1. In defence of ‘race’ and ethnicity as analytical variables in epidemiological research George TH Ellison St George’s – University of London

2. Overview

3. What do ‘race’ and ethnicity actually mean? What are the problems with ‘race’ and ethnicity? Should we use ‘race’ and ethnicity? If so, when? How should we measure ‘race’ and ethnicity?

4. Overview What do ‘race’ and ethnicity actually mean? What are the problems with ‘race’ and ethnicity? Should we use ‘race’ and ethnicity? If so, when? How should we measure ‘race’ and ethnicity?

5. Overview What do ‘race’ and ethnicity actually mean? What are the problems with ‘race’ and ethnicity? Should we use ‘race’ and ethnicity? If so, when? How should we measure ‘race’ and ethnicity?

6. Overview What do ‘race’ and ethnicity actually mean? What are the problems with ‘race’ and ethnicity? Should we use ‘race’ and ethnicity? If so, when? How should we measure ‘race’ and ethnicity?

7. Where do the concepts of ‘race’ and ethnicity come from?

8. ‘Race’ – is traditionally used by biologists as a synonym for ‘subspecies’ (isolated populations of a species that contain individuals who are genetically more closely related to one another than to the rest of the species). Ethnicity – is traditionally used by anthropologists to classify human populations on the basis of shared ancestry, culture and customs.

9. Where do the concepts of ‘race’ and ethnicity come from? ‘Race’ – is traditionally used by biologists as a synonym for ‘subspecies’ (isolated populations of a species that contain individuals who are genetically more closely related to one another than to the rest of the species). Ethnicity – is traditionally used by anthropologists to classify human populations on the basis of shared ancestry, heritage, culture and customs.

10. Are ‘race’ or ethnicity genetic variables?

11. ‘ Race’ – captures little of the modest geographical and sociocultural gradients in genetic variation and there are no genetically discrete human ‘races’. But, ironically… Ethnicity – is routinely measured using aspects of appearance, ancestry and/or culture which are linked to phenotypic, geographical and reproductive factors which reflect/are responsible for genetic variation.

12. Are ‘race’ or ethnicity genetic variables? ‘ Race’ – captures little of the modest geographical and sociocultural gradients in genetic variation and there are no genetically discrete human ‘races’. Yet, ironically… Ethnicity – is routinely measured using aspects of appearance, ancestry and/or culture which are linked to phenotypic, geographical and reproductive factors which reflect/are responsible for genetic variation.

13. Are ‘race’ or ethnicity genetic variables? ‘ Race’ – captures little of the modest geographical and sociocultural gradients in genetic variation and there are no genetically discrete human ‘races’. Yet, ironically… Ethnicity – is routinely measured using aspects of appearance, ancestry and/or culture which are linked to phenotypic, geographical and reproductive factors which reflect or are responsible for genetic variation.

14. What have the concepts of ‘race’ and ethnicity come to mean?

15. ‘Race’ – is seen as a socially-constructed and arbitrary classification based on discredited theories of innate genetic difference between human populations. Ethnicity – has become conflated with ‘race’ and is increasingly used as a (sanitised) synonym for ‘race’, hence the biosocial term ‘race/ethnicity’.

16. What have the concepts of ‘race’ and ethnicity come to mean? ‘Race’ – is seen as a socially-constructed and arbitrary classification based on discredited theories of innate genetic difference between human populations. Ethnicity – has become conflated with ‘race’ and is increasingly used as a (sanitised) synonym for ‘race’, hence the biosocial term ‘race/ethnicity’.

17. Why have ‘race’ and ethnicity been criticised as analytical variables?

18. Reliability

19. Why have ‘race’ and ethnicity been criticised as analytical variables? Reliability Validity

20. Why have ‘race’ and ethnicity been criticised as analytical variables? Reliability Validity Sensitivity

21. Why have ‘race’ and ethnicity been criticised as analytical variables? Reliability There is little consensus on how ‘race’ or ethnicity should be defined or measured. ‘Race’ and ethnicity are fluid, subjective and context-specific characteristics that are therefore inherently unstable.

22. Why have ‘race’ and ethnicity been criticised as analytical variables? Reliability There is little consensus on how ‘race’ or ethnicity should be defined or measured. ‘Race’ and ethnicity are fluid, subjective and context-specific characteristics that are therefore inherently unstable.

24. Why have ‘race’ and ethnicity been criticised as analytical variables? Reliability There is little consensus on how ‘race’ or ethnicity should be defined or measured. ‘Race’ and ethnicity are fluid, subjective and context-specific characteristics that are (therefore) inherently unstable.

25. Why have ‘race’ and ethnicity been criticised as analytical variables? Validity ‘Racial’ and ethnic categories rarely reflect genetically or socioculturally discrete and homogeneous populations. ‘Racial’ and ethnic categories are rarely viewed as the consequences of the structures which make classification possible.

