Migration, ethnicity, racism and the COVID-19 pandemic: A conference marking the launch of a new Global Society.

The inaugural conference of the Global Society on Migration, Ethnicity, Race and Health COVID-19 examined the impact of the COVID-19 pandemic on migrants and ethnic minorities and the role of racism. Migrants everywhere have faced tightening immigration restrictions, more obstacles to healthcare, increased racism and worsening poverty. Higher COVID-19 mortality rates have been otbserved in ethnic/racial minorities in the United Kingdom and the United States. Structural racism has been implicated, operating, for example, through more crowded living conditions and higher-risk occupations. In Brazil, good data are lacking but a seroprevalence survey suggested higher rates of infection among ethnic minorities and slum dwellers. Considerable disruption of services for migrants at the border with Venezuela have occurred. National policy responses to protect vulnerable groups have been lacking. In Australia, with strict COVID-19 control metrtrun 0asures and inclusive policies, there have been few cases and deaths reported in Indigenous communities so far. In most countries, the lack of COVID-19 data by ethnic/racial group or migrant status should be addressed. Otherwise, racism and consequent inequalities will go undetected.

Mortality of ethnic minority groups in the UK: a systematic review protocol.

INTRODUCTION: Growing ethnic diversity in the UK has made it increasingly important to determine the presence of ethnic health inequalities. There has been no systematic review that has drawn together research on ethnic differences in mortality in the UK. METHODS: All types of observational studies that compare all-cause mortality between major ethnic groups and the white majority population in the UK will be included. We will search Medline (OvidSP), Embase (OvidSP), Scopus and Web of Science and search the grey literature through conference proceedings and online thesis registries. Searches will be carried out from inception to 2 August 2019 with no language or other restrictions. Database searches will be repeated prior to publication to identify new articles published since the initial search. We will conduct forward and backward citation tracking of identified references and consult with experts in the field to identify further publications and ongoing or unpublished studies. Two reviewers will independently screen studies and extract data. Two reviewers will independently assess the quality of included studies using the Newcastle-Ottawa Scale. If at least two studies are located for each ethnic group and studies are sufficiently homogeneous, we will conduct a meta-analysis. If insufficient studies are located or if there is high heterogeneity we will produce a narrative summary of results. ETHICS AND DISSEMINATION: As no primary data will be collected, formal ethical approval is not required. The findings of this review will be disseminated through publication in peer reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42019146143.

Heterogeneity/granularity in ethnicity classifications project: the need for refining assessment of health status.

BACKGROUND: Identifying ethnic inequalities in health requires data with sufficiently 'granular' (fine detailed) classifications of ethnicity to capture sub-group variation in healthcare use, risk factors and health behaviors. The Robert Wood Johnson Foundation (RWJF), in the USA, commissioned us to explore granular approaches to ethnicity data collection outside of the USA, commencing with the European Union. METHODS: We examined official data sources (population censuses/registers) within the EU-28 to determine the granularity of their approach to ethnicity. When ethnic information was not available, related variables were sought (e.g. country of birth). RESULTS: Within the EU-28, we found 55% of countries collected data on ethnicity. However, only 26% of these countries (England, Wales, Northern Ireland, Scotland, Republic of Ireland, Hungary, Poland and Slovakia) had a granular approach, with half of these being within the UK. Estonia, Lithuania, Croatia, Bulgaria, Republic of Cyprus and Slovenia collected one to six categories. A 'write-in' option only was found in Latvia, Romania and the Czech Republic. Forty-five percent of countries did not collect ethnicity data but collected other related variables. CONCLUSIONS: (i) Although there is reasonable attention to the diversity of ethnic groups in data collection, a granular approach does not predominate within EU-28 classifications. (ii) Where ethnicity is collected, it is conceptualized in different ways and diverse terminology is used. (iii) A write-in option provides the most granular approach. (iv) Almost half of the countries did not collect data on ethnicity, but did collect related variables that could be used as a proxy.

Assessment of health care, hospital admissions, and mortality by ethnicity: population-based cohort study of health-system performance in Scotland.

