Migration, ethnicity, race and health:

a Scottish-European perspective

Presentation at seventh Quality Healthcare for Culturally Diverse Populations Conference,

Baltimore 2010by

Raj Bhopal CBE, DSc (hon), MD, MPHProfessor of Public Health, University of Edinburgh

Honorary consultant, NHS Lothian

Objectives of the presentation Share insights from an 16 year ongoing

journey trying to improve the health and healthcare of ethnic minority populations

Reflect on insights internationally, especially in a European context

Migration-key to ethnic diversification of societies Fundamentally human behaviour Reasons –

commerce, work, education, ambition, refugecuriosity & change

Europe (and USA) - progressed with migration Not shameful-for individuals or nations Lifting the stigma attached to migrants is top priority

Ethnicity-contested in Europe The group you belong to, or are perceived to belong to, because

of yourculture (language, diet, religion), ancestry, andphysical textures

In Europe, and increasingly the USA, ethnicity incorporates race, and country of birth

In several European countries the concepts of race and ethnicity are met with hostility, partly because of Nazi abuses

Immigration status is preferred This poses difficulties in talking the same language

Ethnic diversity in Europe Europe’s ethnic composition is changing dramatically.

Ethnically disaggregated European data are needed.

The challenge of delivering equitable healthcare and improvements in health status is huge.

European projects developing and testing methods, mostly within countries but sometimes across countries.

Migrating populations, 1990-2000: 175 m. in 2000 (4-fold increase cf. 1975) 230 m. predicted by 2050

Sources: Population Action International 1994, IOM 2003

Scotland’s ethnic composition-not untypical of Europe Emigration historically overshadows immigration Scotland has recently welcomed new immigration 1850-1950 Irish, Lithuanians, Jews, Italians, Poles

immigrate 1950-2000 Indians, Pakistanis, Bangladeshis,

Chinese immigrate 2001-present Asylum seekers, refugees, Eastern

Europeans, and students immigrate Still, only an estimated 4% are non-White

Country of birth of mothers of babies born in Scotland: changing the populationCountry of birth 1991 2007

United Kingdom 63702 51432

EU – pre 2004 countries

770 1100

EU – post 2004 countries

885 2388

Other 2437 3961

Forces - 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 Quality and quantity of healthcare

Perceived status in society Discrimination/bias/inequity

Prioritisation given multiplicity of differences: inequity and inequality Consider whether any of 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?

Multiplicity of challenges for delivering equitable services-

examples varying health behaviours, beliefs and attitudes, and diseases

diagnosis, treatment, intervention, adherence to the intervention, and outcomes varying

language and cultural barriers requirements based on religion lack of information and research personal biases, stereotyped views, individual racism institutional (health system) bias, and laws against it Implementing laws requiring equal opportunities in

employment and other walks of public life

Legal Framework and Policy Consensus In 1997 EU approved the Treaty of Amsterdam Article 13 - powers to combat discrimination on

sex, racial or ethnic origin, religion or belief etc Implemented variably, sometimes vigorously The UK has:

Race Relations Amendment Act 2000 (building on 1976 act)

Public sector duty to promote equality and to demonstrate this

Unusually energetic implementation but still patchy effects

Major recent achievements in Scotland

Implementing the Race Relations Amendment Act 2001, and now Equality Act 2010

HDL (2002) 51 –Fair for All policy focused on ethnicity Energising the Organisation Demographics Access and Service Delivery-equity Human Resources-equality in employment Community Development-strengthening communities

National Resource Centre for Ethnic Minority Health (NRCEMH) 2002-2008

Major achievements in Scotland 2 Integration of the equality strands (race, religion,

age, gender, disability, sexual orientation) in NHS organisation in 2008

Information-responsibility and funding embedded in NHS agency: promotion of ethnic coding in routine information systems

Linkage of Census ethnic codes to mortality and hospitalisation databases providing health status by ethnic group

Ethnic Health Research Strategy, setting 6 priorities

Research and surveillance-health status of ethnic minorities in Scotland Ethnicity not recorded on birth and death

certificates (under consideration) Ethnic coding for in routine NHS records highly

variable So, unable to assess differences in mortality and

morbidity routinely High-level managerial activity to resolve these

problems So country of birth, name search and linkage

methods used

Using linkage methods to provide data Linkage study-heart attacks much more

common in self identified South Asians at 2001 census

More linkage derived findings awaiting publication on cardiovascular disease, cancer, maternal & child health and mental health

Anonymised Linkage of Health Databases to Census Databases:

conceptualising the procedure

Health Database Census Database

Record Linkage

Encrypted CHI Number

Personal Identifiers

Personal Identifiers

EncryptedCensusNumber

Encrypted CHI Number Encrypted Census Number

(Look-up Table)

Death & Hospitalisation from Health databases

Ethnicity and social/economic data

from Census

http://www.biomedcentral.com/1471-2458/7/142/abstract

Directly age standardised incidence ratesper thousand for first AMI (principal diagnosis)Sex/Ethnicity Person

yearsAge

adjusted rate

95% confidence

intervalFemaleNon SA 4,557,730 2.56 2.51 – 2.60SA 24,762 4.86 3.05 – 6.67

What about elsewhere in Europe? MEHO project Impossible to get pan-European perspective

