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Covid-19 - Fair Health Response Racism

Black Lives Matter: the death of George Floyd, health inequalities and Covid-19

A personal reflection on racism and steps for meaningful action by Dr Mariya Aziz, GP, Keighley, West Yorkshire with input from Dr Tom Ratcliffe, Fair Health

Events over the last few weeks, from the brutal killing of George Floyd to the devastating effects of COVID 19 on the BAME community, have highlighted the racial inequalities that lie deep within our institutions and the appalling impact it has on so many.

For those from a BAME background, myself included, it has churned up memories and feelings that we try and suppress and brought them to the forefront.

I cannot pretend that my experiences of racism as a British born Pakistani are the equivalent to those of my Black counterparts. However, the impact is indelible and has shaped me into the individual I am today.

The Health Services Journal reports that 44% of NHS doctors currently self-identify as BAME.  At the height of the epidemic, of the number of doctors who sadly lost their lives to Covid-19, a staggering 95% were from BAME backgrounds. The same pattern is seen in other clinical staff groups (see resources).

Data from the Office of National Statistics (see resources) showed that people from Black, Bangadeshi / Pakistani and Indian ethnic groups were all at a substantially increased risk of death from Covid-19 compared with white ethnic groups, even once multiple other factors, such as age, gender and socioeconomic deprivation, were controlled for. The data standardised for age alone is even starker. This showed that Black men and women were over 4 times more likely to die from Covid-19 than their white counterparts: a shocking disparity that reveals the stark intersection of race and poverty in health inequality.

Risk of COVID-19-related death by ethnic group and sex, England and Wales, 2 March to 10 April 2020 (Age adjusted model)

EthnicitySexOdds ratio of Death compared to White ethnicity Lower CI Upper CI
BlackFemale4.283.814.81
BlackMale4.23.814.63
Bangladeshi/PakistaniMale3.553.134.03
Bangladeshi/PakistaniFemale3.352.84
OtherMale2.682.323.09
IndianFemale2.672.33.1
IndianMale2.392.132.69
OtherFemale2.051.672.52
ChineseMale1.931.412.64
MixedMale1.811.42.34
MixedFemale1.611.142.26
ChineseFemale1.150.721.84
Source: Office for National Statistics, UK

How do we respond? What can we do better? And what we must avoid doing from now on?

First, we must all recognise and challenge the overt and more subtle forms of racism that still exist in healthcare.

Second, we must stop assuming that “not seeing colour,” means racism will go away and adopt a stance of active “anti-racism”.     

Third, we must take extra steps to be more inclusive, recognising that people from BAME backgrounds will often have past experiences that can trigger difficult memories and feelings that can impact on their ability to engage with colleagues, organisations and leadership opportunities. There may also be cultural barriers, which we are not sensitive to, that could also impact their progression to senior positions.

Recognising the challenge of racism

Overtly racist comments and use of unacceptable racial terminology is becoming less common but is certainly not unheard of. I do still hear people ask questions or use language that is unacceptable and have challenged it. Sadly, I have not always felt supported in doing so. I like to think that this not because people condone what others are saying (in the majority of cases) but because people are not always clear about the forms racism can take and feel uneasy about calling it out.

I do not feel this is acceptable. Inaction and failing to challenge racism is to be complicit in racial abuse.

Most difficult to address are comments and actions that are borne from ignorance and form “micro-aggressions”. Insidious in effect, these can create self-doubt and a pervasive worry about the way in which one is perceived. This can be more harmful than the overt racism that most people would easily recognise.

Examples in healthcare include:

  • Patients refusing to see a BAME clinician due to their race;
  • Ill thought out comments such as “your/her English is surprisingly good” in clinical feedback;
  • Unnecessarily prefacing references to colleagues with a racial identifier that would not be used when referring to white colleague (i.e. “the Asian doctor”, “that Asian family”)
  • Asking questions about another person’s cultural or social life out of curiosity but posing these in a way that uses stereotypes disrespectfully (i.e. “are people in your culture allowed to have more than one wife?”)

Being actively anti-racist

Some people conclude that the answer to these issues is to remove race as an issue entirely. Co-workers have reached out to me with comments such as “I don’t see your colour”. Whilst well intentioned, I have never felt such an approach provides comfort or reassurance. For me, it minimises who I am. My race and culture are part of me, not something that can be simply ignored.

In her book, White Fragility, Robin Di Angelo, illustrates this point when reflecting on an interaction between a White woman and African-American man:

“His race meant that he had a very different experience in life than she did. If she were ever going to understand or challenge racism, she would need to acknowledge this difference. Pretending that she did not notice that he was black was not helpful to him in any way, as it denied his reality and kept hers insular and unchallenged. This pretence that she did not notice his race assumed that he was “just like her,” and in so doing, she projected her reality onto him.”

