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2.3 Health inequalities

Health inequalities, in relation to social class, exist in all western European countries, though the causes of death differ between countries (Mackenbach, Bakker, Kunst et al, 2002; Menke, Streich, Rössler et al, 2003). Kunst et al (1998) found higher mortality in manual classes than non-manual classes in 11 Western European countries and while the causes of mortality differ among the countries, the lower mortality rates of people in higher occupational classes is independent of the specific diseases and risk factors involved. Moreover, Brunner and Marmot (1999) have drawn attention to research that demonstrates the absence of a clear distinction between ‘privileged’ and ‘underprivileged’ people in terms of health status and the presence of a gradient with increasing morbidity and mortality with declining socio-economic status.

It is known that rates of ill-health and mortality among minority ethnic groups differ from those of majority populations, and differences exist between the ethnic groups. Diseases of minority ethnic populations do not differ fundamentally from those faced by majority populations. Cardio-vascular disease is a leading cause of death in both developed and developing countries, with marked variations between populations. One early and important study in Britain (Balarajan and Soni Raleigh, 1993) identified the biggest difference in health and illness in relation to coronary heart disease; mortality from coronary heart disease (CHD) being higher among people born in the Indian sub-continent than among the white population and also than other minority ethnic groups. However, later studies (Balarajan, 1996; Bhopal et al, 1999) were able to demonstrate that grouping disparate ethnic groups under one heading can be misleading. When people born in the Indian sub-continent were identified in separate groupings it was found that mortality from CHD was highest among Bangladeshis, followed by Pakistanis, and then Indians. There is a tendency for Indians to enjoy a better socio-economic profile than Pakistanis and Bangladeshis, leading Balarajan to suggest social class as a mediating factor among the determinants of CHD.

Following migration to Europe and North America after the second world war, there has been an assumption that immigrants are always at a health disadvantage, and are importers of disease (Marks and Warboys, 1997). The picture in relation to the effects of migration on health lacks clarity. Mortality rates of migrants are often compared to those in their countries of origin, or to those of the host society. Evidence suggests that following migration, migrants’ mortality rates either stay the same, increase or decrease, in relation to mortality rates in their home countries (McKay, Macintyre and Ellaway, 2003). Mortality rates may also be influenced by the selective nature of migration; whether people with good or poor health migrate. Migrants may be ‘positively’ selected for health, for example, when healthy and ambitious people move to another country in order to improve their job prospects, or ‘negatively’ selected when, for example, poor countries or communities are unable to adequately support members with poor physical or mental health (Smaje, 1996). Mortality rates can also be affected by conditions in the countries of origin, conditions in the host country, access to health services, individual behaviours and whether migration is voluntary or involuntary.

A similar mixed picture exists concerning mental health; migration does not necessarily cause mental illness, but migrants may find the experience of migration stressful and will benefit from social support from both the already established migrant community and from the host community (Beiser, 1991; Baker, Arseneault and Gallant, 1994; McKay et al, 2003). Migration from one culture to another, for whatever reason, may result in cultural bereavement, especially for involuntary migrants such as refugees and asylum seekers. Cultural bereavement is defined as:
“Grieving for the loss of all the familiar cultural reference points that defined who they were and how they were to live their lives.” (Helman, 2000, p214)

The evidence relating to migrants’ health thus suggests that there are many factors involved and any individual’s health will be affected by his/her particular situation though involuntary migration, experienced by refugees and asylum seekers, is known to be more stressful than voluntary migration (Harrell-Bond, 2000). Migrants’ health will, no doubt, also vary depending on the stage at which it is measured or investigated. Menke et al (2003) conclude that across Europe, compared to citizens, the conditions of life are unsatisfactory for most migrants and these are not conducive to good health. Most migrants in Europe experience low-paid work, which is further characterised by unfavourable working conditions, together with poor housing. These factors generally place migrants in low socio-economic positions.

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A key document concerning general health inequalities is:

Commission on Social Determinants of Health (2008) Closing the gap in a generation. Health equity through action on the social determinants of health. Geneva: WHO

See also: Search for Migration and Health


Baker, C., Arseneault, A. M. and Gallant, G. (1994) Resettlement without the support of an ethnocultural community. Journal of Advanced Nursing, 20, pp1064-1072

Balarajan, R. and Soni Raleigh, V. (1993) Ethnicity and health. A guide for the NHS. London: Department of Health

Balarajan, R. (1996) Ethnicity and variations in mortality from coronary heart disease. Health Trends, 28(2), pp45-51

Bhopal, R., Unwin, N., White, M., Yallop, J., Walker, L., Alberti, K. G. M. M., Harland, J., Patel, S., Ahmad, N., Turner, C., Watson, B., Kaur, D., Kulkarni, A., Laker, M. and Tavridou, A. (1999) Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study. British Medical Journal, 319, pp215-220

Brunner, E. and Marmot, M. (1999) Social organization, stress, and health. IN M. Marmot and R. G. Wilkinson (Eds.) Social determinants of health. Oxford: Oxford University Press

Harrell-Bond, B. (2000) Foreword. IN F. L. Ahearn, Jr. (Ed.) Psychosocial wellness of refugees. Issues in qualitative and quantitative research. Studies in Forced Migration Vol. 7. Oxford: Berghahn Books

Kunst, A. E., Groenhof, F., Mackenbach, J. P. and the EU Working Group on Socioeconomic Inequalities in Health (1998) Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. British Medical Journal, 316, pp1636-1642

Mackenbach, J. P., Bakker, M. J., Kunst, A. E. and Diderichsen, F. (2002) Socioeconomic inequalities in health in Europe: An overview. IN J. Mackenbach and M. Bakker (Eds.) Reducing inequalities in health. A European perspective. London: Routledge

Marks, L. and Warboys, M. (1997) Introduction. IN L. Marks and M. Warboys (Eds.) Migrants, minorities and health. Historical and contemporary studies. London: Routledge

McKay, L., Macintyre, S. and Ellaway, A. (2003) Migration and health: A review of the international literature. Glasgow: Medical Research Council Social and Public Health Sciences Unit

Menke, R., Streigh, W., Rössler and Brand, H. (2003) Report on socio-economic differences in health indicators in Europe. Health inequalities in Europe and the situation of disadvantaged groups. Bielefeld: Institute for Public Health NRW

Smaje, C. (1996) The ethnic patterning of health: New directions for theory and research. Sociology of Health and Illness, 18(2), pp139-171

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