Minority Health is Not a Minority Issue but an Issue of Public Health Equity
A commentary published in the Institute of Policy Studies Commons. Here’s the edited and published article https://ipscommons.sg/minority-health-isnt-a-minority-issue-but-an-issue-of-public-health-equity/
Below is the original draft:
The launch of a workgroup to improve the health of ethnic minorities was announced by the Ministry of Health in Parliament last week. We are pleased that steps are being taken towards addressing issues of health equity in Singapore, as it acknowledges, and brings to light key disparities in physical health across different segments of our society. However, a solely race-based approach to health, in our view, undermines other social determinants of health that may potentially confound the association between race and health status among Singaporeans.
The Minister of Health, in response to recent parliamentary questions from myself (May 2020) and Mr Leon Perera (Feb 2021) on the availability of health statistics in subpopulations along the lines of socioeconomic status, cautioned for a nuanced interpretation of such statistics. Specifically, the minister himself also pointed out that many factors influence certain health outcomes, and cited confounding factors. For example, older cohorts of Singaporeans may have lower educational attainment than younger cohorts, or may move to smaller houses following their retirement, and thus health outcomes associated with educational attainment, income quintiles or housing types would partly be a reflection of differences between older and younger cohorts.
In the same vein, shouldn’t we be cautious about organising such a workgroup solely based on race lines without acknowledging the need to examine the link between poorer physical health in ethnic minorities and other social determinants of health?
Minorities are not ‘Risk Factors’
The focus on minority health, with a spotlight on disparities in health outcomes along the lines of minority social identities, is not new in population or public health approaches to disease prevention.
In infectious diseases, a key lesson came from the experience of dealing with epidemics such as HIV, which emerged early on among gay men. While sexual orientation is useful as a starting point in assessing one’s risk for being exposed to HIV, there have been irreversible attributions of the disease solely to one’s sexual orientation, and corresponding stigma and discrimination towards such individuals. The global COVID-19 response had taken the lessons learnt from this, and swift steps were taken by the World Health Organization to find a name for what was originally known as the ‘Wuhan Virus’. Even then, it did not stop the “Chinese Virus” reference made by ex-President Donald Trump at a presidential press conference that is believed to have resulted in many Asian Americans being verbally or physically attacked. Or a pair of teenagers assaulting our very own Singaporean Jonathan Mok almost exactly a year ago in London which Scotland Yard termed a “racially aggravated assault” due to Covid-19 fears.
In the war against diabetes, Prime Minister Lee Hsien Loong pointed out in his speech at the National Day Rally 2017 how diabetes had disproportionately affected racial minorities in Singapore, citing it as a “very serious problem, and especially for the Malays and Indians”. This spotlight on race had subsequently sparked an article that fixated on the role of unhealthy eating habits and types of food consumed by different races in driving such health disparities. Thankfully, many were quick to point out that such attributions were racist, and glossed over other key social determinants such as disparities in socioeconomic status and dwelling types across races, that could also serve as factors for poorer health outcomes.
These past efforts provide lessons and serve as cautionary tales for how the fixation on race as a risk factor for health outcomes may cause fissures in, rather than strengthen the social fabric of Singapore.
A Social Determinants of Health Framework
At the recent parliamentary Ministry of Health’s Committee of Supply debate, we note that phrases such as “poor health habits” and “cultural preferences’’ were cited to justify the development of “culturally-relevant programs”. While this is an important step towards changing health behaviors in a community, there is a risk that such approaches may fall short of addressing root causes of health disparities along the lines of race.
Instead of focusing on race as the cause of health disparities, scientists have now attempted to shift the focus towards how race can provide a lens to the contexts and structures that disadvantage racial minorities. This focus is known as a ‘social determinants of health’ approach. The World Health Organisation defines the social determinants of health as “the conditions in which people are born, grow, live, work, and age” which have an eventual impact on both physical and mental health.