The answer to racism is not to ignore race. It is to be actively anti-racist:

“One either allows racial inequities to persevere, as a racist, or confronts racial inequities, as an antiracist. There is no in-between safe space of “not racist.” The claim of “not racist” neutrality is a mask for racism,” Ibram X. Kendi (from How to be an Anti-Racist).

For most of us, adopting a stance of anti-racism, involves painful self-examination and challenging conversations. It should not need stating, but being BAME does not exempt me from this! Sadly even within my own community, there is a racial hierarchy and there is a need to look inwards and reflect on this.

I also believe that understanding what it means to be an ally is an important first step in the road to becoming an antiracist. Being an ally is not easy. It requires us to step out of our comfort zones and challenge discrimination where we see it but to also be mindful of scenarios where it is not so evident.  There is a need to acknowledge that we may have privileges not afforded to others on the basis of their skin tone and to share the benefits of this privilege.

Learning is an essential part of this process. And this means more than completing an annual mandatory e-learning module on Equality and Diversity. Whilst still worth doing, this is not even going to scratch the surface. You may find some of the resources listed at end helpful in addressing our learning gap.

Below is a chart that I have found helpful in the process of self-evaluation in my journey to becoming an antiracist.

Chart was adapted by Andrew M. Ibrahim MD, MSc from “Who Do I Want to Be During COVID-19” (original author unknown) with some ideas pulled from Ibram X. Kendi’s work.

As Scott wood, American author and poet wrote:

“Yes, racism looks like hate, but hate is just one manifestation. Privilege is another. Access is another. Ignorance is another. Apathy is another. And so on. So while I agree with people who say no one is born racist, it remains a powerful system that we’re immediately born into…It’s a set of socioeconomic traps and cultural values that are fired up every time we interact with the world. It is a thing you have to keep scooping out of the boat of your life to keep from drowning in it…”

I have no words to better this and it stresses even more that the act of being antiracist is a lifetime commitment to self-evaluation and learning.

Empowering BAME people within healthcare

Within my current role, whilst our primary care organisation (and indeed the whole medical profession), is very diverse overall, I am the only senior BAME GP working in my immediate setting. Recent events have made me reflect on the effects of this and my own empowerment.

Being placed in a group where I am in the minority as a person of colour can be paralysing. Whilst not an issue in the safety of my immediate clinical team, stepping out of this protected zone into the large business or commissioning meetings can be daunting.

At times, these experiences have rendered me acutely conscious of my race but also my culture and its variance to that of my peers. I know I speak for myself and others when I say that when placed in an ethnically homogenous environment we have all felt to some degree that we have had to compromise ourselves to blend in. In turn this leads to one feeling apologetic or the need to justify/defend certain behaviours that do not fit into the “White” norm.

I know the reasons for my response to this specific situation are rooted in my own insecurities based on past racial discriminations. The last time I was the only BAME individual in a large group was at school, which was a traumatic time due to race related bullying. Sadly, this experience was not atypical and similar feelings and experiences can be a barrier for those from a BAME background to progressing to roles of senior leadership.

Engagement with my predominantly White colleagues on this topic has not been easy. I acknowledge that race is a sensitive topic and those from a White background can feel defensive or as if they are being attacked equally those on the other side of it are perceived as “having a chip on their shoulder/always making it about race”. Hence it is imperative that we do educate ourselves and I include myself in that.

Being South Asian and Muslim does not exempt me from having my own prejudices and unconscious biases. And simply having a diverse workforce is not sufficient to resolve this issue. In fact, I am conscious that, among BAME colleagues, there is a recognised phenomenon of “pulling up the ladder” and failing to help empower colleagues or, worse still, making their progression harder than it should be.

Practical action

If we are to tackle racism, there will be uncomfortable realities that need acknowledging and challenging. We must be proactive and acknowledge a need for meaningful and sustained education and training around race and its impact within all layers of the NHS. We must translate learning from this into delivery of clinical care and consider how organisation of healthcare in culturally insensitive or inappropriate ways exacerbates health inequalities.

