Raj S. Bhopal (2014), Migration, Ethnicity, Race and Health in Multicultural Societies: Foundations for Better Epidemiology, Public Health, and Health Care

Raj Bhopal’s Migration, Ethnicity, Race and Health in Multicultural Societies (2014) (hereafter ‘Migration’) is an important and timely contribution to the literature on ethnicity and health. Not only does it present its content in a sensitive and pragmatic way, it is highly accessible, engaging and up-to-date. ‘Migration’ is effectively a second edition of Ethnicity, Race and Health in a Multicultural Environment: Foundations for Better Epidemiology, Public Health and Health Care (published in 2007). In this latest edition, Public Health expert Raj Bhopal focuses mainly on the fluidity of defining a person’s identity and how this has developed over time into concepts based on ethnicity, national borders, religion, immigration status, a sense of belonging and identity. The new engagement in this edition with the changing nature of migration and how this affects health-seeking behaviours, the delivery of services and health outcomes is its most significant and novel contribution to current debates.

In what has been described as an era of super-diversity (Vertovec 2007), we can no longer afford to ignore the impact of migratory trajectories on health delivery and outcomes. Bhopal demonstrates the many different ways in which health continues to intersect with ‘race’ and ethnicity but also with migration status (in contrast with Bhopal, I have chosen to place ‘race’ in inverted commas to emphasise the widely contested nature of this concept in sociological theory, of which more later). The significance of the social and political effects of intersecting variables of difference is particularly relevant in the United Kingdom (UK); with the new Immigration Act 2014 enforced in May 2014, we are witnessing an increasing border control creep into health centre waiting rooms. This Act introduces even more restrictive policy to create a ‘hostile environment’ for migrants: it legislates for health care access to be dependent upon immigration status; it further limits rights to citizenship; it increases landlord powers for immigration checks and it reduces the number of appealable immigration decisions. Locating the intersecting nature of migration, ethnicity, ‘race’ and health in this particular political context is essential because of the very immediate implications for better understanding how growing population diversity shapes how we do research, and how increasingly regressive political agendas dictate health policy and practice in the UK and indeed internationally.

Across the book, Bhopal covers a wide range of topics, questions, practical concerns, ethical considerations and political controversies around categorisation and classification processes, data collection and analysis, priority setting agendas, ‘rationing’ of resources and mainstreaming of services. This is provided within a useful comparative framework for analysing the historical development of health and health care services and national responses to health aspects of migration (covering the UK, US, Australia, apartheid-era South Africa, the Netherlands and Hungary), and the various socio-cultural, historical and political imperatives driving policy agendas. Throughout the book, Bhopal effectively demonstrates how categories of analysis come to be categories of practice, the intertwining nature of these concepts and variables, and the ways in which ‘race’ and ethnicity are real in their consequences, regardless of their contestable scientific or indeed biological grounding. The author strongly advocates for data to be collected, measured and analysed within an ethical and legal framework which safeguards minority rights, and forcefully argues that the principle of equity can provide the ‘core ethical principle’ needed to help progress beyond the denial of difference and the continuation of ethnocentric approaches to health care delivery (p. 182). The book makes an important contribution in introducing readers from primarily health-related audiences to a range of concepts such as ‘race’ , ethnicity, population heterogeneity, ethnocentricity and migration status, as well as providing classifications of different migrant categories (for example asylum seekers and refugees, illegal, irregular and undocumented migrants, although the author’s point on ‘authenticity’ – Asylum seekers and refugees [when genuine] are involuntary migrants (p. 11), seems rather ill-judged). This book clearly has a public health focus, yet from a sociological perspective there are three areas of theoretical and empirical inquiry I would now like to address.

