Resources - National

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Afghanistan

Laura Jung, Lilly Khorsand, Anita Afzali, Mariam Mariam Dahir, Mohammad Yasir Essar, and Roopa Dhatt (BMJ)

This article from Women in Global Health (WGH) describes the despair experienced by female health workers in Afghanistan at the prospect of Taliban rule and the enormous potential impact their dis-empowerment could have for the people. 

Ayesha Ahmad, Nazanin Rassa, Miriam Orcutt, Karl Blanchet, Mohammad Haqmal (Lancet)

Everyone is struggling to know what can be done to protect millions of people in Afghanistan from impending disaster. This article was published in the Lancet on August 26.   The Trustees of the Global Society on Migration, Ethnicity, Race and Health think it succinctly sets out the scale of the problem and we endorse their six action points. If you agree, please circulate it within your own networks and do whatever you can to help. If you have other suggestions about practical steps that can be taken, please get in touch. 

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Australia

Alex Brown  (Australian Health Review)

In this Policy Perspective, Alex Brown suggests that the  low numbers of Indigenous cases of COVID-19 by mid-2021 is cause for cautious optimism, and did not come about by chance. He argues that the Indigenous response was "swift, decisive, highly professional, deeply empathetic, and culturally appropriate." Nevertheless, deep-seated inequalities remain and it is hard to be optimistic about the future. He concludes "Whilst we dare to dream about a better future for all, there are dark clouds on the horizon. The pandemic has raised the possibility that our children will experience worse health than our generation, and we will witness worsening environmental decline, poverty, inequity, and marginalisation. Unfortunately, there is something all-too-familiar about that."

Luke P Dawson, Luke Burchill, Jessica O’Brien, Diem Dinh, Stephen J Duffy, Dion Stub, Angela Brennan, David Clark, Ernesto Oqueli, Chin Hiew, Melanie Freeman, Christopher M Reid, Andrew E Ajani, on behalf of the Melbourne Interventional Group Investigators. (Lancet Global Health)

In a large study of  patients undergoing percutaneous coronary interventions (PCI) in urban and larger regional centres, 0.4% were recorded as Indigenous Australians. They were on average younger, more often women, and more likely to have comorbidities. Having had PCI, Indigenous Australians had increased risk of mortality and adverse cardiac events compared to non-Indigenous Australians. Clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI.

Alan J Wigg, Sumudu K Narayana, Gunter Hartel, Linda Medlin, Greg Pratt, Elizabeth E. Powell, Paul Clark, Jane Davies, Kirsty Campbell, Maree Toombs, Michael Larkin, Patricia C Valery. (EClinical Medicine)

Compared with non-Indigenous Australians with hepatocellular cancer (HCC), this study found Indigenous Australians with HCC were on average younger at onset. A higher proportion were female, lived in rural areas, had lower socioeconomic status, and had a higher comorbidity burden. They also had  higher prevalences of alcohol misuse, hepatitis B, and diabetes and more frequent presence of multiple HCC cofactors. 

Sue Kildea, Yu Gao, Sophie Hickey, Carmel Nelson, Sue Kruske, Adrian Carson, Jody Currie, Maree Reynolds, Kay Wilson, Kristie Watego, Jo Costello, Yvette Roe  (Lancet Global Health)

This study has shown the clinical effectiveness of the Birthing on Country (BiOC) service, which was co-designed by stakeholders and underpinned by Birthing on Country principles. The widespread scale-up of this new service should be prioritised. Dedicated funding, knowledge translation, and implementation science are needed to ensure all First Nations families can access Birthing on Country services that are adapted for their specific contexts. 

Kevin Williams, Sean Rung, Heather D’Antoine, Bart J. Currie  (Lancet Regional Health - Western Pacific)

The paper describes the  Australian HOT North (Improving Health Outcomes in the Tropical North). This is designed to tackle the increasing urban-rural/remote health divide by focusing on three components of the health research ecosystem-researcher retention and recruitment, researcher-practitioner collaborations, and knowledge transfer by forming cross-jurisdictional and multi-disciplinary networks and delivering on-country knowledge translation.  The aim is to reduce the health inequities between the Aboriginal and Torres Strait Islander people and the non-Indigenous population.

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Canada

This article in the Canadian Family Physician concludes: The COVID-19 pandemic is amplifying structural inequities. Refugees and newcomers require and deserve effective health care and support during this challenging time. It outlines practical approaches and advocacy priorities for providing care in the COVID-19 context.

