Racism: the other pandemicBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2303 (Published 11 June 2020) Cite this as: BMJ 2020;369:m2303
All rapid responses
COVID-19 Pandemic tragic octad: the evolving conceptual qualitative interventional equation to fight the pandemic
The ‘COVID-19 Pandemic’ is a ‘21st Century Enigma/ Unprecedented Ravaging Public Health Storm’ to be ‘Weathered for Our Common Humanity’ ! As a ‘Rapidly Dynamically Transmuting Scourge’, it readily excites ‘Interconnectedness’, as a ‘COVID Phenomenon’, with various ‘Human Existential-Developmental Possibilities’ !! The ‘On-going George Floyd’-induced ‘Global Black Lives Matter Movement’ amplifies ‘Racism’ in several aspects of ‘Human Existential-Developmental Realities’!! Ipso facto, ‘Racism’ is another ‘COVID Phenomenon’ !! Indeed, the ‘COVID-19 Pandemic’ and ‘Racism’ are both ‘COVID Phenomena’ and are ‘Intertwined Dyadic Unprecedented Human Devastations’!!! Beyond the ‘COVID-19 Pandemic’, ‘Racism’, ‘The Other Pandemic’, is ‘Another 21st Century Pandemic’ ; ‘COVID-19 Pandemic’ cannot be tackled without tackling ‘Racism’: Both are ‘COVID Phenomena’-‘Intricately Intertwined’!!!
With the WHO Definitions of Health (1948, 1984), ‘Health’ and ‘Holism’ are amplified for appreciating ‘Global Holistic Health’ for ALL Peoples so that ‘What Affects ONE Affects ALL’! Any ‘Discrimination-Non-Inclusiveness’ against any ‘Segment of Humanity’ implies compromised ‘Global Holistic Health; ‘Ethnic Minorities Issues’ are, therefore, the ‘Arrowheads’ of ‘Global Mass Movements’ against ‘Racism’ in the ‘COVID-19 Pandemic Era’!! Indeed, ‘Racism in Medicine’ was the ‘BMJ Special Issue Conversational Thrust’ with a highlighted ‘Case-in-Point’ : ‘Why Equality Matters to Everyone’ in the ‘Racism in Medicine Conversation’!!!
For ‘Programmatic Interventional Expedience’ in the ‘Global Fight’ against the ‘COVID-19 Pandemic’, ‘Racism’ is a ‘Public Health Problem’ and ‘Ethnic Minorities’ are located at the ‘Centre’ of the ‘COVID-19 Pandemic’! It is apposite to regard ‘Racism’ as ‘Structural/ Systemic Societal Anomaly’! The Public Health England (PHE) has, in fact, been criticized for not amplifying the ‘Determinant Role and Importance’ of ‘Racism’ in its Report on the ‘COVID-19 Pandemic’ !! The ‘BMJ Special Issue’ induced the ‘NHS Response’: ‘Launched Race and Health Observatory’ !! It needs to be re-emphasized that to successfully ‘Fight’ the ‘COVID-19 Pandemic’, ‘Racism’ MUST be in ‘Inseparable Dyadic Intertwining’ with the ‘Pandemic’!! Thus, the current ‘Communication’ disposes the ‘COVID-19 Pandemic Tragic Octad’ and the ‘Conceptual Qualitative Interventional Equation’ to assure ALL ‘Pandemic Dimensions’ are addressed in envisioned ‘Pandemic Interventions’!!!
A previous ‘Communication’ exposed the ‘COVID-19 Pandemic Quadruple-barrel Tragedy’ disposing ALL Four Dimensions that MUST be addressed in the ‘Pandemic Fight’ ! As the ‘COVID-19 Pandemic’ is ‘Rapidly Dynamically Transmuting’ in ‘Various Dimensions’, the ‘Quadruple-barrel Tragedy’ is rapidly transformed to the ‘COVID-19 Pandemic Tragic Octad’ disposing the ‘EIGHT Dimensions’ that MUST be similarly addressed!! A ‘Tantalizing Teaser’ will be disposed to amplify the ‘Determinant Role and Importance’ of each of the ‘Eight Dimensions’ in the ‘COVID-19 Pandemic Tragic Octad’:
1. SARS-CoV-2 Peculiarities (A, a): The peculiar ‘Unprecedented Rapidly Dynamically Transmuting Novel Coronavirus’, ‘SARS-CoV-2’, was ventilated in previous ‘Communications’ [9-11]! There are ‘Issues’ of ‘Nomenclatural Exactitude’ for the ‘Novel Coronavirus’ and, with ‘Encapsulating Politics’, have implications for ‘Successful Impactful Interventions’ against the ‘COVID-19 Pandemic’. Being a ‘Novel Virus’ means there is no ‘Human Immunity’! Other ‘Issues’ are the ‘Origin’, ‘Natural Biological Agent’/ ‘Human Biological or Economic Terrorism Agent’, ‘Genomic Diversity’, ‘Viral Recombination Capacity’, ‘Lethality’, ‘Transmissibility’, ‘Droplet/ Aerosol-mediated Transmission’, ‘Vaccine Production Diversity Challenges’ etc have posited ‘Interventional Difficulties’ in the ‘Pandemic Fight’ [9-11]!!
