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PUBLIC HEALTH MATTERS |
James Y. Nazroo is with the Department of Epidemiology and Public Health, University College London, England.
Correspondence: Requests for reprints should be sent to James Y. Nazroo, PhD, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Pl, London WC1E 6BT, England (e-mail: j.nazroo{at}public-health.ucl.ac.uk).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSOCIOECONOMIC PATTERNS WITHIN...SOCIOECONOMIC PATTERNING OF...AGE, THE LIFE COURSE,...IMPACT OF RACIAL HARASSMENT...CONCLUSIONReferences |
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Differences in health across ethnic groups have been documented in the United States and the United Kingdom. The extent to which socioeconomic inequalities underlie such differences remains contested, with many instead focusing on cultural or genetic explanations. In both the United States and the United Kingdom, data limitations have greatly hampered investigations of ethnic inequalities in health. Perhaps foremost of these is the inadequate measurement of ethnicity, but also important is the lack of good data on socioeconomic position, particularly data that address life-course issues. Other elements of social disadvantage, particularly experiences of racism, are also neglected.
The author reviews existing evidence and presents new evidence to suggest that social and economic inequalities, underpinned by racism, are fundamental causes of ethnic inequalities in health.
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INTRODUCTION |
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Although there is now substantial data describing differences across ethnic groups, the factors underlying such differences, in particular the role that socioeconomic inequalities may play, remain contested. While in 1845 Engels attributed the poor health and mortality record of Irish people living in England to their poor social circumstances,17 and in 1916 Trask concluded that lower death rates among Whites than Blacks in the United States reflected more favorable social circumstances rather than any inherent differences,18 the role that socioeconomic position may play remains the subject of considerable debate. Some claim that socioeconomic inequalities make a minimal or no contribution to ethnic inequalities in health,19 others suggest that even if they do contribute, the cultural and genetic elements of ethnicity must also play a role,20 and others argue that ethnic inequalities in health are predominantly determined by socioeconomic inequalities.21,22 Given the growing empirical and theoretical sophistication of work on ethnic inequalities in health, it is worrying that crude explanations based on cultural stereotypes and claims of genetic difference persist,23–25 despite a lack of concrete evidence, more than 100 years of research exposing the limitations of the assumptions underlying such explanations,26 and growing evidence that the obvious social and economic inequalities faced by ethnic minority groups are likely to be a fundamental explanation.5,7,15,27–29
In the United Kingdom there has, of course, been a long tradition of investigating socioeconomic inequalities in health. However, in the main this work has not been drawn upon by those investigating ethnic inequalities in health, perhaps as a consequence of Marmot and colleagues’ now classic study of immigrant mortality rates.10 Published shortly after the Black Report had firmly placed inequalities in health on the research agenda,30 this study used a combination of British census and death certificate data to explore the relationship between country of birth and mortality rates. A central finding was that there was no relationship between occupational class and mortality for immigrant groups, even though there was a clear relationship for those born in the United Kingdom. These findings led to the conclusion that differences in socioeconomic position could not explain the higher mortality rates found in some migrant groups in the United Kingdom.10 It was not until 1997 that socioeconomic position reappeared in published national data exploring the relationship between ethnicity and health in the United Kingdom.12,13 But again, conclusions drawn from analysis of immigrant mortality data did not appear to support a socioeconomic explanation,12 although those on morbidity did.13
In the United States, there is also a long tradition of investigating ethnic/racial disparities in health; indeed, and in contrast with the situation in the United Kingdom, in recent decades there has been greater interest in health differences according to "race" than in socioeconomic differentials in health. This is partly due to the limited data on socioeconomic position available in routine US health statistics and the use of race as a surrogate for poverty in many analyses.1 Implicit in this approach is the mistaken assumption that ethnic minority groups in the United States are uniformly disadvantaged and therefore that socioeconomic differentials in health status within ethnic minority groups do not need to be considered. Indeed, until recently there have been few examinations of the socioeconomic stratification of health within ethnic minority groups in the United States.3,8,31 On the other hand, the contribution of socioeconomic factors to, in particular, Black–White health differentials in the United States has been investigated in many studies.2,3,7,32,33 These studies have, however, often been limited by small sample sizes or a reliance on administrative data in which information on factors other than ethnicity and socioeconomic position was not available.
In fact, in both the United States and the United Kingdom, data limitations have greatly hampered investigations of ethnic inequalities in health and how they might be structured by social and economic disadvantages, particularly as obvious data limitations are often ignored by investigators. Perhaps the main limitation is the inadequate measurement of ethnicity in many studies, with the heterogeneity of ethnic groups ignored, observer-assigned ethnicity used instead of self-reported ethnicity, and surrogates such as country of birth used instead of ethnic origin. Also important is the lack of good, or any, data on current socioeconomic position in health studies, let alone data that can deal with changes over the life course and other elements of social disadvantage, such as inequalities related to geography and experiences of racial discrimination and harassment.34
This article illustrates the impact of some of these limitations on how data are interpreted and suggests that social and economic inequalities are fundamental causes of ethnic inequalities in health. It also suggests that an adequate understanding of racism is fundamental to understanding ethnic inequalities in health.
