Covid-19 and ethnic minorities: an urgent agenda for overdue action
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2503 (Published 23 June 2020) Cite this as: BMJ 2020;369:m2503Read our latest coverage of the coronavirus pandemic
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Dear Editor
I refer the rapid response of Helga Rhein (5 July 2020) wherein it is asserted, “To deny a person with a darker skin tone the right to health by ignoring their deficient vitamin D status is discrimination; it is not a racial but a skin tone discrimination” [1].
First, s9, Equality Act 2010 (‘Eq Act’) expressly refers to ‘Race ‘as follows [2]:
“Race
(1)Race includes—
(a)colour;
(b)nationality;
(c)ethnic or national origins.
(2)In relation to the protected characteristic of race—
(a)a reference to a person who has a particular protected characteristic is a reference to a person of a particular racial group;
(b)a reference to persons who share a protected characteristic is a reference to persons of the same racial group.”
Frankly, there is no difference between skin “tone” and “colour”. Hence, if one is denied or ignored the “right to health”[1] or healthcare on the ground of skin “colour”, there is little doubt that it would amount to direct racial discrimination under s13, Eq Act [3]. Alternatively, applying a ‘provision, criterion or practice’, thus putting a racial group at an disadvantage (by reason of skin colour or tone which is a protected characteristic) would amount to indirect racial discrimination as per s19, Eq Act [4].
I therefore have no hesitation whatsoever in disagreeing with the aforesaid assertion of Helga Rhein, “it is not a racial but a skin tone discrimination”[1].
References
[1] https://www.bmj.com/content/369/bmj.m2503/rr-8
[2] http://www.legislation.gov.uk/ukpga/2010/15/section/9
[3] http://www.legislation.gov.uk/ukpga/2010/15/section/13
[4] http://www.legislation.gov.uk/ukpga/2010/15/section/19
Competing interests: No competing interests
Dear Editor
Khunti et al (1) is asking what can be done concerning the health inequalities faced by ethnic minorities and how soon? My answer: something can be done immediately.
Racial inequalities, often institutionalised, are unacceptable, but completely different from health inequalities due to a lack of vitamin D in people with darker skin types.
A dark skin type is designed to protect from strong sunlight and UV rays when living closer to the equator. In human evolution, as people moved gradually North, out of Africa, they lost pigment in order to make use of the scarce sunlight which would bring them the essential vitamin D (2). There are six different defined shades of skin tones (3). Most Europeans represent genetic mixtures, but one can still see a difference between the “olive” skin type of a person from the South of France (skin type III-IV) and the very pale skin type of person from Scotland (skin type I-II)
Many, but not all, ethnic minorities are people with dark skin types, but some are paler, for instance Chinese or Polish people, or myself, originally from Germany (my skin is type III)
Vitamin D is measured by 25-hydroxyvitamin-D blood levels, these are low in people with the darkest skin tone living in the UK, higher in those with the lightest skin tone (4). This has all been well documented for years but for some reason is repeatedly ignored.
A healthy optimal 25-hydroxyvitamin-D level is defined as above 30 ng/ml (75 nmol/l) (5-8). Well researched are the many benefits in metabolic and immune health associated with sufficient 25-hydroxyvitamin-D levels, for instance in the fields of cardio-vascular disease, diabetes, cancers, infections (9-12).
To deny a person with a darker skin tone the right to health by ignoring their deficient vitamin D status is discrimination; it is not a racial but a skin tone discrimination. It leads to health inequalities.
It is only in the present pandemic where a new nasty virus can cause havoc in the immune-compromised D-deficient person that this has become more than obvious. High risk groups for Covid-19 mortality clearly overlap with high risk groups for vitamin D deficiency: people with dark skin types, those who are older, overweight or have underlying health conditions.
Please, Professor Khunti, allow this issue to be discussed in the Independent SAGE committee urgently: testing for 25-hydroxyvitamin-D followed by appropriate D-supplements could be done immediately.
