By Dr Yoga Nathan 5/21/20151

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 5/21/20152

 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 5/21/20153

 The driving force creating multi-ethnic societies  Fundamental human behaviour  Reasons – trade and commerce, demand for work, demand for workers, education, personal aspirations, political refuge curiosity  All are worthy and important 5/21/20154

 What is a species?  Were there several human species on Earth at any point?  How many human species are there on the earth today? 5/21/20155

 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 5/21/20157

 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 5/21/20158

 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 5/21/20159

1991 Census2001 Census WhiteBritish, Irish, Any other white background Black Caribbean, Black African, Black other Caribbean, African, Any other Black background Indian, Pakistani, BangladeshiIndian, Pakistani, Bangladeshi any other Asian background Chinese Any other ethnic group No ‘Mixed’ categoryWhite and Black Caribbean, White and Black African, White and Asian, Any other mixed background 5/21/201510

5/21/ Census in Ireland in 2006 and classification of ethnicity

5/21/ 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. 5/21/201513

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)

IndianPakistaniBangladeshiEuropean Men (S. Asian combined, 33%) Women (S. Asian combined, 3%) /21/ This heterogeneity of South Asians matters in public health

NHP- Prevalence (%) of diabetes years) 5/21/201516

Standard population Bangladeshi men SMR for stroke (ICD 10 I60-69) ( ) 5/21/ SMR = (Observed no. of deaths per year)/(Expected no. of deaths per year).

Health Survey for England /21/201518

Health Survey for England /21/201519

Health Survey for England /21/201520

Health Survey for England /21/201521

Health Survey for England /21/201522

“.. 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) 5/21/201523

 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? 5/21/201524

 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 a n 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. 5/21/201525

 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?. 5/21/201526

“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. 5/21/201527

 “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 5/21/201528

 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 5/21/201529

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 5/21/201530

 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 5/21/201531

 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. 5/21/201532

5/21/201533

006/Census_2006_LHO_by_Ethnicity/ ervices/SocialInclusion/InterculturalGuide/Te rminology.html 5/21/201534

 Ethnic Minority Groups within Ireland  Travellers  Asylum seekers, refugees, low income migrant workers Issues that might exacerbate :  Homeless  People with disabilities  Mental health 5/21/201535

 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 5/21/201536