Morbidity data is far behind mortality

Situation will be worse for other causes

Mapping is resource intensive

Currently data not trustworthy and difficult to standardise

Substantial inequalities still demonstrable

Country specific results may not generalise across EU

Need better information across the EU

What about risk factor data? VENI project –background and aim

Host countries’ environment may differ so project to develop methods

Aim: To develop a foundation to study internationally, starting with the Netherlands & UK, the role of lifestyle, SES and health care factors in explaining differences in risk factors between populations with broadly similar ethnic backgrounds

VENI project -Example of resultsAge-standardised current smoking by ethnic group

Fig. 1a Age-standardised prevalence of current smoking in men

46,3

32,6

22,7

54,5

36,8

28,7

52,5

28,4

35,139,3

0102030405060708090

Prev

alenc

e of

smok

ing (

%)

It seems it matters where one migrates to !

Practical activities in Scotland Interpreting and translation funded for inpatient and

outpatient services (including general practice) Spiritual services in hospital for every religion-by

creating multi-faith spaces and facilities Food in hospitals – appropriate choices Trained staff support minority patients and

communities (Minority Ethnic Health Inclusion Service-MEHIS)

Several community organisations supported to provide appropriate services

Ideas tested out using demonstration projects (Khush Dil) and trials of interventions (PODOSA)

Patient

Health Professional

Link Worker

MEHIS Link Worker Model

Some obstacles on the equitable healthcare delivery pathway-examples Implementation problems, and insufficient

monitoring Insufficient information Mainstreaming successful projects into routine

service problematic Winning hearts and minds Racial tensions and discrimination An attitude that immigrants/minorities should fit

the system, not the other way around

One example-end of life study“Policy directives aimed at improving access to

services and standards of care for ethnic minority groups in Scotland are laudable. It seems, however, that end of life services for South Asian Sikh and Muslim patients remain wanting in many key areas”.

Worth et al BMJ http://ukpmc.ac.uk/articlerender.cgi?accid=PMC2636416

Conclusions 1

Scotland’s progress incremental, incomplete and difficult, but still comparatively strong

Comparing policies to tackle ethnic inequalities in health: Belgium 1 Scotland 4

Built on partnership by a government and institutions promoting equality, and justice

Achieved within a strong NHS Underpinned by research and information Involving ethnic minority groups and individuals as

instigators, leaders, service personnel and users

Conclusions in international context 2 USA: health systems consume much more resources-despite

long recognition, equitable healthcare not yet achieved Europe: patchy progress, subject to political change. Progress

largely in service delivery, rather than governmental policy. New Zealand: innovative, and effective work in relation to

Maoris- political power and will has been instrumental Australian work on aboriginal health-challenge has been

somewhat overwhelming. Multi-ethnic countries in Middle East, China, India etc: much to

do, but issue seems mostly unrecognised

Conclusions 3: the future in Europe Health systems in our multi-ethnic

societies-challenging, interesting, with potential for great advances

Sharing experience across Europe, and between continents, means faster progress.

We must remember our ultimate goal-a healthy society

Acknowledgements

Colleagues including Rafik Gardee, Hector MacKenzie, Laurence Gruer, Aziz Sheikh, Gill Matthews, Vincent Laurent, David Ingleby

People supplying slides-Smita Grant (MEHIS, Lothian NHS) IOM for migration slide Members of the Edinburgh Ethnicity and Health Research Group The conference organisers

Further reading

Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs Assessment for Black and Ethnic Minority Groups 2002 (online) and 2007 (in print) (book chapter –PDF available online at http://www.hcna.bham.ac.uk/documents/04_HCNA3_D4.pdf

Bhopal RS. Ethnicity, race, and health in multicultural societies; foundations for better epidemiology, public health, and health care. Oxford: Oxford University Press, 2007, pp 357. http://www.oup.com/uk/catalogue/?ci=9780198568179

Some URLs for organisations/policies National resource centre for ethnic minority

healthhttp://www.healthscotland.com/about/equalities/raceresources.aspx Planning and Equalities Directorate integrating equality strands

http://www.healthscotland.com/about/equalities/raceresources.aspx Information

http://www.isdscotland.org/isd/5826.html Fair for All

http://www.sehd.scot.nhs.uk/mels/HDL2002_51.pdf Ethnicity and health research strategy

http://www.healthscotland.com/documents/3768.aspx Lothian NHS board

http://www.nhslothian.scot.nhs.uk/news/documents/equalitydiversity_strategy.pdf

MEHIS http://www.saferedinburgh.org.uk/DOSDetails.cfm?ID=75

Equally connected http://www.healthscotland.com/equalities/mentalhealth/equally-connected

Comparing Belgium and Scotland policies http://eurpub.oxfordjournals.org/cgi/content/full/ckq061)