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. 2001 Nov 10;323(7321):1125.

Racism in medicine

Regional arbitration panel may offer solution

B R Pal 1
PMCID: PMC1121607  PMID: 11725748

Editor—I applaud Bhopal for writing the truth about what each one of us has to face, personally and professionally during service in the NHS.1 It is time we all recognised that covert and overt racist practices occur within the NHS, and there needs to be an immediate arbitration panel in each region that can resolve issues speedily and hear both sides of disputes independently.

The Canadians have such a model, and it has been extremely effective in minimising, almost excluding, any racist practices in the health environment. I am from a family of doctors who have worked in the NHS for over 60 doctor years. Each one of us has suffered discrimination. I have always tried to place the personal insults behind me, hoping that my personal and professional abilities would show through. At junior level there was mutual tolerance. The transient nature of work provided relief without the need to speak out. But once I became a consultant, I experienced such gross discrimination that I was forced to resign (only 8% of consultant posts are staffed by doctors of non-white ethnic origin, and even fewer, 2.4%, are staffed by non-white women). Not one person in the trust I worked for thanked me or apologised. The illegal manoeuvres within employment laws were overlooked. I felt the only path open to me was through legal channels but found the legal arena of little help despite the race relations and human rights law. The NHS and those within it collude, have unlimited access to finance, and bring witnesses who are coached to commit perjury. The legal profession is no better; there is plenty of evidence for their institutional racism.

If doctors from an ethnic group speak out, they are seen as difficult, their jobs are placed at risk (which is reflected in references), or they are classified as psychologically unstable, thus victimised for standing up for justice and inducing fear in those who stand by and do nothing. We want to get on with our jobs, feel happy, and fulfil our potential. We are not just workhorses here: we should be given equal rights in the workplace. Someone should take heed and provide a path to quick resolution of any discriminatory incident, so that anger, hurt, insecurity, and discrimination can become history.

References

BMJ. 2001 Nov 10;323(7321):1125.

We need action, not more evidence

Pradip Singh 1

Editor—That racism is deeply entrenched in the NHS is obvious to anyone who cares to see. It does not need more and more evidence as the apologists of institutional racism in the NHS establishment insist, it needs action. Racism does not take the form now that Bhopal experienced as a junior doctor.1-1 It is, however, still pervasive, not all that subtle, and very effective at ruining the career of the people at the receiving end, but it does not take a verbal form.

When I came over to the United Kingdom, despite possessing a postgraduate degree in medicine from India and having passed the first part of the examination to become a member of the Royal College of Physicians, I did not get a single interview for a post as a senior house officer in medicine, not even a locum post, although I wrote hundreds of applications. It was only after I had passed the second part of the royal college's examination that I got my first job in medicine.

Later on in my career, despite good clinical experience in medicine and my specialty and good academic credentials (a research degree from a British university and a few publications in eminent journals), I applied for every single job as a senior registrar in my specialty for three years without getting a single interview. This was at a time when the job market in my specialty was actually quite favourable. But I had no chance until every possible home grown graduate (usually white), however inferior his curriculum vitae to mine, had a job and was not in competition.

One kind consultant wrote to the person then in charge of postgraduate medical education and training in England about me, inquiring why I was not moving up the ladder. His contribution was that he was surprised at my lack of progress and that he would be able to help if I changed my specialty and went into geriatrics. I treated his advice with a certain amount of contempt. I did eventually get a senior registrar job in my specialty, but that was purely through chance as I happened to come in contact with some very straight and fair minded consultants while doing a locum consultant job.

My experience is not unique. The NHS is harming itself by condoning, tolerating, and encouraging institutional racism. It is depriving itself of calibre and promoting a culture of mediocrity.

References

BMJ. 2001 Nov 10;323(7321):1125.

Institutional racism in the BMJ?

Paula McDonald 1

Editor—I was delighted to see that the important new book from the King's Fund on racism in medicine received good coverage in the BMJ, with a news feature and an editorial giving examples of casual racism during the author's career, as well as further coverage in Editor's choice.2-1–2-4 I was therefore astonished that you chose to publish in the same issue a list of terms used in job advertisements with facetious translations, including “interesting and varied case mix” “translated” as “half of the patients do not speak English,” and “multicultural environment” as “neither do the staff.”2-5

The report of the Stephen Lawrence inquiry defined institutional racism as the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin and pointed out that this may occur through unwitting prejudice, ignorance, or thoughtlessness. There could hardly be a better example of this than the publication of this letter. Sanctimonious editorials are not enough. If you are going to talk the talk, you should walk the walk. Otherwise we may not believe that you actually care that medicine is behind some other sectors in exorcising racism.

