Ethnic inequalities in healthEthnic inequalities in health

James NazrooJames NazrooUniversity College LondonUniversity College London

www.ucl.ac.uk/epidemiology

Why is there an interest in ethnic inequalities in health?Why is there an interest in ethnic inequalities in health?

Aetiological investigations

Monitoring

Access to appropriate treatment

Investigating inequalities in health

Concern with ethnic disadvantage, racialisation and social inequalities: health as a component of wider disadvantage

Reported fair or bad health by ethnic Reported fair or bad health by ethnic group and agegroup and age

0%

20%

40%

60%

80%

100%

2-5 5-9 10-12 13-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-60 61-70 > 70

Caribbean Indian Pakistani Bangladeshi Chinese White minority White English

Health Survey for England 1999

Reported fair or bad healthReported fair or bad health

Age adjusted odds ratio compared with white English

0.5

1

1.5

2

2.5

3

3.5

4

Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority

Odd

s ra

tio (a

nd 9

5% C

.I.)

Health Survey for England: Nazroo 2004

Explaining ethnic inequalities in healthExplaining ethnic inequalities in health Statistical artifact

Migration

Differences in genetic risk

Culture and lifestyle

Material disadvantage

Ecological effects

Racism: exclusion and harassment

Paradigms in research on ethnic differences in health (1)Paradigms in research on ethnic differences in health (1)

Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes

Avoiding premature coronary deaths in AsiansAvoiding premature coronary deaths in Asians Asians’ evolutionary history involved adaptation ‘to survive under conditions

of periodic famine’ leading to a high prevalence of insulin resistance.

Central obesity may also develop as a consequence of lifestyle (culture): ‘a diet rich in saturated fats and energy (including ghee) and a sedentary lifestyle’.

“Well Asian clinics” should be set up to address the low use of medical services.

Community leaders should increase awareness of risk factors.

Survivors should relay their experiences to members of their community.

Dietary advice should be given and Asians should be encouraged to increase regular physical activity.

Gupta et al. 1996

Paradigms in research on ethnic differences in health (2)Paradigms in research on ethnic differences in health (2)

Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes

Ethnicity as structure Notions of fixed difference are used to justify exclusionary practices Racism Socioeconomic disadvantage

Ethnic differences in occupational positionEthnic differences in occupational position

20171141282430IV/V

30242839332627IIIm

161416 7141419IIInm

34464513253623I/II

RG class of head of household

75726746596958Male employment rates

White English

White minority

ChineseBangl-adeshi

PakistaniIndianCaribbean

Health Survey for England 1999

Per cent

Ethnic differences in equivalised Ethnic differences in equivalised household incomehousehold income

48% 45%

69%

90%

41%27% 31%

0%

20%

40%

60%

80%

100%

Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority

WhiteEnglish

Bottom tertile Middle tertile Top tertile

Health Survey for England 1999

Experiences of racism and discriminationExperiences of racism and discrimination One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.

Modood et al. 1997

Experiences of racism and discriminationExperiences of racism and discrimination One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.

20% of ethnic minority people report being refused a job for racial reasons, and almost 3/4 of them say it has happened more than once.

20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.

Modood et al. 1997

Experiences of racism and discriminationExperiences of racism and discrimination One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.

20% of ethnic minority people report being refused a job for racial reasons, and almost 3/4 of them say it has happened more than once.

20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.

White people freely report their own prejudice: One in four say they are prejudiced against Asian people; One in five say they are prejudiced against Caribbean people.

Modood et al. 1997

Equivalised income and fair or bad healthEquivalised income and fair or bad health

0%

10%

20%

30%

40%

Caribbean Indian Pakistani Bangladeshi Chinese Whiteminority

WhiteEnglish

Bottom Tertile Middle Tertile Top Tertile

Health Survey for England 1999

Socioeconomic effects and fair or bad healthSocioeconomic effects and fair or bad health

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Caribbean Indian Pakistani Bangladeshi Chinese White minority

Ln O

dds

ratio

com

pare

d w

ith w

hite

Eng

lish

Not adjusted for socioeconomic effects Adjusted for socioeconomic effects

Health Survey for England 1999

Racism, discrimination, occupational class and healthRacism, discrimination, occupational class and health

Predicted per cent reporting fair or poor health

0

10

20

30

40

50

None Verbal Physical orproperty

No or afew

Some ormost

Nonmanual Manual

(Karlsen and Nazroo 2002)

Racial harassment Do employers discriminate? Class

Paradigms in research on ethnic differences in health (3)Paradigms in research on ethnic differences in health (3)

Un-theorised’ ethnicity Appears to be empirically driven Carries an implicit theory of fixed genetic and cultural difference Explanations are often reduced to racialised stereotypes

Ethnicity as structure Notions of fixed difference are used to justify exclusionary practices Racism Socioeconomic disadvantage

Ethnicity as identity Identification with cultural traditions Provides guidelines for action and psychological and material resources Both historical and immediate context influence identity – hybrid identities

Tobacco use*Tobacco use*

Men

0

10

20

30

40

50

60

Cigarettes Any tobacco product

*Use of chewing tobacco products was only asked of the South Asian groups

Women

0

10

20

30

40

50

60

Black Carib

beanIndian

Pakistani

Bangladeshi

Chinese Irish

General p

opulation

Health Survey for England 1999

Typologies of sexual lifestyleTypologies of sexual lifestyle

Multiple partnerships/encounters interleaved with monogamous relationships alongside primary relationships no primary/monogamous relationships

Serial monogamy within marriages only within and/or outside of marriage

Single mongamy since before marriage/outside of marriage within marriage

Pre-coitarchy

Jamaican

African

South

Asian

Sexual History

ExES: Elam et al. 1999

Women looking after the homeWomen looking after the home

0%

20%

40%

60%

80%

BlackCaribbean

Indian Pakistani Bangladeshi Chinese Irish Generalpopulation

Smoking among South Asian PeopleSmoking among South Asian People

0%

5%

10%

15%

20%

25%

30%

35%

Family Origin Age on Migration Gender Class

Pakistani

Bangladeshi

Indian

Manual

No FT worker

Non-manual11 years or older< 11 years Male

Female

Nazroo 1998

Ethnicity as a social identityEthnicity as a social identityrace and ethnicity are intrinsically forms of collective social identity ... Identity confers a sense of personal location, and provides a stable core of individuality. But it is also about social relationships ... In exploring the dynamics of identity, we therefore need to understand the way in which identity grows out of and is transformed by action and struggle, and to ask:

Who is constructing the categories and defining the boundaries?

Who is resisting these constructions and definitions?

What are the consequences of being written into or out of particular categories?

What happens when subordinate groups seek to mobilize along boundaries drawn for the purposes of domination?

What happens to individuals whose multiple identities may be fragmented and segmented by category politics?

Solomos 1998

Ethnic making situationsEthnic making situations

Enslavement of Africans leading to post-slavery societies – post slavery minorities.

Colonial rule and post-colonial states – indigenous minorities, urban minorities (migrant worker populations) and ‘multi-cultural’ plural societies.

Western capitalism and the formation of nation states – proto-nations (people who make a claim to be nations).

Concluding commentsConcluding comments

Diversity of experiences across ethnic groups, classes, gender and generations.

Ethnicity is a form of personal identity.

Ethnicity/race is also an externally imposed identity.

Ethnic identity is historically and socially contingent/constructed.

Central role of social disadvantage in determining the pattern of ethnic inequalities in health.