Specifically, while racial disparities in health outcomes have been documented around the world, a social determinants of health approach would require deeper inquiries into how such disparities are a result of other social, cultural, political and economic factors that put racial minorities ‘at risk of being at risk of’ poorer health outcomes. The assumption is that variations in health status in individuals of a minority race result from variations across races in their exposure or vulnerability to behavioural, psychosocial, material and environmental risk factors and resources.
There are several clues that warrant this holistic approach. A systematic review published in 2018 in the International Journal for Equity in Health found that individuals living in public rental housing in Singapore were more likely to exhibit poorer health outcomes. Correspondingly, the recent General Household Survey in 2015 found that among all ethnic groups, Malays had the greatest proportion of individuals living in 1- and 2-room HDB apartments. A recent report by Beyond Social Services on the impact of COVID-19 on low-income households, found that about two-thirds of 1,200 applicants for its Family Assistance Fund for Covid-19 support were non-Chinese.
No Health Without Mental Health
Beyond physical health, we also urge the workgroup to consider disparities in mental health as there is unequivocal evidence for strong associations between mental and physical health outcomes. For example, individuals who are living with diabetes are at increased risk for depression, anxiety and eating disorder diagnoses, and such mental health comorbidities may result in barriers to treatment adherence. The Centers for Disease Control and Prevention in the United States also found evidence that only about 25 to 50% of people with diabetes who also have depression get diagnosed and treated.
Research has shown that, similar to physical health outcomes, a lower socioeconomic status tends to be associated with poorer mental health outcomes. A 2018 article published in the journal Applied Research in Quality of Life found that staying in public rentals flat neighbourhoods was associated with more mental health problems such as anxiety and depression. And this was in turn associated with identifying as an ethnic minority. Correspondingly, data from the Singapore Mental Health Study and Early Psychosis Intervention Programme services at the Institute of Mental Health have also shown that disparities in mental health, such as duration of untreated mental health disorder and major depressive disorder, do exist across racial lines in Singapore., Such disparities in mental health outcomes across races are also reflected in the Central Narcotics Bureau’s statistics of drug abusers arrested.
By virtue of these trends, we cannot assume that such differences are due to cultural differences alone, and that socioeconomic status may have a role to play in partly explaining the associations between race and poorer mental health outcomes.
Sustainability of a Race-Based Approach
The adoption of a race-based approach stirs up several questions on the sustainability of such a public health policy. First, would a race-based approach also mean adopting a cultural lens to addressing health issues among Chinese Singaporeans as well e.g Hokkien, Teochew, Cantonese etc? Would this cause social divisiveness in Singapore society? Second, what about the upward trend of interracial marriages in Singapore? Would such health policies stand the test of time given how fast social structures and norms are changing? Third, would this race-based narrative increase the cost of insurance for minority groups, given that our gender-based approach is already penalising women to pay higher premiums for CareShield Life?
While the Ministry of Health has stated that it does not collect data on the relationship between socioeconomic status and health in response to Ms Anthea Ong’s parliamentary question on the same in May 2020, we believe that a robust monitoring framework that accounts for a diverse range of social determinants will help us more incisively ascertain the role of culture in driving physical and mental health disparities. This approach to the social determinants of health has been gaining traction in other ethnically-diverse jurisdictions, such as in the United Kingdom and the United States.
In sum, the establishment of a workgroup to address ethnic minority health is a promising start to having meaningful conversations on health disparities in our society but we would be remiss to do this without acknowledging and delving deeper into the social inequities that underpin such disparities, nor including mental health. Further research and data on such social determinants of total health must be a key objective for this workgroup. Let’s build more bridges to reduce health disparities, not further prejudices.
Anthea Ong is a former Nominated Member of Parliament, Social Entrepreneur (A Good Space, Hush TeaBar, WorkWell Leaders Workgroup, SG Mental Health Matters), Leadership Coach and Author of 50 Shades of Love. www.antheaong.com
Rayner Tan is a postdoctoral fellow at the Saw Swee Hock School of Public Health, National University of Singapore and also a member of SG Mental Health Matters. https://nus.academia.edu/RaynerTan