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SOCIOECONOMIC PATTERNS WITHIN ETHNIC GROUPS |
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Figure 1
reports a new analysis of data from the 1999 Health Survey for England.16 (The Health Survey for England is an annual survey commissioned by the UK Department of Health. Interviews are administered to a nationally representative sample identified through a stratified sampling design, which is usually followed by a biomedical assessment. In 1999, the Health Survey for England focused on ethnic minority people.) It shows rates of reporting fair or bad general health for each of the ethnic groups included in the study (in response to a question asking respondents to rate their health as very good, good, fair, bad, or very bad) by household income (equivalized to account for variations in household size and banded into tertiles). As with the US MRFIT all-cause mortality data, there is a clear relationship between reported general health and income for each ethnic group.
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SOCIOECONOMIC PATTERNING OF HEALTH ACROSS ETHNIC GROUPS |
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explores the impact of socioeconomic factors on ethnic differences in reporting fair or bad general health across a range of ethnic groups in the United Kingdom; as in Figure 1
, a new analysis of data from the 1999 Health Survey for England is presented. Once adjustments had been simultaneously made for a variety of socioeconomic indicators (income, housing tenure, economic activity), there is a clear and large reduction in odds ratio for most ethnic minority groups (to give an accurate visual impression of the size of the change in odds, the natural logarithm of the odds ratio compared with that of White English people is used); exceptions are the White minority (predominately Irish) group (which has an odds close to 1) and the Indian group (for whom the reduction in odds ratio is small). Similarly, analysis of the US MRFIT data showed that standardizing for mean household income in area of residence reduced the relative risk for all-cause mortality of Black compared with White men from 1.47 to 1.19; that is, about two thirds of the elevated mortality risk among Black men was statistically explained by this income measure.7 Conversely, adjusting the Black–White mortality differential for a number of medical risk factors (diastolic blood pressure, serum cholesterol, cigarette smoking, existing diabetes, and prior hospitalization for coronary heart disease) only decreased the relative risk from 1.47 to 1.40.7 This demonstrates that socioeconomic position—as indexed by income of area of residence—is a considerably more important determinant of Black–White differentials in mortality in the United States than biological markers of risk and behavioral factors, such as cigarette smoking or diet.
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, which explores the contribution of socioeconomic effects to ethnic inequalities in health for 3 broad ethnic minority groups and 6 different health outcomes. (Data are from the UK Fourth National Survey of Ethnic Minorities, a representative survey of the main ethnic minority groups living in Britain, together with a comparison White sample.35 Topics covered included economic position, education, housing, health, ethnic identity, and experiences of racial harassment and discrimination.) Figure 3 uses the natural logarithm of the relative risk statistic to show how risk of ill health among ethnic minority respondents compared with White respondents changes once socioeconomic position is partially adjusted for use of an indicator of standard of living.15,36 In the figure, a risk equivalent to that for Whites is represented by 0 on the y-axis; a figure above 0 represents a greater risk while a figure below 0 represents a smaller risk. In all cases, the risk for each ethnic minority group compared with Whites is reduced once the socioeconomic control has been applied.
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The implication of this is clear; using either single or crude indicators of socioeconomic position is of little use for "controlling out" the impact of socioeconomic position. Within any given level of a particular socioeconomic measure, the social circumstances of ethnic minority people in the United Kingdom and the United States are less favorable than those of White people. This leads to 2 related problems with approaches that attempt to adjust for socioeconomic effects when making comparisons across ethnic groups. First, if socioeconomic position is simply regarded as a confounding factor that needs to be controlled out to reveal the "true" relationship between ethnicity and health, data will be presented and interpreted once controls have been applied. This will result in the impact of socioeconomic factors becoming obscured, and their explanatory role in determining the health of ethnic minority people will be lost. The second problem is that the presentation of "standardized" data allows the problems with such data13,36–38 to be ignored, leaving both the author and reader to assume that all that is left is an "ethnic/race" effect, be that cultural or genetic.
Nevertheless, if these cautions are considered, there are some benefits in attempting to control for socioeconomic effects. In particular, if controlling for socioeconomic effects alters the pattern of ethnic inequalities in health, despite the limitations of the indicators used, we can conclude that at least some of the differences we have uncovered are a result of a socioeconomic effect. Figures 2 and 3 have suggested that differences in socioeconomic position make a key contribution to ethnic inequalities in health, particularly if we take seriously cautions on the difficulties of making effective adjustments for socioeconomic position.13,36–38 It is also worth emphasizing that the analyses shown here simply reflect current socioeconomic position; data on the life course and on other forms of social disadvantage were not included and are almost never available in existing studies of ethnic inequalities in health.
