The challenges of health and healthcare in multicultural societies Men’s Health Forum 2007 Raj Bhopal CBE, DSc (hon) Professor of Public Health, University of Edinburgh & Chairman, Steering Committee of the National Resource Centre for Ethnic Minority Health

Lecture contents Migration Human species Definitions of race and ethnicity Assessing ethnicity and race Relative and absolute approaches in interpreting variations-some examples in practice and research Forces generating inequalities and inequities Race, clinical medicine and genetics Challenges and potential Example: prevention of diabetes Conclusions and directions

Migration-key to understanding The driving force creating multi-ethnic societies Fundamental human behaviour Permitted humans to leave Africa Reasons – trade and commerce, demand for work, demand for workers, education, personal aspirations, political refuge curiosity All are worthy and important

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? How do we know?

All humans on the earth now are Homo sapiens: race and ethnicity define subgroups. This was not always so

Homo floresiensis (and Homo neanderthalis before that)

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 and political heritage The concept is largely discredited in Europe, where it is displaced by ethnicity

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

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

England: Comparison of the 1991 and 2001 Census ethnic groupings 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

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.

Newcastle Heart Project: Smoking prevalence (%) IndianPakistaniBangladeshiEuropean Men (S. Asian combined, 33%) Women (S. Asian combined, 3%) 15231

Standard population Bangladeshi men SMR for stroke (ICD 10 I60-69) ( ) Mortality for stroke given as standardized mortality ratios (95% confidence interval) in Bangladeshi born men in England and Wales, around 2001 census

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?

Equity and inequality Consider whether the following are inequities:  The lower prevalence of smoking in Sikh Indian compared to White men  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.

Racism, prejudice and inequity Why might ethnic minority patients get worse care in a health setting? Might racism and prejudice play a part? What kinds of racism have you seen? What experiences of racism have you, and close friends or relatives experienced?

The continuing promotion of Hitlerian Views TABERNACLE OF THE PHINEHAS PRIESTHOOD / ARYAN NATIONS PLEDGE: I will conduct myself at all times as a gentleman (or woman) reflecting the superiority of the Aryan Race. (accessed 24th of Feb. 2005)

Race: Ashley Montagu “…. the race problem.. seems to have grown more troubling than ever.…” his formula and analysis of the problem: “race” = the physical appearance (genetic) of the individual + intelligence of the individual + ability of the group to which the individual belongs to achieve a high civilization. “Nothing could be more unsound, for there is no genetic linkage whatever between these three variables.” Ashley Montagu, Man’s Most Dangerous Myth, p31

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

Health-care challenges for a multi-ethnic world Responding to varying health behaviours, beliefs and attitudes differences in the pattern of diseases differences in diagnosis, treatment and outcome 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

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

The future for health professionals My vision of a future health professional: learns about the unity yet diversity of humanity. engages in studies emphasising ethnicity, religion and language that includes bedside teaching. Grasps opportunities for learning about ethnic diversity with a strong focus on how people maintain their heath in different cultures.

The future 2 takes special interest in the health beliefs and attitudes of one or more ethnic minority populations integrates relevant ideas into the advice on healthy living for all patients and populations. makes sure that there is a reason for mentioning the patient's ethnic group, and explains it.

The future 3 takes pride that the health service’s policy makers and peers seek his/her advice on improving services for ethnic minorities. finds that these roles and skills are appropriately recognised in the awards and promotions committees.

Doing things: the evidence based approach-PODOSA A major national project, set in Glasgow and Edinburgh Object-contribute to worldwide efforts to control the epidemic of diabetes About 20% of adult South Asians in the UK have got diabetes compared to about 5% in the population as a whole Why?

Yajnik has 21% fat,Yudkin 9% Yajnik & Yudkin (2004) Lancet.

Stemming the epidemic Tackle the causes Tackle the causes Tackle intermediate states e.g. impaired glucose tolerance (the focus today and to- date) Tackle intermediate states e.g. impaired glucose tolerance (the focus today and to- date) Tackle the disease Tackle the disease

Da Qing, China Study 42 percent reduction in the incidence of diabetes over six years Da Qing, China Study 42 percent reduction in the incidence of diabetes over six years Finnish Diabetes Prevention Study -58 percent reduction in three years Finnish Diabetes Prevention Study -58 percent reduction in three years Diabetes Prevention Programme Study, USA- 58% reduction in three years Diabetes Prevention Programme Study, USA- 58% reduction in three years Indian Diabetes Prevention Programme, Chennai, India - 30 percent reduction in three years Indian Diabetes Prevention Programme, Chennai, India - 30 percent reduction in three years We have been inspired! We have been inspired! It can be done!

New Trial in Edinburgh and Glasgow- Primary prevention of diabetes and obesity in South Asians (PODOSA)

National Prevention Research Initiative: funders

Principal research question does a family-based weight loss and physical activity programme reduce the incidence of type 2 diabetes in South Asians? does a family-based weight loss and physical activity programme reduce the incidence of type 2 diabetes in South Asians?

adapt existing interventions culturally adapt existing interventions culturally apply in families with diabetes apply in families with diabetes Focus on reducing weight and increasing physical activity in adults with IGT Focus on reducing weight and increasing physical activity in adults with IGT 300 families will be randomised into two groups (600 people with IGT in total) 300 families will be randomised into two groups (600 people with IGT in total) One group of 300 will receive 15 contacts over three years One group of 300 will receive 15 contacts over three years one group of 300 will have 4 contacts one group of 300 will have 4 contacts Trial summary

Intervention Goals weight loss of at least 3.5 kg (5% minimum) weight loss of at least 3.5 kg (5% minimum) increase in moderate physical activity to at least 30 minutes daily increase in moderate physical activity to at least 30 minutes daily BMI to less than or equal to 25 or preferably 23 BMI to less than or equal to 25 or preferably 23 reduce waist size to less than 90 cm for men, and less than 80 cm for women reduce waist size to less than 90 cm for men, and less than 80 cm for women

Timescales Participant recruitment-July 2007 through to June 2008 Participant recruitment-July 2007 through to June 2008 Follow-up through to 2010/11 Follow-up through to 2010/11 Trial concludes July/August 2011 Trial concludes July/August 2011

Results so far Trial staff are in place (Anne Douglas, Alex Cellini, Harpreet Bains, Sunita Wallia, Ruby Bhopal, Anu Sharma, Alyson Grubb) Trial staff are in place (Anne Douglas, Alex Cellini, Harpreet Bains, Sunita Wallia, Ruby Bhopal, Anu Sharma, Alyson Grubb) So far: So far: About 150 people screened Many with possible diabetes they did not know about Quite a few with possible IFG about 16people with IGT

Advice and help needed from professional colleagues How to gain referrals into the trial: people with IFG people with IGT people with a family history people at high risk please send them our way Key contact telephone number: Anne Douglas, trial manager, , People can sign up on our website

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. In doing so, we improve the health and healthcare of the entire population

Further reading for such a professional Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs Assessment for Black and Ethnic Minority Groups 2002 (book chapter - in press, available online at Bhopal RS. Ethnicity, race, and health in multicultural societies; foundations for better epidemiology, public health, and health care. Oxford: Oxford University Press, 2007, pp