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Can ethnicity be audited in acute trusts using routine data?
- Ibrahim I Abubakar, David Kanka, Consultant in Public Health Medicine (6 March 2002)
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What is the meaning of south Asian ethnicity?
- Guillermo A Herrera Taracena (9 March 2002)
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Ethnic differences in invasive management of coronary disease: heterogeneity among Indians, Pakista
- Raj S Bhopal (2 August 2002)
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Ethnicity in Medicine
- Abd H Mat Sain (20 October 2002)
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Ibrahim I Abubakar, Specialist Registrar in Public Health CDSC Eastern Institute of Public Health University Forvie Site Cambridge CB2 2SR, David Kanka, Consultant in Public Health Medicine
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Editor - Feder et al reported findings from the ACRE study showing that among those deemed clinically appropriate for coronary artery bypass grafting, south Asians are less likely than white patients to undergo procedures.1 They pointed out the lack of a mechanism to monitor ethnic differences in invasive management of coronary disease in the NHS. The quality of hospital episode statistics (HES) data has improved significantly in many trusts since the ACRE study. In 1999/2000 the quality index for our local trust ethnicity data was 92.8% compared to a national average of 65.4%.2 This contrasts with 62.9% invalid coding in 1995/6.3
We conducted an audit of all patients admitted with unstable angina or acute myocardial infarction in a local trust between July 1999 and June 2000. Information was obtained on age, sex, ethnicity, and Carstairs socioeconomic deprivation category derived from postcode of residence. Record linkage to subsequent HES provided follow up information on procedures up to eighteen months after admission. A total of 53 south Asians and 1556 white patients were analysed using logistic regression models. We found higher access to angiography and coronary artery bypass grafting among south Asians compared to whites in the univariate analysis. No difference in access to angiography (odds ratio– 0.94, 95% confidence interval 0.49 to 1.83) or coronary artery bypass grafting (odds ratio – 1.27, 95% confidence interval 0.62 to 2.62) was noted between south Asian and white patients after controlling for age, sex and Carstairs deprivation category. Despite the small sample size, lack of control for severity or appropriateness we have demonstrated that it is possible to audit access by ethnicity using routine data. Many trusts may currently have the ability to carry out such audit especially in areas with high ethnic minority populations. It may not be long before national audit of ethnic data on access to procedures is possible. 1. Feder, G., Crook, A. M., Magee, P., Banerjee, S., Timmis, A., and Hemingway H. Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography. BMJ 324, 511-516. 2002. 2. DoH. HES Data Quality Report - 1999/00. http://www.doh.gov.uk/hes/data_quality/dqi99/rgn99.html accessed on 05/03/2002 3. Aspinall PJ. The mandatory collection of data on ethnic group of inpatients: experience of NHS trusts in England in the first reporting years. Public Health 2000;114:254-9. Competing interest: None |
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Guillermo A Herrera Taracena, Medical Epidemiologist ECOS, Epidemiology Consultancy Service, Ozvatan Sokak 17-2, Teras Evler, Cankaya, Ankara, Turkey.
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Regardless of the outcome of the study one key question remains unanswered: what is the meaning of south Asian ethnicity? Does this means that people from India, Pakistan, Bangladesh, etc., speak the same language, have the same ancestry, share the same culture, and are of the same religion? India alone is a world in itself, with so many languages and dialects, cultures, religious beliefs, so forth and so on. Even among whites in Great Britain, people from Scotland are different from people in Wales and England. In fact, they do not like to be called English. Ethnicity is now replacing the concept of race. However, this does not make ethnical categories a scientific construct.1 Ethnicity is used because it relates to people where people share time and place and establish common cultural traditions, among many other things.2 In this way, people living in Britain can be considered as one ethnic group. Did the study considered the ethnic origin of the treating and referring physicians? What about medical education? Were they trained in Great Britain or abroad? Were there differences depending on the hospital or University they attended? Were there differences depending on their social-economic background or their ability to speak one of the south Asian languages and dialects? What about the patients diet? Has it changed since they moved to Britain? How? When did they move to Britain or were they born in Britain? Race/Ethnicity in the United States is avoidance: avoidance to deal with social, cultural, religious, and economical issues in an increasingly diverse society. People are group together into Racial and Ethnic categories that mean little or nothing to them until money comes to play. The government uses these funny categories to ‘distribute’ resources targeting education and social development. However, little education or social development deals with what lies beneath the social divide in the United States: poverty, discrimination, lack of bilingual education, lack of respect for the cultures and religious beliefs of these people, etc. There is also a long history of exploitation, racism, and a lack of recognition of basic human rights. Remember that the United States has not ratified the convention on Economic, Social, and Cultural Rights. Therefore, It is easier to deal with Race/Ethnicity than to deal with you own demons. Just consider the following. What does it mean to be Hispanic? Where do Brazilian people fit? How many generations does it take for a Mexican origin ancestry person to become an American considering that their presence and history in America precedes that of the United States? Hispanics/Latinos are multiethnic, multicultural, and multilingual.3 What do we gain from grouping them together? There is no meaning in Racial/Ethnic categories grouping together people of such a diverse background and origin. The only meaning is the meaning the creator of those categories wants to give them. To end with a positive spin, if we are able to group together more than one billion people as one ethnic group we can surely take the next step and consider the rest of the world as one Racial/Ethnic category: Human. In the United States when asked about my Racial/Ethnic origin that is what I like to state: Human. 1. Raj Bophal, Liam D. White, European, Western, Caucasian, or what? Inappropriate labeling in research on race, ethnicity, and health. Am J Pub Health 1998;88:1303-6. 2. Fullilove MT. Comments and Topics of our times. Am J Pub Health 1988;88:1297-8. 3. National Association of Hispanic Publications. Hispanic-Latinos: diverse population in a multicultural society. Washington, DC: NAHP, 1995. |
