The complex interrelationship between ethnic and socio-economic inequalities in health

Abstract

Ethnicity matters in medicine and public health. Health professionals, both in public health and medicine, should be aware of the influence of ethnicity on health (care) and target health (care) services accordingly. In his paper, Bhopal discusses some of the issues that are relevant to health professionals who want to get familiar with this issue. These include the classification of ethnic groups, the use of ethnicity versus race as a basis for classification of groups and the use of absolute versus relative risks to describe inequalities in health. Bhopal also discusses some of the factors that produce ethnic inequalities in health. If health (care) policy is to respond effectively to these inequalities, we need to have a clear understanding of the factors that account for these inequalities, e.g. the higher burden of diabetes mellitus in immigrant populations with a South Asian background can only effectively be prevented if we have a detailed insight into the factors that are responsible for the increased risks of these groups. Currently, there is a paucity of evidence on these factors and mechanisms, and further research into these issues is warranted. An explanation that gets very little attention in Bhopal’s paper is that from socio-economic factors. Ethnic minority groups, in general, do have a lower socio-economic status than the ‘majority’ population in the host country. Given the well-known association between socio-economic status and health, it is not surprising that ethnic inequalities in health are, to at least some extent, socio-economic in nature. Many empirical studies support this hypothesis. As a general rule, explanation of ethnic inequalities in health should recognize that these inequalities are rooted in socio-economic factors. This is not to say, however, that ethnic inequalities in health can simply be understood by generalizing insights in socio-economic inequalities in health in the ‘majority’ population towards immigrant populations. Instead, we should aim to understand the complex way in which ethnic inequalities are linked up with socio-economic inequalities. The first point to realize is that socio-economic position is a multidimensional concept. It includes key components such as educational level and occupational class, but also employment status, income level and other indicators for material welfare. Different types of socio-economic determinants may be relevant to ethnic minority groups as compared with the majority population. For example, first-generation migrants may be disproportionally affected by lack of formal education. The lack of formal education, together with migrants’ problems of acculturation and integration, may particularly affect their later socio-economic career, including occupational positions, wealth accumulation and residential career. Thus, a ‘false start’ early in the socioeconomic career may affect migrant groups in particular. This implies that, if ethnic inequalities are to be addressed by policies on socio-economic determinants of health, particular emphasis may need to be placed on the root socioeconomic factors shaped in the early life of migrants. Second, the pervading relationship between socioeconomic factors and health (care) may take different forms in different ethnic groups. Recent studies showed that socioeconomic inequalities in health within ethnic minority groups often were smaller (or sometimes larger) than in the total national population. Illustrations for this were provided for example in recent Dutch studies on mortality by cause of death, metabolic syndrome prevalence and hospitalization rates. Such an effect modification has been found to be