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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Racism, Discrimination, the NHS and what else?
- L-F Ng (10 January 2003)
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Kudos to Mr. McKenzie
- Carol S. Rein, Philadelphia, PA 19124 USA (10 January 2003)
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Challenge to racism must continue
- Paramjit S Gill, Raj S Bhopal (18 January 2003)
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Racism, stress and Cardiovascular Disease
- Malcolm E Kendrick (20 January 2003)
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Why emphasise the role of racism?
- Kanchan J Bhan, Dipan N. Mistry (22 January 2003)
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Re: Challenge to racism must continue
- Kwame J McKenzie (22 January 2003)
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Re: Why emphasise the role of racism?
- Kwame J McKenzie (23 January 2003)
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No such thing as racism, then?
- Peter Morrell (23 January 2003)
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Racism's Impact on African-American's Health
- Ta'Shia Asanti, Rosalyn B. Harris (23 January 2003)
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Conceptualisation from Shakespeare's Othello
- Karl Marlowe (24 January 2003)
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Re: Conceptualisation from Shakespeare's Othello
- Kwame J McKenzie (27 January 2003)
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Racism and Aboriginal Health
- Ruby Kaul (26 February 2003)
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L-F Ng, Locum Consultant Medical Oncologist Beatson Oncology Centre, Glasgow G11 OPB
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Sir, Kwamie McKenzie states: "Racism stems from the belief that people should be treated differently because of a few phenotypic features. Racism can manifest as individual or group acts and attitudes or institutionalised processes that lead to disparities" I disagree in part. Discrimination stems from the perception of phenotypic characteristics i.e. outward differences. It is related to a basal human instinct of a perceived threat to one's wellbeing and survival. Racism also stems from the perception of genotypic characteristics. Discrimination is not racism but racism is deliberate and callously calculated discrimination. Our minds have to be discriminatory to make logical and practical decisions. Such decisions, if tempered with an intent may have racist implications but often, if disguised with a desire to improve another outcome, for example, the common one being "patient wellbeing", it remains immune from legal action from the defamation point of view. However, from the Race Relations Act point of view this may not be so. The Defamation Act in the UK and the Commonwealth is interesting because, it is silent on the "intent" of a slander except on the sections of "qualified privilege." It was a learned judge who ruled that it is not the intent but the fact of a libel or slander which does matter. In other words if one chooses to slander another, justifying it with the excuse of noble intentions will not do in the context of this being done outside the borders of qualified privilege. The fact that it has been done outside these confines is what determines whether slander is actionable. Hence, why does racism in its crudest and more refined forms continue to thrive across the nation? The answer is simple: proponents continue to get away with it. It would appear therefore that victims of racism should be skilled in collecting and collating solid evidence to support their claims and assertions. Linking it with innuendos of libel/slander may be strategy in tackling it. Better still, agencies and institutions may perhaps work on guidance along these lines. A lot of this is happening daily in the large beast called the NHS and can well deserve to be addressed objectively and opportunities denied to potential proponents. There remains no data on the morbidity this has caused. But, beware! In any defamatory action, the only material winners are the Solicitors. However, disputes of this nature must be vigorously pursued because of a simple basic principle: that every human being has an equal right of fair and free speech, of opportunity and to be treated reasonably. Thank God, in the UK, our defence societies often support us to protect our reputations. Also, with the way forward proposed by McKenzie, I support this entirely. Yours faithfully, L-F Ng, FRCP Competing interests: None declared |
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Carol S. Rein, Instructor Frankford Hospital School of Nursing, Philadelphia, PA 19124 USA
