1. Global inequalities in assessment of migrant and ethnic variations in health Raj Bhopal CBE, DSc (hon) Professor of Public Health, University of Edinburgh Snorri Rafnsson Ph.D. Honorary Senior Research Fellow, University of Edinburgh

2. Aims of the lecture To reflect on migration as the creator of modern multi-ethnic, multiracial populations To illustrate the massive epidemiological potential of migration status and ethnicity To assess whether the potential is being harnessed globally To propose actions to reduce global inequalities in research on this topic

3. Migrating populations, 1990-2000 2000: 175 million; >4x increase from 1975 ; 2050: 230 million; internal migrants are three times that number Population Action International 1994, IOM 2003

4. Migration, ethnicity and health More than 200 million international migrants Equal to the population of fifth largest country in the world (after Indonesia, before Brazil) Adding their offspring might double the number Surprising results across the world  United Arab Emirates 71.4%  Kuwait 62.1%  Switzerland 22.9%  Australia 20.3%

5. WHO 1983-migration and health

6. Migration and health. WHO consultation 1983 (published 1986) “… improve the methods used to collect vital statistics so that comparisons can be drawn within countries” “WHO and national governments should support more coordinated in-depth studies of migrants’ health with special reference to mortality and morbidity…”

7. World health assembly resolution 2008 Resolution (61.17)  emphasised establishing health information systems  calls for nations “to establish health information systems in order to assess and analyse trends in migrants’ health, disaggregating health information by relevant categories”  and makes 3 requests (of 11) to the director- general to take action

8. WHO/IOM global consultation on migrant health 2011, Madrid Priorities:  ensure the standardization and comparability of data  support the appropriate aggregation and assembling of migrant health information;  map good practices in monitoring migrant health, policy models, health system models.

9. Relationship to social determinants of disease 2010 consultation recognised that  Guidelines for health equity surveillance systems as in the WHO’s social determinants of disease programme can be easily adapted for the purposes of migrant health  Need for WHO leadership  Epidemiology is important

11. In all their splendid variety, all humans on the earth are one species. Race and ethnicity define subgroups.

12. Race The group a person belongs to, or is perceived to belong to because of- physical features reflecting ancestry The concept is somewhat discredited-being displaced by ethnicity

13. Ethnicity The group a person belongs to, or is perceived to belong to, because of a mix of culture, language, diet, religion, ancestry, geographical origins and physical textures Ethnicity incorporates race

14. Medline analysis shows ethnicity has overtaken race in medical research: ratio of race to ethnicity (Afshari & Bhopal Int. J. Epidemiol. (2010) doi: 10.1093/ije/dyp382 )

15. Provide challenges for disease control: smoking prevalence Source: Newcastle Heart Project (Bhopal et al BMJ 1999)

16. Ethnic variations are often huge and surprising: Newcastle Heart Project prevalence (%) of diabetes 25-74 years Source: Newcastle Heart Project (Bhopal et al BMJ 1999)

17. Explanations for migration status/race/ethnic variations Social and economic differences Nutritional change Lifestyle factors e.g. physical inactivity and eating patterns Foetal origins and early life Genetic/evolutionary e.g. distribution of adipose tissue or mitochondrial efficiency etc

18. 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)

19. Conclusions on ethnic variations in metabolic dysfunction The causes of such ethnic variations are a worthy challenge for epidemiology Explanatory epidemiology is decades behind descriptive epidemiology within this field

20. Measuring migration status/ethnicity self-assessment-the current gold standard Self classified ethnicity (or race) and migration/generational status assessment using data available in databases  Country of birth  Parents’ and grandparents' national origin or country of birth  Length of residence  Nationality assessment by observer  Skin colour and other physical features  Names (Rajinder Singh Bhopal)

21. Migrant and Ethnic Health Observatory (MEHO) Project Searched for migrant status/ethnicity data on mortality and morbidity from CVD & diabetes 25 EU countries had 72 data sets Two-thirds of data sets came from 8 EU countries Several countries had no published data 24 countries had death registers with an indicator of migration/ethnicity, usually country of birth-mostly not analysed Relevant data are scarce in Europe

22. Migration/ethnicity data globally Searches show:  Information on ethnicity is not available in WHO’s Global Health Observatory  Population d ethnic group characteristics data- sometimes in WHO country profiles  Health Metrics Network - a global partnership for strengthening national health information systems: “ Health status indicators should be available stratified or disaggregated by variables such as sex, socioeconomic status, ethnic group …”

23. Google scholar search for epidemiology, ethnicity and migration CountryHits for migration (thousands) Hits for ethnicity (thousands) USA128145 UK6381 Australia4433 China2933 Brazil1913 Russia1418 Nigeria1417

24. State of global research Limited strategic perspective Legal obligation in USA – global exception? Research driven by narrow perspectives Considerable scepticism and failure to prioritise, partly as politically sensitive Sparse disaggregated monitoring and morbidity data, and death and birth certification Scarcity of disaggregated data in large scale surveys Shortage of major trials and cohort studies providing data by ethnic group and migration status

25. A global research agenda: Priorities for future action on migrant/ethnic health Internationally coordinated research on major health problems Comparative international evaluations of standards of local health and social care services Coordinating and monitoring by WHO/IOM led strategy group Dedicated research units

26. Global consultation WHO/IOM 2011 Standardisation of methods and definitions Integrate monitoring into existing systems Engage target populations Global working group and clearing-house Share internationally Examine global patterns Use data for health and healthcare improvement

27. Epidemiological comparisons Subgroup of interest in relation to  Host population  Same population group living in other countries  Same population group living in the country of origin

28. Migration/ethnicity disaggregated data globally Methodological challenges Which health indicators to include? What types of large-scale, population data to focus on? Where to search for such data?

29. Moving forward International migration is creating exciting, multi-ethnic global societies We have international support in the WHA resolution Resolution needs implementation at country level- political and economic support is essential-challenges and solutions are likely to be country specific Scotland has made rapid progress including a national ethnicity and health research strategy and a linkage cohort study of 4.6 million people Epidemiological studies in multi-ethnic societies are  Methodologically important  Scientifically interesting  Basis of major advances in public health