This will take time, effort and commitment. However, there are practical steps that we can take immediately. I have listed some suggestions below:

  • Within healthcare:
    • Leaders, including Freedom to Speak Up Guardians, should use this opportunity to specifically address the issue of racism within the NHS and invite a more open discussion of this topic
    • Primary care organisations should organise the collection of data in primary care similar to that of the secondary care and CCG WRES reports to support and ensure that BAME colleagues are being given equal opportunities.
    • Healthcare employers should ensure staff surveys specifically mention discrimination relating to race and other protected characteristics
    • Primary care organisations and educators should promote the concept of allyship as part of wider education for all staff on antiracism and the effects of unconscious bias.
    • Mentoring should be provided for BAME colleagues. For example, using the reverse mentorship programme run by Health Education England. This would pair individuals from under-represented groups with healthcare leaders from non-BAME backgrounds in the hope that alliances are created and experience and knowledge shared.
    • Proactively encourage BAME colleagues to pursue leadership opportunities. The NHS leadership academy has courses aimed at supporting BAME individuals progressing within the work place, i.e. the “ Stepping up” and “Ready Now” programmes.
    • Practical steps such as recognising a wider range of religious holidays in organisational timetables, thus empowering people and making them feel valued within the organisation.
  • For patients:
    • Use Health Equity Audit to look at the uptake of primary and secondary prevention and health outcomes by ethnicity, then take steps to address any inequities identified
    • Ensure information is provided in a range of languages and interpreters are easily accessed
    • Ensure that patient councils include a range of individuals and voices that reflect the demographic make up of the patient body, including by ethnicity
    • Ensure that the way that illness presents in different groups is recognised and that clinical staff are aware of how symptoms and signs vary across BAME and white ethnicities
    • Build alliances with organisations that already provide services for the most vulnerable members of the BAME community, for example inclusion health providers and the VCS

The tragic events in the USA and the Black Lives Matter movement have created huge momentum in what is most likely a once in a generation moment. I know having these conversations with our teams, calling out racism in all its forms and adopting a stance of active anti-racism will be difficult. We have to remember that this is about us coming together so that the minority can be part of the majority and receive fair and equal treatment.

Resources

Sources referenced in this blog

How to be an Anti-Racist. Ibram X Kendi

White Fragility. Robin Di Angelo

ONS – deaths from Covid 19 and socioeconomic deprivation

ONS – deaths from Covid 19 and ethnicity

Health Service Journal – analysis of deaths from Covid 19 among UK healthcare professionals

Further reading and viewing

There are many excellent books, films, documentaries covering the topics discussed in this blog. The list below suggests a few that may be of interest and/or provoke further reflection and debate. Please note that a number of these resources include graphic and distressing material that some will find difficult to read, hear and/or watch.

Books:

Non Fiction –

Why I’m No Longer Talking to White People About Race by Reni Eddo-Lodge​. Based on Reni’s blog post of the same name that went viral back in 2014. A must read book exploring what it means to be a person of colour in the UK today. 

The Good Immigrant. A collection of essays featuring people such as Riz Ahmed, Bim Adewunmi, Vinay Patel, Eddo-Lodge and many others exploring race and immigration. 

Inglorious Empire by Shashi Tharoo. Tharoo is an Indian politician and diplomat, whose book examines the effects of British colonialism on India and challenges some of the post-colonial myths about the British Empire.

White Privilege by Kalwant Bhopal. This book explores the myth of a post-racial society.

Black and British: A Forgotten History. David Olusoga. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long (right back to the Roman empire) and interwoven history of the UK and people whose origins lie in Africa.

Between the World and Me by Ta-Nehisi Coates. A letter to his son exploring questions about race in the USA today. 

Fiction –

Girl, Woman, Other by Bernadine Evaristo. Booker prize winning novel exploring the interconected stories of twelve characters raising questions about race and feminism. 

Queenie by Candice Carty-Williams. Darkly funny and candid. Covers a huge range of topics include race, mental health.

Americanah by Chimamanda Ngozi Adichie. The novel explores the story of a Nigerian woman who moves to the USA for university, caught between the two cultures and countries. 

Homegoing by Yaa Gyasi. This novel explores the story of two sisters with different destinies: one sold into slavery and one marrying becoming the wife of a slave trader.

Viewing –

13th, a Netflix documentary exposing racial inequality within the criminal justice system. Title comes from the 13th Amendment, (the abolition of slavery in the USA).

When They See Us, a mini-series from Ava DuVernay about the Central Park Five (uncomfortable viewing including detailed descriptions of rape and scenes of violence).​

Black and British: A Forgotten History.David Olusoga. Available on BBC iplayer. Olusoga explores how British history has been ‘white-washed’ and sheds light on the very long and interwoven history of the UK and people whose origins lie in Africa.  He has also presented a series exploring ‘Britain’s Forgotten Slave Owners’ which is also available on BBC iplayer. 

Selma, a film that chronicles the marches of the Civil Rights Movement. 

The Hate U Give, a film based on the YA novel offering an intimate portrait of race in America.