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I interested and enlightened by Mr. McKenzie's article. I teach Psychiatric-Mental Health Nursing, and I had been discussing cultural aspects of health care with my nursing students who will be entering their clinical rotations next week. Mr. McKenzie shed new light on the impact of racism, in that I have not conceptualized it as a chronic mental health stressor. I have noted in my 25 years of clinical practice that it seemed that more African Americans are diagnosed as psychotic, or with paranoid schizophrenia, than with mood disorders. I wondered whether this was a bias of the practicioners who make these diagnoses, because it did not seem likely to me that biological differences could be the sole explanation for this phenomenon. Mr. McKenzie gave me a new perspective for consideration, and a highly likely explanation at that. Although I do still believe that there are prejudices among the psychiatric community in terms of how diagnostic decisions are made, and that cultural differences between the physician and client may account for some of these, I now can consider that the unique psychosocial stressors of those experiencing or perceiving racism can, in and of itself, result in psychosis. Thank you for enlightening me. Competing interests: None declared |
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Paramjit S Gill, Clinical Senior Lecturer The University of Birmingham, Raj S Bhopal
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Dear Editor, As McKenzie highlights, emphasis to date has been on the role of racism in recruitment and career development. [1] This must continue despite initiatives and legislation such as the recent Race Relations Amendment Act [2], as racism still exists within the NHS. [3] We need to continue to challenge racism not only from our colleagues but also from our patients – there needs to be zero tolerance. [4] The importance of racism on health and health care will not diminish due to increasing migration to the UK particularly from Eastern European countries. The oft times hostile reception of the public, media and some politicians reinforces the negative attitudes prevalent [5] and these may manifest through acute and chronic stress to the detriment of the individual. Research on evaluating the mechanism for racism and health outcomes is in early infancy with the majority of the studies conducted in the USA. We agree with McKenzie that further funding is needed in this area. The biological models alluded to seem plausible but before investigating these further substantial research needs to be done first to define, measure and validate ‘racism’ as an epidemiological variable. Then we need studies to disentangle the effect of racism on health. Indeed there is urgency and opportunity to initiate a national ethnic cohort study within the planned UK Biobank study [6] to include examination of the effect of racism on health outcomes. 1. McKenzie K. Racism and health. BMJ 2003; 326: 65-66. 2. R. Bhopal. Racism in medicine. BMJ 2001; 322: 1503 - 1504. 3.http://www.legislation.hmso.gov.uk/acts/acts2000/20000034.htm (accessed 17/01/03) 4. Wildt de G, Gill P, Chudley S, Heath I. Racism and general practice - time to grasp the nettle. Br J Gen Pract (in press). 5. Modood T, Berthoud R, Lakey J, Nazroo J, Smith P, Virdee S, Beishon S (eds). Ethnic Minorities in Britain. Diversity and Disadvantage. London: Policy Studies Institute, 1997. 6. http://www.ukbiobank.ac.uk (accessed 15/01/03) Competing interests: None declared |
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Malcolm E Kendrick, Medical Director Adelphi Lifelong Learning Adelphi Lifelong Learning, Adelphi Mill Bollington SK10 5JB
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It has been recognised for a number of years that emigration is a major risk factor for CHD. This appears to be especially true for populations emigrating from one 'culture' to another. Currently, the group defined as Asian Indians have demonstated a huge rise is death rates from CHD, and this is particularly true when they move to Anglo-saxon/Christian countries e.g. South Africa, USA, UK. One can speculate that one of the major reasons for this rise in CHD is a sense of living in an 'alien' culture, and being subject to a huge amount of stress from racism - both expicit and implicit. It would be fascinating to study the physiolgical impact of emigration/racism on areas of the neuroendocrine system, specifically the HPA-axis and hypercortisolaemia. Competing interests: None declared |
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Kanchan J Bhan, SHO Ophthalmology Leeds General Infirmary, LS2 9NS, Dipan N. Mistry
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Dear Sir, McKenzie writes that ‘disparities between ethnic minority and majority groups in housing, education, arrests and court sentencing are believed to be due to racism…’.[1] This is not true for all minority groups. Jewish, Indian and Chinese communities living in the U.K. have excelled in educational and economic terms and display low levels of criminal activity.[2,3] Racism, therefore, should not be considered as a major causal factor for social and health inequality of ethnic minorities. Indeed, these inequalities exist within the majority community itself and racism clearly cannot account for this. Instead it is education and economics that are the major determinants of inequality and these are the factors that should be concentrated on in the public health arena. 1. McKenzie K. Racism and health: antiracism is an important health issue. BMJ 2003;326:65-6 2. Research topic paper: ethnicity in education, training and the labour market. Published by the Department for Education and Employment 2000 3. Statistics on race and the criminal justice system: a home office publication under section 95 of the criminal justice act 1991. Published by the Home Office (UK) 2000 Competing interests: None declared |
