‘‘RACE’, ETHNICITY RACE’, ETHNICITY AND HEALTH: A SOCIOLOGICAL AND HEALTH: A SOCIOLOGICAL

PERSPECTIVEPERSPECTIVE

Lyn GardnerLyn Gardner

INEQUALITIES IN HEALTH INEQUALITIES IN HEALTH

• The NHS was set up to provide The NHS was set up to provide appropriate and appropriate and accessibleaccessible care services to the British population care services to the British population

• In order to do this, those who plan and provide In order to do this, those who plan and provide these services need to these services need to respond to the diversity respond to the diversity of ethnic groupsof ethnic groups which make up the British which make up the British populationpopulation

• Care should be planned and delivered which seeks Care should be planned and delivered which seeks to avoid discrimination and to avoid discrimination and promotes inclusionpromotes inclusion and equality of opportunityand equality of opportunity

• Accordingly, nurses are expected to be Accordingly, nurses are expected to be ‘‘competent to practice in a multi-ethnic competent to practice in a multi-ethnic societysociety’ (Gerrish, Husband and Mackenzie, 1996 – ’ (Gerrish, Husband and Mackenzie, 1996 – ENB funded study into nurse education and ENB funded study into nurse education and ethnically sensitive health care) ethnically sensitive health care)

TERMINOLOGYTERMINOLOGY

• ‘‘Race’Race’ – refers to a person’s biological characteristics such – refers to a person’s biological characteristics such as skin tone as skin tone

• Racial hierarchiesRacial hierarchies – used as a way of dividing people, – used as a way of dividing people, whereby white Europeans are viewed as morally and whereby white Europeans are viewed as morally and intellectually superior to Black and Asian racial groupsintellectually superior to Black and Asian racial groups

• HistoricallyHistorically this argument was used to justify the this argument was used to justify the colonisation colonisation of African and Asian countries by Europeansof African and Asian countries by Europeans

• This This ethnocentricethnocentric, or even supremacist, position is , or even supremacist, position is still still evidentevident in contemporary Western society (see for example in contemporary Western society (see for example extremist views of groups such as the British National Party extremist views of groups such as the British National Party – and elsewhere…) – and elsewhere…)

• The term is The term is highly problematichighly problematic - no scientific evidence - no scientific evidence that humans can be categorised according to different that humans can be categorised according to different races. It is a culturally and historically loaded concept which races. It is a culturally and historically loaded concept which offers offers little, if any, explanatory worthlittle, if any, explanatory worth in any discussion in any discussion

TERMINOLOGY - CONTTERMINOLOGY - CONT

• ‘‘Ethnicity’Ethnicity’ is now the more commonly used term – refers is now the more commonly used term – refers to a person’s culture and sense of to a person’s culture and sense of shared cultural shared cultural identityidentity – it may be seen or felt at a social-psychological – it may be seen or felt at a social-psychological level – a sense of level – a sense of consciousness of kindconsciousness of kind..

• ‘‘It is a form of self-categorisation in which we know It is a form of self-categorisation in which we know ourselves through our shared identity with other members ourselves through our shared identity with other members of that ethnic group’ (Gerrish et al, 1998:19)of that ethnic group’ (Gerrish et al, 1998:19)

• Yet we have Yet we have other social identitiesother social identities (gender, class, age (gender, class, age and so on). and so on).

• Wallman (1986) offers a useful insight in the notion of the Wallman (1986) offers a useful insight in the notion of the situational aspect of ethnicitysituational aspect of ethnicity – it becomes relevant in – it becomes relevant in particular contexts, in particular ways and when we are in particular contexts, in particular ways and when we are in the presence of particular peoplethe presence of particular people

• ‘‘We are not like a stick of rock with our ethnicity We are not like a stick of rock with our ethnicity permanently and continuously stamped through us’ argues permanently and continuously stamped through us’ argues Gerrish et al.Gerrish et al.

