Racism in medicine
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1503 (Published 23 June 2001) Cite this as: BMJ 2001;322:1503All rapid responses
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In Bhopal References Editor,
Racism in Medicine
The issue of racism in medicine is sparking interest and passion as
testified by nearly 6000 internet 'hits', over 40 rapid responses, about
10 personal letters to me and 5 newspaper articles (to my knowledge) in
response to my BMJ editorial (1). I predicted that some readers' hearts
would sink at the article, but I judge that more readers' spirits rose
than sank.
The commentary fell into four unequal categories.
(a) The majority view was that there is indeed pervasive racism in
medicine and we are right to open up the issue. The testimony in the
letters, together with that already in the landmark King's Fund book (2),
and in earlier writings, points to the anger, frustration and hurt caused
by injustices perceived as arising from racism.
(b) A substantial viewpoint is that there is a problem but it should be
kept in perspective because either we are making progress or the position
is better than in other countries. Whilst this may be true, such arguments
may impede progress.
(c) An important but minority view was that racism is innate or inevitable
("chin up guys," says Menezes).
(d) Hostility to the principles and specific proposals in the editorial
was rarely expressed. The crucial, and perhaps, unanswerable question is
whether the hostile are disinclined to respond. Abbot 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 our 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. Abbot'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.
Raj Bhopal
References
1. Bhopal R Racism in Medicine BMJ 2001;322:1503-4
2. Coker N (Editor). Racism in Britain. An agenda for change,
London:King's fund, 2001.
Competing interests: No competing interests
Let us accept that racism in the NHS reflects the racism in wider
British (wider-wider Western) society.
...that it is due to ignorance and misunderstanding about the history of
past 5 centuries.
...that if all professionals discharged their duties professionally, the
discrimination would subside over (a long long) time, and
...that the local healthcare-recepients (with or withour interpreters!)are
the MOST to benefit.
Paradoxically, there is a higher proportion of the ethnic minority
races among the providers of the NHS-healthcare than the demographinc
constitution of UK; and probably higher than any other trade/profession.
Just imagine the plight of the minority races in other
trade/professions e.g. police, teachers, solicitors; where they are under-
represented.(I believe they are non existant in the government and senior-
industry-excutives..)
Competing interests: No competing interests
Dear Editor,
It was interesting to read this comment coming from a practitioner in
the US of A.
The % 'wastage' of NHS resources for the FREE healthcare to foreign-
visitors (including those of white Caucacian race!) is minimal.The system
is such that non-English speaking members of EU are entitled to reciprocal
FREE healthcare and most od them do not know English.
Let's come to point under discussion: RACISM in the (WEST in general)
NHS (in particular):
The last 5 centuries of Industrial West / WASPs are bloodied with
their exploitation of the other three continents, where they looted,
pillaged, plundered and raped frreely before locking themselves behind the
arbitrary doors of Immigration and Nationality. They also created the IMF
& the World Bank to laon a part of the loot to the impoverished
colonies to perpetuate global inequality.
It could be argued that
<< the huge capital wealth of UK is a loan 'eXtracted' from the eX-
colonies (from where most of the 'foreigners' come to UK ) and the NHS
resources 'wasted' for the FREE healthcare to foreign-visitors are an
incalculable miniscule % of 'apology-interest' payment for the plunders
and blunders of the past...>>
Where is the WASP ancestral DNA burried, one wonders...
A legal resident 'foreigner' contributor to the NHS.
Competing interests: No competing interests
Dear Sir,
It is with great interest that I read the editorial by Prof. Raj
Bhopal: ‘Racism in Medicine’ (BMJ 23rd June). Equally excellent were many
of the rapid responses, revealing the depth of feeling among individuals.
As the Overseas Doctors Representative in the West Midlands region, I
attend the Higher Training Committee meetings and I will like to take this
opportunity to provide an insight to some of the problems faced by
overseas doctors in my region which I believe apply equally to other
regions in the UK.
