The Pubmed Index and lessons from ethnicity and stroke
I have started using what I have termed the “Pubmed index” to show trends on a particular topic in medical research. In essence, after an unrestricted search in Pubmed to find how many articles mention my search terms, I look at how many hits I get by restricting the search to 10, 5 and 1 years, to find out how much of that research has been done recently, and how “hot” the topic is. “Ethnicity” and “stroke” gives 2411 references, of which 1719 hits are in the last 10 years, 1067 in the last 5 years, and 182 in the last year. In other words, most of the work on ethnicity and stroke has been done in the last 10 years, and the topic is still being researched.
This makes sense because 10-15 years ago, data from the UK and North America showed that there were differences between black and white populations in stroke. For example, there was an excess of haemorrhagic stroke in black populations. In America, this ethnic group had reduced access to stroke services and higher mortality rates, leading to the so-called “stroke belt” in the South-eastern region of the US. The research base for racial or ethnic disparities in stroke has increased across ethnic groups, including Hispanics and South Asians. More recently, with epidemiologic transition and rising prevalence of chronic diseases, data is showing differences in stroke subtypes and risk factors between black and white populations in sub-Saharan Africa.
Ethnicity research has faced hurdles, partly because inadequate definitions and partly due to concerns about political correctness, and ethnic minorities are still under-represented in clinical trials in stroke. With increasing migration within and between populations, a greater consensus is required regarding future studies of ethnic disparities. More comparisons need to be made between ethnic groups as “immigrant populations” versus the ethnic groups in “home populations”, to consider what the effects of migration on disease in its own right are.
Prospective studies which follow populations over time, like the REGARDS(REasons for Geographic And Racial Differences in Stroke) Study in the US, are a preferred methodology than retrospective studies. There has been surprisingly little research about ethnicity in relation to other “non-modifiable risk factors”, such as family history or genome-wide scans, which will help in characterising how ethnicity is associated with risk factors, behaviour, treatment and disease outcomes.
This week, the BMJ published a study online showing that black patients and patients from higher socioeconomic groups were more likely to be admitted to stroke units than white patients and poorer patients in an area of London. These results are interesting because historically data about ethnic disparities, regardless of the country or the setting, has invariably shown that ethnic minorities have less access to services. A rapid response to the article, rightly concludes that we need to know more accurately what is happening overall in the population, rather than having isolated studies. As unwarranted variations in population medicine are increasingly studied and linked with changes in health policy, proactive, rather than reactive studies of ethnicity are required. In other words, it is not enough to just describe variations and disparities, we need to move towards explanations and potential actions which can reduce disparities, and need better population-wide surveillance.
The health service under the BNP
It’s unlikely that anybody living on this island missed the furore surrounding the appearance of British National Party’s chairman, Nick Griffin, on the BBC’s Question Time. I will not comment on Mr Griffin’s misguided views and statements, because they have been covered and analysed to death in the broadsheets, the tabloids, the radio waves and the TV screen
this week. However, I did check out the BNP’s website to look for their health policies, listed under “First Class Health Service for a First World Nation: BNP Health Policy”.
Just like Griffin, the policy statements on the surface may seem vaguely sensible to some people, but you only need look just below the surface to see the true colours: ill-thought-out nonsense. If racism is the fundamental tenet of a political party, it is difficult to hang coherent policies from that hook. Firstly, the BNP would “replace 100,000 NHS bureaucrats with doctors, nurses and dentists” but it does not mention anything about healthcare managers, health economists, and many allied health professionals needed in a modern health service, or how it would conjure up these home-grown 100 000 health workers! Secondly, they would “Train and pay to retain British doctors, nurses and dentists instead of looting the Third World of staff who are desperately needed in their home countries”. Although many doctors and nurses are attracted to work in the UK as economic migrants, they are free to do so as long as there is a demand for health workers in this country. Ethical recruitment from poor countries is a key goal for all UK employers and the brain drain has been increasingly recognised and debated in recent years. However, forcing British doctors to stay in the UK or African doctors to stay in Africa is no more feasible than closing UK’s borders tomorrow. The BNP should acknowledge the extent to which the NHS has relied upon foreign health workers throughout its history and the contributions that ethnic minorities in this and other employment sectors have contributed to the richness of life in Britain today.
The medical literature is rife with examples of the negative health effects of racial disparities from around the world. There is no example yet that racial discrimination will be good for the population as a whole, or for any individual element of the population. Much more reasonable and human ways to address inequalities than the BNP proposals are: better data collection and the use of ethical and human rights frameworks to make sure that every member of our society has access to healthcare.
Perhaps the most chilling policy statement reads “We will see to it that no money is given in foreign aid while our own hospitals are short of beds and the staff to run them”. Mr Griffin and his supporters would do well to read about where government money is currently being spent. It is not just British people that grossly overestimate how much they spend on foreign aid, the Americans do it too. The BNP’s misconception is deeply worrying because the rich nations are already underspending in terms of the UN target of
0.7% of GDP for international development assistance, and there are better ways to save government money.
Remarkably, the BNP is pro-prevention: “….more emphasis must be placed on healthy living with greater understanding of sickness prevention through physical exercise, a healthier environment and improved diets”. This, as far as I can tell, is the only positive in the health service under the BNP.