TERMINOLOGYTERMINOLOGY

• Black Black – refers to people of African or Afro-– refers to people of African or Afro-Caribbean originCaribbean origin

• AsianAsian – refers to people of Indian, Pakistani – refers to people of Indian, Pakistani and Bangladeshi originand Bangladeshi origin

• ‘‘Black’ has been used to encompass both Black’ has been used to encompass both these groups – these groups – danger of overemphasisingdanger of overemphasising the commonalities between these groupsthe commonalities between these groups

• ‘‘Black’ & ‘Asian’ also run risk of implying that Black’ & ‘Asian’ also run risk of implying that everyone who is Black or Asian forms an everyone who is Black or Asian forms an homogeneous grouphomogeneous group

CULTURAL IDENTITIYCULTURAL IDENTITIY

‘‘Cultural identities come from somewhere, Cultural identities come from somewhere, have histories. But, like everything which have histories. But, like everything which is historical, they undergo constant is historical, they undergo constant transformation. Far from being eternally transformation. Far from being eternally fixed in some essentialised past, they are fixed in some essentialised past, they are subject to the continuous ‘play’ of history, subject to the continuous ‘play’ of history, culture and power’.culture and power’.

Stuart Hall (1990) in Rutherford, J. (ed) Stuart Hall (1990) in Rutherford, J. (ed) Identity: Community, Culture, Difference.Identity: Community, Culture, Difference.

Finders KeepersFinders Keepers

This morning on the way to Charing CrossThis morning on the way to Charing CrossI found a stiff upper lipI found a stiff upper lipLying there on the train seatLying there on the train seatFinders KeepersFinders KeepersI was tempted to screamI was tempted to screamBut something about that stiff upper lipBut something about that stiff upper lipLeft me speechlessLeft me speechlessIt looked so abandoned so unlovedIt looked so abandoned so unlovedLike a frozen gloveLike a frozen gloveNobody bothers to pick up Nobody bothers to pick up I could not bear to hand inI could not bear to hand inThat stiff upper lipThat stiff upper lipTo the Lost and FoundTo the Lost and FoundSo I made a place for itSo I made a place for itIn the lining of my coat pocketIn the lining of my coat pocketAnd I saidAnd I saidCome with me to the Third WorldCome with me to the Third WorldYou go thaw offYou go thaw off

John Agard,John Agard, in Mangoes and Bulletsin Mangoes and Bullets

Not everything is culture…Not everything is culture…

• As Henley and Schott (1999) point out, nurses should be As Henley and Schott (1999) point out, nurses should be aware of people’s social, economic and physical aware of people’s social, economic and physical environments – environments – avoid over-attributing everything to avoid over-attributing everything to culture or ethnicity.culture or ethnicity.

• Nurses also need to look at the Nurses also need to look at the impact of racismimpact of racism and its and its consequencesconsequences

• Gerrish et al warn of the problem of nurses becoming Gerrish et al warn of the problem of nurses becoming ‘cultural tourists’ who seek simply to learn what they can ‘cultural tourists’ who seek simply to learn what they can by locating Lonely Planet guides to the range of different by locating Lonely Planet guides to the range of different ethnic and religious groups – instead of ethnic and religious groups – instead of understanding understanding the people in their care on their own terms.the people in their care on their own terms.

• Indeed, Henley and Schott, among others, provide a guide Indeed, Henley and Schott, among others, provide a guide to a number of religions and cultural groups in their book – to a number of religions and cultural groups in their book – yet they offer a warning in their introduction which ‘strongly yet they offer a warning in their introduction which ‘strongly urges’ the reader not to read these sections in isolation urges’ the reader not to read these sections in isolation from the rest of the book.from the rest of the book.

……other factors impact upon other factors impact upon health too.health too.

• Overall, health statuses of minority ethnic Overall, health statuses of minority ethnic groups in the UK appear to be worse than groups in the UK appear to be worse than the white population (Nazroo, 1997)the white population (Nazroo, 1997)

Evidence of Ethnic Differences Evidence of Ethnic Differences in Mental Health/Illnessin Mental Health/Illness

• Rates for depressive illnesses Rates for depressive illnesses appearappear to be lower for ethnic to be lower for ethnic minorities than for white counterparts minorities than for white counterparts

• Diagnosis of Diagnosis of schizophreniaschizophrenia much higher for people of much higher for people of West Indian originWest Indian origin