The current system in obstetrics and gynaecology means that most
overseas doctors end up in Type II or Fixed Term Training Appointment
(FTTA), which does not lead to certification nor has any international
recognition. Therefore if they do stay in this country they are destined
to a life of NCCG or Staff Grade. There are those in the region who are
already in Years 4 and 5 (Stage 2) on the FTTA programme. They have had
exactly the same training and gone through yearly assessments as their
colleagues in Type I programme but have been told they will not be given
CCST by the Specialist Training Authority because they were not appointed
in ‘open’ competition i.e. the Type II appointments were only open to
overseas (including EEC) trainees but not UK residents. The advice from
the STA is that these trainees should apply for Type I post in open
competition, as it is equal opportunity.
However as already mentioned in the rapid responses by Dr Hedge2 and
Vijayakumar3 most trainees know that equal opportunities in the current
NHS is a myth, but to prove the point the above mentioned group of
trainees applied for the Type I post in obstetrics and gynaecology
advertised in the BMJ, 26th May 2001. The posts advertised were for Years
1to 5, and the person specification for the Years 4 and 5 (Stage 2) posts
stated that, the minimum requirements were MRCOG and 3 years of Registrar
training. Predictably these trainees were not shortlisted. In fact their
applications were not considered at all. The explanation given was that
they did not qualify for Stage 1 posts (Years 1-3) as they were over
experienced to be competing in this category and it would be unfair to be
competing with less experienced people. At the same time they were not
shortlisted for Stage 2 (Years 4-5) as only 1 year out of the 4 years of
FTTA training will be considered towards a Type I training. This is in the
same region where they are currently working and shouldering
responsibilities as Year 4/5 trainees, but are not qualified to enter into
a training programme that would grant them a proper certificate i.e. CCST.
In other words they continue to shed sweat so that local trainees could
train in the SpR grade while they are destined to life as Staff Grades.
This is not a knee-jerk reaction but I believe the time is ripe for
overseas trainees to stand up for themselves and fight for what is right
and just. The issue of marginalisation, discrimination and
institutionalised racism in the NHS needs to be addressed honestly and
justly. It is high time that training issues are separated from
immigration issues. For those still in doubt, can anybody explain the
following West Midlands statistics to me - NTN 28, VTN 3, FTTA 57. How
equal is equal opportunity?
Yours sincerely,
Mr O.O.Sorinola
Overseas representative,
West Midlands Region
Specialist Registrar Obstetrics and Gynaecology,
Birmingham Women’s Hospital,
Edgbaston, Birmingham
B15 2TG
E-mail: sorinola@talk21.com
References
1. Bhopal R. Racism in Medicine. B M J 2001; 322: 1503-1504
2. Hedge S. Equal opportunities: myth or real? BMJ 2001; 322. Rapid
electronic responses
3. Vijayakumar K. Equal opportunities: myth or real? BMJ 2001; 322. Rapid
electronic responses.
Competing interests: No competing interests
Dear Sir,
I take pride in my capacity for tolerance generally, but the
following remark by David Abott is hard to accept at face value:
"No check is made to see if the people using it are legal residents of
this country and entitled to do so. Thus the door is wide open for illegal
residents and relatives and friends of legal and illegal residents and
other visitors to freely use the service which is paid for by the long-
suffering British taxpayer"
Can the author who made this remark support his allegation with some
references? I wonder!
Sudheer Manthri.
MBBS MS FRCS
Competing interests: No competing interests
Dear Sir,
Those natives whose ancestral DNA is buried in the soil of
these islands have become used to our institutions being
labelled racist. But to accuse the NHS of being racist is
extraordinary. The system is overused and underfunded, yes.
No check is made to see if the people using it are legal
residents of this country and entitled to do so. Thus the
door is wide open for illegal residents and relatives and
friends of legal and illegal residents and other visitors to
freely use the service which is paid for by the
long-suffering British taxpayer. This use of the system by
ineligible foreigners drains resources from legal citizens.