1. Khunti Kamlesh, Platt Lucinda, Routen Ash, Abbasi Kamran. Covid-19 and ethnic minorities: an urgent agenda for overdue action BMJ 2020; 369 :m2503
2. Hanel A, Carlberg C. Vitamin D and evolution: Pharmacologic implications. Biochem Pharmacol. 2020;173:113595. https://pubmed.ncbi.nlm.nih.gov/31377232/
3. Fitzpatrick scale
4. Rhein HM. Vitamin D deficiency is widespread in Scotland. BMJ. 2008 Jun 28; 336(7659): 1451. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440863/
5. Vieth R. Best Pract Res Clin Endocrinol Metab. 2011 Aug;25(4):681-91. Why the Minimum Desirable Serum 25-hydroxyvitamin D Level Should Be 75 nmol/L (30 Ng/Ml) https://www.sciencedirect.com/science/article/abs/pii/S1521690X1100073X
6. Holick MF et al. Endocrine Society: Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2011, 96 (7):1911 https://academic.oup.com/jcem/article/96/7/1911/2833671
7. Mendes MM, Hart KH, Lanham-New SA, Botelho PB. Suppression of Parathyroid Hormone as a Proxy for Optimal Vitamin D Status: Further Analysis of Two Parallel Studies in Opposite Latitudes. Nutrients. 2020;12(4):E942. Published 2020 Mar 28. https://www.mdpi.com/2072-6643/12/4/942
8. Luxwolda MF, Kuipers RS, Kema IP, van der Veer E, Dijck-Brouwer DA, Muskiet FA. Vitamin D status indicators in indigenous populations in East Africa. Eur J Nutr. 2013;52(3):1115‐1125 https://pubmed.ncbi.nlm.nih.gov/22878781/
9. Gholami, F., Moradi, G., Zareei, B. et al. The association between circulating 25-hydroxyvitamin D and cardiovascular diseases: a meta-analysis of prospective cohort studies. BMC Cardiovasc Disord 19, 248 (2019) https://bmccardiovascdisord.biomedcentral.com/articles/10.1186/s12872-01...
10. Martineau AR,Jolliffe DA, Hooper RL et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ 2017;356:i6583 https://www.bmj.com/content/356/bmj.i6583
11. Manson JE, Bassuk SS, Buring JE; VITAL Research Group. Principal results of the VITamin D and OmegA-3 TriaL (VITAL) and updated meta-analyses of relevant vitamin D trials. J Steroid Biochem Mol Biol. 2019 Nov 13;198:105522. https://pubmed.ncbi.nlm.nih.gov/31733345/
12. Aranow C. Vitamin D and the immune system. J Investig Med. 2011;59(6):881-886. doi:10.2310/JIM.0b013e31821b8755
Competing interests: No competing interests
Dear Editor,
Is it acceptable to allow vitamin D deficiency to persist in the UK, and much more commonly in dark- than pale-skinned people, when there is a reasonable chance that correcting this deficiency, a safe, cheap and easy thing to do, could reduce Covid-19 severity?
This is the question that public bodies should be considering in regard to the increased Covid-19 risks, including mortality, being seen in in the UK in dark-skinned Britons.
The facts underlying this question are:-
Severe vitamin D deficiency runs at ~15% overall and insufficiency at over 50%, all year round. [1]
Vitamin D has multiple mechanistic effects, both genomic, non-genomic and epigenetic, that are not bone-related and known beneficial effects of active hormonal vitamin D help protect almost all tissues in the body through well understood pathways, including effects relevant to reduction in lung damage in severe Covid-19. These include increasing the production of the innate antibacterial and antiviral compounds, cathelicidin and the defensins, stimulating anti-inflammatory cytokine production, reducing pro-inflammatory cytokine secretion [likely to reduce cytokine storm severity] and stimulating lung secretion of the ACE2 enzyme, a known protective factor in acute respiratory distress syndrome by reducing the adverse effects of undue increases in renin-angiotensin system activity. [2.3]
The continuing lack of vitamin D already mentioned across the UK [1] clearly demonstrates that ongoing advice on vitamin D intakes is inadequate overall. However, the increased severity of this problem in south Asians at least has been well- known for ~70 years and its continued neglect in dark skinned Britons is a long-standing racial inequality that must be corrected. [4]
Current definitions of vitamin D deficiency require revision with evolving assay methodology and with increased knowledge of the threshold values of 25(OH)D needed for beneficial tissue effects, as confirmed by the increased 25(OH)D values found to be necessary for activation of many target genes. [5-8]
Since vitamin D deficiency has no health benefits, can do harm, may be aggravating covid-19 severity and contributes to racial inequality in the UK it requires revised UK guidance.