2. COVID-19 Pandemic (B, b): The ‘Interventional Difficulties’ encountered with the ‘COVID-19 Pandemic Fight’ were disposed in previous ‘Communications’ and MUST be addressed in successfully ‘Weathering the Storm’ [1, 12-14]! The peculiar ‘Pandemic Challenges’ include, among others: Analytics, Diagnostics, Therapeutics, Holistics, Changing Manifestations, Differential Population Susceptibilities, Face Masks Use Controversy, Optimal Social Distancing Requirement etc [15-18]!!
3. COVID-19 Infodemic (C, c): With ‘Appropriate Information’, People are empowered to ‘Take Right Decisions’ and ‘Facilitated to Effect Desired Actions’. In contradistinction, the ‘COVID-19 Infodemic’ constitutes ‘Misinformation Pandemic’ that MUST be aggressively countered in the ‘Pandemic Fight’ [12,13]
4. COVID-19 Research Waste (D, d): The ‘Rapidly Dynamically Transmuting Pandemic Specifics’ engender a ‘Deluge of COVID-19 Research’ but, with the ‘Compromised Foundational Pillars/ Principles’ of ‘Research and Data Governance’, dispose ‘Poor Quality Research Output’: ‘COVID-19 Research Waste’ [19-21]! This MUST be addressed in the ‘Pandemic Interventions’!!
5. COVID-19 Pandemic Interventional Precocity in Easing Lockdowns (W, w): In a previous ‘Communication’22, the ‘Disastrous Implications’ of ‘Precocious Easing of Lockdowns’ were explicitly ventilated and are inimical in the ‘Pandemic Fight’!
6. COVID-19 Pandemic Racial Disparities and Other Population Diversity-related Inequalities-Inequities (X, x): The ‘Raging Devastating Storm’ of ‘Racism’ is obvious from previous ‘Communications’ [3-7]! ‘Racial Disparities’ are implicated in the ‘COVID-19 Susceptibilities’, ‘Disease Severity’, ‘Critical Care Prioritization’, ‘COVID-19 Deaths’ etc!! Other ‘Population Diversity’-related Disparities are ‘Age’, ’Sex’, ‘Pre-Existing Medical Conditions’, ‘Economic Status’ etc and MUST be appropriately addressed!!
7. COVID-19 Pandemic Containment-Mitigation Measures Compliance (Y, y): The general level of compliance with the ‘COVID-19 Pandemic Containment-Mitigation Measures’ has implications for the ‘Pandemic Fight’! With ‘Politically-motivated Non-Compliance’, the ‘COVID-19 Epidemic Curves’ are being distorted globally with ‘Surges’, ‘Resurgences’ and ‘Failure to Flatten the Curves’ etc!! For ‘Weathering the Storm’, COMPLIANCE with the ‘Containment-Mitigation Measures’ is a Sine Qua Non!!
8. COVID-19 Pandemic-induced Non-COVID-19 Cases Neglect (Z, z): The mandatory forced attention to ‘COVID-19 Pandemic’ implies ‘Less Attention and Care’ for ‘Non-COVID-19 Cases’ with the POTENTIALITY for ‘Surges’ and ‘Resurgences’ of the ‘Other Morbidities’ [23,24]! This MUST be addressed in the overall ‘Population Holistic Health’ in the ‘COVID-19 Pandemic Era’!!