Now Professor Raj Bhopal (BMJ, 23 June 2001) wants to
further encourage these abuses by insisting that the NHS
provide interpreters for those who do not know English.
Perhaps those legally in our country could bother to learn
English--hundreds of millions around the world have; until
they do, they must take an interpreter with them when they
visit the doctor or hospital, either a family member who
knows English or an interpreter they pay for themselves.
This is a simple and reasonable way to handle the situation.
Expecting the NHS to interpret dozens of different languages
is political correctness gone mad.
This issue points to a larger concern: we cannot afford to
provide health care for everyone regardless of eligibility.
Emergency care is one thing. Cataract extractions,
infertility treatments, translators, etc., cannot be
extended to people from all corners of the globe who have
not contributed to the system and are not eligible for
treatment.
Sincerely yours,
David F. Abbott, MD,
Kingsmere Meadow,
Shawford, Winchester SO21 2BL
davidfabbott@btinternet.com
Competing interests: No competing interests
dear editor,
i read with interest the article by ramakrishnarao r . i always knew
there would be someone who likes to play for the gallery as they say. he
clearly misses the point which the article is trying to bring forth. this
discussion is not a comparative study about the prevailing degrees of
racism in India V/S UK. the problem is indeed rampant in india but should
that mean that we should sit quiet and accept whatever treatment we get
here as appropriate. another point he has missed completely is the borne
form the fact that he is doing a SpR training in a speciality which is
''still up for grabs''in this country,so is the case with specialitties
like geriatrics, psychiatry, microbiology. so what happens Dr ramakrishna if
you happen to be a obstetrician or a gastroenerologist ??.
the carry home lesson is that racism in whatever form is reprehensible and
should be stopped, be it in india,UK or papua new guinea .
let us not sit over these reports which sprouts up in the press time and
again.
let us have some more objective way of testing a candidates skill when it
comes to giving a job at the sho/Spr levels.
Competing interests: No competing interests
Dear Editor,
In view of the recent body blows (eg Bristol, Alder Hey)to the NHS
the informative editorial (1) by Professor Bhopal (23 June) on racism in
medicine deserves further comments.
From 1972 I was in the UK doing my A levels, university, then
postgraduate training before, for family reasons, accepting a consultant
position in this country in 1989. During my 6471 days in the UK I
encountered obvious racism on three occasions. 3 episodes in 6471 days;
truly supporting the statement “I have preferred to emphasise the
thousands of positive interactions, rather than dwell on the relatively
few negative ones”. In any racist encounter one condemns the act but one
needs to be generous and fair enough to remember that the overwhelming
majority of one’s colleagues will find it just as hateful. During my time
in the UK I (and many fellow overseas colleagues) were impressed by and
grateful for the universal practice of meritocracy; also evidenced by the
Professor Bhopal's academic appointment in an august university.
Let’s also remember that intra-racial discrimination also occurs, as
described by Ramakrishnarao(2) in Rapid Responses. Racism is never
unidirectional. There are Asians, including my beloved late grandfather,
who feel that their cultures are superior to the Western ones.
I am not suggesting that there is no room for improvement. Some of
your readers may not be aware that every year March 21st is International
Day for the Elimination of Racial Discrimination; or should that be
International Day for Elimination of Discrimination?
Yours sincerely,
THHG Koh FRCPCH FRACP
Senior Staff Specialist in Neonatal
Paediatrics
Kirwan Hospital,
Townsville,
Great Barrier Reef, QLD 4817, AUSTRALIA
guan_koh@health.qld.gov.au
1. Bhopal R. Racism in medicine. BMJ 2001; 322: 1503-1504.
2. Ramakrishnarao R. Racism in Medicine my experience.
http://www.bmj.com/cgi/eletters/322/7301/1503#EL12 (June 23 2001)
Conflict of interest: The author is not colour blind and has no aims
to further his career.
Competing interests: No competing interests
Peter Morrell concluded his last e-response (1) thus: “…although
small pockets of racism may always be found, one has to be quite hopeful
that most of it will decline in the next 30 years or so”.
