Key:
NH Nahida Zaman
AG Alia Gilani
NH You are listening to Nahida Zaman on Diabetes Radio. My guest today is Miss Alia Gilani. Miss Gilani hello and a very warm welcome to Diabetes Radio.
AG Hi Nahida, thank you very much for inviting me to talk.
NH You are a pharmacist practising in Glasgow. You developed and worked on the MELTS service in Glasgow, the Minority Ethnic Long Term Medicine Service which conducts a medication review service for ethnic minority individuals with long term conditions. Tell us, what motivated you to become a pharmacist?
AG I qualified 11 years ago and the reason I went into pharmacy I had an interest in the science field and the only profession that I could see in the science field that appealed to me was pharmacy and dealing with the public, that was really important to me. I remember as a 16 year old going for work experience in a pharmacy and I liked the fact it was not just dealing with medicine but I was actually dealing with public and I did not want to be stuck in a lab anywhere so that was really the main reason but I think you make that decision as a career choice, you are quite young but thankfully I made the right decision.
NH Can you tell us about the lecture you gave at the 7th National Conference of the Primary Care Diabetes Society, Ethnicity and Inequalities?
AG Yes sure. I believed that the topic had not been covered and I think it is certainly a pertinent issue, not just for diabetes but other long term conditions. I have got a passion for patient care, particularly an interest in the area of diabetes within South Asians and if you look at those two elements, South Asians have got a higher prevalence of diabetes and essentially they are talking about health inequalities which is also local and national interest and a worldwide interest. The World Health Organisation has written quite a few reports on inequalities and I think next year there are going to be a few major reports as well so it is on the agenda, local/national strategic drivers and so health inequality exists among South Asians, particularly ethnic inequalities because we are referring to a minority group so I wanted to ensure that healthcare professionals are aware of the topic and really to get them to think differently about the service they offer their patients and think about these two aspects of care.
NH Healthcare inequalities is an area of huge concern in the United Kingdom for both patients and their healthcare providers. What are some of the contributing factors to healthcare inequalities in the United Kingdom?
AG In the UK we have a huge issue, particularly in Scotland. If you look at, for example, mortality rate Scotland has got the worst mortality, in fact in parts of Scotland the mortality rate is actually worse than the whole of Europe, it is actually on par with Eastern Europe and for a country like the UK that is a shocking statistic and there are many aspects or many drivers which are contributing factors to health inequalities. The Dahlgren & Whitehead Rainbow Model of Health really depicts the social determinance of health and if anybody is interested in what the causative factors are, it is quite an interesting model to look at so every area within the UK has health inequalities and that could be relating to gender, ethnicity, disability, it can be within areas so there are different aspects of inequality, there are socioeconomic, they can be pertaining to a geographical area so it affects every single healthcare professional, irrespective of where they work in the UK. The main drivers for health inequalities are income, education and employment. Poverty is one of the key drivers so poverty can lead to poor health and poor health can lead to poverty so it is one of the fundamental causes and then ethnicity is linked to that but there are separate elements which affect ethnic inequalities.
NH Does ethnicity and healthcare inequality go hand in hand?
AG Aspects of it go hand in hand, however with ethnic inequalities there are separate factors that divide ethnic inequalities. The key factors causing ethnic inequalities are really fundamentally socioeconomic which are similar to health inequality key drivers, however with ethnic inequalities, it is underpinned by racism. There are racial issues. There are things like migration. Migration can cause health inequalities and there are genetic factors as well although genes do not play a whole role and there are things like culture, access, so there are other aspects which are different to health inequalities. Migration is quite an interesting aspect of ethnic inequalities. If you look at migration and you look at the second generation, the second generation you find that the intergenerational mobility is improved, ie the social economic status has improved, however, the actual health status has not. Although they have got a better standard of living if you compared to the first generation, the health inequalities have not improved but both these aspects are key issues for healthcare professionals because mortality in the UK and in the world has reduced over the last few years, however the health inequalities gap is widening and that has been found where the government reports. The first one was done in 1980 which was a black report and following on from that they key report was the Acheson Report in 1998 which showed that social determinance still existed and the fact that mortality in the last 50 years has improved but the gap of health inequalities is widening and more recently the important review with the Marmot Review in 2010 which talks about a social gradient so quite an interesting analogy that shows that those of lower socioeconomic status were worse off and in Scotland it was equally the report in 2008 which had alarming statistics, for example Pakistani men having a higher incidence of heart disease, 50% higher and Pakistani women having an 85% higher rate of heart attacks in Scotland so quite alarming statistics, that is just one aspect.
NH A study by the UK parliament in 2007 revealed that ethnic groups in the United Kingdom have worse health than the overall population, is this accurate in the diabetic and obese patient populations?
