Ethnic inequalities in health
James Nazroo
University College London
www.ucl.ac.uk/epidemiology
Why is there an interest in ethnic inequalities in health?

Aetiological investigations

Monitoring

Access to appropriate treatment

Investigating inequalities in health

Concern with ethnic disadvantage, racialisation and social
inequalities: health as a component of wider disadvantage
Reported fair or bad health by ethnic
group and age
Caribbean
Indian
Pakistani
Bangladeshi
Chinese
White minority
White English
100%
80%
60%
40%
20%
0%
2-5
5-9
10-12 13-15 16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-60 61-70
> 70
Health Survey for England 1999
Reported fair or bad health
Age adjusted odds ratio compared with white English
Odds ratio (and 95% C.I.)
4
3.5
3
2.5
2
1.5
1
0.5
Caribbean
Indian
Pakistani
Bangladeshi
Chinese
White
minority
Health Survey for England: Nazroo 2004
Explaining ethnic inequalities in health

Statistical artifact

Migration

Differences in genetic risk

Culture and lifestyle

Material disadvantage

Ecological effects

Racism: exclusion and harassment
Paradigms in research on ethnic differences in health (1)

Un-theorised’ ethnicity

Appears to be empirically driven
 Carries an implicit theory of fixed genetic and cultural difference
 Explanations are often reduced to racialised stereotypes
Avoiding premature coronary deaths in Asians

Asians’ evolutionary history involved adaptation ‘to survive under
conditions of periodic famine’ leading to a high prevalence of insulin
resistance.

Central obesity may also develop as a consequence of lifestyle (culture):
‘a diet rich in saturated fats and energy (including ghee) and a sedentary
lifestyle’.

“Well Asian clinics” should be set up to address the low use of medical
services.

Community leaders should increase awareness of risk factors.

Survivors should relay their experiences to members of their community.

Dietary advice should be given and Asians should be encouraged to
increase regular physical activity.
Gupta et al. 1996
Paradigms in research on ethnic differences in health (2)

Un-theorised’ ethnicity

Appears to be empirically driven
 Carries an implicit theory of fixed genetic and cultural difference
 Explanations are often reduced to racialised stereotypes

Ethnicity as structure

Notions of fixed difference are used to justify exclusionary practices
 Racism
 Socioeconomic disadvantage
Ethnic differences in occupational position
Per cent
Male
employment
rates
Caribbean
Indian
58
69
Pakistani Bangl- Chinese
adeshi
White
White
minority English
59
46
67
72
75
RG class of head of household
I/II
23
36
25
13
45
46
34
IIInm
19
14
14
7
16
14
16
IIIm
27
26
33
39
28
24
30
IV/V
30
24
28
41
11
17
20
Health Survey for England 1999
Ethnic differences in equivalised
household income
Bottom tertile
Middle tertile
Top tertile
100%
80%
60%
90%
40%
69%
20%
48%
45%
41%
27%
31%
White
minority
White
English
0%
Caribbean
Indian
Pakistani Bangladeshi Chinese
Health Survey for England 1999
Experiences of racism and discrimination

One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.
Modood et al. 1997
Experiences of racism and discrimination

One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.

20% of ethnic minority people report being refused a job for racial
reasons, and almost 3/4 of them say it has happened more than once.

20% of ethnic minority people believe that most employers would refuse
somebody a job for racial reasons, only 12% thought no employers
would do this.
Modood et al. 1997
Experiences of racism and discrimination

One in 8 ethnic minority people experience racial harassment in a year.

Repeated racial harassment is a common experience.

25% of ethnic minority people say they are fearful of racial harassment.

20% of ethnic minority people report being refused a job for racial
reasons, and almost 3/4 of them say it has happened more than once.

20% of ethnic minority people believe that most employers would refuse
somebody a job for racial reasons, only 12% thought no employers
would do this.