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Kwame J McKenzie, Senior Lecturer n6 5jq
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Dear Editor I would agree with Dr Gill and Professor Bhopal that the challenge to racism must continue and there needs to be zero tolerance. Racism is complex and so the response will need to be wide-based and in depth. There has been considerable research in the US and there is a growing literature in the UK concerning the nature of racism. There will always be a need to refine measures and deal with the difficulty of sacrificing validity for repeatability (which is a common problem in epidemiology), but there are a number of measures of perceived racism that have been used in large surveys and longer instruments supported by a robust literature that are being used in the UK. Ecological measures of racism are more in their infancy as are robust measures of institusional discrimination. I would support the need for a national ethnic minority cohort study to try to disentangle the effect of racism on health. However, I consider this to be something which would best be done separate to Biobank. I would specifically be concerned that the sample frame of Biobank would not be able to answer important questions concerning the effects of racism on groups such as younger people or pregnant women and the effects at an ecological level. It would not be able to cope with the changing demographics of black and ethnic minority areas and populations that may be important for the impact of racism on health. Others may be uncomfortable with the scientific paradigm within which Biobank sits and may call for consultation with black and ethnic minority groups. My view would be that an over sampling of people of black and ethnic minority communities in Biobank would seem useful so that subgroups are large enough for meaningful statistical analysis. I would consider this important for equity of access to this research effort. If the sample simply reflected the percentage of the population of ethnic minority groups over 45 in the UK then there may not be the power for sub-group analysis. It could be argued that the research would not have delivered equity because it is not as useful to minority groups and it could be argued that it is therefore discriminatory. I am unsure whether this could lead to a challenge under the Race Relations Ammendment Act. However, I do not think that oversampling should be confused for a proper research effort which specifically addresses the issue of racism and health. Biobank may be useful, but it is too limited to be the answer. Competing interests: None declared |
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Kwame J McKenzie, Senior Lecturer NW3 2PF
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The histories of specifc ethnic groups, the reception that they receive and the economic and macro-social processes at work will all conspire to racism playing out differently in different minority groups. This is underlined by educational achievement which is different for different South Asian groups in the UK. Not all South Asian groups do well! Study after study cited in the editorial demonstrate that even when socio-economic factors are taken into account racism is independently associated with a number of physical and psychological health problems (1). What this means in practice is that a similarly educated and similarly rich person say of Caribbean origin in the UK is less healthy than a someone who is white. Poverty is associated with poorer health but being from an ethnic minority group and poor is much worse for your health. There is ample evidence in the UK that there is discrimination in housing, education, job application, and in the police and justice system. The case for this does not need to be made and I am surprised that it has to be reiterated. That such discrimination does not lead to significant socio-economic inequality is hard to beleive. Racism has specific independent effects that require better research before anyone concludes that racism or socio-economic factors are more or less important. It is not whether socio-economic or racism should be investigated or concentrated on by public health, they should both be concentrated on. I am sure that the authors do not really believe that if everyone were to be equally well educated and equally paid there would be no racism? McKenzie K Racism and health: antiracism is an important health issue BMJ 2003 326 65-6 Competing interests: None declared |
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Peter Morrell, freelance researcher, history of medicine, UK ST4 2DG
