This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information
Ethnic minority demography, disease patterns and pathways to care
Section one: Understanding epidemiology and diversity
'Women who teach (nursing) in India must know the languages, the religions, superstitions and customs of the women to be taught... it ought to be a truism to say the very same for England'.
(Florence Nightingale 1894, cited by Dobson 1991 p76)
Introduction to epidemiology
Epidemiology is the science of relating disease patterns to population groups. This may mean finding connections between the places where people live and the diseases from which they suffer, or the ways in which they choose to live, and their health. One of the earliest reported examples of the use of this approach was the work of John Snow, a 19th century doctor who observed that cases of cholera were all concentrated among families who drew their water from the Broad Street pump in London (see Donaldson 2000:105). When he removed the handle from this pump, whose water supply had become polluted, the epidemic came to an end. Similarly, clues to the origin of heart disease were found by studying the way in which Japanese Americans, who had very low rates of death from this cause, began to change as they adopted an ‘American’ diet richer in meat and with less fish, seaweed and rice. The benefits of a ‘Mediterranean’; diet rich in fruit and vegetables and using olive oil rather than animal fats, have become a staple theme of food advertising in Britain, because of the epidemiological evidence.
However, there is more to epidemiology than discovering the causes of ill-health. An understanding of disease patterns, lifestyles and cultures, and of diversity among population groups, is essential for proper management and care of people’s health. Indeed, Ahmad and others have argued very persuasively that research into ethnic diversity, at least until recently, has been of greater benefit to scientists and those working on the health of the majority white population, than it has been in terms of improving the health and health care of people of minority ethnic origin (Ahmad 1991, 1993). It is certainly true that by looking at the different lifestyles of people from a variety of cultural backgrounds we can suggest that these ways of life may provide a degree of protection against certain diseases. One might, for example, note that some religions prohibit the use of tobacco or alcohol. Adherence to a religion may provide a sense of security and help people to meet difficulties with less stress. A vegetarian diet, which is more likely to be found among people whose families belong to certain cultures, can be shown to have its benefits. Equally, people from any of these groups may find it hard to understand why they are given ‘health promotion advice’ which either runs counter to their beliefs (‘eat some more red meat to raise your iron levels’), or which merely tells them not to do something they would never wish to (‘give up smoking’).
The link between health and lifestyle is now quite well known. Equally, it is also common knowledge that environment affects disease patterns. Malaria, a disease transmitted by the bite of the anopheles mosquito, is no longer endemic in Britain and northern Europe as the winters are too cold for the mosquito to survive - although with global warming this may change. However, other diseases such as measles were once only found in northern Europe, and when brought to the Pacific by early European sailors, had a devastating impact on the populations who had no immunity to them. Similarly, migration from one part of the world to another may expose people to other diseases which are little known in their culture, for which they may have no words to describe the symptoms and treatment, or which react with their physiology and diet in unexpected ways. An understanding of the components of ‘ethnicity’ may alert the health care professional to some of these difficulties, and assist in the management of patients from different backgrounds.
There is a well developed literature which has established significant variations in health among migrant and minority ethnic populations. Confusingly, not all research demonstrates the same differences, and there are certain conditions (and services or procedures) where the minority groups are found to show under-representation, and others where there are clear excesses of morbidity, mortality, or treatment. Some difficulties of interpretation arise from differing categories of description - country of birth or ‘origin’ not always being clearly linked with other personal or genetic characteristics, and yet the former is most commonly the only information recorded routinely on medical (or death) files and certificates. These matters are discussed in greater detail below.
Particular attention has been paid to the question of ‘ethnic health’ in Britain since the 1991 report of the Medical Officer of Health (Calman 1992), which drew attention to the facts which had been established, and fitted them into the context of the developing ‘Health of the Nation’ programme (Balarajan & Raleigh 1993). More recently available data have enabled a clearer look at the relationship between ‘ethnic health’ (more properly, minority ethnic health) and the health variations selected for consideration in the Health of the Nation strategy (Balarajan 1995). The current move towards a broader focus on health inequalities and variations has accentuated, rather than reduced, the significance of these findings, while at the same time enabling greater consideration of certain other differences.
Ethnicity and diversity
There are difficulties in using the term ’ethnicity’, and in trying to divide the population of the world into ‘ethnic groups’. Some of these problems are political, since labels have meanings and associations. Others are ‘scientific’, and may depend on your use of science or interpretation of evidence. Traditional anthropology defined four major human races, usually described as ‘Caucasian’ (‘white’ or European), ‘Negroid’ (Black or African), ‘Mongoloid’ (Asian, Chinese or Indic), and ‘Australoid’ (that is, the group of people described as ‘Aboriginal’ to Australia). These terms have largely fallen out of use, although they still are used occasionally. Strictly, we should say that the majority of people from the Indian sub-continent belong to the same ‘race’ (as it used to be defined, in terms of skull shape and hair type) and the same language group (Aryan, Indo-Sanskritic) as the inhabitants of Europe. Indeed, the label ‘Caucasian’ can be argued to be misleading, as the people who actually live in the Caucasus mountains are mostly quite dark-skinned! To try and describe all the inhabitants of Europe as Aryan or Caucasian ignores significant genetic (or heredity-linked) variation within the populations of western Europe. The term is said to have been originated by a German professor of natural history who sought to trace the origins of humanity to the grounding of Noah’s Ark on Mount Ararat in the Caucasus mountains (Spencer, 1996). This might be felt no longer to fit with current science.