White people freely report their own prejudice:
 One in four say they are prejudiced against Asian people;
 One in five say they are prejudiced against Caribbean people.
Modood et al. 1997
Equivalised income and fair or bad health
40%
Bottom Tertile
Middle Tertile
Top Tertile
30%
20%
10%
0%
Caribbean
Indian
Pakistani Bangladeshi Chinese
White
minority
White
English
Health Survey for England 1999
Socioeconomic effects and fair or bad health
Ln Odds ratio compared with white English
Not adjusted for socioeconomic effects
Adjusted for socioeconomic effects
1.4
1.2
1
0.8
0.6
0.4
0.2
0
Caribbean
Indian
Pakistani
Bangladeshi
Chinese
White minority
Health Survey for England 1999
Racism, discrimination, occupational class and health
Predicted per cent reporting fair or poor health
50
40
30
20
10
0
None
Verbal
Physical or
property
Racial harassment
No or a
few
Some or
most
Do employers discriminate?
Nonmanual Manual
Class
(Karlsen and Nazroo 2002)
Paradigms in research on ethnic differences in health (3)

Un-theorised’ ethnicity

Appears to be empirically driven
 Carries an implicit theory of fixed genetic and cultural difference
 Explanations are often reduced to racialised stereotypes

Ethnicity as structure

Notions of fixed difference are used to justify exclusionary practices
 Racism
 Socioeconomic disadvantage

Ethnicity as identity

Identification with cultural traditions
 Provides guidelines for action and psychological and material resources
 Both historical and immediate context influence identity – hybrid identities
Tobacco use*
tio
n
sh
la
Iri
pu
po
er
al
an
di
se
G
en
ck
Bl
a
G
en
er
al
po
Ca
rib
pu
l
be
an
at
io
n
Iri
Ch
i
es
hi
Ba
n
gl
ad
ki
st
an
Pa
In
di
be
ne
0
Ch
i
0
es
hi
10
ad
10
i
20
gl
20
Ba
n
30
ki
st
an
30
Women
Pa
40
sh
40
ne
se
50
i
50
an
60
an
60
Ca
rib
ck
Bl
a
Any tobacco product
In
Cigarettes
Men
Health Survey for England 1999
*Use of chewing tobacco products was only asked of the South Asian groups
Typologies of sexual lifestyle
Jamaican
African
South
Asian
Sexual History
Pre-coitarchy
Single mongamy
 since before marriage/outside of marriage
 within marriage
Serial monogamy
 within marriages only
 within and/or outside of marriage
Multiple partnerships/encounters
 interleaved with monogamous relationships
 alongside primary relationships
 no primary/monogamous relationships
ExES: Elam et al. 1999
Women looking after the home
80%
60%
40%
20%
0%
Black
Caribbean
Indian
Pakistani Bangladeshi
Chinese
Irish
General
population
Smoking among South Asian People
35%
30%
Indian
Pakistani
11 years or
older
< 11 years
Female
Non-manual
Male
Manual
Bangladeshi
No FT worker
25%
20%
15%
10%
5%
0%
Family Origin
Age on Migration
Gender
Class
Nazroo 1998
Ethnicity as a social identity
race and ethnicity are intrinsically forms of collective social identity ...
Identity confers a sense of personal location, and provides a stable core
of individuality. But it is also about social relationships ... In exploring the
dynamics of identity, we therefore need to understand the way in which
identity grows out of and is transformed by action and struggle, and to
ask:

Who is constructing the categories and defining the boundaries?

Who is resisting these constructions and definitions?

What are the consequences of being written into or out of particular
categories?

What happens when subordinate groups seek to mobilize along
boundaries drawn for the purposes of domination?

What happens to individuals whose multiple identities may be
fragmented and segmented by category politics?
Solomos 1998
Ethnic making situations

Enslavement of Africans leading to post-slavery societies – post
slavery minorities.

Colonial rule and post-colonial states – indigenous minorities,
urban minorities (migrant worker populations) and ‘multi-cultural’
plural societies.

Western capitalism and the formation of nation states – protonations (people who make a claim to be nations).
Concluding comments

Diversity of experiences across ethnic groups, classes, gender
and generations.

Ethnicity is a form of personal identity.

Ethnicity/race is also an externally imposed identity.

Ethnic identity is historically and socially contingent/constructed.

Central role of social disadvantage in determining the pattern of
ethnic inequalities in health.