Amy Hui, Wanda Philips-Beck, Rhonda Campbell, Stephanie Sinclair, Connie Kuzdak, Erin Courchene, Maxine Roulette, Wendy Mousseau, Doloris Beaulieu, Eric Wood, Gloria Munroe, Frances Desjarlais, Sora Ludwig, Brandy Wicklow, Jonathan McGavock, Elizabeth Sellers, Nathan Nickel, Depeng Jiang, Kellie Thiessen, Christy Pylypjuk, Margaret Morris, Garry X. Shen. (EClinical Medicine)

The findings suggest that online prenatal education is feasible and effective for improving the breastfeeding rate and engaging pregnant women to participate in the prenatal program in rural or remote First Nation communities in Canada. The online prenatal education remained active during COVID-19 in the participating communities, which suggests an opportunity to expand online prenatal education in other Indigenous communities.

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Ecuador

Leticia Cuellar, Irene Torres, Ethan Romero-Severson, Riya Mahesh, Nathaniel Ortega, Sarah Pungitore, Nicolas Hengartner and Ruian Ke.(Int J Epidemiology)

This paper shows  that  deaths in Ecuador from 1 January to 23 September 2020 were 71% higher than the expected number in the same period in a typical year. In some provinces, deaths were more than double the expected number. Only 20% of the excess deaths were due to confirmed cases of COVID-19, with the assumption that most if not all of the remainder were unreported cases of COVID-19.  Analysis by ethnicity showed that the highest rates of excess deaths were among Indigenous groups. When analysed by age and sex, young Indigenous women were at much higher risk than women of the same age in other groups.

Germany

Marie Tallarek, Kayvan Bozorgmehr and Jacob Spallek (BMJ Global Health)

This article argues that pre-existing discrimination against asylum seekers and refugees has been exacerbated by COVID-19. "Inclusionary and diversity-sensitive approaches to public health  not only serve human rights but also contribute to better health for everyone."

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Ghana

Jessica Michgelsen, Daniel Boateng, Karlijn A.C. Meeks, Erik Beune, Juliet Addo, Silver Bahendeka, Karien Stronks and Charles Agyemang (Int. J. Environ. Res. Public Health 2021, 18, 2451)

This study concluded that Christian religious Ghanaian men living in Europe seem to have lower CVD risk compared with their non-religious counterparts, while Christian religious women in Ghana appear to have increased CVD risk..

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India

Joshy Jesline, John Romate, Eslavath Rajkumar and Allen Joshua George (Humanities and Social Science Communications).

This powerful report describes the disastrous effects of the 2020 Indian lockdown on several hundred million internal migrants. Damaging consequences reverberate to this day. The authors recommend a relook at national migration policies. 

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Italy

Gianfrancesco Fiorini and eight colleagues, Journal of Public Health Research

This is thought to be the first study describing health conditions among undocumented migrants during the COVID-19 pandemic. The records were examined of 272 undocumented migrants with respiratory symptoms attending a clinic in Milan, Italy. Eighteen were found to have COVID-19 and all had risk factors predisposing them to COVID-19. These results are discussed in the light of the need to provide better healthcare for undocumented migrants.

Leonardo Mammana, Chiara Milani, Paola Bordin, Lorenzo Paglione and Chiara Salvia. (International Journal of Environmental Research and Public Health).

Decentralising health services to the regional level produces variations in healthcare offered to asylum seekers (ASs) across the different Italian regions, even if they are entitled to healthcare through the national health service. This qualitative study mapped the healthcare path and regional policies for ASs upon arrival and identified challenges and best practices in four regions.

Three models of care were found.  Problems encountered included:  fragmentation and barriers to access; a weakness in or lack of governance, with the presence of many actors involved; and variability in the response between regions. The inclusion of ASs in healthcare services requires intersectoral actions, involving healthcare services and other actors within local social structures, in order to add value to local resources and practices, reinforce networks and contribute to social integration.

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Netherlands

This qualitative study with 25 participants found “Migration-related, socio-cultural, and socioeconomic factors shape uptake of COVID-19 preventive measures amongst persons of Ghanaian and Eritrean origin in The Netherlands.” They make a number of practical recommendations aimed at addressing this.

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New Zealand

Michael D Keall, Hope Tupara, Nevil Pierse, Marg Wilkie, Michael G Baker, Philippa Howden-Chapman, Chris Cunningham (Lancet Public Health)

This study aimed to assess the rate of fall injuries at home with and without home modifications in houses with Māori occupants. After adjustment for previous falls and geographical region, there was an estimated 31% reduction in the rate of fall injuries at home per year in households exposed to the intervention compared with those in the control group.