The ‘COVID-19 Pandemic Tragic Octad’ is amplified in the ‘Conceptual Qualitative Interventional Equation’ evolved to dispose the ‘Pandemic Dimensions’ that MUST be addressed in the ‘Pandemic Fight’. The ‘Interventional Equation’ also disposes the ‘Total COVID-19 Cases (T) and Deaths (t)’, ‘Specific Dimensions-related COVID-19 Cases (A, B, C, D, W, X, Y) and Deaths (a, b, c, d, w, x, y)’ and ‘COVID-19-induced Non-COVID-19 Cases (Z) and Deaths (z)’ and is disposed hereunder:
1. T = A + B +C + D + W + X + Y + Z (For Total Cases (T) and Specific Dimensions-related Cases)
2. t= a + b + c + d + w + x + y + z (For Total Deaths (t) and Specific Dimensions-related Deaths)
This ‘Communication’ disposes the ‘COVID-19 Pandemic Tragic Octad’ to assure that ALL Dimensions of the ‘Pandemic’ are addressed in mounting ‘Pandemic Interventions’ for a ‘Win’ in the ‘War’ against the ‘COVID-19 Pandemic! This is an ‘Appropriate Programmatic Pandemic Interventional Tool’!!
1. Godlee F. COVID-19: Weathering the storm. BMJ 2020; 368:m1199 of 26th March 2020
2. Eregie CO. COVID Phenomenon: An innovative conceptual coinage in human development and sustainable development in the 21st Century. https://www.bmj.com/content/368/bmj.m1199/rr-17 of 9th April 2020
3. Godlee F. Racism: the other pandemic. BMJ 2020; 369:2303
4. Adebowale V, Rao M. Racism in medicine: why equality matters to everyone. BMJ 2020; 368:m530
5. Douglass C, Fyfe M, Lokugamage AU. Structural racism in society and the covid-19 ‘stress test’. https://blogs.bmj.com/2020/06/08/structural-racism-in-society-and-the-co... of 8th June 2020
6. Covid-19: PHE has failed ethnic minorities; leaders tell BMJ. BMJ 2020; 369:m2264
7. Kmietowicz Z. NHS launches Race and Health Observatory after BMJ’s call to end inequalities. BMJ 2020; 369:m2191
8. Eregie CO. COCID-19 and the quadruple-barrel tragedy: matters still evolving for the works. https://www.bmj.com/content/369/bmj.m2197/rr of 19th June 2020
9. Shen Z, Xiao Y, Kang L et al. Genomic diversity of SARS-CoV-2 in Coronavirus Disease 2019 patients. Clin Inf Dis. https://doi.org/10.1093/cid/ciaa203 of 9th March 2020
10. Ji W, Wang W, Zhao X, Zai J, Li X. Cross-species transmission of the newly identified coronavirus 2019-nCoV. J Med Virol 2020; 92:433-440
11. Eregie C.O. COVID-19 Pandemic: The difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-10 of 31st March 2020
12. Barro R, Ursua J, Weng J. Coronavirus and the lessons we can learn from the 1918-1920 Great Influenza Pandemic. https://www.weforum.org/agenda/2020/03/coronavirus-great-influenza-pande... of 23rd March 2020
13. Eregie C.O. COVID-19 Pandemic: Still on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-13 of 2nd April 2020
14. Eregie C.O. COVID-19 Pandemic: Further perspectives on the difficult unresolved increasing challenges in weathering the storm. https://www.bmj.com/content/368/bmj.m1199/rr-16 of 5th April 2020
15. Mask WebMD. Coronavirus Face Masks: What You Should Know. https://www.webmd.com/lung/coronavirus-face-masks of 18th May 2020
16. Eregie C.O. COVID-19 Pandemic and face mask use: Limitless matters for extant conversation. https://www.bmj.com/content/369/bmj.m2030/rr-0 of 11th June 2020
17. Schroter RC. Social distancing for covid-19: is 2 meters far enough? BMJ 2020; 369:m2010
18. Eregie CO. COVID-19 and social distancing: more work in the works to be there. https://www.bmj.com/content/369/bmj.m2010/rr-1 of 12th June 2020
19. Clinical Trials.gov. History of changes for study. NCT04280705, 1 May 2020. https://clinicaltrials.gov/ct2/history/NCT04280705?A=10&B=15&C=Side-by-S....