Would Peter Morrell be so kind as to tell us how he obtained this
quite precise figure of “30 years or so”? Which part(s) of the world
do(es) this figure concern?
Competing interests: No competing interests
Institutional Racism -- An Academic View
I have followed the exchange in your journal on the presence of
racism in the practice of medicine with great interest. As a PhD student
of Asian-American descent, a woman born and grown up in the United States,
and having worked in 6 of the 7 continents over the last 8 years, I can
attest to the presence of racial and gendered exclusionary practices in
most places in the world. I can also personally many instances where
individuals -- citizens, administrators, and noncitizens, marginalized
people, and so on -- went out of their way to help me, both within
institutions, as well as in the context of interpersonal interactions,
that go beyond color and gender lines. However, the debate, it seems to
me, needs to be informed by the extensive scholarship in the social
sciences and humanities on the pervasiveness of race and racial projects
(cf. Omi & Winant 1994) in structuring social relationships.
First of all, race is a pervasive structuring element in modern,
postcolonial society. _Race_ is understood as a socially constructed
category that creates differences marked on phenotype (this can mean
visible, physical, as well as microbiological, or other phenotypical --
piercings, mannerisms, clothing -- characters). Race as an idea arises
from European contact with other brown, black, red, yellow folk in the
Americas, and as a concept is redefined and expanded with subsequent waves
of colonization, colonialism, imperialism, and the Washington and
postWashington consensuses. For more detailed discussion of the genealogy
of this concept, see Omi & Winant 1994, Cornel West 2001, WEB Du Bois'
Black Reconstruction, published around 1934.
Racism can be personal and individualized, but it also has pervasive
institutional forms, which are much more than the simple sum of individual
acts. Often, current legislation is ill-equipped to deal with racism at
the institutional level, and thus focuses deabte and legislation and
policymaking at the level of interpersonal relations.
Institutional racism has been attempted to be addressed through
policies such as affirmative action. This is important because it takes
into account the history of past injustice in order to try and correct for
it in the present.
The existence of racism in groups that are not white does not justify
or naturalise its existence, rather, it shows the pervasiveness and
acceptance of structures of political and ehtical thought that allow for
domination in social relations.
However, racism, whether institutional or personal, has effects that
are _societal_. Exclusions of women, of brown people, or poor people, as
well as the naturalisation of those differences results in a society that
makes white male elite privilege invisible, and also can prevent alliances
between people in similar situations that perceive themselves as
different, thus preventing effective challenges of power, or social
change. Which is, I presume, what we are talking about -- the need for,
and the best avenues by which to approach, a little bit of social change,
in the places where we work. Thus it is in the best interest of most of
us to create, progessively, environments where we can talk openly about
(a) the existence of biases in practice, in hiring, and so forth, and (b)
ways in which to remedy perceived injustices, change policies that prevent
integration, and achieve the goal of more diversity in our institutions.
This includes creating groups where people can learn to think and
talk about racial issues, in all their complexity, and where those who are
most threatened by questions of race can learn to listen and talk about
it. In the process of learning well over a century's worth of serious,
academic, intellectual thinking on issues of race and societal relations -
- which is not to make invisible the value of personal experiences, but
rather, to place them within a much broader historical, political, social
and economic context -- I think the medical professions are in a
particularly interesting place to think about the relevance of those
studies to their own profession, the impact on patients -- this is well-
documented in the United States, where medical practictioners with social
compentencies and language skills, as well as cultural competencies, that
are not necessarily coded by race, practice and relate with their patients
very differently, with measurable differences in health care quality.
In fact, I would argue that if the medical establishment were to take
the issue of race and racism seriously, it would commission a series of
social scientists to work with medical practictioners and policymakers
understand and identify sources of racism, the effects of racism in
practice and health care, and to think seriously about a plan for
implementation that would attempt to cahnge the dynamics that so many
people have identified.
Sincerely,
Diana Wu
Competing interests: No competing interests