Evidence and policy priorities
There are stark ethnic inequalities in health: Black Caribbean, Pakistani, and Bangladeshi people have between six and nine fewer years of disability-free life expectancy than do White British people
How do we understand this diversity?
Making sense of ethnic inequalities in health – The epidemiological method
‘Epidemiology is the study of the distribution and determinants of disease. The main method of study, particularly for investigating the causes of disease, is to compare populations with different risks of disease. Ethnicity is a variable that is used increasingly to define populations for epidemiological studies.’
Senior and Bhopal (1994)
- But this encourages an unreflexive and uncritical use of the concept of ethnicity. Ethnic groups are treated as pre-constituted entities with pre-specified properties, with an emphasis on the different/exotic.
- Explanations are then ‘read’ from the ethnic and disease categories available in data. The presumed properties of ethnic groups, be they cultural or genetic, become the source of explanation for the disease outcome.
- Rather, we need an approach that pays attention to the processes that lead to the construction and racialisation of ethnic identities, and how these processes shape life chances – what might be called fundamental causes.
Ethnicity, social relationships and social structure
Racial and ethnic groups … are discursive formations, calling into being a language through which differences are accorded social significance, and by which they may be named and explained. What is of importance for social researchers studying race and ethnicity is that such ideas also carry with them material consequences for those who are embraced by them and those who are excluded from them.
The ways in which identities are perceived, valued, mobilised and interacted with are shaped by economic, cultural, legal, political and symbolic resources. Important here is how emotions are attached to symbolic resources, emotions around risk, danger, fear and disgust, which then shape the practices of individuals and institutions. ‘Racial life [is] suffused with shared passions, imageries and fantasies’.
Emirbayer and Desmond 2015
Racism as the fundamental cause
- Racism has its origins in ongoing historically determined systems of domination that serve to marginalise groups on the base of phenotypic, cultural or symbolic characteristics, thereby generating a racialised social order.
- Explanation, then, needs to examine the role of three inter-related dimensions of racism – structural, interpersonal and institutional.
- Structural racism is reflected in disadvantage in access to economic, physical and social resources. This does not have just material implications, but also cultural and ideological dimensions, material inequality justified through symbolic denigration.
- Interpersonal racism (ranging from everyday slights, through discrimination, to verbal and physical aggression) is a form of violence/trauma and emphasises the devalued status of both those who are directly targeted and those who have similarly racialised identities, thereby engendering meaningful psychosocial stress.
- Institutional racism (first coined by Carmichael and Hamilton 1967) is reflected in routine processes and procedures that translate into actions that shape the experiences of racialised groups within these institutions.
- These disadvantages, accumulating across a life course, are the drivers of ethnic inequalities in health outcomes.
Standardising for socioeconomic position:
This reflects both the particular economic location of ethnic minority groups and the multi-dimensional nature of the economic and social inequalities they face, meaning that no realistic statistical adjustment can plausibly simulate randomisation.
Racialised socioeconomic inequalities mean:
- Lower incomes;
- Lower status occupations;
- Poorer employment conditions;
- Higher rates of unemployment and longer periods of unemployment;
- Poorer educational outcomes;
- Concentrated in economically and environmentally depressed areas (but positive effects of ethnic density);
- Housing tenure;
- Poorer quality and more overcrowded accommodation.
- And inequalities that accumulate across the life course and across generations.
Experiences of racism and discrimination:
- One in eight 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 three-quarters 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.
Research across outcomes and contexts consistently shows the adverse impact of racism on health (for example, Wallace et al. 2016
Racism, discrimination and health:
Changes in levels of racism 1993-2009
Institutional racism in health services?
Access to and outcomes of care:
- No inequalities in access to GP services.
- No inequalities in outcomes of care for conditions that are largely managed in primary care settings:
- Hypertension, raised cholesterol and, probably, diabetes.
- The effect of healthcare systems – a health service with universal access and standardised treatment protocols?
- Marked inequalities in access to dental services.
- And marked inequalities in the US insurance based system.
- And institutional racism evident in some areas:
- Some inequalities in access to hospital services.
- Ethnic inequalities in reported levels of satisfaction with care received.
- And, mental illness and psychiatric services …
- Racisms are fundamental drivers of observed ethnic inequalities in health.
- In investigating this, it is important to examine the ways in which structural, interpersonal and institutional racisms operate and constitute one another.
- Structural conditions of socioeconomic disadvantage and interpersonal experiences of racism both create an increased risk of poor health for ethnic minority people.
- They also shape encounters with institutions that have policies and practices that lead to unequal outcomes – education, employment, housing, criminal justice, politics, etc., as well as health and social care.
- Institutional settings represent sites where we see the concentration and mediation of structural forms of disadvantage and interpersonal racism. This is produced via both the unwitting practices and overt agency of individuals operating within particular structural conditions.
- Institutional racism will take different forms, will operate differently, across institutions with a different focus – for example, the functions of institutions dealing with cancer screening compared with those implementing coercive treatments for severe mental illness.
Reflecting on Policy
- There has been little development of policy to specifically address ethnic inequalities in health, only occasional, limited and local intervention, with no real evaluation of the impact of specific or general policy on ethnic inequalities in health.
- For example, a shocking neglect of ethnic inequality in the Marmot Review – assumption that socioeconomic inequalities are unimportant for ethnic inequalities in health, or that general policies to address questions of equity will also address ethnic inequalities.
- But not a policy vacuum, there are clear policies around identity, culture, community, segregation and migration, all of which are likely to negatively impact on ethnic inequalities in health.
- And ethnic minority people have been disproportionately impacted on by public sector retrenchment (austerity measures).
- In fact, the evidence base strongly suggests that policy development should focus on the social and economic inequalities faced by ethnic minority people.
- Need short term policies to address economic inequality (tax, employment, welfare, housing, etc.).
- However, the economic inequalities faced by ethnic minority people cannot be addressed by policies targeted at on average reductions in economic inequalities, because such policies don’t address processes impacting on ethnic minority people – reflected in institutional practices.
- Example: early years investments, which don’t address the emergence and persistence of racial disadvantage in the education system and labour market.
- Example: failure of favoured ‘up-stream’ interventions, such as SureStart, to engage with and meet the needs of ethnic minority groups.
- Example: public sector workers bearing the cost of the recession.
- Example: rise in part-time work and zero hours contracts.
- Rather need long-term policies that promote equitable life chances and that address racism and the marginalisation of ethnic minority people – a focus on institutions, including politics and Government, is crucial.
Institutional reform: an example
- As an employer, the public sector has the opportunity to provide significant leadership.
- For example, in 2017 the NHS directly employed 1.2 million people, indirectly many more, so employment practices within the NHS are able to impact on the labour market nationally and regionally.
- Ethnic minority people are over-represented in the NHS (and public sector) workforce – 22 per cent of NHS staff are not White, compared with 13 per cent of all workers.
- Discussion around public sector employment has focussed on enhancing efficiency by reducing labour costs, consequently opening up opportunities for private investment.
- Instead could use this as an opportunity to implement positive and equitable employment practices, setting a standard: employment rights, holidays, sick leave, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights.
- Such changes are likely to mostly benefit those in lower employment grades and more precarious employment conditions – ethnic minority workers.
- Could also address the marked ethnic inequalities within the public sector workforce – ‘snowy white peaks’ – rethinking institutional structures and practices, and addressihng pay differentials.
- Reforming institutional cultures – the whiteness of institutions – and addressing discrimination and racism in the workplace.
This was presented at our conference Public Health Priorities for Labour