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AGE, THE LIFE COURSE, AND MIGRATION |
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Evidence from the Fourth National Survey of Ethnic Minorities suggests that ethnic inequalities in health in the United Kingdom increase with age, with relatively small differences at younger ages and larger differences emerging from the mid-30s onwards.15 Variations in ethnic inequalities in health across the life course are also apparent in US data, but these take the opposite form, with an apparent narrowing of differences at old ages (there has been much discussion of possible "cross-over" effects for Black–White differences and how far these might be an artifact of the data).44,45 The interpretation of the contrasting UK and US patterning of ethnic inequalities in health with age is not straightforward, but such data do point to the need for sophisticated approaches to the explanation of ethnic inequality that takes account of life-course issues. In particular, we need to place ethnic inequalities in health within a wide social context. For example, the increasing ethnic inequalities in health with age in the United Kingdom could reflect a number of coexisting explanations, including accumulation of risks over the life course and the long-term consequences of exposure to hazards in early life. In the UK context, the cross-sectional pattern of increasing differences in risk over age could also reflect differences between first- and second-generation migrants, since older people are first-generation migrants and younger people second-generation migrants. This final point is a reminder of the need to be aware of a number of potential effects related to migration.
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IMPACT OF RACIAL HARASSMENT AND DISCRIMINATION ON HEALTH |
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Experiences of racial harassment and discrimination appear to be related to health in the few studies that have been conducted. US studies have shown a relationship between self-reported experiences of racial harassment and a range of health outcomes, including hypertension, psychological distress, poorer self-rated health, and days spent unwell in bed; they have also found that differences in rates of hypertension between Black and White respondents were substantially reduced by taking into account reported experiences of, and responses to, racial harassment.5,27,51,52 In the United Kingdom, analyses of the Fourth National Survey of Ethnic Minorities also suggested a relationship between experiences of racial harassment, perceptions of racial discrimination, and a range of health outcomes across ethnic groups.29,53 Table 1 presents a logistic regression model drawn from these analyses. It shows that reporting experiences of racial harassment and perceiving that employers discriminate against ethnic minority people are independently related to the likelihood of reporting fair or poor health, and that this relationship is independent of socioeconomic effects as indexed by occupational class. This may represent 3 dimensions of social and economic inequality operating simultaneously: economic disadvantage (as measured by occupational class); a sense of being a member of a devalued, low-status group (British employers discriminate); and the personal insult and stress of being a victim of racial harassment.
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CONCLUSION |
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Nevertheless, a large body of convincing evidence now supports the possibility that ethnic inequalities in health are largely a consequence of socioeconomic differentials. This applies in both the United States and the United Kingdom, across a range of ethnic minority groups and outcomes. There is also a growing body of evidence from both countries suggesting that experiences of racial harassment and discrimination, and perceptions of living in a discriminatory society, contribute to ethnic inequalities in health. These findings, however, need to be placed within a wider explanatory framework. There are 2 routes, not mutually exclusive, that can be followed.
First, these findings could be investigated in terms of how they relate to the individual embodiment of social risks. How do such markers of social inequality relate to psychological and biological markers of stress, and how does this translate into disease outcomes? Here, the emphasis is on the causal pathways linking "exposures" to social and economic inequality with disease outcomes. Importantly, the processes involved might vary across ethnic groups, given differences in social context and suggested genetic variations across ethnic groups. For example, from an epidemiological perspective it might be fruitful to explore how social inequality translates into hypertension-related diseases for Black American people in the United States and Black Caribbean people in the United Kingdom but into cardiovascular disease for Pakistani and Bangladeshi people in the United Kingdom.