Some scientific reports, as recently as 1999, were still using a mixture of the above terms, and the term ‘Europid’ (White Caucasian of European origin) also appears. None of these labels are regarded by most present-day geneticists as being of great scientific validity or practical value. New ways of describing people have developed, with an increasing reliance on concepts of ‘ethnicity’, based on traditions of common descent or intermarriage and shared culture or history. This recognises that, in a world of migration and mixing, cultures and societies are dynamic rather than fixed.
The root of the problem of scientific usage is that the terms used are at present most carefully debated by social scientists, following an agreement under the auspices of the United Nations that the term ‘race’ had no scientific validity. The different words used (Afro-Caribbean, African-Caribbean, etc) have various implications and are claimed or promoted by a variety of schools of thought, and may have political overtones. At the same time, they are also words in ‘common parlance’ and change their meaning with little recourse to formal definitions. There are further international differences - for example, American usage is to refer to ‘race’, defined as ‘Black’ and non-black; and to map across that and categories based on ‘geographies of origin’ (African, American, Pacific Island) the category of ‘Hispanic’, implying a Spanish language and cultural heritage (Hahn & Stroup 1994). Frequently only context (and footnotes in scientific journals) can be relied upon to clarify ‘common sense’ interpretation. However, at the same time, it can be shown that discrimination and aspects of disadvantage, as well as genetically-linked disorders and lifestyle behaviours are closely associated with the groups labelled in these ways: in short, there is little alternative to using a selection of these labels and categories (Bhopal 1997).
UK practice
The original legislation relevant to formal record keeping in Britain was the Race Relations Act 1976, which (Sect 3) defined a ‘racial group’ as ‘a group of persons defined by reference to colour, race, nationality or ethnic or national origins...’, while the scientific concept of ‘race’ had already been officially discredited for several years. ‘Ethnicity’ became more formally defined in UK law by a House of Lords decision (Mandla v Lee 1983) as relating to group with ‘a long shared history and a distinct culture’. Other ‘relevant’ characteristics in defining an ethnic group include ‘a common geographic origin or descent from a small number of common ancestors; a common language; a common literature; a common religion and being a minority within a larger community’. For practical purposes, however, in most arenas of social policy, the ten or so groups identified by the 1991 UK Census have become adopted as the most significant groups.
The Department of Health & NHS guidance, in setting up the requirement that ‘ethnic group’ data be collected on all in-patient episodes, was that these Census categories should be the minimum, but that additional groups might be added if local circumstances required. This was meant to ensure that data collected was compatible with that from national sources and the local authority. In the national Census conducted in 2001, a new set of categories was used, and once the data from that are released, it is expected that people will start to use these new terms.
The following table gives the 'supplied' categories used in the 1991 census and those which were asked in the Census in 2001. It can be seen that there are some differences, but that most of the ‘old’ categories can be located in the new ones. Many people had asked for the inclusion of a ‘mixed’ category, allowing them to recognise both sets of ancestral heritage. For those who actually wrote in ‘Mixed’ in 1991, a special group was created and can be used in analysing the data. The census in 2001 expected to find many more people who wish to describe themselves in this way (since nearly all in 1991 were younger people) and has allowed for this. The ability to self-describe by writing in ‘other background’, is also made clearer. While the 2001 census uses the term ‘Ethnic Group’, it also makes it clear that this is seen as a matter of ‘cultural background’. For Scotland and Northern Ireland, the categories were however closer to those used in 1991 - except that in Northern Ireland there is an additional group: ‘Irish Traveller’ - a group which is recognised by law in the Republic of Ireland.
Table A: Categories of ethnic group recorded in the UK Censuses of 1991 and 2001
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(Note: this table does not show the precise layout of the question, but shows the groups which most people ticked, and the relationship between the categories used in the two census forms). (Adapted from ONS forms: Crown Copyright acknowledged).
In the 2001 census, there was also a question on people’s religious affiliation although it was not compulsory. This is shown below, for information.
Figure I: Question 10 of the 2001 census
10: What is your religion?
- This question is voluntary
- (Tick) one box only
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(Cm 4253, 1999) and Census 2001 England Household Form page 6
Subsequent to the 1991 census, new groups of interest to health policy have emerged, some due to recent refugee movements of population (Kurds, Bosnians etc). These are not recorded in the Census and there are no reliable statistics available on the numbers and locations of refugees and asylum seekers. The questions used in the Census of 2001 do however reflect some changes such as a growing tendency for young people of African-Caribbean origins born in Britain to determine their own identity as ‘Black British’. Similarly, the 2001 census asked people about their religion, which may make it easier to make projections of the numbers of people from the main religious groups, and anticipate the needs they may bring to the health service for religious observance, diet and counselling.