20. Glasziou PP, Sanders S, Hoffmann T. Waste in covid-19 research. BMJ 2020; 369:m1847
21. Eregie CO. COVID-19 Pandemic: The multifaceted picture of compromised COVID-19 research and the ‘COVID Phenomenon’. https://www.bmj.com/content/369/bmj.m1847/rr-12 of 10th June 2020
22. Eregie CO. COVID-19 Pandemic Interventions: Lockdown is not lockout; avoid interventional precocity with easing lockdowns. https://www.bmj.com/content/369/bmj.m2202/rr-4 of 14th June 2020
23. Koltar B. Amidst the COVID-19 Pandemic, We Must Remember Maternal Health-Maternal Health Task Force. https://www.mhtf.org/2020/04/18/amidst-the-covid-19-pandemic-we-must-rem...
24. Krubiner C, Keller MD, Kaufman J. Balancing the COVID-19 Response with Wider Health Needs: Key Decision-Making Considerations for Low- and Middle-Income Countries. https://reliefweb.int/report/world/balancing-covid-19-response-wider-hea...
Professor Charles Osayande Eregie,
MBBS, FWACP, FMCPaed, FRCPCH (UK), Cert. ORT (Oxford), MSc (Religious Education),
Professor of Child Health and Neonatology, University of Benin, Benin City, Nigeria.
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria.
UNICEF-Trained BFHI Master Trainer,
ICDC-Trained in Code Implementation,
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Code Implementation Project in Nigeria.
*No Competing Interests.
Competing interests: No competing interests
Fiona Godlee describes racism and the other pandemic, with advocacy for change to guide us to a better place (1).
Racism and the other pandemic are both complex systems – colliding, crashing and amplifying each other like waves at the seashore, with the potential of recurrent waves and reflection .
Neither should happen. Both need serious rethinking – on how and why things happen and change.
It’s both simple and complex, intertwined, a chaos/complexity complex systems thinking.
Complexity Hidden Amidst Observed Simplicity and Simplicity Observed Amidst Hidden Complexity (2).
So for a simple chaos/complexity/mantra/approach described in previous writings: Editorials on Race, Ethnicity/Diversity and Health (Can J Cardiology 1995, American Heart Journal 2010), small book chapter (p165-74) on “Chaos, Diversity and Health” in “Tsunami Chaos Global Heart” 2005, book chapter for Radcliffe Medical Press in “Complexity and Healthcare Organizations: a view from the street” 2004, etc.
Racism: FACE the reality with Feedback, Adaptation, Change and Emergence of better.
Pandemic: FACE the reality with Feedback, Adaptation, Change and Emergence of better.
Interconnections : FACE the reality with Feedback, Adaptation, Change and Emergence of better (2).
Sometimes waves collide and wipe each other out. This happens all the time all over the world, and I used this imagery a few years ago in a presentation on Complexity in Medical Education at a seaside conference in Brighton, UK.
Public sentiment, public policy, and individual and collective actions can do the same for racism and the pandemic. It depends on us, individually and together, creating waves to stop both, as proposed in the Tsunami Chaos Global Heart book. A complexity thinking could help, with subtitle of the Tsunami book – using complexity science to rethink and make a better world (2).
Creating a global heart could help, as in the Tsunami book, with medicine seen as the art and science of caring for humanity, and as the Dalai Lama advocated in a BBC interview a few days ago – “seven billion people need a sense of oneness.”
This is the reality we should FACE. And using complexity thinking to address issues of complex systems, especially when they collide.
1 Godlee F. Racism: the other pandemic. Ed. BMJ 2020; 369m2303 doi: https://doi.org/10.1136/bmj.m2303 (Published 11 June 2020).
2 Rambihar VS, Rambihar SP, Rambihar VS Jr. Tsunami Chaos and Global Heart: using complexity science to rethink and make a better world. 2005. Vashna Publications. Toronto, Canada. http://femmefractal.com/FinalwebTsunamiBK12207.pdf (accessed June 16, 2020).
Competing interests: No competing interests
We agree with the editor's comments around racism, however when discussing issues relating to migration, ethnicity and race, although each subject contains unique issues, we believe the three are intrinsically linked. This overlap is particularity pertinent when discussing issues of colonialisation, and migration policies, as harmful policies can damage the health of migrants here and abroad, as well as black, asian and ethnic minority citizens within the UK, and around the world.
