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EDITORIALS: Wendy Pollock and James F King Inequalities in maternal health BMJ 2009; 338: b357 [Full text]

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Making Ethnicity Count

Mark RD Johnson   (8 April 2009)

Making Ethnicity Count 8 April 2009
Mark RD Johnson, Director, Mary Seacole Research Centre Charles Frears Campus, Leicester LE2 1RQ Send response to journal: Re: Making Ethnicity Count	As a long-term advocate of Ethnic Record Keeping and Monitoring (I wrote an editorial with Paramjit Gill in 1995: 'Ethnic monitoring and equity: Collecting data is just the beginning' BMJ 310 :890.) I was interested to read the editorial by Pollock and King (21 March BMJ 2009; 338 :b357) highlighting the value of data from obstetric surveillance systems, as displayed in the linked article by Knight & colleagues from UKOSS (BMJ 338 :b542). We have know for a long time that ethnicity (or membership of a minority 'ethnic group') is a marker of poor health outcomes, and a diversity of inequalities, and recognise that it is not only a complex variable in its own right (as I explore in an article on the NHS Library site of the Specialist Library for Ethnicity & Health: www.library.nhs.uk/ethnicity ) but also that it is correlated with many other deprivation factors. Correlation is not, of course, causation, and we need to collect and examine such data carefully at the finest level available, to identify the salient elements and effects. Religion, culture, family structures, location of communities, language and other issues are all important. As also are the responses and knowledge or skills of the health care teams and their 'cultural competence'. There are two problems. One is (as suggested by the authors) that we do not ask enough questions. For example, we cannot disaggregate the 'migrant' effect by asking about citizenship status, length or residence etc. The other problem is that asking these questions is not a trivial task. It risks not merely controversy but also unwanted effects that themselves may create or worsen inequalities. For instance, many practice staff are hard pressed and may even resent having to ask 'ethnicity' questions of all their users - and the 'majority' users may feel that they are being marginalised or misunderstand the reasons for the questioning: forgetting that we ALL have an ethnic identity, which needs to be taken into account. However, NHS record systems are not good enough to ensure that one can 'ask once and not again'. The Department of Health has taken some steps to include incentives for ethnicity data collection in its Quality Outcomes Framework and Directed Enhanced Schemes, but this will not alone create the database that the NHS needs nor answer all the technical and organisational problems that exist. I and colleagues from all over Europe will be debating some of these issues at a forthcoming meeting of the EU 'COST' (Commttee on Science and Technology) Action IS0603 "HOME" (Health of Migrants in Europe)workshop in Utrecht after Easter, and hopefully we may be able to work towards some solutions and better understanding at a European level as well as appreciating the insights and support from Australia offered by Pollock and King. Competing interests: None declared