In terms of epidemiological research, the tendency has been to rely upon the commonly recorded variable ‘place of birth’. This information is, for example, normally available on death certificates. Consequently much of the current information on ethnic variation in health relies upon the analyses conducted (see Balarajan et al 1984; Balarajan & Raleigh 1993; Marmot et al 1984) on those data and compared against the denominator of the Census. However, there are clear problems in this, since in 1971 it was estimated that perhaps as many as 10% of those ‘born in India’ were of white ethnic origin, while in 1981 at least 5% of the heads of household (the proxy variable used in that Census) of Asian ethnic origin were UK-born. At the time of the 1991 Census, over half the population in the ‘Black’ categories (54% Black Caribbean, 84% Black Other, and 36% Black African) were UK-born, as were half of those giving their ethnic group as Pakistani, 42% of ‘Indians’ and 37% of ‘Pakistanis’. Clearly, with relatively high birth rates and a youthful age profile, these figures will now have increased to the point that considerably less than 40% of the minority ethnic population can be identified by birthplace - and increasingly few by the birthplace of their parents.
Certain other groups which need to be considered in any discussion of ethnicity and health service costs, are not recorded in any sense either in the census data nor in any other database providing a denominator for epidemiological studies or a basis for estimation of needs in any other sense. These include, in particular, ‘gypsies’ (Roma or travellers - McKee 1997) regarding whose health there is already a considerable lack of knowledge but growing interest (Feder et al 1993). The second, larger and more problematic but less easily defined, is the growing population of refugees and asylum seekers (for a review of the literature on this group, see Johnson & Akinwolere 1997). Both groups place particular demands on the health service, including a necessity of specialist knowledge and peripatetic service provision, as well as having distinctive language and cultural needs and creating problems for administrative record keeping when they have no long-term fixed residential address.
It is also important to note that while the greater proportion of minority ethnic groups are located within urban metropolitan districts, this is certainly not necessarily the case for gypsy groups. The consensus of expert opinion is that most refugees are located in London, with lesser concentrations in other metropolitan areas, most of which may have their own minority ethnic concentrations some of which are able to assist with linguistic or cultural support. However, there is no necessary correlation between these, and many formal refugee resettlement camps were located in places such as Rugby, or on former military bases in the countryside. Recent flows of refugees have included groups (Kurds, Bosnians) for whom there are few ‘traditional’ UK-based communities of settlement, although some such as the Somalis have been able to locate long-established communities in Wales, Merseyside Birmingham and London (amongst others).
It may be clear that there are a number of ways of describing minority ethnic groups, and that all of these have some relevance to the delivery of health care. Figure II shows some of the key factors which contribute to the concept of ethnicity, and which may be used in describing ethnic groups. It can also be seen that these are related to each other, and that many of them have a direct relevance to the health of the individual.
Figure II: key factors which contribute to the concept of ethnicity
Exercise 1.1 Reflection
We have included in the model the category ‘Race’.
Why this might have been written inside ‘Quote’ marks?
Note
This is a shorthand way of dividing the world’s population into a small number of groups, which (as stated earlier) were once thought to have very clearly defined characteristics. While most scientists now do not use the term, it is often used in political speech, or as a way of discriminating against people.
Read the following
The fundamental characteristic of ‘Race’ is that it is inherited as are many other characteristics (such as a tendency to have red hair, or to be at risk of certain diseases). The genetic inheritance of a person is essential to understanding their medical risks but it is also important for their identity. Some ethnic and religious groups (notably Jews and Parsees) will normally only consider children whose mothers were of that faith to be eligible to call themselves members too.
Naturally, in historical times, people tended to marry and have children with others who came from the same area so geographical factors have a strong influence on ethnic identity and also on health risks, and on inherited diseases or genetically linked conditions. They also affect cultural matters, depending on the environmental resources and conditions that obtain in any place so English clothing and traditions are adapted to a fairly rainy, mild climate, for example. However, ‘geography’ often gets confused by historical factors, such as the definition of national boundaries, and the effects of having different citizenship. The origins of Pakistan and Bangladesh (formerly East Pakistan) as homelands for Muslim people of the Indian subcontinent are well known, and have led to the development of distinctive cultural identities in areas such as the Punjab and Bengal, on either side of the borders. When people migrate, they often take and try to retain these familiar elements of their culture in their new homes, at least for some time until they feel secure in their new place. It is, however, very important not to assume that citizenship is the same as geography or country of origin. Many British people have emigrated and become citizens of Australia, Canada, and so on: similarly, people of Indian or Caribbean origin in Britain may well have been born here or adopted British citizenship. Consequently, they have all the rights to equal quality of treatment that go with that legal status.
Exercise 1.2 Group Activity
Thinking point: What sorts of difference might you expect to find in the culture of people living on either side of a national border that has been created in the last 100 years? Think of some examples where a new national boundary has been created in recent times.
What effect might these have on health, health education, or health care?
