Global inequalities in assessment of migrant and ethnic variations in health Raj Bhopal CBE, DSc (hon) Professor of Public Health, University of Edinburgh.
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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
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