The NHS’s complicity in the anti-immigration hostile environment now embedded in our health care system is just one example of how Britain continues to benefit from its colonial past. Looking at the list of NHS staff from outside the EU: Indian (25,809), Filipino (22, 043), Nigerian (8,241), Pakistan (4,313), Zimbabwe (4192), Ghana (2863) – its easy to see that Britain’s ties with its ex-colonies are still strong. Health care professionals are often actively recruited to come and work in the NHS from these countries, thus strengthening our countries health system, whilst diminishing others. Human capital acting as the raw minerals of the day extracted for the benefit of the UK. We benefit from a greater number of health professionals per head of the population, and enjoy an average life expectancy of around 80 years, while in Nigeria it is only 53 years and India, 67. However, despite perpetuating these inequalities when patients from these countries are seeking healthcare in the UK, we charge them. This is through the health surcharge or at 150% cost of the treatment they seek, thus widening the global gap. An analysis of the nationalities of those charged as part of the “charging of overseas visitors guidance” has highlighted that patients from previous British colonies make a significant proportion of those targeted.
These toxic policies extend from causing harm to migrants to also being harmful to British foreign-born nationals and their families, as well as to the British black, asian and ethnic minority communities, as was laid bare by the Windrush scandal. This was not an accident: the Department of Health acknowledged these risks in 2015 in its equality assessment. Sparse damage limitation was undertaken however. Were these groups merely seen as a necessary collateral damage in the pursuit of ever more aggressive immigration policies?
Whilst it’s easy to point out faults, the difficulty comes in enacting change. The toxic mixture of personal biases (both conscious and unconscious), institutional silence, and the dearth of education on these topics create barriers to action. Whilst the prime minister “hears” the #BLM protests, he continues to hand out lucrative contracts to Serco for the “track and trace” system, whose track record on treatment of immigration detainees includes paying as little as £1/hour for cleaning. The Public Health England report on coronavirus deaths in the black and ethnic minority communities failed to mention institutional racism as a contributing factor. Another commission, a tool of inertia, under the pretence of action, is not what is needed. As health professionals, fleetingly elevated to the status of heroes during the pandemic, we need to use our voices to demand change.
Competing interests: No competing interests
Vitamin D and Covid-19
It has been widely reported that BAME (Black And Minority Ethnic) individuals have a much higher death rate from Covid-19, although the reason for this is not currently understood. However, I note the following facts:
1) Vitamin D is needed for many body systems, not just calcium metabolism, and in particular the immune system , although exactly how this system is affected by deficiency is unclear.
2) As you might expect people with darker skin colour. and particularly black skin, have much lower vitamin D levels , mostly at what are considered as probable deficiency levels A significant number of white individuals also have abnormally low levels in spring in northern climes  - and in some this will be year-round if they see little sun in the summer, such as some older persons and those with disabilities.
One's reaction to a Covid-19 infection is clearly dependent on many factors, but could Vitamin D deficiency help to explain in part the higher death rate? It seems to me that it would be useful to have Vitamin D levels done on everyone admitted to hospital with Covid-19; this should quickly show whether vitamin D deficiency was involved. Also, it would be very interesting to try giving Vitamin D supplements to all Covid-19 patients. Ideally of course this should be in a randomised controlled clinical trial, but it could be argued this was unethical if patients were Vitamin D deficient anyhow because of the other substantial benefits of supplementation.
I would therefore suggest using higher strength Vitamin D (i.e. the 25 mcg. Tablet) on admission. This would be safe until serum levels show whether there was a deficiency (when the higher strength would be indicated anyhow), or not when it could be stopped. Sunlight produces inactive vitamin D. Active vitamin D3 is derived from this by liver enzymes and then enzymes in the kidneys and some other tissues; high doses of sunlight produce other (non-active) compounds in the skin in a dynamic equilibrium so 'sun light' Vitamin D excess does not occur 
1. As summarized by Aramow C., J.Invest.Med. 59(6) p881 (2011)
2. As summarized by O'Connor et al. Proc. Cardiovasc. Dis. 56(3) p261 (2013)
3. Sievenpiper et al. BMJ 336 p1371 (14/June/2008)
4. Wacker M. & Holick M. Dermatoendocrinology 5(1) 51 (2013)
Competing interests: No competing interests
There are currently a number of serious wrongs against the BAME medical community which would have even raised an eyebrow in antediluvian England. One of the most egregious injustices being that of Sellu. A conscientious surgeon who despite doing his best for a patient found himself serving 15-months in prison, following his release the conviction was overturned by the Appeal Court and he was subsequently exonerated by the GMC.1,2
The compelling account which sends a shiver down the spine of most surgeons, describes a scenario few seasoned practitioners have not experienced and whispered to themselves 3 ‘There but for the grace of God ..’.