• Black people are more likely to admitted to a mental Black people are more likely to admitted to a mental hospital via the hospital via the criminal justice systemcriminal justice system or a compulsory or a compulsory order under the order under the MHAMHA

• Black people are more likely to be given Black people are more likely to be given physical forms of physical forms of treatmenttreatment (medication, ECT for example) rather than be (medication, ECT for example) rather than be offered ‘talk’ therapies/interventionsoffered ‘talk’ therapies/interventions

• It is problematic to take the above at face value – need to It is problematic to take the above at face value – need to explore further and consider impact of cultural differences, explore further and consider impact of cultural differences, ethnocentrism, misdiagnosis and racismethnocentrism, misdiagnosis and racism

Explanations for Health Explanations for Health DifferencesDifferences

• GeneticGenetic

• MigrationMigration

• RacismRacism

• Access to servicesAccess to services

• Materialist explanationsMaterialist explanations

• CultureCulture

GENETIC FACTORSGENETIC FACTORS

Specific genetic factors that are broadly Specific genetic factors that are broadly correlated with ethnic identitiescorrelated with ethnic identities

• Sickle cell anaemia (inherited blood Sickle cell anaemia (inherited blood disorder which affects 1 in 3-400 people of disorder which affects 1 in 3-400 people of African-Caribbean decent)African-Caribbean decent)

• Thalassaemia (inherited blood disorder Thalassaemia (inherited blood disorder affects people of Mediterranean, Middle-affects people of Mediterranean, Middle-Eastern and Asian decent)Eastern and Asian decent)

• Tay-Sachs (degenerative brain disease)Tay-Sachs (degenerative brain disease)

MigrationMigration

Potential negative effects on health:Potential negative effects on health:

• Loss of support networksLoss of support networks

• Stressful situationsStressful situations

• Financial commitmentsFinancial commitments

• Exploitation in labour marketsExploitation in labour markets

RacismRacism

1.1. Racism in health service provision Racism in health service provision delivery – individual/institutionaldelivery – individual/institutional

2.2. Indirect – linked to economic Indirect – linked to economic disadvantagedisadvantage

3.3. Exposure to stressorsExposure to stressors

4.4. Language barriers inadequately/not Language barriers inadequately/not addressedaddressed

Institutional RacismInstitutional Racism

‘‘The collective failure of an organisation to The collective failure of an organisation to provide an appropriate and professional provide an appropriate and professional service to people because of their colour, service to people because of their colour, culture or ethnic origin. It can be seen or culture or ethnic origin. It can be seen or detected in processes, attitudes and detected in processes, attitudes and behaviour which amount to discrimination behaviour which amount to discrimination through unwitting prejudice, ignorance, through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping thoughtlessness and racist stereotyping which disadvantages minority ethnic people’which disadvantages minority ethnic people’

Macpherson, 1999 Macpherson, 1999

Materialist ExplanationsMaterialist Explanations

• People in ethnic minority groups are People in ethnic minority groups are vulnerable to socio-economic disadvantagevulnerable to socio-economic disadvantage

• People from minority ethnic groups are People from minority ethnic groups are more likely to be unemployed, be in low more likely to be unemployed, be in low paid jobs, live in poor housing and in areas paid jobs, live in poor housing and in areas which lack adequate social and educational which lack adequate social and educational resources – ‘Black people share the resources – ‘Black people share the disadvantages of white working-class disadvantages of white working-class people and more.’ (Blackburn, 1991)people and more.’ (Blackburn, 1991)

Cultural FactorsCultural Factors

Nursing/midwifery attempts to Nursing/midwifery attempts to understand the role of culture in understand the role of culture in health have tended to emphasize health have tended to emphasize ‘unusual’ practices which are then ‘unusual’ practices which are then viewed as deviant from the healthy viewed as deviant from the healthy norms of the ethnic majority.norms of the ethnic majority.