BACKGROUND: Ethnic minorities often experience barriers to health care. We studied six established quality indicators of health-system performance across ethnic groups in Scotland. METHODS: In this population-based cohort study, we linked ethnicity from Scotland's Census 2001 (April 29, 2001) to hospital admissions and mortality records, with follow-up until April 30, 2013. Indicators of health-system performance included amenable deaths (ie, deaths avertable by effective treatment), preventable deaths (ie, deaths avertable by public health policy), avoidable deaths (combined amenable and preventable deaths), avoidable hospital admissions, unplanned readmissions, and length of stay. We calculated rate ratios and odds ratios (with 95% CIs) using Poisson and logistic regression, which we multiplied by 100, adjusting first for age-related covariates and then for socioeconomic-related and birthplace-related covariates. The white Scottish population was the reference (rate ratio [RR] 100). FINDINGS: The results are based on 4·61 million people. During the 50·5 million person-years of study, 1·17 million avoidable hospital admissions, 587 740 unplanned readmissions, and 166 245 avoidable deaths occurred. South Asian groups had higher avoidable hospital admissions than the white Scottish group, with the highest reported RRs in Pakistani groups (RR 140·6 [95% CI 131·9-150·0] in men; RR 141·0 [129·0-154·1] in women). There was little variation between ethnic groups in length of stay or unplanned readmission. Preventable and amenable mortality were higher in the white Scottish group than several ethnic minorities including other white British, other white, Indian, and Chinese groups. Such differences were partly diminished by adjustment for socioeconomic status, whereas adjustment for country of birth had little additional effect. INTERPRETATION: These data suggest concerns about the access to and quality of primary care to prevent avoidable hospital admissions, especially for south Asians. Relatively high preventable and amenable deaths in white Scottish people, compared with several ethnic minority populations, were unexpected. Future studies should both corroborate and examine explanations for these patterns. Studies using several indicators simultaneously are also required internationally. FUNDING: Chief Scientist's Office, Medical Research Council, NHS Research Scotland, Farr Institute.

Mortality, ethnicity, and country of birth on a national scale, 2001-2013: A retrospective cohort (Scottish Health and Ethnicity Linkage Study).

BACKGROUND: Migrant and ethnic minority groups are often assumed to have poor health relative to the majority population. Few countries have the capacity to study a key indicator, mortality, by ethnicity and country of birth. We hypothesized at least 10% differences in mortality by ethnic group in Scotland that would not be wholly attenuated by adjustment for socio-economic factors or country of birth. METHODS AND FINDINGS: We linked the Scottish 2001 Census to mortality data (2001-2013) in 4.62 million people (91% of estimated population), calculating age-adjusted mortality rate ratios (RRs; multiplied by 100 as percentages) with 95% confidence intervals (CIs) for 13 ethnic groups, with the White Scottish group as reference (ethnic group classification follows the Scottish 2001 Census). The Scottish Index of Multiple Deprivation, education status, and household tenure were socio-economic status (SES) confounding variables and born in the UK or Republic of Ireland (UK/RoI) an interacting and confounding variable. Smoking and diabetes data were from a primary care sub-sample (about 53,000 people). Males and females in most minority groups had lower age-adjusted mortality RRs than the White Scottish group. The 95% CIs provided good evidence that the RR was more than 10% lower in the following ethnic groups: Other White British (72.3 [95% CI 64.2, 81.3] in males and 75.2 [68.0, 83.2] in females); Other White (80.8 [72.8, 89.8] in males and 76.2 [68.6, 84.7] in females); Indian (62.6 [51.6, 76.0] in males and 60.7 [50.4, 73.1] in females); Pakistani (66.1 [57.4, 76.2] in males and 73.8 [63.7, 85.5] in females); Bangladeshi males (50.7 [32.5, 79.1]); Caribbean females (57.5 [38.5, 85.9]); and Chinese (52.2 [43.7, 62.5] in males and 65.8 [55.3, 78.2] in females). The differences were diminished but not eliminated after adjusting for UK/RoI birth and SES variables. A mortality advantage was evident in all 12 minority groups for those born abroad, but in only 6/12 male groups and 5/12 female groups of those born in the UK/RoI. In the primary care sub-sample, after adjustment for age, UK/RoI born, SES, smoking, and diabetes, the RR was not lower in Indian males (114.7 [95% CI 78.3, 167.9]) and Pakistani females (103.9 [73.9, 145.9]) than in White Scottish males and females, respectively. The main limitations were the inability to include deaths abroad and the small number of deaths in some ethnic minority groups, especially for people born in the UK/RoI. CONCLUSIONS: There was relatively low mortality for many ethnic minority groups compared to the White Scottish majority. The mortality advantage was less clear in UK/RoI-born minority group offspring than in immigrants. These differences need explaining, and health-related behaviours seem important. Similar analyses are required internationally to fulfil agreed goals for monitoring, understanding, and improving health in ethnically diverse societies and to apply to health policy, especially on health inequalities and inequities.