Meanwhile, however, advising adults in the population to take at least 1000 IU/day through this pandemic [and up to 4000 IU/day if obese, dark-skinned, elderly, confined indoors or avoiding the sun] could be done overnight within current safety guidance. This measure would provide improvement in vitamin D status and some protection against more minor respiratory tract infections, [9] even if the benefits for Covid-19 severity prove to be negligible.
1 Lips P, Cashman KD, Lamberg-Allardt C, et al. Current vitamin D status in European and Middle East countries and strategies to prevent vitamin D deficiency: a position statement of the European Calcified Tissue Society. Eur J Endocrinol. 2019;180(4):P23-P54.
2. Grant WB, Lahore H, McDonnell SL, et al. Evidence that Vitamin D Supplementation Could Reduce Risk of Influenza and COVID-19 Infections and Deaths. Nutrients. 2020;12(4):988.
3. Malek Mahdavi A. A brief review of interplay between vitamin D and angiotensin-converting enzyme 2: Implications for a potential treatment for COVID-19 [published online ahead of print, 2020 Jun 25]. Rev Med Virol. 2020;10.1002/rmv.2119.
4. Bivins R. "The English disease" or "Asian rickets"? Medical responses to postcolonial immigration. Bull Hist Med. 2007;81(3):533-568.
5. Boucher BJ, Grant WB. Re: Scragg-Emerging Evidence of Thresholds for Beneficial Effects from Vitamin D Supplementation. Nutrients. 2019;11(6):1321.
6. Shirvani A, Kalajian TA, Song A, Holick MF. Disassociation of Vitamin D's Calcemic Activity and Non-calcemic Genomic Activity and Individual Responsiveness: A Randomized Controlled Double-Blind Clinical Trial. Sci Rep. 2019;9(1):17685.
7. Fan X, Wang J, Song M, et al. Vitamin D status and risk of all-cause and cause-specific mortality in a large cohort: results from the UK Biobank [published online ahead of print, 2020 Jul 4]. J Clin Endocrinol Metab. 2020;dgaa432.
8. Shirvani A, Kalajian TA, Song A, et al. Variable Genomic and Metabolomic Responses to Varying Doses of Vitamin D Supplementation. Anticancer Res. 2020;40(1):535-543.
9. Martineau AR, Jolliffe DA, Hooper RL, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583.
Competing interests: No competing interests
Dear Editor,
I hope this comment will be of help to the BAME medical communities who are being misled by an oracle they are trained to trust. The oracle's edict is not referee'd and I intend here to briefly dispute its findings, which are here: https://www.gov.uk/government/news/insufficient-evidence-for-vitamin-d-p...
The panel managed to find 6 lines of evidence that failed to convince them of a role for the hormone D3 in preventing acute respiratory tract infections. Yes, SIX. A search of Google Scholar with the string "COVID + 25(OH)D3" returns over 400 hits. We see there is an abundance of research that the trio of oracles NICE/SACN/PHE neglect.
Without any doubt whatsoever, science points to a central role for D3 in promoting immune defenses against viruses,bacteria and fungi, and has been doing the task for 500 million years. The question is: how much do we need as optimum? The physiological serum 25(OH)D3 is between 100 and 150 nmol/L. Dr Helga Rhein a D3-expert Edinburgh GP summarises the topic succinctly in the context of COVID: https://www.qnis.org.uk/blog/covid-vitamin-d/
But for BAME persons there is an added complication. Compared with Caucasians, Africans and SE Asians compound their known lower serum 25(OH)D3 with lower responsivity to the hormone
https://www3.uef.fi/documents/696977/913295/2020-1.pdf/61e0f67c-6aef-402... Rapid evolution of humans migrating out of Africa northwards over the past 10,000 years endows them with D3 genetic advantages. Furthermore, within Europeans there are low/medium/high responders also. Four groups in total. The authors conclude:
"Concerning vitamin D this suggests a personalized-nutrition approach by determining the vitamin D response index and supplement with appropriate daily vitamin D3 doses (10–100 μg) for reaching the individual’s optimal vitamin D status or to supplement everyone to 25(OH)D3 serum levels of the times before the migration out of Africa (more than 100 nM) "
So...NICE/SACN/PHE we fall into four camps of D3-responsivity. I do not see mention of that in your edict. Why not? That's a rather large elephant you ignore.
