Mixed Heritage: Perspectives On Health And Welfare Prof Mark Johnson
Introduction To a significant extent, the development of the UK social care system was intimately affected by the growth of populations of mixed heritage, or 'mixed race'; the result often of liaison between Black (African and Asian) workers in the merchant marine and women in major port towns such as Liverpool. The subsequent children, whose presence sparked something of a moral panic in the early 20th century,(1) drew the attention of social reformers and charitably inclined researchers, and became the focus for the work of organisations like the Liverpool 'Settlement' (on the same model as the Oxford and Cambridge 'settlements' in inner-city London). The focus in social care on the welfare (and management) of 'mixed-race' children continued well up until the end of the century, and has not disappeared from current literature and policy. The same concerns were also present in health care and policy, especially in regard to the development of 'port health' and health promotion initiatives in the middle part of that century. It is to be hoped that by now there is a more mature understanding of the issues and less concern about 'miscegenation' and 'racial purity' - and recognition that public health is not threatened by bicultural couples. However, it is clear that underlying concerns or lack of awareness, understanding and empathy (or sympathy) among health and social care workers remain, and may poison the relationship between the health/welfare care system and communities of dual or multiple heritage. The problem would appear that throughout all health and social care research, while attention has been paid to a number of specific minority ethnic communities, as defined in terms of geographical origin, language or religion, the concerns of people defined as being of 'Mixed', dual or multiple ethnic heritage are almost never separated out from those of the 'BME' main groups (whether the Census 16 headings or the four major groups: White, Asian, 'Black' and 'Other') but are included in that 'Other' catchall residual category, and if identified at all, are regarded as a pathogenic group.
Child Care issues
In terms of health and welfare we cannot ignore the issue of children of multiple or dual heritage admitted to care - especially because this has considerable implications for their own well-being and mental health. As Barn (1999) and others have repeatedly stated, in the 1970s and 1980s at least, young people of 'mixed race' origins were significantly over-represented in the numbers admitted to care, although Banks (2004) and some others have recently disputed the extent to which this group really is over-represented in the care system, given the poor data we have on the population as a whole. Whatever the facts, it remains true that there has existed, and continues to exist, a 'moral panic' or folk devil around the issue. For the individual child or young person, the experience of being taken into care because of a lack of familial or community support remains psychologically damaging.
Debates over appropriate 'matching' of children and foster-parents or other care providers have also raised anxieties and public controversy, and worse, have led to significant delays in moving from an institutional to a 'family' setting.(2) While it is undoubtedly true that carers from or sharing the same cultural identity(ies) should know more about the specific needs of the young person, it is not necessarily true that they will, or that such knowledge cannot be held or acquired by well-motivated others. There are also many examples of people who have been brought up 'outside' their birth-communities but who have retained an awareness of and ability to engage with that culture, and of course there are those who might formally meet the criteria but have no real empathy with the cultures into which they were born themselves, or the culture of their partners!(3) The debate about identity formation, self-awareness and self-esteem, learning techniques to cope with racism and the relevance of matching will continue: (4) to date it does not seem to have been conclusively determined. (5)
Issues of mental health tend to cross the boundary between social care and bio-medicine and consequently there may be issues of culture and upbringing, social expectation and reception, and 'clinical susceptibility' involved in the detection, diagnosis and care of people with mental health problems. Some of these, again, depend on the stereotypes and views held by practitioners, in the way they define and describe those they care for and the conditions that they treat. Consequently, early social writings on the position of those 'between two cultures' have tended to pathologise this situation, and to suggest that added mental stress or coping behaviours may engender greater mental distress and predispose to mental illness. If a diagnosis such as 'cannabis psychosis' or the need for restraint and forcible medication is associated with a specific 'ethnic identity' (in this case, usually males of African/Caribbean heritage), then it is probable that the minority identity associated with the worst-case scenario (or highest tariff treatment) will be applied to an individual who might regard themselves as being able to negotiate or move between that 'racialised' identity and another, including the 'majority' one.