The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study: a cluster randomised controlled trial testing the clinical effectiveness and cost-effectiveness of a multifaceted obesity prevention intervention programme targeted at children aged 6-7 years.

BACKGROUND: Systematic reviews suggest that school-based interventions can be effective in preventing childhood obesity, but better-designed trials are needed that consider costs, process, equity, potential harms and longer-term outcomes. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) study intervention, compared with usual practice, in preventing obesity among primary school children. DESIGN: A cluster randomised controlled trial, split across two groups, which were randomised using a blocked balancing algorithm. Schools/participants could not be blinded to trial arm. Measurement staff were blind to allocation arm as far as possible. SETTING: Primary schools, West Midlands, UK. PARTICIPANTS: Schools within a 35-mile radius of the study centre and all year 1 pupils (aged 5-6 years) were eligible. Schools with a higher proportion of pupils from minority ethnic populations were oversampled to enable subgroup analyses. INTERVENTIONS: The 12-month intervention encouraged healthy eating/physical activity (PA) by (1) helping teachers to provide 30 minutes of additional daily PA, (2) promoting 'Villa Vitality' (interactive healthy lifestyles learning, in an inspirational setting), (3) running school-based healthy cooking skills/education workshops for parents and children and (4) highlighting information to families with regard to local PA opportunities. MAIN OUTCOME MEASURES: The primary outcomes were the difference in body mass index z-scores (BMI-zs) between arms (adjusted for baseline body mass index) at 3 and 18 months post intervention (clinical outcome), and cost per quality-adjusted life-year (QALY) (cost-effectiveness outcome). The secondary outcomes were further anthropometric, dietary, PA and psychological measurements, and the difference in BMI-z between arms at 27 months post intervention in a subset of schools. RESULTS: Two groups of schools were randomised: 27 in 2011 (n = 650 pupils) [group 1 (G1)] and another 27 in 2012 (n = 817 pupils) [group 2 (G2)]. Primary outcome data were available at first follow-up (n = 1249 pupils) and second follow-up (n = 1145 pupils) from 53 schools. The mean difference (MD) in BMI-z between the control and intervention arms was -0.075 [95% confidence interval (CI) -0.183 to 0.033] and -0.027 (95% CI -0.137 to 0.083) at 3 and 18 months post intervention, respectively. The main analyses showed no evidence of between-arm differences for any secondary outcomes. Third follow-up included data on 467 pupils from 27 G1 schools, and showed a statistically significant difference in BMI-z (MD -0.20, 95% CI -0.40 to -0.01). The mean cost of the intervention was £266.35 per consented child (£155.53 per child receiving the intervention). The incremental cost-effectiveness ratio associated with the base case was £46,083 per QALY (best case £26,804 per QALY), suggesting that the intervention was not cost-effective. LIMITATIONS: The presence of baseline primary outcome imbalance between the arms, and interschool variation in fidelity of intervention delivery. CONCLUSIONS: The primary analyses show no evidence of clinical effectiveness or cost-effectiveness of the WAVES study intervention. A post hoc analysis, driven by findings at third follow-up, suggests a possible intervention effect, which could have been attenuated by baseline imbalances. There was no evidence of an intervention effect on measures of diet or PA and no evidence of harm. FUTURE WORK: A realist evidence synthesis could provide insights into contextual factors and strategies for future interventions. School-based interventions need to be integrated within a wider societal framework and supported by upstream interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN97000586. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 8. See the NIHR Journals Library website for further project information.

Life expectancy of different ethnic groups using death records linked to population census data for 4.62 million people in Scotland.