Competing interests: No competing interests
Dear Editor
Measure serum Vitamin D3 serum levels now!
Emeritus Professor Peter Cobbold believes that The National Institute for Health and Care Excellence (NICE) has already failed us all miserably by not conducting UK studies months ago which included measuring blood levels of Vitamin D3 (25(OH) D3 or cholecalciferol). [1] Randomised control trials (RCTs), and no other science input, have led NICE to decide that >25nmol/L 25(OH)D3 is not deficient whereas evolution of D3 signalling over 500 million years has refined our innate and adaptive immunity and endowed us with a physiological level of 100 to 150 nmol/L.
He believes that NICE is addicted to RCTs and needs to stop treating Vitamin D3 as if it were a xenobiotic. Instead, a report is needed about how Vitamin D3 relates to immune defences. The dramatic results of the observational studies from Indonesia, Philippines, Belgium, Louisiana, India, all point to a dramatic reduction in COVID severity or death at when D3 levels are >75nmol/L. Professor Cobbold is distressed to see British biological expertise being out-paced by developing countries and he thinks that NICE's dilatory intransigence is the culprit. The fact that African and Asians are less responsive to 25(OH)D3 than Caucasians, compounds the impact of their known lower 25(OH)D3 levels.
We need to know our vitamin D3 levels now. Not all of us will have another five years to wait not taking Vitamin D in a trial.
1 Cobbold PH. NICE blinkered by RCTs. https://www.bmj.com/content/369/bmj.m2475/rr
Competing interests: No competing interests
Dear Editor,
The COVID-19 pandemic shines a light onto the depth of social and racial inequalities in the UK. There is no doubt that these inequalities existed long before this pandemic, although these have taken on a greater significance in the last few months. Perhaps this may be a direct result of the death of George Floyd and the ongoing ‘Black Lives Matter’ protests, which have certainly brought the issue of inequalities and institutional bias to the forefront of public consciousness. The National Health Service, for all its merits, should not be exempt from scrutiny.
The circumstances surrounding the publication of the Public Health England (PHE) are a perfect illustration of the issue at hand. The apparent delay in publication and potential suppression as described by Khunti et al (1) is particularly striking: if we were not in the middle of worldwide anti-racism protests, would this report have quietly gone unnoticed?
Although the reasons for the adverse effects of COVID seen among the BAME population are subject to debate, ranging from differences in genetics to socioeconomic factors (2), there is to some extent an insidiously dangerous mindset on behalf of policymakers and major stakeholders. For example, the predominance of sickle-cell disease in the Afro-Caribbean population and the prevalence of diabetes in the South Asian community are well known, although it is rare that these issues are described as key national policies for the betterment of public health.
Our categorisation and characterisation of these issues is also problematic as these issues are often being framed as intriguing statistical variations among ethnic groups rather than key priorities for public health policy. Combatting these inequalities is naturally a difficult and multifactorial process which will not be easy to reverse. Nevertheless, as a society and particularly as healthcare professionals we must take a collective responsibility to resolve these issues.
Using the example of COVID, this inevitably brings us to a sombre reflection: through our inability and reluctance to solve these inequalities, have our actions (or lack thereof) as healthcare professionals and as a wider society contributed the steep death toll of COVID-19 in the BAME community?
1. Khunti K, Platt L, Routen A, Abbasi K. Covid-19 and ethnic minorities: an urgent agenda for overdue action. BMJ. 2020;369:m2503.
2. Abuelgasim E, Saw L, Shirke M, Zeinah M, Harky A. COVID-19: Unique public health issues facing Black, Asian and minority ethnic communities. Current Problems in Cardiology. 2020;45(8):100621.
Competing interests: No competing interests
Dear Editor,
Knowing the interest of you and your readers, I am writing to provide further detail on the government’s work to tackle the health disparities caused by COVID-19, following the recent Public Health England (PHE) review and subsequent stakeholder report.
