Transcript McGill and Edinburgh - Men's Health Forum Scotland

The challenges of health and
healthcare in multicultural societies
Men’s Health Forum 2007
Raj Bhopal
CBE, DSc (hon)
Professor of Public Health, University of Edinburgh &
Chairman, Steering Committee of the National Resource Centre for Ethnic
Minority Health
Lecture contents
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Migration
Human species
Definitions of race and ethnicity
Assessing ethnicity and race
Relative and absolute approaches in interpreting
variations-some examples in practice and research
Forces generating inequalities and inequities
Race, clinical medicine and genetics
Challenges and potential
Example: prevention of diabetes
Conclusions and directions
Migration-key to understanding
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The driving force creating multi-ethnic societies
Fundamental human behaviour
Permitted humans to leave Africa
Reasons –
trade and commerce,
demand for work,
demand for workers,
education,
personal aspirations,
political refuge
curiosity
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All are worthy and important
Human species
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What is a species?
Were there several human species on Earth at any
point?
How many human species are there on the earth
today?
How do we know?
All humans on the
earth now are
Homo sapiens: race
and ethnicity define
subgroups. This was
not always so
Homo floresiensis (and Homo
neanderthalis before that)
Race
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The group a person belongs to, or is perceived
to belong to because ofphysical features reflecting ancestry
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Increasingly concept emphasises a common
social and political heritage
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The concept is largely discredited in Europe,
where it is displaced by ethnicity
Ethnicity
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The group a person belongs to, or is
perceived to belong to, because ofculture, language, diet, religion, ancestry,
and
physical textures
Ethnicity subsumes race
Assessing ethnicity: three approaches
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3 main approaches i.e.
self-assessment
assessment by another using data
assessment by another by observation.
However you do it, you need to create a
classification-difficult
UK has taken the task seriously only in the
last 20 years or so
England: Comparison of the 1991 and 2001 Census
ethnic groupings
1991 Census
2001 Census
White
British, Irish, Any other white
background
Black Caribbean, Black African,
Black other
Caribbean, African, Any other
Black background
Indian, Pakistani, Bangladeshi
Indian, Pakistani, Bangladeshi any
other Asian background
Chinese
Chinese
Any other ethnic group
Any other ethnic group
No ‘Mixed’ category
White and Black Caribbean, White
and Black African, White and
Asian, Any other mixed
background
Assessing variations by ethnic group
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Absolute risk approach: examine patterns
within each group (primary).
Then compare with other ethnic groups-the
relative risk approach (secondary).
The interpretation will be different.
Maximise value by doing both.
Newcastle Heart Project: Smoking prevalence (%)
Indian
Men
Pakistani
Bangladeshi
European
14
32
57
33
1
5
2
31
(S. Asian
combined,
33%)
Women
(S. Asian
combined,
3%)
Mortality for stroke given as standardized mortality ratios
(95% confidence interval) in Bangladeshi born men in
England and Wales, around 2001 census
SMR for stroke
(ICD 10 I60-69)
Standard
population
Bangladeshi
men
100
249
(213-292)
Forces generating ethnic health inequalities
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Culture and lifestyle
Social, educational and economic status
Environment before and after migration
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Early life development
Generational effects
Genetics
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Access to and concordance with health care advice
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Question: Are ethnic inequalities inequities i.e. injustices?
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Equity and inequality
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Consider whether the following are
inequities:
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The lower prevalence of smoking in Sikh Indian
compared to White men
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?
One deep problem is racism.
Racism, prejudice and inequity
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Why might ethnic minority patients get
worse care in a health setting?
Might racism and prejudice play a part?
What kinds of racism have you seen?
What experiences of racism have you, and
close friends or relatives experienced?
The continuing promotion of Hitlerian
Views
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TABERNACLE OF THE PHINEHAS PRIESTHOOD /
ARYAN NATIONS
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PLEDGE: I will conduct myself at all times
as a gentleman (or woman) reflecting the
superiority of the Aryan Race.
http://www.aryan-nations.org/about.htm (accessed 24th of Feb. 2005)
Race: Ashley Montagu
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“…. the race problem.. seems to have grown more
troubling than ever.…”
his formula and analysis of the problem: “race” = the
physical appearance (genetic) of the individual +
intelligence of the individual + ability of the group to
which the individual belongs to achieve a high
civilization.
“Nothing could be more unsound, for there is no
genetic linkage whatever between these three
variables.”