References

  • 2-1.Coker N, editor. Racism in medicine: an agenda for change. London: King's Fund; 2001. [Google Scholar]
  • 2-2.Gulland A. Ethnic minority doctors hit glass ceiling in NHS. BMJ. 2001;322:1505. . (23 June.) [PMC free article] [PubMed] [Google Scholar]
  • 2-3.Bhopal R. Racism in medicine. BMJ. 2001;322:1503–1504. doi: 10.1136/bmj.322.7301.1503. . (23 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-4.Editor's choice. Apoptosis and racism: a long time coming and a long time going. BMJ 2001;322 (7301). (23 June.)
  • 2-5.Campbell C. Job advertisements. BMJ. 2001;322:1547. . (23 June.) [Google Scholar]
BMJ. 2001 Nov 10;323(7321):1125.

Environment for open, constructive debate is needed

Nisha Dogra 1,2, Niranjan Karnik 1,2

Editor—We are a female physician who has grown up in the United Kingdom and a male sociologist in medical training in the United States, both of Indian origin. We are compelled to comment on the current debate about racism in the NHS. We wonder whether the lack of progress made is related to the failure to create an environment in which we can have constructive and open debate. There is clearly racism in the NHS and other institutions, but racism cannot be considered as an isolated issue as we have both experienced different forms of discrimination outside of race.3-1,3-2 This has often been at the hands of men from ethnic minority groups who want equality for themselves on the basis of race but are unprepared to give the same courtesy to others with differences.

As Bhopal says in his editorial, antiracism is best seen as a component of the struggle against oppression.3-3 Until we do that and work towards creating equality on all fronts (including sex, age, religion, disability, and sexual orientation), each group of minority or vulnerability will forward its own case without necessarily leading to the kind of broad culture in which equality is a given. However much we may try to separate out these forms of discrimination, they are interlinked at an institutional and societal level.

At Leicester University the component on race and cultural diversity of the human diversity module (other components include sexuality and gender, religion, and disability) has been shown to be effective in helping students to address personal prejudices early and start challenging their views of all kinds of people.3-4 There is a need to acknowledge that we all have prejudicial views of one sort or another before the impact of these views on professional practice can be addressed. A key to the success of this module has been the willingness of staff to broach sensitive issues and engage students in such a crucial dialogue. In the module, cultural awareness is not about denigrating the majority perspective, but about learning that we all need to have an awareness and sensitivity to cultures different from our own.

There is clearly a need for debate and action, at all levels, including personal and organisational. It is, however, important not to oversimplify the complexity of institutional oppression by focusing exclusively on one strand of this process.

References

  • 3-1.Coker N. Racism in medicine: an agenda for change. London. King's Fund, 2001.
  • 3-2.Carvel J. Secret government report finds racism flourishing in NHS. Guardian 2001 June 25;A1:4.
  • 3-3.Bhopal R. Racism in medicine. BMJ. 2001;322:1503–1504. doi: 10.1136/bmj.322.7301.1503. . (23 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3-4.Dogra N. The development and evaluation of a programme to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232–241. doi: 10.1046/j.1365-2923.2001.00734.x. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Nov 10;323(7321):1125.

Everyone should be treated with respect and dignity

Charles Essex 1

Editor—The NHS is not racist. Bhopal and most of the electronic respondents describing their experiences of working in the NHS do not have the experience of not being black.4-1 Except for comments made specifically about colour or race, they have been on the receiving end of horrible behaviour that most doctors have encountered.

I worked with a consultant who would not shake my hand when I initially introduced myself, theatre staff who despised me, an outpatient sister who turned against me because I did not respond to her flirtations, paramedical staff who badmouthed me to patients, and unhelpful and obstructive ward staff. In one post colleagues ostracised me for two years because I was promoted ahead of them, which they believed was because I was white and they were Asian (they also conducted a vendetta against the doctor who was promoted to acting head of the department; he was Asian). I have not been shortlisted for jobs I thought I was suitable for, not got jobs when I thought I was the best candidate, and the list goes on.

But I may not have been the best candidate, or the interviewers were looking for someone with different skills, or my behaviour or attitude may have engendered some of the hostility that I faced. This isn't “blaming the victim,” but I didn't see the curricula vitae of the other candidates who applied, and I have some responsibility in interpersonal relationships.

