Postgrad Med J: first published as 10.1136/postgradmedj-2019-137295 on 22 January 2020. Downloaded from On reflection

an awareness in their students of multicul- Ethnic inequalities in health: should we turalism and social justice, in the hope that this may lead to more equitable care.10–12 talk about implicit white supremacism? Yet all these proposed fixes, and many others, are presented in isolation from John Launer each other. The discussion seems to be constrained by an unexpressed rule not to speak about the bigger picture. If you live in the United States or the increase existing racial inequalities in I want to suggest that the unspoken 5 United Kingdom and have black or brown health. bigger picture is in fact the long and skin, your health is likely to be poorer on The same kinds of implicit bias appear enduring shadow of colonialism. People average than if you have white skin. You to play a part in the experiences of staff with black or brown skin who live in soci- are also likely to receive healthcare of a from ethnic minorities in health services. eties that are mostly populated by people lower standard. The statistics are dismal.1 According to a report on Workforce Race 6 with white skin, and largely ruled by them, Between 1991 and 2011, for example, Equality in the UK, white applicants are not there by random chance. Although Pakistani and Bangladeshi women in the within the National Health Service are the trajectory of each individual, family or UK had mortality rates 10% higher than 1.45 times more likely to be appointed group may have been entirely different, white women. Long-term­ illness in men to roles from shortlisting, compared with their forebears are all likely to have lived over 65 was reported by 69% of Pakistani Black and Minority Ethnic (BAME) appli- in remarkably similar circumstances. They men and 64% of Bangladeshi men, cants. BAME staff are also 1.24 times were under the subjection of people who compared with 50% of white men. relatively more likely to enter the formal either came from very far away (like the Women of the same ethnic groups reported disciplinary process compared with white English in India), or had the military and even higher rates of long-­term illness staff. Within the medical profession, naval power to transport others from far compared with white women. Black 1.1% of BAME doctors were referred to away (like slave traders). In both cases, Caribbean men also had higher rates of the General Medical Council (GMC) by the ruling people also had the power long-term­ illness than white men. Simi- employers during 2012–17 compared 7 to make their subjects do as they were larly, a report from Public Health England with 0.5% of white doctors. As the told – in some instances relatively, but in 2017 showed that children in black GMC report points out, the influences in others absolutely. One could elaborate ethnic groups have higher than average leading to these disproportionate rates this picture in many ways, and touch on levels of infant mortality. The black Carib- of referral are ‘multiple and intricately aspects of history like the exploitation of bean group also had significantly worse linked.’ Risk factors for BAME doctors natural resources and labour leading to levels of low birth weight and readiness include their status as social 'outsiders’, 2 pressure to emigrate, or mass displace- for school. isolated or segregated working, lack of the ments of people and extermination. Even There are of course some variations support and feedback that would be given without doing so, a common thread in all and exceptions within ethnic disparities. to ‘insiders’, and organisational cultures these ancestral experiences is the convic- People from certain minorities may do seeking a vulnerable individual to blame tion possessed by their conquerors, in better than others in different respects, when something goes wrong. many cases backed up by spurious scien- while specific individuals may manage to tific theories, that they were innately supe- http://pmj.bmj.com/ buck the trend. Some of the evidence is The bigger picture rior to those they had conquered.13 also complicated by the effects of social Two things are striking about all these and educational deprivation, as well as statistics. One is how consistent they are in poverty, which all intersect with ethnicity relation to both recipients and providers Implicit white supremacism as determinants of health inequality, and of healthcare. The other is that they are In many ways, this colonial history remains spread beyond these groups. Having said usually presented in a compartmental- with us. It persists most obviously in the that, ethnicity generally acts as an inde- ised way, rather than as a single social or lessons that our children are still taught, on September 26, 2021 by guest. Protected copyright. pendent variable, augmenting other disad- political phenomenon. It is rare to come where they may learn ‘how the west was vantages. Racism and racial prejudice across accounts that join up the dots, or won’ in the US, or how the British Raj 3 appear to be contributing factors here. explain that these are largely different ‘civilised’ India, rather than seeing these These operate in many ways, but one of manifestations of the same underlying through the eyes of the native inhabitants them is through racial biases in the provi- causes. The also applies, broadly speaking, (and of most modern historians). Iron- 4 sion of healthcare. In ‘Just Medicine: A to the remedies prescribed for these prob- ically, these narratives may be internal- Cure for Racial Inequality in American lems. At the level of population health, ised by many of the descendants of those Healthcare’, Danya Bower Matthews, for researchers rightly point to the need for who were once occupied or enslaved. example, cites studies showing how physi- better housing, education and employ- It continues to be echoed in the media, cians with implicit biases as measured by ment opportunities in the kinds of areas where the failings of politics in the west psychological testing are more likely to where poorer minorities live.8 Within the are depicted as aberrations, but portrayed prescribe pain medications or thrombol- health service in the UK, staff are tested as the norm in so-called­ ‘less developed’ ysis to white patients than to black ones. regularly on their knowledge of equality countries.14 15 Beyond that, colonialism She argues that such unconscious biases and diversity policies, and there are may sometimes be present in a reflex held by healthcare professionals further mandatory procedures aimed to prevent assumption of members of the dominant unfair job selection or promotion – even ethnic group that outsiders (especially though these seem to be largely ineffec- if their ancestors originated from the Correspondence to Dr John Launer, Postgraduate 9 Medical Journal, London WC1H 9JP, UK; tive. Meanwhile, medical educators are southern hemisphere) have more to learn johnlauner@​ ​aol.com​ now using imaginative ways to promote from white people than vice versa. Such