However, this story of an innocent BAME surgeon who wrongly goes to gaol has never been fully ventilated in public. 3,4
Anyone reading the popular press at the time ‘A scalpel in the back: How hospital buried evidence that could clear surgeon jailed…’ 5 would be forgiven from inferring that evidence exists which suggests someone perverted the course of justice. This of course is potentially either
1. a serious actionable slur or
2. a contemptible violation of a common law offence resulting in an innocent man losing amongst many things his precious liberty.
Whatever it is, it is unfinished business and attempts to raise this issue with the appropriate bodies have met with tergiversation and indifference.
I don’t want statues harmed nor their narrative retired and hidden in a museum. Justice should be public and transparent: those guilty of unequivocal evil should be held to account; we should know who they are and what they are? But might I suggest we start with the last 5 years and work back!
3. Did He Save Lives? A Surgeon's Story Paperback – 4 July 2019 by David Sellu (Author) Whitefox Publishing Ltd ISBN: 9781912892327
Competing interests: No competing interests
Racism is a public health concern because it kills people (1). As with any public health emergency tackled by global healthcare organisations, there must be a concerted effort whose purpose is to assess, improve, maintain, promote and modify health for communities plagued by this pandemic.
The concern is why is it taking us so long. For decades, healthcare research has called for systems to recognise racial disparity and give it as much importance as is given to other serious public health issues with lifelong sequelae (2). Even as early as the 1980’s, disconcerting research found that after socioeconomic adjustment, racial disparities remained a determining differential in the quantity and quality of care (3).
The WHO show that to instigate successful public health interventions, the first step is to identify the target. This is the defined entity on which subsequent actions are carried out. A pressing matter is that as of yet, we do not truly understand what this fundamental target is. In our evidence-based world, researchers must strive to better understand the root-causes of racial disparities, so as to understand how best to tackle it. A major barrier to however, is how to get insight to the explanatory of causative factors contributing to racial and ethnic disparities in health care.
Historically, the terms ‘race’ and ‘ethnicity’ have been used interchangeably and although closely related, have significant cultural differences. Race is a historic social construct, defined by those in power and imposed upon the oppressed. It was used to divide people into pseudo-biologically distinct groups, and often cited to justify support of imperialism, slavery or eugenics (4). Race has been used in medical research as a surrogate in place of detailed social and environmental considerations to explain disparity. However, this outdated approach ignored intrinsic biosocial determinants of health – at best it can be described as an approximation, at worst, a gross simplification.
Ethnicity on the other hand, reflects an individual’s self-identification that encompasses social characteristic and is complex, multifaceted and subjective. Whilst data on ethnicity is routinely collected in official statistics they are to an extent, arbitrary. A flaw in categorising populations this way, is that the ethnic group itself cannot be considered homogenous (5). Within these groups there can be great heterogeneity that make defining innate health issues challenging. For example, two people who identify as British-Asian can include an immigrant from the continent of Asia but also an Asian person born and raised in the UK. These are both classified identically for research purposes but will have distinct cultural, social and health-related values and resultant health outcomes.
Medical research has sought other parameters to explain the difference in health outcomes but these also have limitations. Some used the concept of ‘culture’ as a distinct variable from race or ethnicity (6). This aimed to define unique integrated patterns of behaviour within social groups that can be learned and shared, including language, customs, beliefs and values. ‘Acculturation’ is another concept based on the assumption that cultural knowledge, attitudes, and beliefs cause people to behave in certain ways and make specific health choices. This is based on a premise of a ‘mainstream culture’ and an ‘ethnic culture’ which deviates from this (7). Yet, within literature using culture alone, it was found this does not reliably predict health behaviours, rather it was found to be more prudent to identify specific cultural traits that can be tested (8). Furthermore, a systematic review of studies examining acculturation found that the definition of the ‘ethnic culture’ being investigated was often vague and imprecise, if even defined at all.
At present researchers do not have a classification that is valid and meaningful across all contexts but we must strive towards this. With the current tools available and their limitations, examining ethnicity and with race has provided researchers with important public health data, such as the increased risk of arrhythmia-related stroke in South Asians (9). However, researchers must remain aware of the validity and remain cautious when interpreting and applying their findings.
