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

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

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

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%

WHO 1983-migration and health

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…”

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

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.

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

In all their splendid variety, all humans on the earth are one species.

Race and ethnicity define subgroups.

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

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

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 )

0

0.5

1

1.5

2

1966-1970

1971-1975

1976-1980

1981-1985

1986-1990

1991-1995

1996-2000

2001-2005

Race:E

thn

icit

y R

ati

o

USA

All combined

Rest of the world

Provide challenges for disease control: smoking prevalence

0

10

20

30

40

50

60

Indian Pakistani Bangladeshi White

Pre

va

len

ce

of

cu

rre

nt

sm

ok

ers

(%

)

male

female

Source: Newcastle Heart Project (Bhopal et al BMJ 1999)

Ethnic variations are often huge and surprising: Newcastle Heart Project prevalence (%) of diabetes 25-74 years

0

5

10

15

20

25

Men Women

European

Indian

Pakistani

Bangladeshi

Source: Newcastle Heart Project (Bhopal et al BMJ 1999)

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

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)

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

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)

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

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 …”

Google scholar search for epidemiology, ethnicity and migrationCountry Hits for migration

(thousands)Hits for ethnicity (thousands)

USA 128 145

UK 63 81

Australia 44 33

China 29 33

Brazil 19 13

Russia 14 18

Nigeria 14 17

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

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

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

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

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?

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