Getting to grips with health inequalities at last?

Dear Editor,

David Hunter and colleagues are right to highlight the potentially
important contribution that the 'Marmot Report' makes to England's efforts
to tackle the persistent problem of inequalities in health and life
expectancy. In particular, an attempt to focus on redressing deep-rooted
socioeconomic inequalities (a crucial counter to the 'lifestyle drift'
that has characterised much recent intervention), the emphases on delivery
systems and leadership, and the desire to draw lessons from past
experiences, are all welcome. However, it is shocking to find that such a
high profile and important report, intended to shape policy and practice
responses for our multiethnic society, pays such little attention to
ethnic inequality. While the report includes passing reference to the
social and health disadvantage experienced by particular ethnic groups in
a number of places, it fails to give any meaningful attention to this key
dimension of identity and division of modern British society (1).

There can be no doubt that poor socioeconomic status is a major force
in the lives of many ethnic minority people in Britain. It is also clear
that the major inequalities in health outcomes observed both between and
within ethnic groups are in large part explained by social and economic
disadvantage, operating at both an individual and a neighbourhood level
(2).

However, the poorer socioeconomic position of many ethnic minority
people, and the contribution of this to ethnic inequalities in health,
cannot be redressed by an attempt to deliver an on average reduction in
socioeconomic inequalities, even if implementation of the recommendations
from the Marmot report led to such a reduction. These inequalities result
from the particular disadvantages faced by ethnic minority people as a
result of their racialised social identities.

Socioeconomic deprivation inter-relates closely with racialised
hierarchies of exclusion and discrimination across the life-cycle. There
is evidence that health outcomes of some minority ethnic groups are worse
than would be expected on the basis of their socioeconomic circumstances
alone, and that the direct and indirect experience of racism in everyday
life is an important contributory factor (3). Interventions aimed at
countering socioeconomic disadvantage - such as the early years
investments advocated by Marmot - may have little effect on minority
ethnic individuals and families if structures of racist discrimination
persist within the education system and labour market.

In fact, there is compelling evidence that in the absence of explicit
attention the needs and experiences of minority ethnic individuals and
communities are overlooked by those who design, deliver and evaluate
interventions aimed at improving health and wellbeing. Indeed, even with
a strong legal framework and numerous policy directives, the NHS has
frequently failed to deliver services that achieve equitable outcomes and
high levels of satisfaction among minority ethnic patients. Of particular
importance is the growing evidence of differential access to key primary
and secondary preventive interventions including: smoking cessation
services; cancer screening; and some treatments for CVD (4). Even the most
obvious services designed to minimise ethnic inequalities in access, such
as interpreters, are under threat in an era where increased ‘efficiency’
is demanded of public services. It is also important to note that the
types of 'up-stream' interventions that Marmot advocates - such as
SureStart - have to-date shown limited success in engaging with and
meeting the needs of minority ethnic communities (5).

The Marmot review fails to highlight the systemic factors that
persistently reproduce inequitable experiences and outcomes in healthcare
for minority ethnic people, including: poor patient-provider
communication; a failure of programmes to address issues of most concern
to minority people; a lack of visible minority presence among staff;
dismissive and disrespectful attitudes and behaviour by staff; feelings of
exclusion and mistrust on the part of minority clients; a lack of cultural
sensitivity in service provision; and short-term, vulnerable funding. The
Review thereby misses the opportunity to make explicit the ways in which
public services reproduce the social and ethnic hierarchies present in
wider society, and so fails to challenge commissioners and providers to
recognise their contribution to ensuring equitable outcomes. In the
absence of such explicit attention, the advocated scaling up of investment
in interventions that have been shown to serve ethnic groups
differentially can only exacerbate inequality over time.

Understanding and addressing ethnic inequalities in health can not be
portrayed as an additional detail for consideration at either a national
or local level. Rather, sustained attention to ethnic diversity and
inequality must be part-and-parcel of the mainstream health inequalities
agenda. The evident separation between the work of the Equalities and
Human Rights section of the Department of Health and the 'core' health
inequalities work of the Department is illustrative of the way in which
these programmes of work need to become more closely aligned. In this
respect, the Marmot report seems to be a step backwards from the Acheson
report (1988), which gave more considered attention to ethnic health
inequalities.

Furthermore, addressing the health needs of minority ethnic
communities is not just a matter of social justice. The major
contribution of minority ethnic groups to premature mortality in the
'spearhead' areas means that a failure to take their health needs
seriously undermines efforts to meet national targets. Work to reduce
infant mortality in minority ethnic groups, for example, could have the
greatest impact on reducing inequalities linked to socio-economic status
(6).

Yet, while some PCTs are making significant progress towards
understanding and meeting the health needs of their minority ethnic
populations, many more continue to operate in the absence of adequate data
(7) and to commission services without any attention to 'additional
efforts and investments and diversified provisions' (8). A more
mainstreamed approach to ethnic inequalities would likely reap benefits
for many at the lower end of Marmot's social gradient, regardless of their
ethnic identity. Challenging the power imbalances and taken-for-granted
ethnocentric assumptions embedded in much policy and practice would likely
also enhance the appeal and relevance of services to disadvantaged White
British people who can also feel marginalised by policies and services
that seem divorced from the realities of their daily lives.