To move towards fairer, more just and informed healthcare, we must examine racial disparity in our healthcare systems with the scientific rigour we approach other health concerns. Whilst the answer is not a simple one, in striving to understand the legacy of power, discrimination and oppression on health outcomes, we must undertake systematic and conscious examination of their influence on not only heath and social care systems, but also our personal beliefs, values and biases. Disparities in care may be occurring despite absence of intent so healthcare professionals must reflect on their own practice. Systemic change can be slow but introspection can be instantaneous.
Research is needed to better define which racial, ethnic or cultural factors contribute to health care disparities and identify strategies to minimise or eliminate their effects on health. The harrowing events in America as well as the recent Public Health England reports of the disproportionate impact of on COVID-19 in ethnic minorities act as a glaring reminder that we must tackle racism with as much importance as is given to other serious public health issues.
1. Godlee F. Racism: the other pandemic. BMJ. 2020;369:m2303.
2. Williams D, Rucker T. Understanding and addressing racial disparities in health care. Health Care Financ Rev. 2000;21(4):75–90.
3. Wenneker M, Epstein A. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA. 1989;261(2):253–7.
4. Fullilove M. Comment: abandoning “race” as a variable in public health research--an idea whose time has come. Am J Public Health. 1998;88(9):1297–8.
5. Egede L. Race, ethnicity, culture, and disparities in health care. J Gen Intern Med. 2006;21(6):667–9.
6. Pasick R. Health behavior and health education: theory, research, and practice. San Francisco: Jossey-Bass Inc; 1997.
7. Hunt L, Schneider S, Comer B. Should “acculturation” be a variable in health research? A critical review of research on US Hispanics. Soc Sci Med. 2004;59(5):973–86.
8. Hunt L. Health research: what’s culture got to do with it? Lancet (London, England). 2005;366(9486):617–8.
9. Mathur R, Pollara E, Hull S, Schofield P, Ashworth M, Robson J. Ethnicity and stroke risk in patients with atrial fibrillation. Heart. 2013;99(15):1087–92.
Competing interests: No competing interests
As we have observed in the covid-19 pandemic, excellently highlighted by Godlee, there has been a disproportionate number of deaths amongst the BAME population (1). Godlee rightly stresses that “racism is a public health issue because it kills people” (1). I argue that a lack of diversity in teaching at UK medical schools, mirrored by many medical textbooks, perpetuates racial inequality.
As a medical student myself, physiology and anatomy textbooks were the backbone of my education in my first few years at medical school. However, it’s difficult not to notice that the overwhelming majority of clinical images and case presentations are illustrative only of white patients. This is not representative of the society we live in. Reflecting on this, I felt increasingly unsure how I would identify features such as cyanosis, erythema, and pallor in patients of different skin colour.
Although slightly dated, Plataforma SINC raised this issue over a decade ago, demonstrating the historical nature of this matter, which should have been addressed a long time ago (2). More recently an American study found that in leading textbooks the skin tones represented were 74.5% light, 21% medium, and 4.5% dark, compared to a distribution of 62.5% white, 20.4% black, and 17.0% person of colour in the wider US population (3).
Failure to educate medical students in the variety of presentations and clinical signs seen in all ethnicities, propagates racial inequality. If healthcare professionals are unable to identify these signs, potentially unwell patients will not be appropriately treated leading to increased morbidity and mortality amongst the BAME population. Recently this topic has gained attention amongst medical students throughout the country in the form of a petition calling for a change to their curriculums (4).
Acknowledging and addressing the lack of ethnic diversity in the medical school curriculum will ensure the doctors of tomorrow have a better ability to recognise, diagnose, and treat patients from all ethnic backgrounds. Representation is vital for doctors to provide the same high level of care to all patients, reflecting the principle of justice in medical ethics.
1. Godlee F. Racism: the other pandemic. BMJ [Internet]. 2020 Jun 11 [cited 2020 Jun 13];369:m2303. Available from: http://www.bmj.com/lookup/doi/10.1136/bmj.m2303
2. Plataforma SINC. Medical Textbooks Use White, Heterosexual Men As A “Universal Model” -- ScienceDaily [Internet]. Science Daily. 2008 [cited 2020 Jun 13]. Available from: https://www.sciencedaily.com/releases/2008/10/081015132108.htm
3. Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med. 2018 Apr 1;202:38–42.
4. Agu C. Petition · Medical schools must include BAME representation in clinical teaching · Change.org [Internet]. Change.org. 2020 [cited 2020 Jun 13]. Available from: https://www.change.org/p/gmc-medical-schools-must-include-bame-represent...
Competing interests: No competing interests