Amanda Kvalsvig, Nick Wilson, Cheryl Davies, Carmen Timu-Parata, Virginia Signal, Michael G. Baker. (Lancet Regional Health - Western Pacific)

Aotearoa New Zealand’s (NZ) initial pandemic response communication and implementation contributed to successful elimination of Covid-19. However,  it no longer aligns well with new evidence and the much more sophisticated response to recent outbreaks, where the aim is to maximise health benefits while minimising social and economic harm. Importantly, several aspects of the Alert Level design and implementation have not worked adequately for Māori, the Indigenous people of Aotearoa NZ. In this proposed revision the authors consider the evolving requirements for the system to address outbreaks before the population is substantially vaccinated and to establish a more sustainable future role in protecting population health.

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Nordic Countries

This report compares policies on education, health and the labour market and their impact on young migrants in Denmark, Norway, Sweden and Finland. It also includes a comparative study of unaccompanied refugee minors in Norway and Sweden. 

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South Africa

Thea de Gruchy, Jo Vearey, Calvin Opiti, Langelihle Mlotshwa, Karima Manji and Johanna Hanefeld. (Globalization and Health)

This pilot project assessed the feasibility of using WhatsApp as a research tool with migrant and mobile populations in South Africa. It showed that  WhatsApp can be used as a tool for data collection with migrant and mobile populations, and has informed the finalisation of a larger study. Key lessons learnt include the importance of research design and processes for participant enrolment, and ensuring that the ethical concerns associated with WhatsApp are addressed.

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Syria

Sharmila Devi (Lancet)

This Lancet World Report provides a timely reminder that the situation in Syria remains dire - due to a conflict lasting 11 years so far, in which Russia has played a leading military role. "A record 14·6 million people (in Syria) are in need of aid this year, an increase from 13·4 million last year, as conflict, economic crisis, and the COVID-19 pandemic takes its toll on the country." Rising food and fuel prices will only worsen the situation. The UNHCR estimates there are around 6.8 million Syrian refugees hosted in 128 countries.

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United Kingdom

Richard Powell,  Chidi Njoku, Ramyia Elangovan, Ganesh Sathyamoorthy, Josephine Ocloo, Sudhin Thayil, Mala Rao. (BMJ)

This article draws attention to the ways in which the health research process in the UK is subject to ethno-racial biases in numerous ways from beginning to end: White dominated research commissioning; under-representation of ethnic minorities in patient participation and public involvement; and racism in academia, the assessment of research excellence and research dissemination.  The authors make a range of proposals on how these can be addressed.  They conclude: “Stakeholders in the UK must change their structures, systems, and processes to reflect the diversity of the population, optimise innovation, and inform inclusive decision making. They must implement a transformative, anti-racist, equity-based research agenda. By committing to this agenda, we can make substantive and permanent change tackling the structural determinants of health inequalities.” 

Olivia Farrant, Sarah Eisen, Chris van Tulleken,  Allison Ward, Nicky Longley (BMJ)

Many asylum seekers in the UK find themselves in a maze of paperwork that can lead to a total absence of healthcare. In this paper, the authors describe Respond, an integrated model of care designed to meet the complex needs of asylum seekers in temporary accommodation. Based in the London Borough of Camden, it begins with primary care registration. At the initial appointment, families are assessed holistically. Investigations follow a protocol and referrals are made to relevant services as required. Currently being evaluated, this model has the potential to be extended to primary care services across the country - and perhaps other countries. 

Office for National Statistics

This article shows that between 2011 and 2014 people of White and Mixed ethnic groups had lower life expectancy at birth than all other ethnic groups, with the Black African group having significantly higher life expectancy than most other groups. It also found the White ethnic group were more likely to die of cancer than their Black or Asian counterparts, while for both sexes, ischaemic heart disease mortality was highest in the Bangladeshi, Pakistani and Indian groups. Further research is required to investigate the reasons for the differences. These results reveal important patterns in life expectancy and mortality by ethnic group which are complex, but consistent with most previous studies.

Office for National Statistics 

This article presents experimental statistics on ethnic differences in leading causes of death in England and Wales, using death registrations linked to self-reported ethnicity from the 2011 Census. The White ethnic group accounted for more than 95% of registered deaths in each of the three-year rolling periods, between 2012 to 2019

In the latest period, 2017 to 2019, the White group had a statistically significantly higher age-standardised mortality rate (ASMR) from all-causes than any other ethnic group and had higher ASMRs than most other ethnic groups for many leading causes of death including dementia and Alzheimer’s disease and a range of common cancer.

Looking at the most common causes of death, ischaemic heart disease featured for all ethnic groups, and the highest ASMRs across time have been in the Bangladeshi, Pakistani and Indian ethnic groups. The White, Mixed, and Black Caribbean ethnic groups had the highest dementia and Alzheimer’s disease ASMRs. 

