The recent unfortunate events that we’ve seen around the world have got me to really reflect on the topic of racism, and in particular racism in healthcare. We all know racism exists very prominently in today’s society – a sad reality that’s obvious to all those who pay attention to it. Whether that’s in the form of micro-aggressions or overt racism the point is it’s there. In my opinion, there is huge journey ahead to create change in society; many discussions to be had and forms of education to be implemented in order for society to function differently as a whole.
The one thing I think we don’t think or talk about enough is racism applied to the context of healthcare. I think one of the reasons for this is because we like to view the provision of healthcare as an altruistic, inherently good act and we don’t like to relate it to something as horrible as racism. Truth be told, racism does exist in Medicine, often implicit, but reading into it further has made me realise the sheer enormity of the consequences it is able to have.
I expect many of you readers will be aspiring medics and medical students and some of you may be thinking racism is an issue that doesn’t affect you, You may think that it’s too political and so far from the career you’re going in to that you don’t have to think about it; something that you won’t have to think about or address as a doctor. Let me tell you, racism is an issue that is very much central to medicine right at the heart of healthcare; directly affecting the provision of care. In this blog post I wanted to make you more aware of some of the issues surrounding racism and Medicine and why it’s important for medical students to advocate for race inequalities.
1. Racism is a public health issue
I’m putting this out there, top of the list. Racism is not merely a political matter when it is in fact directly impacting healthcare outcomes. There are many common conditions we can think of being much more prevalent in ethnic minorities (hypertension, high cholesterol, heart disease etc.) and often these are just attributed to genetic and socioeconomic factors. Though these may have a small role to play, the shocking truth is that recent research has shown that these disparities are actually linked to outcomes of racism. Looking at a national scale we see that countries such as Finland and Germany have the highest rates of hypertension globally, compared to countries such as Nigeria with the lowest – so why is it that within the UK health system we find that to be reversed in terms of Black and European individuals?
There’s a saying that postal code determines your health outcomes more than genetic code. A greater proportion of people from a black and ethnic minority background live in deprived areas and that directly impacts their health. This is an example of systemic racism and this context the effects of this type of racism leads to significant disparities in health.
2. Huge differences in health outcomes
Here are some shocking facts for you to digest:
• Black women in the UK are 5 times more likely to die in pregnancy than white women
• Black women are twice as likely to have a stillborn baby compared to their white counterparts
• Black women are 4 times more likely to be detained under the mental health act compared to white women
• 23% of inpatient admissions in mental health services are from black and ethnic minority groups
• Black patients detained under the mental health act are 50% more likely to be placed in seclusion than white patients.
• Black women are less likely to have their pain believed and are 22% less likely to receive pain medication for it
• Infant mortality is nearly 3 times higher in black babies compared to white babies in the US
• 95% of doctors who died in first month of lockdown (due to Covid-19) were from an ethnic minority background
These differences are of course due to a multitude of different contributing factors, but undeniably, one of those is the difference in the provision of healthcare to individuals of certain groups.
I was shocked to recently read about “bibi-itis” or “Mrs Bibi syndrome” – an old medical stereotype that old ethnic women tend to exaggerate their health concerns. It is stereotypes and ideas like this that often lead to people from an ethnic minority background to have their health concerns not taken as seriously which in turn leads to worse outcomes.
3. Direct link between discrimination and mortality
“High levels of day-to-day discrimination is an indicator of premature mortality” – beyond worse health outcomes, racism is literally the factor in itself that’s responsible for mortality!
When talking about racism it doesn’t always mean a big action of hatred, but these the reality of these health differences is that they’ve been noticed with little day-to-day indignities (what we call micro-aggressions). It doesn’t even have to be the act of being discriminated again, but simply feeling the threat of discrimination and having to remain extra vigilant because of that all the time worsens health outcomes. Think about the stress model, generalised anxiety increases inflammation, increasing your chances of developing a variety of health conditions. Studies have shown that there is a rapid increase in the development of heart disease for people who experience this day-to-day discrimination. Every day discrimination increases cognitive decline over time. High levels of discrimination is linked to visceral fat (visceral fat is a predictor of cardiovascular disease which is higher in BAME individuals).
This really makes you wonder how many of these conditions that we consider to be higher in ethnic minorities actually stem from racism or are solely dependant on racism. Thinking about this on an even deeper level, there have been studies conducted on asylum seekers which have shown a decline in physical health since arriving in the UK – this indicates that the usual answer of claiming it’s all due to genetics is not enough of an answer at all.
4. Diverse patient population
In the UK, the patient population is so varied with people from so many different ethnic backgrounds. Simply thinking about Medicine from the perspective of one patient group does not work at all.
In terms of clinical presentation, just think about how varied the presentations of skin conditions will be on white skin compared to black skin. To care for all people we have to truly be able to consider conditions, clinical signs and be taught these in order to be able to recognise them in different populations. When medical textbooks don’t have examples of the depictions of a disease on non-white skin it is the individuals from those minority groups that ultimately suffer, leading to worse health outcomes and increased mortality. An example of this being Lyme’s disease, a condition in which the failure to recognise the early rash on black skin has resulted in increased rates of late manifestations in black people.
Brown Skin Matters is a page which shares depictions of dermatological conditions on non-white skin.
5. Diverse workforce
The NHS employs over 200 different nationalities so you have to accept that by entering medicine you’ll be working alongside so many different people. Medicine isn’t a lone job, you do it in a team and as a team you have to be able to understand the barrier that other team members are having. Over the past few years the percentage of NHS staff reporting racism has increased. Racism is there and it doesn’t go away if you ignore it. You have to be able to support the colleagues around you, work with them. Staying silent and not acknowledging the problem is never a means of support.
There has also been shown to be a direct link between the way staff are treated and the outcomes patients receive and how satisfied they are with their care. Trusts which have greater rates of racism have shown more adverse patient outcomes and lower rates of patient satisfaction. Staff being subject to discrimination therefore directly impacts patient care.
6. “A patient’s advocate”
I’m going to put it out there simple and clear: if racism doesn’t make you angry, you’re pursuing the wrong profession. It is a doctor’s role to advocate for their patients – medicine is after all a science applied to humanity. To truly enable yourself to help people, understanding and empathising with barriers they face in their day-to-day lives is central. Racism is more than just a mere barrier though, it’s a significant factor affecting very aspect of healthcare from a patient’s individual physical and mental well-being to staff’s ability to deliver effective care.
Implicit bias exists, but ignoring it and ignoring the manifestation of biases in clinical practice is something that doesn’t help solve the problem. While the solution isn’t obvious nor easy, I feel like education is so important and we all need to do our own part. Please have a listen to the podcast episodes and TED talks I’ve linked below – each of them hit me with another realisation of how how racial inequality is currently impacting healthcare.
Resources & References
Of course, I’m not an expert by any means. This post was merely a collection of my thoughts and something which I think we need to pay more attention to. All the information I got was from the resources listed below. I highly recommend you go and have a look at these in greater depth in order to give yourself a more complete picture as they capture the essence of racism and its implications in medicine. If you are going into or are currently in Medicine, the podcast episodes and TED Talks are a must listen.
Sharp Scratch podcast: Episode 21 (Racism in Medicine); Special episode (Yvonne Coghill is trying to fix racism in the NHS)