Firstly, I find the way in which ‘race’ is used problematic. The author goes to great lengths, and successfully so, to challenge the myth of ‘race’ on the basis of biological difference. Bhopal unpacks the widely-accepted position that ‘race’ as a biological concept has no scientific grounds, and effectively argues that it is in fact a social and political construct. He makes direct reference to the way in which the biological concept of ‘race’ has been used and abused to justify atrocities; he states on page 16, race should be used with caution for its history is one of misuse and injustice. And he is right. This is particularly important given the current socio-political context of the book, the connections made between migration, ‘race,’ ethnicity and health, and the historical racialisation of immigration in Western societies. Nonetheless, the continued use of ‘race’ suggests there are biological differences between different groups of human beings – ultimately different ‘races’ – which only perpetuates ‘race’ as a viable biological concept.

This reveals the very real problem and challenge of how to write about social and political constructs without reifying those very same constructs. In ‘Migration,’ Bhopal sets out in a very systematic way the problem with certain concepts and classifications, but then continues to use them because they are the dominant concepts which everyone understands. One way forward (following Miles and Brown 2003) for critically engaging with this challenge is to use scare quotes (‘race’) to emphasise that ‘race’ is not a real attribute of human biology, is socially constructed and discursively perceived. As late as Chapter 10, Bhopal comes tantalisingly close to presenting the strongest sociological argument for challenging the continued use of ‘race’ in an unproblematic way, but then resigns himself to the position that because such concepts are part of the ‘core dialogue in the field of minority health,’ they continue to have analytical value. As a result, ‘race’ as difference in biology comes to be continuously held up as some sort of scientific truth. 

Bhopal’s response to the question that social construction needs to be based on something ‘real’ is also problematic; it ignores the social construction of difference and the power asymmetries underpinning social construction – how we identify skin colour, language, and dress is of course political. Bhopal is aware of this – he peppers his book with illuminating reflective stores of his own experience of being constructed as different and ‘other’. He engages with racialisation and reification (again following Miles and Brown 2003), making it clear that these are the processes at work when racialised and ethnic divisions are conceived of as real. What is not clear to me is how his continued use of ‘race’ might follow a non-reifying approach. A worrying corollary of this is that migration comes to be racialised along colour lines, and so the emerging scholarship around migration and whiteness is missing from Bhopal’s analysis of the complex interplay of migration, ‘race,’ ethnicity and health. Whiteness often goes unexamined in the literature on health disparities (Daniels, Schulz, 2006), but given its strong association with privilege and social mobility, it has been argued that next waves of research on immigrants must interrogate this construct and examine its relationship with health disparities (Viruell-Fuentes, Miranda, Abdulrahim 2012: 2101).

Following from this point on the racialisation of migrants is the issue of the book’s focus on South–East (SE) Asian migrants. SE Asian migrants represent a historically and politically important migrant population in the UK and continue to be so today. However other migrant populations are represented in the UK, particularly in the wake of European Union (EU) accession and migration from Central and Eastern Europe. Bhopal only makes passing reference to these migrant populations and so how immigration status, migration trajectory and experiences of health care intersect with the ‘whiteness’ of these migrants is largely obscured by the book’s dominant construction of migrants along colour lines. The SE focus also detracts from the insights to be drawn from different types of migrants. This reflects a wider related issue with ‘Migration’: with only passing reference to gypsy travellers, Roma, asylum seekers and refugees, the very heterogeneity that exists within the ‘migrant category’ is unfortunately obscured, with ‘migrants’ sometimes coming across as a homogenous mass. Absent from this analysis is any sustained engagement with the ways in which differences in immigration status and migration trajectory intersect with ‘race’ and ethnicity and increasingly impact upon health behaviours, access, delivery and experiences. This is a missed opportunity: it would have been both instructive and timely to read more about the health inequalities of increasingly diverse migrant populations and how whiteness as a racialised identity intersects with immigration status to produce further hidden inequalities.