Lung cancer ASMRs were highest among male Bangladeshi, Mixed, and White ethnic groups, and in female White and Mixed ethnic groups. While not one of the most common causes of death, suicide ASMRs in males were higher in White and Mixed ethnic groups than in other groups, and in females the rate for the Mixed ethnic group was higher than other groups. 

The results reveal important patterns in causes of death between ethnic groups that are complex but consistent with most previous studies; further research is required to investigate the reasons for the differences, with potential explanations including past migration patterns, socio-economic composition of the groups, health-related behaviours, and clinical and biological factors.

Raghib Ali, Veena Raleigh, Azeem Majeed, Kamlesh Khunti, British Medical Journal

This BMJ Editorial comments on the above two reports 

Charlotte Woodhead and 16 colleagues - Ethnicity & Health, DOI: 10.1080/13557858.2021.1936464

This qualitative study explores in detail the range of attitudes towards COVID-19 vaccination in a sample of 25 clinical and management staff of differing ethnic backgrounds, seeking explanations for why some are much more hesitant about accepting the vaccine than others. (A summary of the study for non-professional readership can be found HERE ).

Mathur R et al, Lancet

This large study found that some minority ethnic populations in England have excess risks of testing positive for SARS-CoV-2 and of adverse COVID-19 outcomes compared with the White population, even after accounting for differences in sociodemographic, clinical, and household characteristics. Causes are likely to be multifactorial, and delineating the exact mechanisms is crucial. Tackling ethnic inequalities will require action across many fronts, including reducing structural inequalities, addressing barriers to equitable care, and improving uptake of testing and vaccination.

Raghib Ali, Avirup Chowdhury, Nita Forouhi, Nick Wareham. MRC Epidemiology Unit, University of Cambridge.

This report provides much of the detail that contributed to the Health Chapter of the Commission report. It draws heavily on work carried out by the Office of National Statistics (ONS) and the Scottish Health and Ethnicity Linkage Study. It examines the relationships between health, ethnicity and socio-economic circumstances, and demonstrates that, as the analysis by ethnic group and by disease or health condition becomes more detailed e.g. from South Asian to Indian, Pakistani and Bangladeshi or from overall mortality to heart disease and cancer types, so a more complex picture of advantage and disadvantage emerges. 

This wide-ranging report from 10 Government-appointed commissioners, all but one of whom has an ethnic minority background, has generated huge controversy. While acknowledging that racism and ethnic inequalities persist, it argues that considerable progress has been made in recent decades. In particular, it demonstrates the complexity of the variations in health, with some ethnic minorities faring better than the White majority in overall life-expectancy and pointing out, for example, that the White majority has the highest death rates due to 9 of the 11 most common forms of cancer.

Razai M, Kankam HKN, Majeed A, Esmail A, Williams D. ,British Medical Journal

The authors argue that although socioeconomic status partly explains ethnic disparities seen with covid-19, cultural and structural racism also adversely affect health.

Laurence Gruer and 10 colleagues, Journal of Public Health

This is the last analysis from Phase 4 of the Scottish Health and Ethnicity Linkage Study (SHELS). It examines rates of hospitalisations and deaths related to all infections and 15 different infection categories. It also looks at ethnic differences for serological diagnoses of HIV, HBV and HBC. The study demonstrates very varied, and sometimes enormous, ethnic differences, pointing to a complex mix of causative factors. The paper also provides a useful context for the recent findings of  higher rates of morbidity and mortality due to COVID-19 among some ethnic minorities in the UK.

Emma M. Davidson, Anne Douglas, Nazmy Villarroel, Katy Dimmock, Dermot Gorman, Raj S. Bhopal.

Journal of Public Health

This article describes how the National Health Service in Lothian (the region in Scotland, UK, that includes Edinburgh) succeeded in increasing the recording of the ethnicity of patients attending hospital from 3% to 90% in three years. The focus is on attendances for Accidents and Emergencies.  This is an impressive achievement. However, another recent article from Scotland (below December 2019) shows that even if ethnicity recording rates are relatively high, they may not be enough to enable reliable comparisons between ethnic groups to be made.

Christine Campbell, Anne Douglas, Linda Williams, Geneviève Cezard, David H Brewster, Duncan Buchanan, Kathryn Robb, Greig Stanners, David Weller, Robert JC Steele, Markus Steiner, Raj Bhopal. (BMJ Open)

This study found important variations in uptake of bowel cancer screening by ethnic group and religion in Scotland, for both sexes, that require further research and targeted interventions.