However, such an approach avoids more fundamental explanations for the health, economic, and social inequalities related to ethnicity. Second, therefore, it is important to consider the centrality of racism to any attempt to explain ethnic inequalities in health. Not only are personal experiences of racism and harassment likely to influence health, but racism as a social force will play a central role in structuring the social and economic disadvantage faced by ethnic minority groups. The socioeconomic differences between ethnic groups should not be considered as somehow autonomous (which is a danger of an approach that attempts to examine the extent to which socioeconomic differentials "explain" ethnic differentials in health). As Oliver and Shapiro demonstrate,40 the socioeconomic disadvantage of Black people in the United States is the outcome of a long history of institutional racism and discrimination that has produced the current levels of disadvantage. Similarly, while the postwar migration of ethnic minority people into the United Kingdom was driven by a shortage of labor, this process and the socioeconomic disadvantage faced by ethnic minority migrants was, and continues to be, structured by a racism that has its roots in colonial history.54,55
It is worth carefully considering the motives for undertaking work on inequalities in health. These motives seem to be related to competing desires to expose the extent and consequences of wider social inequalities and to uncover etiologic processes, and I have argued elsewhere that this focus on etiologic processes has great potential for racializing inequalities in health.56 For studies of inequalities in health to contribute to our understanding of etiology, we need a tight focus on the pathways that lead from social and economic disadvantage to poor health, particularly if we are to meet the requirement that social causes of inequalities in health must be biologically plausible. There is no reason why such pathways should be identical for different health outcomes or for different dimensions of social and economic inequality. However, such a focus on pathways produces an exclusive concern with inequalities in health as an adverse outcome, and how the complex pathways leading to this outcome can be understood and broken. The root cause, wider social inequalities, becomes obscured from view. The policy implications of this are clear: the more difficult and dramatic interventions to address social inequalities can continue to be avoided and public health can focus on improving our understanding of pathways and designing interventions along them. Inequalities in health become a problem requiring technical interventions tailored to individual diseases and individual circumstances; they become a problem for individuals rather than a reflection of social malaise. Williams and colleagues’ comments in this regard are worth citing:
There is a temptation to focus on identified risk factors as the focal point for intervention efforts. In contrast, we indicate that the macrosocial factors and racism are the basic causes of racial differences in health. The risk factors and resources are the surface causes, the current intervening mechanisms. These may change, but as long as the basic causes remain operative, the modification of surface causes alone will only lead to the emergence of new intervening mechanisms to maintain the same outcome.28(p36)
However, understanding how the macrosocial factors indicated by Williams and colleagues operate and designing appropriate policy interventions are by no means straightforward. Certainly, there is a need to recognize the overriding importance of national and historical context on the "making" of ethnic groups, how this is related to economic processes and inequities in economic position, and how this influences the lives of ethnic minority and migrant populations and the disadvantages that they face. Racism can be considered to be fundamentally involved in the structuring of economic, social, and health opportunities for ethnic minority people. At an institutional level, it is clear that discrimination influences the economic opportunities that people have, as well as the quality of health and social services that they receive. In addition, historically racism has fundamentally structured the construction of ethnic minority groups and patterns of migration at both an international level (when, why, and where to) and a national level (which locations, which industries). For example, Fenton,57 building on Eriksen’s work,58 has distinguished 5 types of ethnic-making or migration situations:
While this typology might not be comprehensive, it does point to the different contexts within which ethnicity or race becomes mobilized to form distinct groupings. Implicit is that the differing processes listed will lead to different forms of racialization, of subsequent disadvantage, and to different historical trajectories for the groups concerned. Understanding the process and the context within which it occurs should aid in understanding disadvantage and how it might develop. Understanding how they are related to future trajectories for ethnic minority groups (across generations and cohorts) and individuals (over time) is important to any understanding of ethnic difference, including ethnic inequalities in health, and appropriate policy responses.
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Acknowledgments |
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Footnotes |
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Accepted for publication October 8, 2002.
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References |
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S. Harding, M. Whitrow, M. J Maynard, and A. Teyhan Cohort profile: The DASH (Determinants of Adolescent Social well-being and Health) Study, an ethnically diverse cohort Int. J. Epidemiol., July 30, 2007; (2007) dym094v1. [Full Text] [PDF]
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 J. Lillis and S. C. Hayes Applying Acceptance, Mindfulness, and Values to the Reduction of Prejudice: A Pilot Study Behav Modif, July 1, 2007; 31(4): 389 - 411. [Abstract] [PDF]
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 S. O. Utsey, M. A. Bolden, Y. Lanier, and O. Williams III Examining the Role of Culture-Specific Coping as a Predictor of Resilient Outcomes in African Americans From High-Risk Urban Communities Journal of Black Psychology, February 1, 2007; 33(1): 75 - 93. [Abstract] [PDF]
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 E. Wadsworth, K. Dhillon, C. Shaw, K. Bhui, S. Stansfeld, and A. Smith Racial discrimination, ethnicity and work stress Occup. Med., January 1, 2007; 57(1): 18 - 24. [Abstract] [Full Text] [PDF]
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 S. WAMALA, G. BOSTROM, and K. NYQVIST Perceived discrimination and psychological distress in Sweden The British Journal of Psychiatry, January 1, 2007; 190(1): 75 - 76. [Abstract] [Full Text] [PDF]
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K. Pantzer, L. Rajmil, C. Tebe, F. Codina, V. Serra-Sutton, M. Ferrer, U. Ravens-Sieberer, M.-C. Simeoni, and J. Alonso Health related quality of life in immigrants and native school aged adolescents in Spain. J. Epidemiol. Community Health, August 1, 2006; 60(8): 694 - 698. [Abstract] [Full Text] [PDF]
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