AG Yes absolutely. When we talk about ethnic minorities in the largest group comprising ethnic minorities are South Asians so a lot of the research has been done in this ethnic minority group but we must not forget there are other ethnic minority groups who have health inequalities so South Asians which includes Indian, Pakistani, Bangladeshi and Sri Lankan are up to six times more likely to have diabetes. They are more likely to get it ten years younger and at a lower BMI, ie body mass index so a lower weight, there is much more risk of developing diabetes and further they are much more at risk of diabetic complications, retinopathy and kidney problems and heart disease as well so there is huge inequality there. Apart from that, other ethnic minority groups who have things, African Caribbeans who are at high risk of things like stroke, hypertension, certain eye conditions, they also have Roma travellers, if you look at the migration pattern in the UK there is an influx in recent years of asylum seekers, travellers and Roma travellers have got one of the worst mortality rates in the whole of Europe so we must not forget other ethnic minority groups although much of our focus in the work I have done in research in the UK is in South Asians.
NH Miss Gilani who have been very vocal about the role that primary care can play in helping to tackle inequalities in the United Kingdom, how can primary care help to tackle these inequalities?
AG We are lucky in that in primary care we are gatekeepers, we access even the hard to reach who are difficult to engage with, they are able to enter our door whether it is a surgery or a pharmacy or nurses so we have that opportunity to make a difference. One person can do a lot and I always use the example of Julian Tudor Hart, a GP in Wales who, in 1971, described the Inverse Care Law showed availability of good medical care can vary inversely with the need for the population served so those that are in greatest need do not get that medical care and he showed by giving intensive support to a high risk population a 28% reduction in mortality over a 25 period so although healthcare professionals can sometimes find it difficult with targets, QOF points, appointment times and lots of pressures, you must not forget one person can do a lot so one example, the key determinance of health are not going to be related to medicine, we tend to focus so much in the medical model and I think as healthcare professionals we need to step back and think outside the box because the current medical model is not working, the health inequalities gap is widening so we need to think differently, we need to look at the population and adapt your service that meets your needs and improve access, that helps addressing inequalities, you need to engage more with the wider determinance of health and although national policy can help health inequalities it has to be delivered locally and the healthcare professionals can affect patients, they can affect community and they can affect policy so there are lots of things and I think there has to beyond the current healthcare professionals market if you like, I think medical students and healthcare professionals and training the workforce needs to be more focused on social determinance and it takes, for example, between two and four years the World Health Organisation has listed that that length of time it takes to build an enduring relationship, most of our healthcare professionals have that length of time involved with patients so you can make a difference, you cannot just deal with their medical issues but help them engage and deal with their social aspects that are going on in their lives. As healthcare professionals to sum up we cannot eliminate health inequalities but we can have a role in reducing the impact of the effect of health inequalities.
NH Islam in the United Kingdom’s second largest religion after Christianity. During the month of Ramadan a diabetic Muslim will make a number of adjustments to their mealtimes, food types and lifestyle which will affect their ability to control their diabetes. What does a diabetic Muslim do during Ramadan that a healthcare professional should be aware of?
AG In diabetic patients, most of them it is found in studies, the EPIDIAR study which was the largest Ramadan study in the world, 12,500 individuals in 13 different countries and they found that 80% of type II diabetics will fast so Muslim diabetics and there are approximately over 400,000 Muslim diabetics in the UK so if you think about it 80% of them approximately will partake in fasting. Fasting is one of the pillars of Islam of which there are five pillars. It is a very key part of the religious practice and that entails fasting which is abstaining from food, water and medicines between sunrise and sunset. The Islam calendar is such it is approximately 354 days so it goes behind 11 days of the year so at the moment Ramadan started in 2011 on August the 1st, next year it will go behind 11 days so that means for the next ten years they are looking at Ramadan falling in the summer period which means fasting lasts between 15 to 21 hours depending where you are in the UK so a diabetic patient will essentially not be able to eat in that whole period and that has health implications in terms of causing low sugar levels, hyperglycaemia and high sugar levels, hypoglycaemia, and if it is not done appropriately in terms of dawn adjustment or they are too frail, it is can adverse health outcomes.
NH Finally do you have some advice that healthcare professionals should give to their patients during Ramadan?
AG Yes I think every healthcare professional, if they have a Muslim population, needs to get in touch with them two to three months before the month or Ramadan. In 2012 it will fall approximately July the 20th and they need to do a review of whether it is suitable for them to fast or not and tell them how to adjust their medicine or if they are on insulin and whether it is safe for them to do so and there are many resources out there, literature is becoming a topic that is of interest to healthcare professionals so there are resources out there. I published an article in one of the journals on Ramadan and I have also got the resource pack which is available on Glasgow for Healthcare Professionals, it tells what you should do and what the evidence is in terms of those adjustments so really a healthcare professional can access these resources and go through it with their patient and it is also an opportunity for them to get their patients to stop smoking and encourage them to do so and really make sure they are fasting in a safe manner but it is unIslamic for a patient to fast if it is detrimental to their health so I think healthcare professionals need to be aware and if they have a Muslim population they really need to understand what Ramadan means because it is a huge part for Muslin patient advice.
NH Miss Alia Gilani, thank you so much for taking the time to speak to us today.