This leads to the third area of contention which, I would argue, relates to a central omission: Bhopal writes about the intersecting nature of variables of difference without theoretical engagement with intersectionality (Anthias 2008) as a potentially powerful theoretical framework for studying, exposing and addressing the intersecting nature of migration, ‘race,’ ethnicity and health inequalities. This theoretical framework very effectively highlights the negative politics of hidden multiple inequalities (Werbner 2013: 403) and – as Bhopal indeed suggests – adds importance to examining the multiple ways in which social inequalities are intensified by simultaneous membership in a range of stigmatised or devalued categories with gender, ‘race,’ age, ability, sexuality, and ethnicity (Crenshaw 1989). An intersectional framework also demonstrates the cumulative effects of these variables in health-seeking behaviours and experiences of health care. 

This would be in line with the currently growing diversity turn in health research where intersectional perspectives are used to move beyond ‘language’ or ‘culture’ to explore how multiple dimensions of inequality intersect to impact health outcomes (for example Hankivsky, Cormier 2009; Ingleby 2012 and Krause, Gabriele, Parkin 2012). Foregrounding this theoretical framework would have provided insights into how to integrate an intersectional approach into health research and health policy making, as well as how an intersectional perspective may be applied to research, education and day-to-day practice. Part of the problem may be the issue of ‘disciplinary blinkers,’ and so arguably an interdisciplinary approach to theory building could inform Bhopal’s question as to how to move forward the theorising of ‘race,’ ethnicity and migration with health, and how public health research might move away from ‘race’ as biological to ‘race’ as one of many intersecting variables producing and perpetuating social inequalities which affect health care delivery and access.   

In conclusion, ‘Migration’ achieves that rare thing of being applicable to the widest range of audiences and provides a necessary bridge across health and social sciences. It is an important and useful addition to reading lists for teachers, lecturers and students across a range of disciplines from health care research generally to a wider audience of social scientists, medical scientists, human geographers, public policy makers, educators, and clinical practitioners. Undergraduates would find this a useful text book for entry level study into the concepts of migration, ‘race’ and ethnicity and multiculturalism, as would postgraduates, particularly in interdisciplinary areas of study. However, there needs to be a critical engagement with theoretical perspectives that go beyond the public health discipline, as with ongoing debates into how lay terms come to be adopted and used by academics and practitioners, and how such terms intersect to produce further inequalities. 

References

Anthias F. (2008). Thinking Through the Lens of Translocational Positionality: An Intersectionality Frame for Understanding Identity and Belonging. Translocations, Migration and Change 4(1): 5–20.

Crenshaw K. (1989). Demarginalizing the Intersection of Race and Sex: A Black Feminist Critique of Antidiscrimination Doctrine, Feminist Theory and Antiracist Politics. The University of Chicago Legal Forum: 139–67.

Daniels J., Schulz A. J. (2006). Constructing Whiteness in Health Disparities Research, in: A. J. Schulz, L. Mullings (eds), Gender, Race, Class, and Health: Intersectional Approaches, pp. 89–127). San Francisco, CA: Jossey-Bass.

Hankivsky O., Cormier R. (2009). Intersectionality: Moving Women’s Health Research and Policy Forward. Vancouver: Women’s Health Research Network.

Ingleby D. (2012). Ethnicity, Migration and the ‘Social Determinants of Health’ Agenda. Psychosocial Intervention 21(3): 331–341.

Krause K., Gabriele A., Parkin D. (2012). Medical Knowledge, Therapeutic Practice and Processes of Diversification. MMG Working Paper 12-11: Online: http://www.mmg.mpg.de/fileadmin/user_upload/documents/wp/WP_12-11_Concep... (accessed 17 September 2014).

Miles R., Brown M. (2003). Racism (second edition). Routledge: London.

Vertovec S. (2007). Super-Diversity and Its Implications. Ethnic and Racial Studies 30(6): 1024–1054.

Viruell-Fuentes E. A., Miranda P. Y., Abdulrahim S. (2012). More than Culture: Structural Racism, Intersectionality Theory, and Immigrant Health. Social Sciences and Medecine 75(12): 2099–2106.

Werbner P. (2013). Everyday Multiculturalism: Theorising the Difference between ‘Intersectionality’ and ‘Multiple Identities.’ Ethnicities 13(4): 401–419.