Suggestions:
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Language and religion are both part of what is sometimes called ‘culture’. Culture really is just a name for the set of rules, traditions or habits which inform how we live, and save us having to think ‘from scratch’ about every choice we might make! Religious rules or traditions may suggest what is seen as appropriate behaviour in many aspects of life. Culture, however, is much more complex it includes local (geographical) traditions, those which come from the history of a group (not just religious traditions) and often many sanitary rules such as eating with the right hand, or washing clothes in a separate basin from that used for preparing food. Post-war migrants to Britain were appalled by the British tradition of milk and bread being delivered and left on the doorstep, which they saw as being very unhygienic maybe they were right! However, that was an urban tradition which grew up when it became impossible for everyone to collect these foods from a local farm or market every day.
Exercise 1.3 Group activity
Make a list of other elements of ‘culture’ that might affect people’s lifestyle choices, or be relevant to their health and to people trying to give them ‘health promotion’ advice.
Suggestions:
-Music and dance
-Clothing
-Attitudes towards sport and exercise
-Diet and food preparation
-Use of rooms in a house for different purposes
-Traditions of washing
-Observance of prayer times and holy days
-Fear of being attacked as an ‘outsider’ (racial harassment)
The ‘minority ethnic population’ of Britain
Demographic details
There are many volumes describing the geography and social/economic condition of the minority ethnic population as it was in 1991. However, most of these are now probably somewhat out of date, although the deprivation and inner-city location described then will have had an impact of the life chances of the present population. In 1991, it was estimated that 5.5% of the population in Great Britain was of Black and minority ethnic group origins (BMEG). This represented 4.5% of all households, since BME households are slightly larger than White households on average. By 1998, the BME proportion is estimated to have risen to about 7.3% (one in 14) of the total population (Scott, 2001). This is still a relatively young population. On the other hand, in 1991 only 1.2% of the BME population was of pensionable age, compared to nearly one in five of the white population, and so there were few households of retired older people from these groups. The 2001 census will show a great change in this pattern.
The basic facts can be briefly summarised:
Geography
Over one in eight of the black and minority ethnic population in 1991 lived in the Greater London area or the west Midlands, with smaller concentrations in other major metropolitan centres such as Manchester, Sheffield, Liverpool and Cardiff. Certain towns such as Leeds and Bradford, despite newspaper coverage, in fact did not have very large populations of minority origins, although those who were living in these towns were often concentrated in small areas, and also suffered from considerable deprivation and racial harassment.
Some towns or metropolitan boroughs became known for local concentrations of people from particular ethnic origins. Relatively large numbers of people from Somali backgrounds were found in Liverpool, Sheffield, Cardiff and Birmingham: more than half the UK population of Bangladeshi origin lived in the ‘East End’ of London, mostly in Tower Hamlets. The Vietnamese population, many of whom had been refugees in the 1960s and 1970s, have mostly moved to live in London, with smaller numbers in towns such as Nottingham and Derby. Similarly, Leicester has become known as a town whose economy has grown since the resettlement of Asian people (many of them Gujerati speakers) seeking asylum from events in East Africa in the 1970s, while Coventry’s Asian population is predominantly Punjabi-speaking. Birmingham has large populations of Punjabi, Pakistani (and/or Kashmiri) background, as well as a significant population of Caribbean background. The largest number of people of West African background are found in south-east London. The majority of people of South Asian origin in the northern towns of Yorkshire and Lancashire are of Pakistani origin, many of their forebears having moved from the Mirpur area of Kashmir. All of these, however, are generalisations!
Demography and household type
The current demography of most minority populations is significantly different from that of the white majority. In particular, they tend to be younger, with more children and fewer people in older age groups. Total population fertility (the numbers of children in a family) has also historically been greater, although this is now changing to resemble more closely the UK average. While among newer migrant groups (including most refugee populations) the sex ratio has been heavily skewed, so that males have outnumbered females, this is no longer true for established populations.
There is a strong stereotype in much existing literature that ‘typical’ minority ethnic households are large, with many children, that ‘West Indian’ or African-Caribbean households frequently have a single (female) parent, and that South Asians prefer to live in ‘extended’ (multi-generational) households. This pattern is changing. For example, as the proportion of older people in the South Asian communities rises, there are increasing numbers of older people living alone, in sheltered accommodation and in flats adjacent to, rather than part of, family homes. This has considerable implications on the potential for informal care provision by members of the family.
Table B: Household Type In 1991
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Source: Owen 1993
Language
The necessity to provide for the needs of people whose first (or only) language is not English (Non-English-speaking background: NESB) has been a major concern for public services (Audit Commission 1994). The main policy problem has been one of identifying the numbers and levels of need associated with different languages Many of the sources of information are old, and much of the research into bilingualism has been more concerned simply to identify and list the numbers of languages represented, particularly among children. There is, also, a constantly changing picture with the migration of new groups, including refugees, and the learning process undergone by settlers. At the same time, those who have acquired English as a second language do age, and may lose their acquired facility. These factors necessitate a constant process of 'ethnic monitoring' if services are to be aware of the current situation.
