Dr Gill's presentation on how inequality creates sick people and sick communities and why migrants particularly are at risk at the conference "Universal Healthcare in the Age of Migration" 2011.

1. How inequality creates sick people and sick communities, and why migrants are particularly at risk RCGP Clinical Champion for Social Inclusion, Clinical Reader in Primary Care Research & GP Primary Care Clinical Sciences [email_address]

4. ‘ If we believe that men have any personal rights at all as human beings, they have an absolute right to such measure of good health as society, and society alone, is able to give them’ Aristotle (> 2000 years ago)

5. Reviews of socially stratified health inequalities 1980 The Black Report drew attention to the marked differences in morbidity and mortality rates between individuals in the top and bottom social groups. 1998 The Acheson Report showed that although these rates had fallen in all social groups, the differences in rates at the top and bottom of the social scale had increased.

6. Inequalities widening

8. 2005 DH Tackling Health Inequalities: A Programme for Action confirmed ‘despite improvements, the gap in health outcomes between those at the top and bottom ends of the social scale remains large and in some areas continues to widen’. 2010 Marmot Review Fair Society , Healthy Lives identified social inequalities as root causes of health inequalities.

12. Migration phases framework

14. Migration to UK Know little about the first people who inhabited Britain except that they were from else where – immigrants ! This is NOT new!

15. Before 1066 1000-150 BC Celts 43-410 AD Romans 800-1000 AD Danes 1066 Normans 1066-1900 1555-1833 Slaves from West Africa 1830-1860 Irish migration 1900 - 1933-45 Refugees from the Third Reich 1948-71 Caribbean 1950-71 West Africa, Hong Kong , ISC 1968-76 East African Asians 1990 - Eastern Europeans, refugees & asylum seekers

16. CHD Breast cancer

17. Muller-Nordhorn, J. et al. Eur Heart J 2008 0:ehm604v2-11 Age-standardized mortality from cardiovascular disease, i.e. ischaemic heart disease and cerebrovascular disease combined, in European regions (men; age group 45-74 years; year 2000)

18. SMR for IHD in men (20-74 yrs) Bangladeshi 151 ( 136-167) Pakistani 148 (138-158) Indian 142 (137-147) Irish 124 (120-127) White 100 Caribbean 62 (58-67) Chinese 44 (36-54) Gill in http://www.hcna.bham.ac.uk/series/bemgframe.htm

19. Possible explanations for the excess CHD risk amongst BMEGs include : possible differential susceptibility to established risk factors ( hypertension , hyperlipidaemia , smoking, diabetes ) along with exposure to “emerging” risk factors (insulin resistance, early life factors, racism , factor X ) and migration

20. BC BA I P B C I General Men 25 21 20 29 40 21 30 24 Women 24 10 5 5 2 8 26 23 Self-reported cigarette smoking status, by minority ethnic group and sex; HSE 2004

23. Societal influences Individual psychology Biology Activity environment Individual activity Food Consumption Food Production

24. Some health care challenges…

25. CHD Prevention options Natural Course of CHD Hanlon, Capewell et al 1997

26. CHD mortality rates started falling long before effective treatments used widely Source:WHO statistics 2005 Men aged 35 - 74, Standardised Per 100,000 USA Goldman & Cook 1984 Annals Int Med 1984; 101: 825) Beaglehole 1986 BMJ 1986 292 33 CABG  Thrombolysis  Statins  New Zealand

27. Studies indicate that approximately 45–75% of the recent fall in CVD deaths in industrialised countries was as a result of prevention activities. Around 25–45% of the decrease was due to treatment. Capewell Heart 2009;94:1105

28. Julian Tudor Hart, Glyncorrwg Disease register, screening and management of CVD

29. Inverse Care Law (1971) The availability of good medical care tends to vary inversely with the need for it in the population served … consultations in deprived areas: time constraints; greater morbidity; less patient enablement; greater practitioner stress RCGP Scotland. Time to Care: Health inequalities, deprivation and General Practice in Scotland

30. Prof Graham Watt ‘In at the Deep End’

31. Secondary Care Pharmacist Primary Care Dentist LA SELF CARE Voluntary sector Social Worker Provision of Health Care 90%

32. Common Barriers to Access Low levels of cultural competency in staff Case complexity, diagnostic and other overshadowing Negative previous experiences of services Health not a priority Communication, language and literacy Inflexible processes, Including registration and Appointment systems Transport and other costs Lack of understanding of ’ system’, rights and responsibilities Discrimination, stigmatisation

39. The Consultations 717 Consultations in English 290 other languages (1 missing data) 57 relative/friend interpreted 6 professional interpreter (5 in same practice!) No relationship between Practitioner characteristics and need for interpreting

40. Language used in consultation (where other than English)

45. THANK YOU