BACKGROUND: Few countries record the data needed to estimate life expectancy by ethnic group. Such information is helpful in assessing the extent of health inequality. METHOD: Life tables were created using 3 years of deaths (May 2001-April 2004) linked to Scottish 2001 Census data for 4.62 million individuals with self-reported ethnicity. We created 8 ethnic groups based on the census definitions, each with at least 5000 individuals and 40 deaths. Life expectancy at birth was calculated using the revised Chiang method. RESULTS: The life expectancy of White Scottish males at birth was 74.7 years (95% CI 74.6 to 74.8), similar to Mixed Background (73.0; 70.2 to 75.8) and White Irish (75.0; 74.0 to 75.9), but shorter than Indian (80.9; 78.4 to 83.4), Pakistani (79.3; 76.9 to 81.6), Chinese (79.0; 76.5 to 81.5), Other White British (78.9; 78.6 to 79.2) and Other White (77.2; 76.4 to 78.1). The life expectancy of White Scottish females was 79.4 years (79.3 to 79.5), similar to mixed background (79.3; 76.6 to 82.0), but shorter than Pakistani (84.6; 82.0 to 87.3), Chinese (83.4; 81.1 to 85.7), Indian (83.3; 80.7 to 85.9), Other White British (82.6; 82.3 to 82.9), other White (82.0; 81.3 to 82.8) and White Irish (81; 80.2 to 81.8). CONCLUSIONS: Males and females in most of the larger ethnic minority groups in Scotland have longer life expectancies than the majority White Scottish population.

A cluster-randomised controlled trial to assess the effectiveness and cost-effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6-7 year old children: the WAVES study protocol.

BACKGROUND: There is some evidence that school-based interventions are effective in preventing childhood obesity. However, longer term outcomes, equity of effects and cost-effectiveness of interventions have not been assessed. The aim of this trial is to assess the clinical and cost-effectiveness of a multi-component intervention programme targeting the school and family environment through primary schools, in preventing obesity in 6-7 year old children, compared to usual practice. METHODS: This cluster randomised controlled trial is set in 54 primary schools within the West Midlands, UK, including a multi-ethnic, socioeconomically diverse population of children aged 6-7 years. The 12-month intervention consists of healthy diet and physical activity promotion. These include: activities to increase time spent doing physical activity within the school day, participation in the 'Villa Vitality' programme (a programme that is delivered by an iconic sporting institution (Aston Villa Football Club), which provides interactive learning opportunities for physical activity and healthy eating), healthy cooking skills workshops in school time for parents and children, and provision of information to families signposting local leisure opportunities. The primary (clinical) outcome is the difference in body mass index (BMI) z-scores between arms at 3 and 18 months post-intervention completion. Cost per Quality Adjusted Life Year (QALY) will also be assessed. The sample size estimate (1000 children split across 50 schools at follow-up) is based on 90% power to detect differences in BMI z-score of 0.25 (estimated ICC ≤ 0.04), assuming a correlation between baseline and follow-up BMI z-score of 0.9. Treatment effects will be examined using mixed model ANCOVA. Primary analysis will adjust for baseline BMI z-score, and secondary analysis will adjust for pre-specified baseline school and child level covariates. DISCUSSION: The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study is the first trial that will examine the cost-effectiveness and long term outcomes of a childhood obesity prevention programme in a multi-ethnic population, with a sufficient sample size to detect clinically important differences in adiposity. The intervention was developed using the Medical Research Council framework for complex interventions, and outcomes are measured objectively, together with a comprehensive process evaluation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN97000586 (registered May 2010).

Risk of respiratory hospitalization and death, readmission and subsequent mortality: scottish health and ethnicity linkage study.