In reality, of course, there is plenty of evidence that those who are able to adopt more than one identity and be happy in either and/or both of them, are generally more resistant to such threats to well-being and mental ill-health as excessive use or abuse of alcohol,(6) although some other data suggests higher usage of illicit drugs among people from a 'mixed' background: (7) the differences between these findings has not yet been explored. Similarly, Sinha et al (2005) suggest that early sexual activity is more frequent among young males of 'Black Caribbean and Mixed ethnicity' (but did not examine differences within the 'mixed' group' or if there was an 'Asian Mixed' group, suggesting perhaps that 'Black Mixed' men simply behaved like their Black peers). I do not believe that the data (whichever way they show the differential) actually help to show causation or that the mixed heritage of the people concerned is necessarily significant, and feel that this is something that needs to be properly and sensitively researched.
Medical issues are different, insofar as they relate to infectious and inherited organic diseases, which are increasingly being recognised as having a close association with the genetic makeup ('genome') of the individual, and there may be some sense in recognising that a shared genetic heritage carries risks for the individual which merit special attention. Genomic medicine is still an emergent science about which more is being discovered daily, and which may one day show that membership of a specific ethnic group, particularly if it is one marked by 'endogamy' (marriage within the group, rather than 'out' of it) raises risks of specific conditions There are for example several medical conditions which are commonly referred to as 'ethnic' diseases because of their close association with one or other ethnic group. This is true not only for the minority groups who have Black/African, Asian, Jewish or Mediterranean ancestral origins: the white 'majority' community also carries genetic markers for conditions such as cystic fibrosis, and 'factor V Leiden' (relating to blood clotting and the risk of heart attacks, especially among those of northern European ancestry). Even simple problems like dietary allergies or intolerance may be associated (in a probabilistic manner) with membership of certain ethnic groups (Bhatnagar & Aggarwal 2007) - but probability is not the same as causation or determination. That is the risk of and the cause of, stereotypes, however useful they may be in raising the 'index of suspicion' - leading the medical practitioner to consider an alternative 'differential diagnosis' - which can be a lifesaving action, and should therefore be kept as a benefit of having some knowledge of and access to, 'stereotypes' of ethnic group.
People of mixed heritage may be ignorant of the risks associated with one or other of their heritages, and those charged with their medical care may also ignore or fail to recognise the presence of those other risk factors. This has been classically demonstrated in relation to the blood disorder 'Sickle Cell Disease', a haemoglobinopathy associated particularly but not exclusively with people of West African descent.(8) Cases have been observed in 'white blonde Yorkshire' children, which may or may not be related to the early presence of Roman soldiers of Mediterranean and African origin in York in the first centuries of the Christian era. The risks to people of more recent linkages to the areas of the world where this disease is prevalent are considerable and have recently been recognised by the implementation of a national screening programme to ascertain and warn prospective parents. However, during the trial period when this screening was being developed, it became apparent that not all health professionals were asking all those who might be at risk about their ethnic background, and that significant numbers of people were not asked, probably on the basis of the sorts of stereotype referred to above.(9)
The implication for policy and practice is that once again, the focus is on the preparedness and ability of health care staff to recognise and address, without fear or prejudice, the possibility that people have more than one heritage and may be at risk from a wider range of conditions. Therefore that it is not only legitimate but essential to undertake 'ethnic monitoring', or rather, to ask sensitively and intelligently about a person's ethnic identity and not to insist on forcing responses into one of the simple 'classic' boxes: and of course, equally important that people of multiple heritages will need to feel comfortable in responding to such enquiries. At the same time, it is important that families educate their members fully in their ethnic heritage and history, to avoid a failure to recognise where a genetically transmitted risk may exist. In both cases, this means people being comfortable with the concept of mixed heritage and the right of people to assert their diverse origins and to move between and exist in more than one 'universe', if necessary at the same time!
(1) Ifekwunigwe (2004)
(2) Selwyn et al (2004)
(3) Banks (1998)
(4) Banks (1992)
(5) Tizard & Phoenix (1994)
(6) Purser et al (2001); Orford et al (2004)
(7) Aust & Smith (2003)
(8) Dyson (1998)
(9) Dyson et al (2007)
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