Letters

Heterogeneity among Indians, Pakistanis, and Bangladeshis is key to racial inequities

EDITORFeder et al recently confirmed and extended observations pointing to inequity in the invasive management of coronary disease.¹ They conclude that the inequity is not due to physician bias or socioeconomic status and emphasise as explanations patients' understanding of risks and benefits, and barriers in the healthcare system after placement on a waiting list.

Similar observations in the United States have led to intense debate, particularly on the potential role of racism. In my overview on racism, which focused on the extensive data on racial inequalities in treating heart disease in the United States, I concluded that the emerging, somewhat reluctant, interpretation is that racism is important.² Whittle et al included racism as a component of the explanation for their findings in a US study on the same theme.³ I also wrote that even if patients' preferences are partly responsible for the disparities, racism will not be wholly exonerated.²

Within the data of Feder et al are buried important observations on heterogeneity within the South Asian population that shed light on the issue. For angioplasty, the deficit of operations was only in Bangladeshis (hazard ratio 0.23) and Pakistanis (0.34), and not in Indians (1.22). In coronary artery bypass grafting the deficit was greater in Bangladeshis (hazard ratio 0.56) and Pakistanis (0.78) than in Indians (0.89).

Heterogeneity between Indians, Pakistanis, and Bangladeshis has been unequivocally shown for socioeconomic circumstances and cardiovascular risk factors and for degree of understanding about coronary heart disease and diabetes. ^{4 5} Incredible though it may seem, in many respects relevant to cardiovascular diseases, Indians are closer to the reference "white" population than they are to Bangladeshis. The category Asian/South Asian, while of some value, has pitfalls and can lead to false interpretations and conclusions.

Such heterogeneity helps interpret Feder et al's work.

Firstly, we can conclude that crude racism based on colour prejudice is not at play.

Secondly, the factors at play are affecting Bangladeshis most and Indians least. I am not aware that Bangladeshis have different attitudes to health care and to medical advice, but they are comparatively poor, less educated,⁴ uninformed about heart disease,⁵ and probably less well able to take advantage of the NHS. Yet they have the worst profile of cardiovascular risk factors and the highest risk of disease.

In pursuit of the goal of healthcare equity and acquiescence with the Race Relations Amendment Act 2000, the NHS will need to adapt services to help ethnic minority populations overcome institutional barriers, which may, unwittingly, disadvantage them.²

Raj S Bhopal, Bruce and John Usher professor of public health. 
Public Health Sciences, University of Edinburgh, Edinburgh EH8 9AG raj.bhopal{at}es.ac.uk