

95%

C.I

.)

Health Survey for England 199904/18/23 18

0

20

40

60

80

100

2-5 5-9 10-12 13-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-60 61-70 > 70

Ab

so

lute

pe

r c

en

t

Caribbean Indian Pakistani Bangladeshi Chinese White minority White English

Health Survey for England 199904/18/23 19

Men

0.5

1

1.5

2

2.5

3

3.5

Women

0.5

1

1.5

2

2.5

3

3.5

Health Survey for England 199904/18/23 20

Men

0

1

2

3

4

5

Women

0

1

2

3

4

5

Health Survey for England 199904/18/23 21

Men

0

0.5

1

1.5

2

Women

0

0.5

1

1.5

2

Health Survey for England 199904/18/23 22

“.. 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)

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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?

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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.

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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?.

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“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. 04/18/23 27

“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

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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 open04/18/23 29

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 promotion04/18/23 30

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

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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.

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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

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Ethnic Minority Groups within Ireland Travellers Asylum seekers, refugees, low income migrant

workers

Issues that might exacerbate : Homeless People with disabilities Mental health

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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

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