Ashley Montagu, Man’s Most Dangerous Myth, p31
Pharmacological variations by ethnic
group: BiDil
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Finding of the efficacy of isosorbide dinitrate plus
hydralazine (BiDil) in black patients (Taylor, N Engl J Med
2004, 351 p 2055)
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FDA approval for populations describing themselves as
black (unique and controversial decision)
The race, medicine and genetics debate is wide open
Health-care challenges for a
multi-ethnic world
Responding to
 varying health behaviours, beliefs and attitudes
 differences in the pattern of diseases
 differences in diagnosis, treatment and outcome
 language and cultural barriers
 calls for a service sensitive to cultural differences
 personal biases, stereotyped views, individual
racism, and institutional racism
 laws requiring equal opportunities in employment
and promotion
Medicine and diversity
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In an increasingly diverse society, which serves to
enrich our lives and experiences, doctors must learn
to value ethnic diversity to deliver effective health
care. In doing so, they will bring mutual benefits for
their patients and themselves.
J Kai et al. Medical Education 1999 p622
The future for health professionals
My vision of a future health professional:
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learns about the unity yet diversity of humanity.
engages in studies emphasising ethnicity,
religion and language that includes bedside
teaching.
Grasps opportunities for learning about ethnic
diversity with a strong focus on how people
maintain their heath in different cultures.
The future 2
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takes special interest in the health beliefs and
attitudes of one or more ethnic minority
populations
integrates relevant ideas into the advice on
healthy living for all patients and populations.
makes sure that there is a reason for mentioning
the patient's ethnic group, and explains it.
The future 3
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takes pride that the health service’s policy makers
and peers seek his/her advice on improving services
for ethnic minorities.
finds that these roles and skills are appropriately
recognised in the awards and promotions
committees.
Doing things: the evidence based
approach-PODOSA
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A major national project, set in Glasgow and
Edinburgh
Object-contribute to worldwide efforts to
control the epidemic of diabetes
About 20% of adult South Asians in the UK
have got diabetes compared to about 5% in
the population as a whole
Why?
Yajnik has 21% fat,Yudkin 9%
Yajnik & Yudkin (2004) Lancet.
Stemming the epidemic
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Tackle the causes
Tackle intermediate states e.g. impaired
glucose tolerance (the focus today and todate)
Tackle the disease
It can be done!
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Da Qing, China Study 42 percent reduction in the incidence of
diabetes over six years
Finnish Diabetes Prevention Study -58 percent reduction in three
years
Diabetes Prevention Programme Study, USA- 58% reduction in
three years
Indian Diabetes Prevention Programme, Chennai, India - 30
percent reduction in three years
We have been inspired!
New
Trial in Edinburgh and GlasgowPrimary prevention of diabetes and
obesity in South Asians (PODOSA)
www.podosa.org/index.html
National Prevention Research
Initiative: funders
Principal research question
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does a family-based weight loss and
physical activity programme reduce the
incidence of type 2 diabetes in South
Asians?
Trial summary
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adapt existing interventions culturally
apply in families with diabetes
Focus on reducing weight and increasing physical activity in
adults with IGT
300 families will be randomised into two groups (600 people with
IGT in total)
One group of 300 will receive 15 contacts over three years
one group of 300 will have 4 contacts
Intervention Goals
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weight loss of at least 3.5 kg (5% minimum)
increase in moderate physical activity to at least 30
minutes daily
BMI to less than or equal to 25 or preferably 23
reduce waist size to less than 90 cm for men, and
less than 80 cm for women
Timescales
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Participant recruitment-July 2007 through to
June 2008
Follow-up through to 2010/11
Trial concludes July/August 2011
Results so far
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Trial staff are in place (Anne Douglas, Alex
Cellini, Harpreet Bains, Sunita Wallia, Ruby
Bhopal, Anu Sharma, Alyson Grubb)
So far:
About 150 people screened
Many with possible diabetes they did not know about
Quite a few with possible IFG
about 16people with IGT
Advice and help needed from professional
colleagues
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How to gain referrals into the trial:
people with IFG
people with IGT
people with a family history
people at high risk
please send them our way
Key contact telephone number:
Anne Douglas, trial manager,
650-3213, [email protected]
People can sign up on our website
Conclusions
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International migration and exchange are creating multiethnic global societies.
The concept of ethnicity can improve public health,
health care, and clinical care, and advance science
The greatest goal is that people should be long-lived,
free of disease and disability, brimming with energy,
creative and full of ideas.
Ethnicity can contribute to this goal.
In doing so, we improve the health and healthcare of the
entire population
Further reading for such a professional
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Gill PS, Kai J, Bhopal RS, Wild SH. Health Needs
Assessment for Black and Ethnic Minority Groups 2002
(book chapter - in press, available online at
http://hcna.radcliffe-oxford.com/bemgframe.htm
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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