I’m glad that a respected specialist publication such as yours is taking the time to cover this important story. I strongly agree with the key point in your editorial, that the PHE review doesn’t go far enough, particularly as ‘no original or secondary data [is] presented and ‘the proposals lack detail’. This is why the Prime Minister and the Health Secretary have asked me to take forward further work to ensure everything possible is being done to protect our minority communities.
However, I’d also like to set the record straight on a misinformed narrative that is running in several publications, including the BMJ. I refer to accusations that the government ‘delayed’ the review and even ‘suppressed’ parts of it.
The truth is that the government commissioned PHE to conduct an epidemiological review to analyse how different factors can impact on people's health outcomes from COVID-19. There was no delay to this work and it was published in full – as findings but without recommendations - on 2nd June, the next available sitting day in Parliament.
In parallel, Professor Fenton, PHE's regional director for London, engaged with a significant number of individuals and organisations within BAME communities, to hear their views, concerns and ideas about the impact of COVID-19. This was separate to the epidemiological review and therefore had a different path to publication on 16th June. None of the content was removed before publication. As Duncan Selbie, Chief Executive of PHE, has made clear it was PHE’s communications on these pieces of work which conflated the two pieces of work.
The findings of the initial PHE review are clearly concerning and we are moving quickly to start to build a clearer picture of the disparities caused by COVID-19 and the significance of and relationship between the key risk factors. We will continue to focus on age, sex, occupation, obesity, geography as well as ethnicity whilst taking this work forward.
As I set out on 4th June, some of the issues highlighted will take some time to address. To support this, we are commissioning new research and analysis as well as examining the need for development of new policy. I will be working with the Race Disparity Unit in the Cabinet Office and the Department of Health and Social Care to expedite this work.
Broader issues of racial inequality will be considered by the Commission for Race and Ethnic Disparities which the Prime Minister recently pledged to establish and which I will oversee. This new cross-government commission will explore these issues as well as champion the success of Black, Asian and minority ethnic groups, and will report by the end of the year.
I’m very proud to be taking forward this work and I’d like to place on record just how seriously I am taking it. I am confident the new research and data gathered will enable us to build on what is already being done and help us make a real difference to people’s lives.
Yours Sincerely,
Kemi Badenoch MP
Exchequer Secretary to the Treasury & Minister for Equalities
Competing interests: No competing interests
Dear Editor
Two articles in the current edition of the BMJ strike me as being directly related. BAME minorities are no doubt disproportionately affected by Covid-19 as your editorial points out. In the news analysis section Ingrid Torjesen summarises evidence that vitamin D may 'augment innate antiviral immune responses while simultaneously dampening down inflammation, a major problem in covid-19'. Indeed a rapid national effort is going on to explore the potential for vitamin D to influence the incidence and course of covid-19 infections.
Given that relative vitamin D deficiency is a known problem for BAME populations living in our sunlight deprived northern country, especially toward the end of winter. Perhaps this may help explain the different severity of covid-19 in BAME populations. I do not see how high status BAME doctors should be more susceptible to dying from covid-19 if this is just put down to socio-economic deprivation and inherent cultural racism in the UK health service.
Competing interests: No competing interests
Dear Editor,
May I say for the hundredth time that if you want to drag in ethnicity, or race, please define your terms.
As for BAME, it is even worse.
BLACK? This is a political statement.
ASIAN? Surely you know where Asia starts from and where it ends?
MINORITY ETHNIC? There are (or were, before BREXIT vote) a million Poles here. Do you suggest that being a Pole puts you at greater risk of COVID-19?
Please, ladies and gentlemen, do try to get your terminology right.
Next. You will need to arrange a coroner’s inquest for every death believed to be, or proven to be, due to COVID19. Not just Coroner’s post-mortem. But actually an inquest so that nothing remains hidden.
Some fatalities may be due to diabetes, some to Thalasaemia. Some to myocardial disease. Some multifactorial. Some due to lack of protective equipment, some to incorrect use of protective equipment. And so on.
Any objections to Coroners’ inquests?
Competing interests: No competing interests
COVID-19 and ethnic minority students
Dear Editor,
Addressing health inequalities facing ethnic minorities is urgently demanded by Khunti et al. [1] We agree this is essential. Moreover, we want to call attention to the problems of ethnic minority students in the health professions.