Some information can be obtained from local studies and from surveys or monitoring conducted by education departments through schools. The national requirement for this was abolished many years ago, but some boroughs have continued the procedure for their own purposes. Other problems arise from the variety of languages spoken by UK residents: the Linguistic Minority Project recorded 87 different home languages spoken in Haringey (Stubbs 1985), the Inner London Education Authority recorded over 100 across London and the London Borough of Tower Hamlets educational strategy group noted that 74 languages were used by pupils in their schools in 1993. Recent data estimates that over three hundred languages are used as ‘mother tongues’ in London (Baker & Eversley 2000). Speaking a language, however, does not always imply literacy in it, nor lack of English. Levels of skills in English also vary, both between people speaking different languages, and also from town to town between people who appear to be of similar ethnic origin.
Best current estimates are that there are more than three million speakers of other languages in England and Wales, but probably only one per cent (300,000) of these have no ability in English. Levels of need for interpretation will be higher in respect of technical language. The majority of NESB people live in the major cities such as London, the West Midlands, Leicester, Cardiff, and Leeds-Bradford, but the needs of the small numbers in more rural areas are no less real, and may indeed present greater problems because of the lack of suitable interpreters and even of relatives and members of their linguistic community living locally. The use of family members and other untrained workers for interpreting is not safe nor desirable, either in health care or even for administrative purposes. Apart from anything else, it risks the rights of the individual to privacy, and may cause important information to be withheld because of personal shame. In America, this has been recognised as a matter of ‘human rights’, and federal government funding for health programmes requires provision to take account of language needs. Clearly, with visual impairment, there may be different issues from the usual run of debates about translation and interpreting - or in relation to availability of large print and Braille texts: there is as far as we can identify, no research on those specific questions (Johnson & Scase 2000).
Religion
Numbers of Muslims in Britain are estimated variously at 1 million and two million: many of these are not members of minority ethnic groups. On the other hand, the PSI study (Modood et al 1997) found that less than five per cent of 'Asian' groups surveyed said they had 'no religion', compared to about a third of the white population. A recent study of ‘second generation’ (British born and/or educated people of minority origin) found that most of these also identified strongly with their parental religions (Purser, Johnson & Orford 2001). Religion is clearly very important to most people from a minority background, and may be a key part of their ethnic identity - although it should be remembered that there are Christians of Pakistani and Bangladeshi origin.
Care must be taken not to assume that such ethnic groups are used as religious labels. About half of the 'Indian' group in the PSI study said they were Sikhs, while a further third were Hindu. About half of those who said they were 'East African Asian' (a group mostly found in certain towns where they settled as refugees) gave their religion as Hindu. Many Vietnamese are members of the Roman Catholic faith, while others are Buddhist (as are many Indians and Chinese, and some Pakistanis).
One of the fastest growing religious groups has been membership of evangelical Protestant churches, many of which have strong associations with African and Caribbean congregations. These are particularly popular among younger people, while many of the older generation are members of the historic churches such as the Church of England, Presbyterian and Methodists.
Exercise 1.4 Group activity
A short quiz on religion and cultural festivals
See how many of the following questions you can answer on your own, in ten minutes. Then try with a friend, or using the library.
1. When is HANNUKAH?
2. If something is HARAM, what does this mean?
3. What would you expect to find, or get, in a LANGAR?
4. When is the Queen’s Birthday Holiday?
5. Why is PRASAD important and to whom?
6. What does a MOHEL do and for which group?
7. What might you do on RAKHSHA BANDHAN?
9. Which side of a CHORTEN or STUPA would you walk?
10. What is the AVE MARIA?
Answers to Exercise 1.4
NB: This task might be used for formative assessment
- Hannukah Jewish Festival celebrating restoration of the Temple 10th-17th December
- Haram Islamic term meaning Not permitted, ritually impure
- Langar The Sikh ‘Free Kitchen’ and food provided for all-comers and the poor.
- Queen’s Birthday an official holiday in Australia etc; Actual Birthday is 21st April, Official Birthday (holiday) around 8th June
- Prasad A holy food (resembling semolina) given at Sikh religious occasions
- Mohel Official who can circumcise Jewish boys
- Raksha Bandhan (spellings vary) Hindu festival when sisters visit their older brother, tie a thread on wrist, and generally affirm family ties, usually around November
- Chorten/Stupa Buddhist monuments should be walked around in clockwise direction
- Ave Maria A religious verse (or MANTRA, in Buddhist terms) recited mostly by Christians of the Roman Catholic tradition.
Geographical distribution
Because of the economic factors which brought the 'first generation' of minority ethnic migrant settlers to Britain, the majority of the present minority population are still located in Greater London, seaports and other metropolitan districts which had a need for their labour power at the time of migration. Over three-quarters are to be found in London and the west Midlands. Significant populations are also found in the former 'mill towns' of Yorkshire and Lancashire, although the economic rationale may no longer exist. However, the minority ethnic population finds it harder, in many cases, to move to other areas. One significant factor has been the existence of racist attacks in areas without a tradition of minority populations, but other issues such as access to religious and social institutions, and indeed the provision of interpreting and 'special needs' facilities, can make it more difficult to move. Economic factors also enter the equation: those who came in the first period after the war were often unable to obtain local authority social housing, and had to invest in inner-city owner occupation. Prices of these properties have not kept pace with the general rise in house values, and thus poverty prevents mobility. Even those who did obtain, and subsequently purchased, 'council housing', may find their homes unsaleable. Early patterns laid down and structured by discrimination, retain their power to determine subsequent outcomes.