The NHS is staffed by imperfect people, many of whom have important needs of their own. Paradoxically in the caring professions, these people try to ameliorate their needs at the expense of colleagues and patients. Some prejudices (preconceived opinions of an individual based on opinions about the many) have names—such as racism, sexism, or ageism. Other neologisms could be doctorism, surgeonism, or obstetricianism. These are only descriptions of unpleasant, unassertive, dishonest, or unprofessional attitudes.

A sign in one waiting room said, “We promise to treat you with respect and dignity irrespective of your race, age, sex, gender, or sexual orientation.” Why not treat everyone with respect and dignity, irrespective of anything? Prejudice of all types must be challenged, firstly, within ourselves and, secondly, by people at every level of every discipline. Derogatory generalisations reflect prejudices that are unacceptable in all walks of life but especially in the caring professions and especially by those who are in positions of authority and influence.

References

BMJ. 2001 Nov 10;323(7321):1125.

Evidence base is needed

J V R Barbour 1

Editor—Like Dadabhoy, who was quoted in Gulland's news item on ethnic minority doctors and the glass ceiling in the NHS, I am a general practitioner.5-1 Like him, while a junior doctor, I explored the possibilities of a specialist career but made very little progress.

I could try to claim that this was because I was a man from Northern Ireland working in the south of England, but the truth was otherwise. My consultants recognised that I was temperamentally unsuited to the life of a general surgeon and that I could not lay claim to above average physical dexterity. Also I have to admit that I was rather slow in shedding some rather adolescent personality characteristics. (Indeed, the fact that I embarked on posts as a surgical senior house officer was prompted by a temporary period of concern, soon after I qualified, about whether I could manage to get satisfaction from looking after people with chronic disorders who were not going to get better. In general surgery the contact with the patient seemed more decisive, and more limited, and more glamorous.)

I have now been in general practice for 20 years; although I often feel overworked, quite often frustrated, and occasionally simply frightened, my life is free of boredom and I enjoy a good income. I trust the outcome for Dadabhoy has been as satisfactory.

The period of surgical involvement has stood me in good stead in several ways. A particular stroke of luck while I was doing a course for the final examination to become a fellow of the Royal College of Surgeons was meeting a female registrar recently arrived from India. We became friends, and, after a couple of years, she agreed to marry me. I do not believe that her rise to her current rank of professor in her specialty was greatly delayed by her being Indian.

Like Bhopal, your editorialist (who I note in passing has also reached the rank of professor), I am all for extirpating racism in medicine, if it can be found.5-2 Neither the news item nor the editorial contain much more than anecdotes. The medical profession may have to admit to being chronically, hopelessly institutionally racist, and if so, then our antagonists in government and the press will have another stick with which to beat us. But if we are going to adopt a self lacerating stance on this issue, can we not at least have evidence based self laceration?

References

BMJ. 2001 Nov 10;323(7321):1125.

Author's summary of responses

Raj Bhopal 1

Editor—The issue of racism in medicine sparks interest and passion, as testified by nearly 6000 internet hits, over 40 rapid responses,6-1 about 10 personal letters to me, and at least five newspaper articles in response to my editorial. I predicted that some hearts would sink at the article, but I judge that more spirits rose than sank.

Comment fell into four unequal categories.

(1) The majority view was that there is indeed pervasive racism in medicine and it is right to open up the issue. The testimony in the letters, together with that already in the landmark book from the King's Fund and in earlier writings,6-2 points to the anger, frustration, and hurt caused by injustices perceived as arising from racism.

(2) A substantial viewpoint was that there is a problem but it should be kept in perspective because either progress is being made or the position is better than in other countries. Although this may be true, such arguments could impede progress.

(3) An important but minority view was that racism is innate or inevitable (“Chin up, guys,” says Menezes).

(4) Hostility to the principles and specific proposals in my editorial was rarely expressed. The crucial, and perhaps, unanswerable question is whether those who are hostile are disinclined to respond. Abbott defended the institutions of “those natives whose ancestral DNA is buried in the soil of these islands” against being labelled racist, blamed illegal residents for draining the NHS, and suggested that those legally in this country “bother to learn English.” (My mother's English remained broken, despite her passion for education, which was fulfilled through her children, seven of whom graduated from university.)

The dialogue must continue, and there is much to be gained from examining the spectrum of opinion. Abbott's indignance, Morrell's scholarly stance, and the cries for justice from most correspondents, all have a place as we merge research and opinion and work to free the world from the grip of racism. Overall, most people now seem to accept we have a problem—the key step to a solution.

References

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

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