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Sir, "Racism, therefore, should not be considered as a major causal factor for social and health inequality of ethnic minorities. Indeed, these inequalities exist within the majority community itself and racism clearly cannot account for this. Instead it is education and economics that are the major determinants of inequality and these are the factors that should be concentrated on in the public health arena." [1] If racism is more a function of socio-economic inequality, as Dr Bhan maintains, rather than of ethnicity, then how would Dr Bhan suggest tackling it? Presumably, this can only be tackled through educational and socio-economic enhancement measures of all people operating in society completely regardless of their ethnic background. This at least would seem to be the logical consequence of the position he has presented. [1] Kanchan J Bhan, BMJ letter, 22 Jan 2003, Why emphasise the role of racism? http://bmj.com/cgi/eletters?lookup=by_date&days=2#28995 Competing interests: None declared |
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Ta'Shia Asanti, Journalist, Author Urban Spectrum Newspaper, Rosalyn B. Harris
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I was very moved by the recent article by Dr. McKenzie on Racism and Public Health. As a journalist, author and civil rights activist I can attest to my personal experiences with racism and how it has affected my overall health. After launching a class action suit against a multi- million dollar corporation based on racism in the workplace, my health declined in such a manner that I was incapable of working. I was depressed, had severe insomnia, joint pain and had incidents of high blood pressure. Doctors were baffled, as I was clearly in good health before this happened. But being told by a recruiter that the company wanted to hire Americans only and when asked to define what she meant by Americans, being told, "Blonde hair, blue eyes and male," I was devastated. I can also attest to how racism has impacted my fellow colleagues. This includes not only their physical health but their mental health too. Racism effects Blacks in every area of their life including education, employment, law, religion, sex and war. Simple functions of life such as buying a car or home, getting a job, going to college, getting medical care, shopping for clothing or even walking down the street are influenced and affected by one's racial background. Its important to note that discrimination and racism are two different things. Discrimination, hate or dislike of someone can't determine the quality of their entire lives. As an African-American, I can dislike what someone from another race does, I can dislike an entire ethnic group, but I don't have the power to control the quality of their life experience. I can't decide where they'll live, go to school, get their education or the quality of their medical treatment. This is simply because either I nor any group of African-Americans control these areas. Racism is about power, power of one race over another, and it is clear in every sense of the word that Blacks do not have power on the planet earth. The stress induced by fear of racist treatment and experiences of racism has never been monitored or catalogued, yet it in itself contributes to illnesses that are frequent in Black populations such as high blood pressure and heart disease. In addition, as a result of poor nutritional habits handed down from slavery and generationally stemming from a lack of knowledge of nutrition, Blacks are among the high numbers of those with diabetes, colon cancer, prostrate cancer, fibroid tumors, and much more. The spraying of pesticides (drugs to kill roaches and rodents) in poor Black communities causes asthma and other respiratory problems and many other environmental illnesses. I hope that more studies are done in this area and that the medical community will begin to address the effects of racism on Black's mental health as well. Thank you, again, for publishing a truly informative and enlightening article by Dr. McKenzie. Ta'Shia Asanti Competing interests: None declared |
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Karl Marlowe, SpR in Psychiatry South London & Maudsley NHS Trust, London SW9
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Sir, McKenzie (1) discusses racism’s impact on mental health from recent research. It may be interesting to note the observation from 400 years ago in the writing of an archetype of European culture. Shakespeare identifies the impact of this association in the play Othello. He places a black man as a tragic hero who marries fair Desdemona, which causes her father to rant “to fall in love with what she feared to look on”. Even though Othello is a respected member of society and general, his enemy identifies that he inwardly feels alienated, is insecure and lives with the paranoia of the outsider. A perception of alienation transforms a confident and respected leader, to a path of violence via morbid jealousy. It is known that 2nd generation black people in the UK have increased rates of psychosis (2), even though for them there is no trauma of emigration to a new culture. It is from the ambivalence of seeming to be accepted but having a perception of being treated differently by society, which lies at the core of racial insecurity. Using this conceptualisation it may be worthwhile pursuing an inclusive public health policy rather than continue a divisive perception of separation, which maintains a them:us dichotomy. Reference 1.McKenzie, K 2003 Racism and health. BMJ, 326; 65- 66. 2. van Os, J, Castel, D.J. Takei,N., Der, G & Murray, R.M 1996 Psychotic illness in ethnic minorities from the 1991 census. Psychol Med, 26; 203-208. Competing interests: None declared |