See the discussion of the ‘structural dimension’ of ethnicity in section two of the module The Politics of Diversity by Charles Husband.
Socio-economic status and deprivation
It is clear from the geographical distribution that many people from minority backgrounds live in areas of socio-economic as well as environmental deprivation. Social researchers have described a process by which migrants arrive and first live in inner city areas, until they start to obtain educational qualifications and experience, perhaps in the second generation, then move out into more suburban areas. This pattern has not been so clearly followed by post-war British minority ethnic groups. Many of the earlier 'New Commonwealth' migrants were already well qualified (for example, as health service workers); the housing cost trap has kept many of those who were successful from moving out. Data from the Department of Environment's English Housing Survey (DoH, 1996) show the effect on minority families: while about one in five (19%) of the white population live in areas described as 'council estates and low income areas', about two in five (40%) of the Black and Indian groups, and as many as two in three (63%) of the Bangladeshi/Pakistani population live in such areas. On the other hand, nearly a third (31%) of the white population live in areas described as 'Affluent Suburb, Affluent Family, or Rural', compared to only 6% (one in nineteen) of those from Black, Pakistani or Bangladeshi backgrounds, and 14% (one in seven) of those with an Indian origin. It should not be assumed that residence in an area where the majority population is associated with deprivation and low socio-economic status, necessarily predicts low occupational or educational standing among minority people. Many people from more affluent or professional backgrounds also live in these areas because of proximity to valued cultural resources (religious buildings, for example) or because of fear and experience of racial harassment in otherwise 'nicer' areas.
Census and other national survey data provide additional information on other forms of deprivation associated with housing. In particular, minority ethnic groups (particularly those of Pakistani and Bangladeshi origin) are consistently found to be living in conditions of relative overcrowding (measured as more than one person per 'living' room). This is partly due to the larger family sizes since these groups tend to have more children, and are also more likely to be caring for a resident elder family member. Overall, the dependency ratio (relationship between numbers of people of working age and children or retired people) for ethnic minorities shows that there are considerably more children in the minority population (see table C) but rather fewer older dependants. However, black and Asian communities contain very many more young people who are 'looking after' a dependant child or older person. There is some, mostly anecdotal, evidence that there is a degree of shame associated with letting a person with a disability (including frailness due to age) live in sheltered, voluntary or statutory special needs accommodation: this may lead to overcrowding and unsuitable provision when such individuals - including those with visual impairments, share the family home.
Table C: Indicators of potential family stress
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- Percentage of females aged 14-25 who performed this task: Home Office Youth Lifestyle survey (1993)
- Other data from Census and ONS. Pakistani & Bangladeshi combined for information derived from sample survey data.
Other standard measures of deprivation, such as car ownership and tenure, are more problematic to analyse and interpret. The data show that nearly two thirds of Bangladeshi households have no car, compared to only one in three white homes (in 1991): however, Indian households (1/4 with no car) appear to be better off, until one considers the numbers of potential adult users. Census data cannot show the 'need' for a car. Similarly, while two thirds of white families are in owner-occupied housing, this is true of about 80% (four fifths) of South Asian households - except for Bangladeshis (under one in three), and only about 40% of black African-Caribbean households. As suggested earlier, ownership does not necessarily equate to affluence: in general, the prevalence of double glazing, garages, central heating and other such amenities are lower in Asian home owners as well as for Bangladeshis in social rented housing (Housing Association and Local Authority homes).
In terms of employment, minority ethnic groups can be shown fairly consistently to be deprived, even though Indian men are much more likely to be of 'professional or of managerial' status (13% compared to 8% of whites). Black, and Bangladeshi or Pakistani men, are much more likely than whites to be employed in semi or unskilled manual occupations. Further, for the past twenty years, minority ethnic unemployment rates have been consistently double those of their white peers - and those for young people are double the rates of those aged between 25 and 50. Were higher numbers of South Asian (particularly Muslim) females to enter the employment market, these rates might worsen. The rates do not reflect unemployability in terms of qualifications: the PSI study showed that overall, minority ethnic youth were very similar to white youth in their levels of qualification, and more likely to be continuing their education after school age. Black Caribbean-origin men aged 20-24 were more than two and a half times as likely than whites to be in full time post-compulsory education: African-Caribbean and Indian females were rather better qualified than their white peers. Nevertheless, the return for this investment in training was considerably less both in terms of employment rates, and in respect of average earnings (on an per-hour basis).