Launer J. Postgrad Med J February 2020 Vol 96 No 1132 117 Postgrad Med J: first published as 10.1136/postgradmedj-2019-137295 on 22 January 2020. Downloaded from On reflection attitudes, both psychological and phys- Provenance and peer review Not commissioned; england.nhs.​ ​uk/wp-​ ​content/uploads/​ ​2018/12/​ ​wres-​ ical, are not always passed on consciously. internally peer reviewed. 2018-report-​ ​v1.​pdf [Accessed 1 Nov 2019]. 7 General Medical Council. Fair to refer? reducing © Author(s) (or their employer(s)) 2020. No commercial They are conveyed from generation to disproportionality in fitness to practise concerns re-­use. See rights and permissions. Published by BMJ. generation even without words, but they reported to the GMC. London: general medical Council, guide people as to whether to ask or not 2019. Available: https://www.gmc-​ ​uk.org/-/​ ​media/​ to ask certain questions, to listen or not to documents/fair-​ ​to-refer-​ ​report_pdf-​ ​79011677.pdf​ [Accessed 1 Nov 2019]. listen to the answers, and to decide what To cite Launer J. Postgrad Med J 2020;96:117–118. 8 Marmot M. Fair Society, Health Lives: The Marmot action to take. review. Available: http://www.inst​ ​ituteofh​ ​ealthequity.​ ​ Postgrad Med J 2020;96:117–118. org/resources-​ ​reports/fair-​ ​society-healthy-​ ​lives-the-​ ​ Most of us rarely come across explicit doi:10.1136/postgradmedj-2019-137295 white supremacism in as brutal a form as it marmot-review/​ ​fair-society-​ ​healthy-lives-​ ​full-report-​ ​ pdf.​pdf [Accessed 1 Nov 2019]. existed previously, although in recent years References 9 West M, Dawson J, Kaur M. Making the difference: it has been shocking to see it re-­emerge 1 Bécares L. Which Ethic Groups Have the Poorest diversity and inclusion in the NHS, London, Kings publicly in a way that was unimaginable Health? Ethnic Health Inequalities 1991 to 2011. Fund, 2015. Available: https://www.​kingsfund.org.​ ​uk/​ publications/making-​ ​difference-diversity-​ ​inclusion-nhs​ for a very long time. Yet implicit white Manchester: Manchester University and Joseph Rowntree Foundation, 2013. Available: http://​ [Accessed 1 Nov 2019]. supremacism may still be with us far more hummedia.manchester.​ ​ac.uk/​ ​institutes/code/​ ​ 10 Kumagai AK, Lypson ML. Beyond cultural competence: than we are willing to concede – at every briefingsupdated/which-​ ​ethnic-groups-​ ​have-the-​ ​ critical consciousness, social justice, and multicultural level from the individual to the organisa- poorest-​health.​pdf [Accessed 1 Nov 2019]. education. Academic Medicine 2009;84:782–7. 11 White AA, Logghe HJ, Goodenough DA, et al. Self-­ tion and entire society.16 If we cannot now 2 Public Health England. Public Health Outcomes Framework: Health equity report - focus on ethnicity. awareness and cultural identity as an effort to reduce name it, help people to become aware of London: Public Health England, 2017. Available: bias in medicine. J Racial and Ethnic Health Disparities its pervasive nature, and address it explic- https://assets.​ ​publishing.service.​ ​gov.uk/​ ​government/​ 2018;5:34–49. itly, all our other efforts at addressing uploads/system/​ upl​ oads/attachment_​ data/​ file/​ 73​ 3093/​ 12 Sukhera JI. Bias in the Mirror: Exploring implicit bias in PHOF_Health_​ ​Equity_Report.​ ​pdf [Accessed 1 Nov health professions education. Maastricht: Maastricht ethnic inequalities in health may only be 2019]. University Press, 2018. tinkering at the margins. 3 Matthews D. The impact of ethnicity on health 13 Nazroo JY. Genetic, cultural or socioeconomic inequality. Nursing Times 2015;111:18–20. vulnerability? Explaining ethnic inequalities in health. Twitter John Launer @JohnLauner 4 Institute of Medicine. Unequal Treatment: Confronting In: Bury M, Gabe J, eds. The sociology of health and racial and ethnic disparities in health care. illness: A reader. Abingdon: Routledge, 2004. Funding The authors have not declared a specific Washington, DC: National Academy Press, 2002. 14 Hickel J. The Divide: a brief guide to global inequality grant for this research from any funding agency in the 5 Matthew DB. Just Medicine: A Cure for Racial and its solutions. London: Windmill Books, 2018. public, commercial or not-­for-­profit sectors. Inequality in American Healthcare. New York: NYU 15 Chang H-­J. 23 Things they don’t tell you about Press, 2015. Capitalism. London: Penguin, 2011. Competing interests None declared. 6 NHS Workforce Race Equality Standard. Data analysis 16 Eddo-Lodge­ R. Why I’m no longer talking to white Patient consent for publication Not required. report for NHS trusts, 2018. Available: https://www.​ people about race. London: Bloomsbury, 2017. http://pmj.bmj.com/ on September 26, 2021 by guest. Protected copyright.

118 Launer J. Postgrad Med J February 2020 Vol 96 No 1132