Attempts to ‘resocialize–out-of-Attempts to ‘resocialize–out-of-inappropriate-practices’inappropriate-practices’

• Asian Mother & Baby CampaignAsian Mother & Baby Campaign

• Stop Rickets CampaignStop Rickets Campaign

• Campaigns on use of ‘Surma’Campaigns on use of ‘Surma’

• Campaigns against consanguinityCampaigns against consanguinity

Pitfalls with the Cultural Model Pitfalls with the Cultural Model (Ahmad 1996)(Ahmad 1996)

1.1. Attempts to learn ‘cultures’ ignore Attempts to learn ‘cultures’ ignore diversity within cultures and diversity within cultures and similarities between ethnic groupssimilarities between ethnic groups

2.2. Cultures are continually changingCultures are continually changing

3.3. Cross-cut by gender, class and Cross-cut by gender, class and power relationspower relations

4.4. May be a source of nurturing and May be a source of nurturing and strengthstrength

Nurses’ responsibility when Nurses’ responsibility when working with someone whose working with someone whose culture differs from your ownculture differs from your own

• Be aware of your own cultural values and norms and how Be aware of your own cultural values and norms and how these may be affecting your thinking and judgmentsthese may be affecting your thinking and judgments

• Notice any assumptions you are making about the other Notice any assumptions you are making about the other person and try to suspend them (person and try to suspend them (Rogerian concept of Rogerian concept of non-non-judgementalismjudgementalism))

• Listen with respect, set aside any defensiveness, and be Listen with respect, set aside any defensiveness, and be willing to understand this person on their terms (willing to understand this person on their terms (Rogerian Rogerian concept of concept of unconditional positive regardunconditional positive regard))

• Ask them about their needs – they are the expert – and Ask them about their needs – they are the expert – and respond flexibly and sensitivelyrespond flexibly and sensitively

• Accept that cross-cultural encounters can be Accept that cross-cultural encounters can be difficult and difficult and confusingconfusing for both sides ( for both sides (but remember that you are the but remember that you are the service provider and have a duty of careservice provider and have a duty of care))

From Henley and Schott, 1998:21From Henley and Schott, 1998:21NB Additional material in italicsNB Additional material in italics

References & ReadingReferences & ReadingBasic texts on reading list – plus:Basic texts on reading list – plus:

Acheson Report (1998) Acheson Report (1998) Independent Inquiry into Inequalities in HealthIndependent Inquiry into Inequalities in Health. The Stationery Office: . The Stationery Office: London.London.

http://www.official-documents.co.uk/document/doh/ih/ih.htmhttp://www.official-documents.co.uk/document/doh/ih/ih.htm

CAL distance learning pack - CAL distance learning pack - http://http://www.nottingham.ac.uk/~lqzweb/dlp/welcome.htmlwww.nottingham.ac.uk/~lqzweb/dlp/welcome.html

Ahmad (1996) The Trouble with Culture in Kelleher, D. & Hillier, S. Ahmad (1996) The Trouble with Culture in Kelleher, D. & Hillier, S. Researching Cultural Researching Cultural Differences in Health. Differences in Health. Routledge: LondonRoutledge: London

Culley, L. & Dyson, S. (eds) (2001) Culley, L. & Dyson, S. (eds) (2001) Ethnicity & Nursing Practice. Ethnicity & Nursing Practice. Palgrave: Basingstoke.Palgrave: Basingstoke.

Nazroo, J. (1997) Nazroo, J. (1997) The Health of Britain’s Ethnic Minorities.The Health of Britain’s Ethnic Minorities. Policy Studies Institute: London. Policy Studies Institute: London.

Schott, J. & Henley, A. (1996) Schott, J. & Henley, A. (1996) Culture, Religion and Childbearing in a Multiracial Society. Culture, Religion and Childbearing in a Multiracial Society. Butterworth-Heinemann: Oxford.Butterworth-Heinemann: Oxford.

Henley, A. & Schott, J. (1999) Henley, A. & Schott, J. (1999) Culture, religion and patient Care in a Multi-Ethnic Society. Culture, religion and patient Care in a Multi-Ethnic Society. Age Age Concern:London.Concern:London.

Ali, M.Ali, M. (2004) (2004) Brick Lane. Brick Lane. Black Swan: London.Black Swan: London.

Jayaweera, H. et al (2004) A local study of childbearing Bangladeshi women in the UK, Jayaweera, H. et al (2004) A local study of childbearing Bangladeshi women in the UK, Journal of MidwiferyJournal of Midwifery, 9,3., 9,3.

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