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Rapid response to:


How can we make better use of ethnicity data to improve healthcare services?

BMJ 2023; 380 doi: (Published 30 March 2023) Cite this as: BMJ 2023;380:p744

Linked Feature

Ethnic inequalities in health and care show diversity in need and disadvantage

Rapid Response:

Making better use of ethnicity data to reduce inequality: intervention examples using a chaos, complexity and complex systems approach

Dear Editor

Martin, Mathur and Naqvi ask how can we make better use of ethnicity data to improve healthcare services? (1). They state that “to date, however, we have been more successful in using data to identify and understand inequalities than to reduce them” (1).

An experience using ethnicity data to reduce inequalities is reported, with a complexity/complex systems approach to make better use of such data (2). A suggestion was made to use a similar complexity/complex systems approach for cancer data in a BMJ 2022 Rapid Response (3).

Ethnicity data on heart disease in South Asians, reported first from Singapore by Danaraj in 1959 and Muir in 1960, and by Balarajan, McKeigue and many others in the UK and across the South Asian/Indian diaspora since, consistently show excess and premature heart disease and diabetes, with increased mortality (4).

After observing this in Toronto and Canada in the 1990s, we collected ethnicity data, which was used as evidence and inspiration for a multi pronged awareness, advocacy and health promotion campaign, with many similar initiatives independently globally.

A novel complexity approach was used to understand the complex dynamics involved and needed in this complex intervention by an interdisciplinary network of health professionals and the community. It included raising awareness and actions at multiple levels locally and globally, achieving individual, population and system change and inspiring further research. The interaction of ethnicity and health is complex, changing, and different in time and place, but with similar patterns emerging, which intervention and assessment should also reflect.

This experience was reported as a book chapter “Using complexity science in community health promotion” for Radcliffe Medical Press “Complexity in Healthcare Organization: a view from the street” (2), and as an example of the use of complexity thinking in “Chaos 2000 a new science for nursing for a new millennium,” among other publications.

Outcomes were not measured, being difficult to attribute direct causation in complex systems. There are, however many individual, community, system and policy changes and publications after interventions that should help to reduce inequality and inspire further interventions and research.

Policymakers and those involved in collecting ethnicity data, can be assured of the immense value of their work, not only in reducing inequality, but in helping to understand complexity in healthcare, and as a model for achieving change, which can be translated to other complex 21st century challenges and crises like the pandemic, the economy, climate change, planetary health, etc. (5).

1. Martin G, Mathur R, Naqvi H. How can we make better use of ethnicity data to improve healthcare services? BMJ 2023; 380 doi: (Published 30 March 2023)Cite this as: BMJ 2023;380:p744
2. Rambihar VS. Using complexity science in community health promotion, in “Complexity in Healthcare Organization: a view from the street. Radcliffe Medical Press 2004. Oxford
3. Rambihar VS. Rethink Cancer with data, and chaos, complexity and complex systems, the science for weather, climate change and the Covid-19 pandemic. Rapid response BMJ
4. Rambihar VS, Rambihar SP, Rambihar VS Jr. Race and Ethnicity: a challenge for cardiology for the 21st century. Am Heart J. 2010 Jan;159(1):1-14. doi: 10.1016/j.ahj.2009.10.020
5. Rambihar VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada. (accessed 11th April 2023).

Competing interests: No competing interests

12 April 2023
Vivian S Rambihar
Adjunct Assistant Professor of Medicine, University of Toronto