Hunter at al. are also right to question whether there is sufficient
genuine and sustainable political will to tackle health inequalities.
Their observation that: 'There are few votes in health inequalities' may
not be entirely true given the obvious social injustice associated with
marked socioeconomic differentials in life expectancy – even if the
policies necessary to address such inequalities would be hard to stomach
for those with economic and political power. But it is likely to ring true
when the focus is on ethnic health inequalities. Despite sustained
attention to the 'real and imagined problems' of immigration and ethnic
diversity since the 1960s (9), UK policy has lacked coherence, with
initiatives relating to immigration control and citizenship clashing with
those relating to race equality(10). UK health policy and practice
struggles to reconcile these conflicting messages and fails in
establishing improved services and outcomes for minority ethnic
populations, frequently locating the causes of poor health with those who
are deprived (11).

Though the impact of the Marmot report is uncertain in the face of
economic hardship and political uncertainty, all the major political
parties have, nevertheless, confirmed their commitment to tackling health
inequalities. This being so, it is troubling that such a significant
document has overlooked the importance of ethnic diversity and persistent
racial discrimination in shaping the health outcomes of our population.

Sarah Salway, Reader in Public Health, Sheffield Hallam University;

James Nazroo, Professor of Sociology, University of Manchester;

Ghazala Mir, Senior Research Fellow, University of Leeds;

Gary Craig, Professor, University of Durham;

Mark Johnson, Trustee Afiya Trust and Professor of Diversity in
Health & Social Care, De Montfort University;

Kate Gerrish, Research Professor of Nursing, Sheffield
Hallam University.

References:

(1) Anthias, F. (2001) ‘The concept of ‘social division’ and
theorising social stratification: looking at ethnicity and class’
Sociology 35: 835-54. Eriksen , T.H. (2002) Ethnicity and nationalism:
anthropological perspectives (2nd edition) Pluto: London.

(2) Chandola, T. (2001)'Ethnic and class differences in health in
relation to British South Asians: using new National Statistics Socio-
economic classification' Social Science & Medicine 52: 1285-1296.
Nazroo, J.(1998) 'Genetic, cultural or socio-economic vulnerability?
Explaining ethnic inequalities in health' Sociology of Health &
Illness 20:710-730. Nazroo, J.Y. (2001) Ethnicity, class and health,
London: Policy Studies Institute.

(3) Harris, R., Tobias, M., Jeffreys, M., Waldegrave, K., Karlsen, S.
and Nazroo, J. (2006) ‘Racism and Health: The relationship between
experience of racial discrimination and health in New Zealand’, Social
Science and Medicine, 63, 6, 1428-1441. . Karlsen,S., Nazroo,J. (2004).
Fear of racism and health. Epidemiology and Community Health 58, 1017-
1018. Nazroo, J. (2003) ‘The structuring of ethnic inequalities in health:
economic position, racial discrimination and racism’, American Journal of
Public Health, 93, 2, 277-284. Karlsen, S. and Nazroo, J.Y. (2002) ‘The
relationship between racial discrimination, social class and health among
ethnic minority groups’, American Journal of Public Health, 92, 4, 624-31.

(4) Webb, R. et al. (2004) 'Uptake of cervical screening by ethnicity
and place-of-birth: a population based cross-sectional study' Journal of
Public Health 26(3): 293-296.Szczepura, A. (2005) Access to healthcare for
ethnic minority populations' Postgraduate Medical Journal 81: 141-147.
Crosier A.and McNeill A. (2003) Mapping black and minority ethnic tobacco
prevention resources, Department of Health.

(5) Craig, G. et al. (2007) Sure Start and Black and minority
populations DfES: London.

(6) Department of Health 2007 Review of the Health Inequalities
Infant Mortality PSA Target Department of Health

(7) Raleigh, V.S. (2008) 'Collection of data on ethnic origin in
England' BMJ 337:a1107

(8) The Strategic Review of Health Inequalities in England, section
1.1.5, page 39.

(9) Gouldbourne, H. (1998) Race relations in Britain since 1945
Basingstoke: Macmillan Press Ltd.

(10) Hepple, B. (1992) 'Have twenty-five years of the Race Relations
Acts in Britain been a failure?' in Hepple, B. and Szyszczak (eds.)
Discrimination : the limits of the Law. London: Mansell.

(11) Atkin, K. and Chattoo, S. (2007) ‘The dilemmas of providing
welfare in an ethnically diverse state: seeking reconciliation in the role
of a ‘reflexive practitioner’ Policy & Politics, 35(3):377-93.

Competing interests:
None declared

Evan Lloyd ably describes a successful social intervention with major
multiple health-promoting effects. It is commendable for that reason..
not because it had an effect on 'health inequality'. It is also
commendable because it was more cost-effective than medical methods, and
had beneficial spin-offs for society.

Would we not support the effort whether or not there were other
people in better health ?

The question of where best to direct limited resources thus raises a
moral dilemma - Should we spend money where it will bring the most health
gains per pound, or spend differentially on the least healthy, however
small the benefits - in order to reduce 'health inequality' ?

I believe NICE has declared that the NHS should promote the former.

Competing interests:
None declared