S. Knox, RS. Bhopal, CS. Thomson, A. Millard, A. Fraser, L. Gruer, D. Buchanan

Journal of Public Health

This article analyses in-patient rates by ethnicity in Scottish Hospitals in 2013.  It reports that the completeness of ethnicity coding on hospital admission records was 76%, a marked improvement since 2010. However, the validity of admission rates based on these data was variable across ethnic groups and further improvements are required to support monitoring of inequality.

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United States of America

Alan Weil, editor. (Health Affairs)

The American journal Health Affairs has devoted its entire February 2022 issue to the topic of racism and health in the US. The 22 Open Access articles include 11 overview and analysis papers and nine presenting original research.  While most focus on the African American experience, there are also contributions analysing the ongoing stereotyping and disadvantage affecting Native Americans and people of Asian origin.

Linked to this special issue is an interview with the eminent writer and medical ethicist, Harriet Washington, author of the influential book Medical Apartheid. You can watch it at: https://www.youtube.com/watch?v=YVPFUlRAgUU

In this news release, the APA acknowledges failures, accepts responsibility, pledges change for psychology.

GBD 2019 Police Violence US Subnational Collaborators, Lancet 

This landmark study estimates that 30,800 people died in the USA as a result of police violence in the 40 years 1980-2019 – more than twice as many as officially reported.  Age standardised rates were much higher among Blacks and Hispanics than Whites and varied greatly between states.

Editorial, Lancet 

This editorial, accompanying the above article, argues that a lack of accurate data has  been one of the major impediments to adopting a public health approach to deaths caused by police violence. Complete and accurate recording of cases, including the victim's race/ethnicity, is essential if the true extent and nature of the problem are to be seen and preventive measures taken. 

The US Centers for Disease Control and Prevention (CDC) have used Covid-19 to justify using a public health law facilitating the deportation of migrants arriving in the US from Mexico. Read here why Jamille Tellez Lieberman and Joe Amon think this is unjustified and harmful. 

M Lazo and colleagues, Drexel University.

Latino communities in Philadelphia have been disproportionately affected by both the public health and the social components of this pandemic. The Latino population of Philadelphia has seen some of the highest incidence, hospitalization, and mortality rates of all racial/ethnic groups in the city, and have had the lowest rates of testing. The Philadelphia Department of Public Health, together with multiple partners of the community responded decisively and earnestly to address the needs of the Latino population. However, disparities have remained which suggest that additional efforts will be needed to address the fundamental drivers of differential exposures and vulnerability levels.

This is a  complex, well-organised  website providing a wealth of quantitative data from twelve of  largest US cities, comparing cities, ethnic/racial groups within cities, neighbourhoods etc. Inequities abound in every dimension, showing in particular the way in which African American and Latinx/Hispanic communities have faired least well in the pandemic, but to a varying extent in different cities.

This is a collaboration between the Covid Tracking Project and the Boston University Center for Antiracism Research. It provides constantly updated data on Covid-19 cases and deaths by race and ethnicity in most US states and territories. 

This web encyclopaedia offers numerous articles about racism and health in the United States. It has a section devoted to Covid-19, including a link to the Covid Racial Data Tracker.

This report by the American Medical Association focuses on Latinx/Hispanic communities, who make up 18% of the US population but have had 33% of Covid-19 cases. It draws on information provided by 30-45 minute interviews with 16 people with knowledge and experience of how pre-existing circumstances have combined with the pandemic to impact on  Latinx communities. While arguably from too narrow a range of  spokespersons to give a complete picture, nevertheless the report achieves its aim of  providing "guidance in identifying and understanding the vulnerabilities, needs and opportunities present in the Latinx community in order to allow physicians, essential health care workers and health care organizations to serve this community in a more equitable manner."

Dolores Acevedo-Garcia and nine colleagues, Health Affairs

This study uses a composite metric to assess the neighbourhood conditions that children experience today across the US. Overall, the Child Opportunity Score for White children (73) was much higher than for Black (24) and Hispanic (33) children.  The authors conclude that to improve children’s health and well-being, the health sector must move beyond a focus on treating disease or modifying individual behaviour to a broader focus on neighbourhood conditions.

S Barber and colleagues, Drexel University

Racially segregated communities in Philadelphia are being disproportionately impacted by the COVID-19 pandemic. Neighborhoods with the highest levels of residential segregation are more likely to have structural characteristics that increase likelihood of exposure, community transmission, and mortality, making segregation a fundamental driver of racial inequities in the city. These findings have implications for both short- and long-term multi-sectoral solutions to mitigate inequities.