Many minority ethnic employees work unsocial hours shifts, or longer hours, in order to maintain their incomes. The industrial and occupational sectors in which minority ethnic employees are most likely to be found remain also the less desirable, more insecure, or worst paid. In particular, ethnic minorities are still disproportionately employed in 'service', retail and transport occupations, and within such professions as medicine and nursing, to fill less popular specialities and shifts. These patterns, which were accepted by the immigrant generation as part of the price for the opportunities gained in migration, are still found amongst the UK-born and educated population.
Exercise 1.5 Activity
How much do you know about your local area’s ethnic demography? Compile a short report, drawing out features of importance for local health services.
-How many languages are spoken (in the schools)?
-What is/are the largest minority ethnic groups?
-What birthplaces are represented?
(NB: most people aged under 45 in BME groups will be UK-born what might be the significance of non-UK birth, from the point of view of meeting needs?)
-What is the breakdown of age groups among the minority groups?
- What ‘New’ groups can be identified (e.g. refugees) where are they from?
Hints:
- Visit the website of the regional Public Health Observatory (via www.pho.gov.uk).
- Ask the Director of Public Health (at the strategic health authority or PCT).
- Ask the local Education Authority, Social Services department, Equal Opportunity department of the District Local Authority, or the local Race Equality Council.
- For a formative or summative assessment, this could be made into a project.
Refugees
In mid-2001, there were reported to be nearly 50,000 asylum seekers waiting for a decision whether they might be allowed to stay in Britain. All through the summer of that year, the newspapers carried stories about the numbers of people seeking asylum in Britain and elsewhere in Europe. Over 100 would-be refugees drowned while trying to cross from Africa to Spain. Firsat Dag Yildiz, a young Turkish Kurd who was waiting to hear if he would be allowed to stay in Britain because of the political situation and risk to his life in Turkey, was stabbed to death in a racist attack in Glasgow. The politics of ‘asylum seekers’ seemed to dominate much of the discussion in the media and was an important issue in the General Election.
Britain has attracted people seeking refuge from revolution, persecution and disaster for as long as history can recall. Many people are descended from the Huguenots, who brought their skills in weaving and machinery to Coventry and other towns, when it became impossible for them to worship as Protestant Christians in France. Jews were fleeing from Russia in 1904, and many others fled from the Russian revolution later. Since the end of World War 2, there have been at least five phases of asylum seekers coming to Britain. Immediately after the war, about 300,000 Poles were settled here, including civilians, military personnel, and a group called ‘European Voluntary Workers’ or ‘Displaced Persons’ who had lost their homes, families (and often their citizenship papers) in the aftermath of the war. Many lived for years in former military barracks. In 1972, about 29,000 Ugandan Asians who held British passports fled the tyranny of Idi Amin, and many settled in Leicester or London. In the early 1980s, about 20,000 people were helped to settle in Britain after escaping from Vietnam some of them had been held in camps in Hong Kong, and others were picked up from leaky boats in the China Sea. During the 1990s, there were two programmes to resettle people from Bosnia and Kosova who were displaced during ethnic cleansing and other atrocities following the break-up of the former Yugoslav republic. Some of these have been able to return to their homes, but there continue to be refugees from the Balkans.
Internationally, there has been a marked rise in the numbers of people seeking to leave their homelands and seek asylum, or just the possibility of something like a normal life. During the 1990s, applications for recognition as a refugee in Britain rose from about 4,000 per year (1998) tenfold to nearly 45,000 in 1991, and 75,000 in the year 2000. Similar numbers of people were also asking for refugee status in other European countries such as Sweden, Germany and the Netherlands. Sources of these asylum seeking migrants included Sri Lanka, Afghanistan, Uganda, Sudan, Somalia and Ethiopia, Turkey and Iraq, in all of which there were civil wars or other forms of unrest, persecution and terror. A significant number of Roma (Gipsy) people have tried to leave Eastern Europe, as they feel severely discriminated against in countries such as the Czech republic. A small group of people were also allowed to move to Britain when the volcano in Montserrat erupted and rendered the island uninhabitable.
Definition:
British immigration law recognises three major groups who may be described in popular terms as ‘refugees’:
- Asylum Seekers are those people who ‘have reached the UK and requested asylum under the terms of the 1951 United Nations Convention’ and are awaiting a decision on their request’. Since 1999, they have been the responsibility of the Home Office National Asylum Support Service (NASS) and are generally offered accommodation in a town outside the area of South-East England and London while their case is considered.
- Refugees with Exceptional Leave to Remain (ELR) do not qualify under the UN definition set out in the 1951 Declaration (as ‘having a well-founded fear of persecution’) but are recognised as being in great danger if they return home. They are usually offered ‘temporary protection’ and the right to live here for up to four years.
- Refugees with Indefinite Leave to Remain (ILR) meet the UN terms, and have no time limit on their right to live in Britain. In nearly all respects, their rights are the same as a British passport-holder, and many settle here permanently.
All three of these groups have the full entitlement to NHS treatment available to all legal residents in Britain, and do not have to pay fees or otherwise prove their rights.