The coronavirus disease 2019 (COVID-19) pandemic has resulted in most medical teaching going online. Minority students may face a variety of discriminatory or racist practices in online teaching. For example, one US study found that teachers may more likely respond to online comments posted by white male students than Chinese, Black or Indian students. [2] Another study found that US librarians were less likely to respond to Arabic or African-American associated names and their responses were less informative and less polite. [3] We do not know how this is for medical students. We therefore asked teachers and students around us in the Netherlands to come up with cases in which minority medical students were discriminated, excluded, intimidated or otherwise did disproportionally encountered problems in online teaching. We see two patterns:
Minority students are intimidated during online teaching by other students
Some minority students encountered online aggressive or bullying behavior by fellow students. One student received angry responses by other students on regular questions about exams in electronic learning environments. In student WhatsApp groups racist comments were made. This may be understood as ‘just fooling around’ of students, but can also be seen as ‘micro-aggressions’, cut downs hidden in interpersonal communication that convey stereotypes and demean a person’s ethnic orientation. [4]
Minority students are disproportionally disadvantaged because of online teaching and assessment
Some minority students encountered problems when tests went online. One school changed knowledge tests, which were deemed too susceptible to fraud in online assessments, to open book knowledge casus tests with open ended answers. This caused problems for students with a language barrier, who were not able to read and write all the open questions within the given time. After discussing this with the student counselor, however, a student was allowed ten minutes extra time and the assessors were instructed to assess the content of the answers and not the language use. Another example comes from a student from an Islamic family who returned home during the COVID-19 crisis. The student was not allowed to put on the camera during online teaching. As a consequence the student could not participate to the classes about communication skills because this involves practicing with simulated patients and it was necessary for the patient to see the (non-verbal cues of the) student. However, when the student needed to do the assessment, a solution that all parties could agree upon was that a relative of the student was present during the online assessment.
We did not encounter any cases of minority students who found themselves being confronted with intimidating or biased teachers. In contrast, the teachers we spoke did their utmost to support the students. However, we know that in the offline world biased medical teachers are not uncommon, and this may result in lower grades and fewer minority students receiving a degree [5], yet the evidence is limited and very mixed. [6]
What can medical and nursing schools do?
Study advisors and assessors can take into account individual needs of students, medical teachers can organize virtual coffee meetings (as some of us did) to invite students to talk about their problems. Teachers need to be aware of biases and to create a safe environment and speak up to students who display unprofessional behavior. They also can engage in ‘courageous conversations’ with minority students to address ethnic disparities. [7] Schools should realize there may be unequal access to teleworking facilities and that not all students have good internet access and take measures to support students if needed. [8] Only by taking into account specific needs, we can realize inclusive schools with equal opportunities for all students, whether online or offline.
References
1. Khunti K, Platt L, Routen A, Abbasi K. Covid-19 and ethnic minorities: an urgent agenda for overdue action BMJ 2020; 369 :m2503
2. Baker R, Dee IT, Evans B, John J. 2018. Working Paper No. 18-055 Bias in Online Classes: Evidence from a field experiment. Stanford Institute for economic policy research, Stanford. https://siepr.stanford.edu/sites/default/files/publications/18-055.pdf.
3. Schachaf P, Horowitz S. ‘Are virtually reference services colorblind’? Library and information science research 2006;28(4):501-520.
4. Espaillat A, Panna DK, Goede DL, Gurka MJ, Novak MA, Zaidi Z. An exploratory study on microaggressions in medical school: What are they and why should we care? Perspect Med Educ; 2019, 8:143–151
5. Low D, Pollack SW, Liao ZC , Maestas R, Kirven LE, Eacker AM, Morales LS. Racial/Ethnic disparities in clinical grading in medical school. Teach Learn Med 2019;31(5):487-496.
6. Yeates P, Woolf K, Benbow E, Davies B, Boohan M, Eva K. A randomised trial of the influence of racial stereotype bias on examiners' scores, feedback and recollections in undergraduate clinical exams. BMC Med 2017 Oct 25;15(1):179.
7. www.courageousconversation.com (accessed 9 July 2020)
8. https://uvadiversity.blog/wp-content/uploads/2020/04/Memo-Diversity-in-t... (accessed 9 July 2020)
Competing interests: No competing interests