BACKGROUND: Limited and dated evidence shows ethnic inequalities in health status and health care in respiratory diseases. METHODS: This retrospective, cohort study linked Scotland's hospitalization/death records on respiratory disorders to 4.65 million people in the 2001 census (providing ethnic group). For all-respiratory diseases and chronic obstructive pulmonary disease (COPD) from April 2001 to 2010 we calculated age, country of birth and Scottish Index of Multiple Deprivation (SIMD) adjusted risk ratios (RRs), by sex. We calculated hazard ratios (HRs) for death following hospitalization and for readmission. We multiplied ratios and confidence intervals (CIs) by 100, so the reference Scottish White population's RR/HR = 100. RESULTS: RRs were comparatively low for all-respiratory diseases in Other White British (84.0, 95% CI 79.6, 88.6) and Chinese (67.4, 95% CI 55.2, 82.3) men and high in Pakistani men (138.1, 95% CI 125.5, 151.9) and women (132.7, 95% CI 108.8, 161.8). For COPD, White Irish men (142.5, 95% CI 125.3, 162.1) and women (141.9, CI 124.8, 161.3) and any Mixed Background men (161, CI 127.1, 203.9) and women (215.4, CI 158.2, 293.3) had high RRs, while Indian men (54.5, CI 41.9, 70.9) and Chinese women (50.5, CI 31.4, 81.1) had low RRs. In most non-White groups, mortality following hospitalization and readmission was similar or lower than the reference. CONCLUSIONS: The pattern of ethnic variations in these respiratory disorders was complex and did not merely reflect smoking patterns. Readmission and death after hospitalization data did not signal inequity in services for ethnic minority groups.

Disparate patterns of hospitalisation reflect unmet needs and persistent ethnic inequalities in mental health care: the Scottish health and ethnicity linkage study.

OBJECTIVES: The presence and extent of mental health inequalities in Scotland is unclear. We investigated ethnic variations in psychiatric hospitalisations and compulsory treatment in relation to socioeconomic indicators. DESIGN: In a retrospective cohort study design, using data linkage methods, we examined ethnic variations in psychiatric [any psychiatric, mood (affective), and psychotic disorders) hospitalisations and use of the Mental Health (Care and Treatment) (Scotland) Act 2003 (Emergency Detentions (ED), Short-Term Detentions (STD) and Compulsory Treatment Orders (CTO)] using age (and sex for compulsory treatment), car ownership, and housing tenure adjusted risk ratios (RR). 95% CIs for the data below exclude the reference White Scottish group value (100). RESULTS: Compared to the White Scottish population, Other White British men and women had lower hospitalisation from any psychiatric disorder (RR = 77.8, 95% CI: 71.0-85.2 and 85.8, 95% CI: 79.3-92.9), mood disorder (91.2, 95% CI: 86.9-95.8 and 83.6, 95% CI: 75.1-93.1), psychotic disorder (67.1, 95% CI: 59.9-75.2 and 78.5, 95% CI: 67.6-91.1), CTO (84.6, 95% CI: 72.4-98.9) and STD (88.2, 95% CI: 78.6-99.0). Any Mixed Background women had higher hospitalisation from any psychiatric disorder (137.2, 95% CI: 110.9-169.6) and men and women had a higher risk of psychotic disorder (200.6, 95% CI: 105.7-380.7 and 175.5, 95% CI: 102.3-301.2), CTO (263.0, 95% CI: 105.4-656.3), ED (245.6, 95% CI: 141.6-426.1) and STD (311.7, 95% CI: 190.2-510.7). Indian women had lower risk of any psychiatric disorder (43.2, 95% CI: 28.0-66.7). Pakistani men had lower risk of any psychiatric disorder (78.7, 95% CI: 69.3-89.3), and higher risk of mood disorders (117.5, 95% CI: 100.2-137.9). Pakistani women had similar risk of any psychiatric and mood disorder however, a twofold excess risk of psychotic disorder (227.3, 95% CI: 195.8-263.8). Risk of STD was higher in South Asians (136.9, 95% CI: 109.0-171.9). Chinese men and women had the lowest risk of hospitalisation for any psychiatric disorder (35.3, 95% CI: 23.2-53.7 and 44.5, 95% CI: 30.3-65.5) and mood disorder (51.5, 95% CI: 31.0-85.4 and 47.5, 95% CI: 23.2-97.4) but not psychotic disorders and higher risk for CTO (181.4, 95% CI: 121.0-271.0). African women had higher risk of any psychiatric disorder (139.4, 95% CI: 119.0-163.2). African men and women had the highest risk for psychotic disorders (230.8, 95% CI: 177.8-299.5 and 240.7, 95% CI: 163.8-353.9) and were also overrepresented in STD (214.3, 95% CI: 122.4-375.0) and CTO (486.6, 95% CI: 231.9-1021.1). Differences in hospitalisations were not fully attenuated when adjusted for car ownership and housing tenure and the effect of these adjustments varied by ethnic group. CONCLUSION: Our data show disparate patterns of psychiatric hospitalisations by ethnic group in Scotland providing new observations concerning the mental health care experience of Chinese, Mixed background and White subgroups not fully explained by socioeconomic indicators. For South Asian and Chinese groups in particular, our data indicate under and late utilisation of mental health services. These data call for monitoring and review of services.