Until the start of the dispersal programme run by the Home Office NASS in 2000, most asylum seekers and refugees were likely to settle in London, unless they had relatives in another town, or had been ‘dispersed’ in one of the earlier programmes for Polish, Ugandan Asian, Vietnamese or Yugoslav people. This also meant that most of the specialised services, such as interpreters or skilled counsellors with training in dealing with ‘survivor syndrome’ or the after-effects of torture, were also based in London (Aldous et al 1999). Since 2000, asylum seekers have been dispersed under Home Office programmes to rented housing in towns such as Glasgow, Newcastle, Leicester and Birmingham and or to special ‘camps’ around Britain, often in more rural areas where there are few facilities or members of similar cultural groups for support, and little local knowledge about the needs of such minorities. With dispersal, designed to prevent the housing and health services in London from being over-burdened, it is possible that refugees will be found in any part of the country, and also that they may be the only person from that cultural background in the neighbourhood. This also has implications for health care providers (Audit Commission 2000).
Exercise 1.6 Reflective exercise
1. Imagine that you have 20 minutes before you have to leave your home and flee to another country. What will you take with you (it must all be carried in a small rucksack).
Point for reflection: Did you include your medical records, and those of your family or children?
2. Now, on your own or with a friend (and preferably in a foreign language) try to recall your medical history, including screening, immunisations, and investigations.
The Health needs of refugees
The health problems facing asylum seekers were described in a set of three articles in the BMJ, which are also available on the BMJ.com website. These noted that:
‘many…have difficulty in obtaining health care,… register(ing) with General Practitioners or… health check, screening or immunisation’.
(Burnett & Peel 2001a-c)
A number of clinical indications were given in the second article. Searching the British Nursing Index (BNI 1994-2001/02, RCN Journals 1985-1996 and other nursing journals) using the search term ‘refugee or asylum seeker or victim of torture or displaced person’ generates more than 100 references. A small number describe projects in Britain (sometimes for wider needs including traveller gypsy and homeless people) and many report experiences in refugee camps in former Yugoslavia or Africa. Others report good practice in Canada and other states, while there are many descriptive reports of the cultural aspects of specific groups (notably Cambodians in North America).
Many reports are descriptive of differing clinical pictures, exotic illnesses associated with recent migrants, the consequences of flight, torture and experience of ‘refugee-ism’ (Hauffe & Vaglum 1993). There is a reasonable amount of research-based publication on clinical issues relating to the refugee/asylum seeking communities in Europe, particularly published from Scandinavian and less frequently, Dutch, authors. It is however important to recognise that most refugees are actually very healthy, resourceful and well-educated people: problems often arise some time after their arrival, as they start to rebuild their lives. It is at this point that the health services often fail to meet their needs:
Refugees were infrequent users of emergency services, saw few specialists, missed few appointments … diagnoses of mental disorder were rare ... (but) even when refugees seek medical care … their unique problems are rarely addressed.
(Weinstein et al 2000 :303)
British health research literature has tended to concentrate on questions of access (Jones & Gill 1998, Johnson & Akinwolere 1997, Grant & Deane 1995) or on projects to increase service delivery effectiveness (Hoggart 2000, Wiggs 1994). A smaller number of UK studies have examined the needs of specific groups, notably the Vietnamese (Tang 1994, Lam & Martin 1997, Lam & Green 1994). Most of these studies have been carried out in London, where the great majority of refugees have always been found (Aldous et al 1999). The Vietnamese have also been the subject of research conducted outside London (notably in Nottingham: Woods 1996) but such studies are rare (cf Johnson & Akinwolere 1997). A few studies have examined mental health problems (Brinkman 1998) and there is a growing literature specifically examining the needs of children (Hodes 1998, 2000).
Key findings from Woodhead 2000
- Most asylum seekers and refugees arrive in apparent good health
- An important minority are victims of torture or other trauma
- Health needs are unlikely to emerge until other priorities (e.g. shelter) are met
- GPs may not be aware of prescribing patterns in countries of origin
- Overcrowding and conditions in hostels create health and hygiene problems
- Fear that HIV status may compromise asylum applications leads to concealment
- There is a lack of information on both sides
- Interpretation and Language support is crucial and inadequate
- The voucher system may lead to inadequate nutrition affecting health
- “GP surgeries that offer good and appropriate services to asylum seekers… become well known…This leads to a disproportionate number…using these services and puts pressures on them” (page 4).
Point for reflection: Is it an incentive to be good at delivering a service, if that means everyone wants to come to you for help? Especially if the users then ask you to help in other aspects of their lives for which you are not resourced or trained?
A limited number of more recent publications have begun to provide information for health care professionals about the care needs of refugees and asylum seekers, including those by Levenson and Coker (1999), Pank (2001), and Levenson and Sharma (1999). These all begin by stressing the entitlement of refugees and asylum seekers to treatment including routine health surveillance. Attention is also drawn to less common problems such as female genital mutilation (and the legal position under the Prohibition of Female Circumcision Act 1985).
Exercise 1.7 Group activity
Discuss with a colleague the following Question:
- Are refugees ‘an ethnic minority’?
Point for reflection:
Which of the comments and thoughts outlined above are specific concerns for refugees and asylum seekers, and which might apply to anyone?