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Raj S Bhopal, Bruce and John Usher Professor of public health Public Health Sciences, University of Edinburgh, Edinburgh EH89AG
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Editor, Ethnic differences in invasive management of coronary disease: heterogeneity among Indians, Pakistanis and Bangladeshis is key to interpretation Feder et al have 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 socio-economic status and emphasise as explanations patients’ understanding of risks and benefits, and barriers in the health care system after placement on a waiting list. Similar observations in the USA have led to intense debate, particularly concerned about the potential role of racism. In my recent overview on racism, which focused on the extensive data on racial inequalities in treating heart disease in the USA, I concluded "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 USA study on the same theme. (3) I also wrote…"even if patients’ preferences are partly responsible for the disparities, racism will not be wholly exonerated.” (2) Within the data of Feder et al1 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 socio-economic circumstances and cardiovascular risk factors,(4) and for levels of understanding about coronary heart disease and diabetes. (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 (6). Such heterogeneity helps interpret Feder et al’s work. First, we can conclude that crude racism based on colour prejudice is not at play. Second, that 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 less well equipped to take advantage of the NHS. Yet, they have the worst profile of cardiovascular risk factors (4) and most disease. In pursuit of the goal of health care 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) 1. Feder GG, Crook AM, Magee P, Banerjee S, Timmis A D, and Hemingway H. Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography BMJ 2002; 324: 511-516 2. Bhopal R S. The spectre of racism in health and health care: lessons from history and the USA. Br Med J 1998;316:1970-1973 3. Whittle J, Conigliaro J, Good CB, Lofgren RP. Racial differences in the use of invasive cardiovascular procedures in the Department of Veterans Affairs medical system. N Engl J Med 1993;329:621-7 4. Bhopal, R S, Unwin N, White M. et al. heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin populations: cross sectional study. BMJ 1999;319:215-220 5. Rankin J, Bhopal R. Understanding of heart disease and diabetes in a South Asian community: cross sectional study testing the `snowball' sample method. Pub Health 2001; 115: 253-260. 6. Bhopal R S, Phillimore P, Kohli H S. Inappropriate use of the term "Asian": an obstacle to ethnicity and health research. J Pub Health Med 1991;13:244-246 |
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Abd H Mat Sain, Associate Professor Dept of Surgery, School of Medical Sciences, Universiti Sains Malaysia,Kubang Kerian,Kel.,Malaysia
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Editor - The issue of classifying ethnic and race in the medical and health research has been controversially debated for a long time. In the pre-genomic era, the studies of demography as part of the broader epidemiologic investigations were incomplete without race/ethnic classifications. Ethnicity or race seems a natural distinguishing parameter(phenomenon) existing in any society ready for investigators to sudy. Most societies in any country in the world now are plurally heterogenious due to the acceptance of globalization as an inevitable socio-economic process which transcends national(political) boundaries. Together with the imbibition of liberal democracy in almost all the modern states and hence empowerment to people regardless of ethnicity giving rise to multiculturism and pluralism in most modern countries in the world with the exception of perhaps the East Asian Sino-Japanese stocks. Hence, using race/ethnicity as a parameter in any study or even itself as the main subject of inquiry in any discipline is quite acceptable. Race and ethnicity can be an important differential factor in many social processes such as education, attitudes on social issues, economic prosperity and hence health status. The intent of studying race/ethnicity will have its immense value only if the outcomes address the above social functions. As such the observations made by Feder et al(1) in their study that the South Asians were less likely to undergo the prescribed invasive treatment needs a follow up study to explore the reasons for this social inequity. The discovery of reasons for this inequity will make the study on race/ethnicity more useful for the authority to respond appropriately in terms of redeployment of resources. Bhopal et al has rightly suggested that South Asians are not homogeneous people insofar as the socio-economic status is concerned which in turn is much related to educational and cultural diversity among them(2). The study on race/ethnicity has taken a new conception with the advent of human genome project. The biological basis for the heterogeneity of people transcends the conventional superficial descriptions of race and ethnicity. The genetic similarity of people is much related to the historical and anthropological relationships. Before 1947, there were no countries by the names of Pakistan and Bangladesh. It was only India or more generically Indian sub-continent. These people then and also today were broadly of two different anthropological stocks, namely the Aryanic from the North and the Dravidian South. The Aryanic Northern India bears semblance in physical features and perhaps their genotypes to the other Aryanic stocks which make up most of Europe. This could explain the the similarity in cardiovascular risk factor between the Indians and that of the “whites”(3). In conclusion, despite the controversy of defining people by race and ethnicity in investigating health related issues, there is immense knowledge gained for further fundamental research and also useful utilizable information for equitable disbursement of health resources. References 1. Feder GG, Crook AM, Magee P, Banerjee S, Timmis A D, Hemingway H. Ethnic differences in invasive management of coronary disease: prospective cohort study of patients undergoing angiography. BMJ 2002; 324: 511-516. 2. Heterogeneity among Indians, Pakistanis, and Bangladeshis is key to racial inequities Raj S Bhopal BMJ 2002; 325: 903. 3. Rankin J, Bhopal R. Understanding of heart disease and diabetes in a South Asian community: cross sectional study testing the `snowball' sample method. Pub Health 2001; 115: 253-260. |
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