ethnic minority health - Though health authorities are doing better than primary care groups, the health needs of people from ethnic minorities are still being neglected by both, argue Mohammed Memon and colleagues

The 1991 census identified more than 3 million people from ethnic minorities - about 6 per cent of the population of England and Wales.

1Many people from ethnic minority groups are socially excluded owing to illness, disability, poverty and racism, and social exclusion can itself contribute to ill-health.

The government has given its commitment to reduce inequalities.

2This includes improving the health of the population as a whole by increasing the length of people's lives and the number of years people spend free from illness; but it also means improving the health of the worst off in society.

The NHS plan pointed out that the 'inverse care law', whereby communities in greatest need were least likely to receive the health services they require, still applies in too many parts of the country.

'Inequity in access to services is not restricted to social class and geography; people in minorityethnic communities are less likely than affluent ones to receive the services they need, ' it said, pointing out that by 2003, reducing inequalities would be a key criterion for allocating NHS resources to different parts of the country. It said that, for the first time, action on tackling health inequalities would be measured and managed through the NHS performance assessment framework.

'The NHS will need to address local inequalities, including issues such as access to services for black and ethnic minority communities, ' it pointed out.

Narrowing the health gap will mean addressing the health inequalities of ethnic minorities because diseases have worse outcomes in these populations.

Ethnic minorities on the whole perceive their health to be worse than that of the general UK population.

3There are particular concerns about the incidence of coronary heart disease and strokes, hypertension, diabetes, mental illness, sickle cell anaemia and thalassaemia and tuberculosis (see panel, page 24).

The authors identified districts of England where a high proportion - 10-45 per cent - of the population were from ethnic minorities. They contacted 20 health authorities and 64 primary care groups in those areas, asking for their annual reports or public health reports. Replies were received from 13 HAs and 22 PCGs (see box 2).

Each annual report was reviewed to identify the healthcare issues of black and ethnic minority populations and what action was being taken to address these. Both HA and PCG reports indicated that the main healthcare issues were:

coronary heart disease;

stroke;

hypertension;

diabetes;

mental health;

sickle cell anaemia and thalassaemia;

tuberculosis;

inequalities in access to healthcare services.

Of the 13 HA reports received, one made no mention of the health of black and ethnic minority populations.

The remaining 12 (92 per cent) identified health issues of black and ethnic minority populations and 10 of these (77 per cent) indicated projects to address these issues.

The most frequently identified concern was the high prevalence of diabetes in black and ethnicminority populations (mentioned in more than two-thirds of reports). But only four (31 per cent) of HAs outlined any initiatives being undertaken in response to this particular concern.

The number of HAs outlining any initiatives was lower than those mentioning the issues.While 92 per cent indicated issues of concern, only 77 per cent of HAs were taking action to address these.

Unfair shares: illness in people from ethnic minorities Coronary heart disease in South Asians and and stroke rates among Afro-Caribbeans are considerably higher than in their European counterparts.

In the UK,30 per cent of middle-aged South Asians and 25-30 per cent of Afro-Caribbeans have been found to have hypertension, compared with the overall national prevalence of 10-20 per cent.Afro-Caribbean men are three to four times more likely to die from illness associated with hypertension than white men, and Afro-Caribbean women are six to seven times more likely to die.The high rates of hypertension also probably contribute to the high incidence of endstage renal failure in ethnic groups.

Diabetes has been reported as being up to 3.8 per cent higher among people of South Asian and African origin in the UK than among the general population.

Research has shown an excess of diagnosed schizophrenia among Britain's black population, ranging from twice to seven times the rate among the white population.Admission rates to psychiatric hospitals for African-Caribbeans are also higher.

Sickle cell anaemia and thalassaemia are genetically determined blood conditions that only affect people of particular ethnic origins.In the UK they are almost specific to black and ethnic-minority communities.Sickle cell disorder mainly affects people from the Caribbean and African populations, whereas beta thalassaemia (the main type of thalassaemia in Britain) affects Asian people from the Mediterranean and Middle East.Between 3-25 per cent of the members of the different black and ethnic-minority groups in the UK are carriers of a thalassaemia or sickling trait.

The relative risk of tuberculosis has been reported to be 10-30 times higher in the population of immigrants from the Indian sub-continent.Groups originating from the Indian subcontinent have notification rates 25-30 times that in the white population.And the rates among West Indians are over four times as high.In the white population poverty is significantly associated with TB, but no such relation exists for those of Asian ethnicity.

For example, while more than half the HAs mentioned inequalities as a cause of concern, only 38 per cent were taking action on the issue.

Only 10 (45 per cent) of the PCGs that responded identified healthcare issues affecting black and ethnic minority populations. Only eight set out action to address these.

Coronary heart disease and diabetes were the most frequently identified healthcare issues, but even these were mentioned in fewer than a third of reports. Six PCGs identified inequalities as an issue and all were taking action to address these.

The healthcare needs of black and ethnic minority groups differ from those of the indigenous population, and healthcare commissioners need to be aware of this difference so that particular needs can be met.

2Inequality can only be addressed if the commissioning bodies all support programmes to promote well-being among the disadvantaged groups of the community.

We recommend that HAs and PCGs with conurbations of ethnic minority populations should state in their annual reports their awareness of the major health issues of these populations. The health experience of ethnic minority populations in the UK differs from the white population in many disease areas, such as diabetes, where the outcomes are worse.

We also recommend that annual reports should include those initiatives that are being taken to tackle the major health issues of ethnic minority populations. This would promote confidence among black and ethnic minority communities.

REFERENCES 1Balarajan R. Ethnic Diversity in England and Wales.An analysis by health authorities based on the 1991 census.

London: NIESH, 1997.

2DoH. Saving Lives, Our Healthier Nation.The Stationery Office, 1999.

3Health Education Authority.

Black and Ethnic Minority Groups in England - Health and Lifestyles. BPC Wheatons Ltd, 1994.

4DoH/ National Statistics.

Health Survey for England:

Health of Minority Ethnic Groups '99. Stationery Office, 2000.

5Memon M, Abbas F.

Reducing health risks in ethnic minorities.Nursing Times 1999; 95 (27): 49-51.

6Cappuccio FP, Cook DG, Atkinson RW, Strazzullo P.

Prevalence, detection and management of cardiovascular risk factors in different ethnic groups in south London.

Heart 1997; 78: 555-563.

Key players: survey participants Primary care groups South Kensington, Chelsea and Westminster City West Leicester Newham West Haringey Sutton Coldfield Brent North North Camden Brent Central Bradford City Edgbaston Ladywood South Lewisham Northfield Harrow West Hyndburn North Lambeth South Lambeth Tower Hamlets North Southwark South Southwark South Brent Harrow East and Kingsbury Health authorities North West Bradford Bedfordshire Leicestershire East Lancashire Ealing Hammersmith and Hounslow Merton, Sutton and Wandsworth Wigan and Bolton Birmingham Camden and Islington Wolverhampton Enfield and Haringey Redbridge and Waltham Forest Dr Mohammed Memon is associate specialist, Guild Community Healthcare trust, and honorary lecturer, postgraduate medical school, University of Central Lancashire, Preston.

Dr Farha Abbas is research co-ordinator, Guild Community Healthcare trust. Dr Iqbal Singh is consultant physician, Queens Park Hospital, Blackburn.

Dr Romesh Gupta is consultant physician, Chorley, South Ribble and Preston Acute Hospitals trust.