Consideration of ethnicity in guidelines and systematic reviews promoting lifestyle interventions: a thematic analysis.

BACKGROUND: There is a growing body of evidence supporting lifestyle interventions for the prevention of chronic disease. However, it is unclear to what extent these evidence-derived recommendations are applicable to ethnic minority populations. We sought to assess the degree of consideration of ethnicity in systematic reviews and guidelines for lifestyle interventions. METHODS: Two reviewers systematically searched seven databases to identify systematic reviews (n = 111) and UK evidence-based guidelines (n = 15) on smoking cessation, increasing physical activity and promoting healthy diet, which were then scrutinized for ethnicity-related considerations. Evidence statements were independently extracted and thematically analysed. RESULTS: Forty-one of 111 (37%) systematic reviews and 12 of 15 (80%) guidelines provided an evidence statement relating to ethnicity; however, these were often cursory and focused mainly on the need for better evidence. Five major themes emerged: (i) acknowledging the importance of diversity and how risk factors vary by ethnicity; (ii) noting evidence gaps in the effectiveness and cost-effectiveness of interventions for ethnic minorities; (iii) observing differential effects of interventions where these have been trialled with ethnic minority populations; (iv) suggesting adaptation of interventions for ethnic minority groups; (v) proposing improvements in research on interventions involving ethnic minority populations. CONCLUSIONS: Despite increasing recognition of the challenges posed by ethnic health inequalities, there remains a lack of guidance on the extent to which generic recommendations are applicable to, and how best to promote lifestyle changes in, ethnic minority populations. These important evidence gaps need to be bridged and tools developed to ensure that equity and population context is appropriately considered within evidence syntheses.

Systematic review and meta-analysis of out-of-hospital cardiac arrest and race or ethnicity: black US populations fare worse.

BACKGROUND: Several studies have reported racial/ethnic variation in out-of-hospital cardiac arrest (OOHCA) characteristics, which engendered varying conclusions. We performed a systematic review and meta-analysed the evidence for differences in OOHCA survival when considering the patient's race and/or ethnicity. METHODS: We searched Medline and EMBASE databases up to and including 1 Oct 2011 for studies investigating racial/ethnic differences in OOHCA characteristics, supplemented by manual searches of bibliographies of relevant studies. We selected studies of any relevant design that measured OOHCA characteristics and stratified them by ethnic group. Two independent reviewers extracted information on the study population, including: race and/or ethnicity, location, age and OOHCA variables as per the Utsein template. We performed a meta-analysis of the studies comparing the black and white patients. RESULTS: 1701 potentially relevant articles were identified in our systematic search. Of these, 22 articles describing original studies were reviewed after fulfilling our inclusion criteria. Although 19 studies (18 within the United States (US)) compared the black and white population, only 15 fulfilled our quality assessment criteria and were meta-analysed. Compared to white patients, black patients were less likely to receive bystander cardiopulmonary resuscitation (OR = 0.66, 95%CI = 0.55-0.78), have a witnessed arrest (OR = 0.77, 95%CI = 0.72-0.83) or have an initial ventricular fibrillation/ventricular tachycardia arrest rhythm (OR = 0.66, 95%CI = 0.58-0.76). Black patients had lower rates of survival following hospital admission (OR = 0.59, 95%CI = 0.48-0.72) and discharge (OR = 0.74, 95%CI = 0.61-0.90). CONCLUSION: Our work highlights the significant discrepancy in OOHCA characteristics and patient survival in relation to the patient's race, with the black population faring less well across all stages. Most studies compared black and white populations within the US, so research elsewhere and with other ethnic groups is needed. This review exposes an inequality that demands urgent action.