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Kwame J McKenzie, Senior Lecturer in psychiatry N6 5JQ
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Dr Lowe is correct to cite Othello as an example of racism's effects on psychological health from 400 years ago. Another point worth considering is that Shakespeare wrote Othello for the masses and the play relies on the audience recognising and understanding common stereotypes of black men. These stereotypes were so prevalent in the seventeenth century that Shakespeare believed he was on firm ground and many, such as the stereotype of sexual appetite, are just as prevalent today. This our tragedy! Dr Lowe is correct that any public health policy would need to be inclusive. It also needs to target the problems in an imaginative way. For instance in smoking prevention strategies rightly started by targetting smokers. Latterly, nicotene patches have helped as has stigmatising smoking. Discussing the impact of passive smoking may be useful as may banning smoking from the work-place. Any public health response to racism would need to be similarly wide- ranging. It may target racism at both an individual and institutional level. It may try to decrease the impact of racism on individuals, and what about banning racism from the work-place? Public health policy is rightly based on need. There is a clear need for initiatives concerning racism. Racism is bad for everyone - it seems to effect the health of black and white, possibly through the way it undermines civilised society (1). That public health policy supporting anti-racism would be divisive is in my mind a mis-reading of the public sentiment. There is agreement from political parties that have over 95% support from the voting public that racism is wrong I am unaware of any survey produced in the last 20 years in which even a significant minority of people have stated that they think that racism is OK. Surely we can agree that there is a mandate for action to rid our country of this social cancer? Kennedy, B. P., Kawachi, I., Lochner, K., et al (Dis)respect and black mortality. Ethnicity and Disease, 1997 7, 207-214 Competing interests: None declared |
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Ruby Kaul, Epidemiologist Deaprtment of Health and Community Services, Alice Springs, NT 0871 Australia
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Racism and Aboriginal Health McKenzie has highlighted the association between racism, morbidity and mortality (1). I respond as an epidemiologist for Aboriginal health in central Australia. About 20,000 Aboriginal people live in Central Australia and most of them are in small communities scattered across the vast desert area. Aboriginal Australians suffer a disproportionate burden of ill health when compared to their non-aboriginal counterparts. Their life expectancy is about 20 years lower and 58% of Aboriginal deaths occur before the age of 55 (2). Their morbidity load is far greater than the non-aboriginals and the bulk of morbidity is due to chronic diseases such as diabetes, heart diseases, chronic obstructive airways diseases (COAD) and renal disease. From birth weight to life expectancy, there are glaring disparities in health indicators, between the two populations. Much of the research work in the past has been directed at socioeconomic status, cultural factors and position in the social hierarchy. Not much attention has been given to racism and its effects on health status. Editorial by McKenzie suggests that racism may be aetiologically important in the development of illness (3). Overt or implicit racial discrimination is recognised to be the underlying cause for poor health status (4). Although research based evidence is scant to demonstrate racism being the underlying cause for health inequalities in central Australia, there are some set backs in the system that may be aggravating the disparity and they are: * Inappropriate responses from health services
These factors may well be the consequences of intrinsic racism in the system. The disturbing health inequalities between Aboriginal and non- aboriginal population are acknowledged time and again but no appropriate action seem to be in place to address these problems and reduce the inequity gap. Requisite skills and knowledge to rectify these problems may be lacking among key managerial staff. I do hope the above factors are given serious consideration while planning services that would in turn generate effective solutions. Ruby Kaul, Epidemiologist, Department of Health & Community Services, PO Box: 721, Alice Springs, Northern Territory 0871, Australia. Reference: 1. McKenzie K. Racism and Health. BMJ 2003; 326:65-66. 2. The Health and Welfare of Territorians, Epidemiology Branch, Territory Health Services, Darwin 2001. 3. Gee GC. A multilevel analysis of the relationship between institutional and individual racial discrimination and health status. Am J Public Health 2002; 92: 615-623 4. Winnie MS. Statement of World Health Organization, Durban Sept. 2001 Competing interests: None declared |
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