26. Why have ‘race’ and ethnicity been criticised as analytical variables? Validity ‘Racial’ and ethnic categories rarely reflect genetically or socioculturally discrete and homogeneous populations. ‘Racial’ and ethnic categories are rarely viewed as the consequences of the structures which make classification possible.

28. Why have ‘race’ and ethnicity been criticised as analytical variables? Validity ‘Racial’ and ethnic categories rarely reflect genetically or socioculturally discrete and homogeneous populations. ‘Racial’ and ethnic categories are rarely viewed as the consequences of the structural forces which make classification possible.

29. Why have ‘race’ and ethnicity been criticised as analytical variables? Sensitivity ‘Race’ and ethnicity tend to essentialise any differences observed as intrinsically genetic or sociocultural rather than the consequence of extrinsic structural forces. Using ‘race’ and ethnicity as if they were precise markers of difference tends to generalise, stereotype and stigmatise.

30. Why have ‘race’ and ethnicity been criticised as analytical variables? Sensitivity ‘Race’ and ethnicity tend to essentialise any differences observed as intrinsically genetic or sociocultural rather than the consequence of extrinsic structural forces. Using ‘race’ and ethnicity as if they were precise markers of difference tends to generalise, stereotype and stigmatise.

32. Why have ‘race’ and ethnicity been criticised as analytical variables? Sensitivity ‘Race’ and ethnicity tend to essentialise any differences observed as intrinsically genetic or sociocultural rather than the consequence of extrinsic structural forces. Using ‘race’ and ethnicity as if they were precise markers of difference tends to generalise, stereotype and stigmatise.

33. When should we use ‘race’ and ethnicity in epidemiology?

34. Reliability Some definitions of ‘race’ and ethnicity can be reliably measured in some populations, in some contexts, at some times. Validity The characteristics used to classify ‘race’ and ethnicity (appearance, ancestry and culture) can be correlated with determinants of health status: genes; behaviour; and class.

35. When should we use ‘race’ and ethnicity in epidemiology? Reliability Some definitions of ‘race’ and ethnicity can be reliably measured in some populations, in some contexts, at some times. Validity The characteristics used to classify ‘race’ and ethnicity (culture, appearance and ancestry) can be correlated with determinants of health status: culture; class; and genes.

36. HealthRace/ethnicity Taken from: Nazroo (1997) The Health of Britain’s Ethnic Minorities. When should we use ‘race’ and ethnicity in epidemiology?

37. Health Culture Class Genetics Race/ethnicity Taken from: Nazroo (1997) The Health of Britain’s Ethnic Minorities. When should we use ‘race’ and ethnicity in epidemiology?

38. Access to services Health Culture Class Genetics Migration Discrimination Race/ethnicity Taken from: Nazroo (1997) The Health of Britain’s Ethnic Minorities. When should we use ‘race’ and ethnicity in epidemiology?

39. Reliability Some definitions of ‘race’ and ethnicity can be reliably measured in some populations, in some contexts, at some times. Validity The characteristics used to classify ‘race’ and ethnicity (appearance, ancestry and culture) can be correlated with determinants of health status: culture; class; and genes. Sensitivity ‘Race’ and ethnicity are crucial markers of the tendency to generalise, stereotype and stigmatise.

41. Three ‘tests’ when using ‘race’

42. Reliability – Can it be reliably measured? Validity – Is it the most reliable proxy? Sensitivity – Is it acceptable?

43. Three ‘tests’ when using ‘race’ Reliability – Can it be reliably measured? Validity – Is it the most reliable proxy? Sensitivity – Is it acceptable?

44. Three ‘tests’ when using ‘race’ Reliability – Can it be reliably measured? Validity – Is it the most reliable proxy? Sensitivity – Is it acceptable?

55. Summary and recommendations

56. Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring its (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

57. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring its (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

58. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring its (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

59. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring its (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

60. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring their (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

61. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring their (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

62. Summary and recommendations Using ‘race’ or ethnicity remains contentious. There have been exaggerated claims about their unreliability, invalidity and (in)sensitivity. They are useful (if not crucial) in some contexts: - as a proxy when no others are available; and - for measuring their (potential) consequences. Their principal utility is a consequence of their past/present use to stigmatise and discriminate. To reduce these effects the reasons for their utility should always be explained and they should only be used when absolutely necessary.

63. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark?

64. Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

65. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

66. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

67. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

68. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

69. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

70. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? Data are not routinely collected using traditional ‘racial’ or ethnic categories (such as ‘Caucasian’ or ‘Black’). Danish populations are likely to be unfamiliar with these traditional ‘racial’ or ethnic categories. Few analyses have therefore been conducted on inequalities in health related to traditional ‘racial’ or ethnic categories. But… Data are available on two of the characteristics that are traditionally used to classify ‘race’ and ethnicity: Ancestry – place of birth and country of origin. Culture – language, religion and various behaviours.

71. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? A review of the literature on ‘race’ and ethnicity in Denmark suggests that there is evidence for many of the pathways within Nazroo’s model linking race/ethnicity to inequalities in health: Genetics – existing sociocultural stratification might facilitate genetic stratification, as would migration from geographical regions where specific disease alleles are more/less prevalent than in Denmark. Culture – socioculturally isolated and ‘acculturated’ populations may have differing prevalence of risk. Class – prior migrant disadvantage and subsequent discrimination are likely to create populations with different health risks.

72. Access to services Health Culture Class Genetics Migration Discrimination Race/ethnicity Taken from: Nazroo (1997) The Health of Britain’s Ethnic Minorities. When should we use ‘race’ and ethnicity in epidemiology?

73. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? A review of the literature on ‘race’ and ethnicity in Denmark suggests that there is evidence for many of the pathways within Nazroo’s model linking race/ethnicity to inequalities in health: Culture – socioculturally isolated and ‘acculturated’ populations may have differing prevalence of risk. Class – prior migrant disadvantage and/or social discrimination are likely to create populations with different socioeconomic status and related risks. Genetics – existing sociocultural stratification might facilitate genetic stratification, as would migration from geographical regions where specific disease alleles are more/less prevalent than in Denmark.

74. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? A review of the literature on ‘race’ and ethnicity in Denmark suggests that there is evidence for many of the pathways within Nazroo’s model linking race/ethnicity to inequalities in health: Culture – socioculturally isolated and ‘acculturated’ populations may have differing prevalence of risk. Class – prior migrant disadvantage and/or social discrimination are likely to create populations with different socioeconomic status and related risks. Genetics – existing sociocultural stratification might facilitate genetic stratification, as would migration from geographical regions where specific disease alleles are more/less prevalent than in Denmark.

75. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? A review of the literature on ‘race’ and ethnicity in Denmark suggests that there is evidence for many of the pathways within Nazroo’s model linking race/ethnicity to inequalities in health: Culture – socioculturally isolated and ‘acculturated’ populations may have differing prevalence of risk. Class – prior migrant disadvantage and/or social discrimination are likely to create populations with different socioeconomic status and related risks. Genetics – existing sociocultural stratification might facilitate genetic stratification, as would migration from geographical regions where specific disease alleles are more/less prevalent than in Denmark.

76. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark?

77. The data are available to conduct preliminary analyses exploring inequalities in health that are associated with ancestry and culture. These analyses are likely to illuminate the potential contribution of ‘race’ and ethnicity to health inequalities in Denmark. It may not be necessary or desirable to collect data using traditional ‘racial’ or ethnic categories to assess the contribution of ‘race’ and ethnicity to health inequalities. Beware of collecting data on ‘racial’ or ethnic identity that might create the potential for discrimination where none currently exist.

78. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? The data are available to conduct preliminary analyses exploring inequalities in health that are associated with ancestry and culture. These analyses are likely to illuminate the potential contribution of ‘race’ and ethnicity to health inequalities in Denmark. It may not be necessary or desirable to collect data using traditional ‘racial’ or ethnic categories to assess the contribution of ‘race’ and ethnicity to health inequalities. Beware of collecting data on ‘racial’ or ethnic identity that might create the potential for discrimination where none currently exist.

79. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? The data are available to conduct preliminary analyses exploring inequalities in health that are associated with ancestry and culture. These analyses are likely to illuminate the potential contribution of ‘race’ and ethnicity to health inequalities in Denmark. It may not be necessary or desirable to collect data using traditional ‘racial’ or ethnic categories to assess the contribution of ‘race’ and ethnicity to health inequalities. Beware of collecting data on ‘racial’ or ethnic identity that might create the potential for discrimination where none currently exist.

80. What is the relevance of ‘race’ and ethnicity to epidemiology in Denmark? The data are available to conduct preliminary analyses exploring inequalities in health that are associated with ancestry and culture. These analyses are likely to illuminate the potential contribution of ‘race’ and ethnicity to health inequalities in Denmark. It may not be necessary or desirable to collect data using traditional ‘racial’ or ethnic categories to assess the contribution of ‘race’ and ethnicity to health inequalities. Beware of collecting data on ‘racial’ or ethnic identity that might create the potential for discrimination where none currently exist.

81. Further reading: Ellison GTH. ‘Population profiling’ and public health risk: when and how should we use race/ethnicity? Critical Public Health 2005; 15: 65-74. Ellison GTH, Rees Jones I. Social identities and the ‘new genetics’: scientific and social consequences. Critical Public Health 2002; 12: 265-282. Ellison GTH, De Wet T, IJsselmuiden CB, Richter LM. Desegregating health statistics and health research in South Africa. South African Medical Journal 1996; 86: 1257-62.