Racism in medicineInstitutional racism and the medical

profession

Aneez EsmailUniversity of Manchester

Black and ethnic minority Black and ethnic minority communities are not getting the services communities are not getting the services that they are entitled to…that they are entitled to…‘… ‘… the institutional racism that is the institutional racism that is responsible for this is a disgrace and a responsible for this is a disgrace and a festering abscess which is at present a festering abscess which is at present a blot upon the good name of the NHS.’blot upon the good name of the NHS.’

The Bennett Inquiry – April 2004The Bennett Inquiry – April 2004

Institutional racism

‘Institutional racism is the collective failure of an Institutional racism is the collective failure of an organisation to provide an appropriate and organisation to provide an appropriate and professional service to people because of their colour, professional service to people because of their colour, culture or ethnic origin. It can be seen or detected in culture or ethnic origin. It can be seen or detected in processes, attitudes and behaviour which amount to processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping, which thoughtlessness and racist stereotyping, which disadvantage minority ethnic people’disadvantage minority ethnic people’

Sir William McPherson in the Stephen Lawrence Inquiry 1999

What is the evidence ?The professional legacy

• Applications to medical school

• Examinations

• Getting a job– Career progression and promotion

• Remuneration

• Complaints and suspensions

Medical School SelectionMedical School Selection

• Ethnic minority applicants disadvantaged

– McManus et al 1989– Esmail et al 1995– McManus et al 1998

Getting a Job

• Controlled trial using identical CV’s with English and Asian names

• White candidates twice as likely to be shortlisted compared to Asians

» Esmail and Everington BMJ 1993;306:691» Esmail and Everington BMJ 1997;314:1619

• Less than 10% of trusts carried out equal opportunities monitoring

Getting a job - Career progressGetting a job - Career progress

• 66% of medical workforce is white but 80% of all consultant appointments are taken by white doctors (DoH 2000)

• 42% of white doctors shortlisted for consultant appointments (12% successful) but only 28% (6% successful)of ethnic minority doctors shortlisted (CRE 1996)

Getting stuck in a job

• 66% of staff grade doctors and 65% of associate specialist grades qualified overseas (DoH 2001)

• 44% of all locums qualified in South Asia or West Africa. 70% of long term locums qualified overseas(Audit Commission 1995)

• In nearly 80% of trusts surveyed, one or more locums employed for more than 12 months (Atherton and Murray 2001)

Complaints• Overrepresentation of doctors from ethnic

minorities in cases brought before the GMC

• Esmail and Everington BMJ 1994;308:1374

• Ethnic minority doctors 6 times more likely to be charged with offences compared to white doctors

• Complete lack of transparency in process

Offences with which doctors were charged

Offence EM White OR

Improperrelationships

3 19 0.7(0.2-2.5)

Indecentbehaviour

19 7 12.4(4.9-32)

Disregard ofresponsibility to

patients

97 48 9.2(6-13)

BMJ 1994;308: 1374BMJ 1994;308: 1374

‘Thus in the three studies conducted over a period of nine years, the PSI found unexplained differences in the treatment by the GMC of overseas qualifiers as compared with UK qualifiers; the overseas qualifiers were more severely dealt with. This may or may not indicate that there is racial bias within the GMC….. It ought to be possible to refute a suggestion of bias if it can be demonstrated that decisions are taken according to objective criteria and by the consistent application of established standards. Professor Allen has repeatedly advised the GMC that it will be unable to refute the allegations of racial bias unless and until it develops objective standards and criteria….. without such standards and criteria, the GMC will be unable to satisfy the public that it is complying with its duty to protect patients.’

Dame Janet Smith – The Shipman Inquiry

Racism objectifies and makes a person into a thing and a thing by definition has no capacity for human relationships….

The unique complexity of a human being cannot be summed up and reduced by the colour of the skin. The patient who feels understood and cared for, who felt taken seriously and respected was less likely to be assaultative than one who felt rejected, powerless, despised, put down or dismissed.

Frantz Fanon

Suspensions

• Mainly anecdotal • Almost a third of ethnic minority staff

experienced bullying and harassment(Positively Diverse, DoH 2001)

• 45% of black and asian doctors reported being bullied at work compared with 34% of white doctors (Quine 2002)

Distinction and Discretionary Awards

• 5.4% of distinction awards held by ethnic minorities (22% of all consultants) ACDA 2000

• White consultants 3.5 times more likely to obtain award (Esmail et al BMJ 1998;316:193-195)

• White consultants nearly 2 times more likely to receive discretionary points (4 times more likely if higher awards considered)

Discretionary pointsDiscretionary points

“Such a high level of subjectivity is anathema to the successful application of equal opportunity guidelines since it works to the disadvantage of ethnic minorities, both in operation and perception… This case falls into the worst category of racial discrimination against a senior medical professional” (Dr M Nasr v. Salisbury NHS Trust)

The professional response

• It’s all ‘out there’• My best friends are black• ‘We are professionals – we don’t

discriminate’• How can we – ‘many of us are black

anyway’

If it is only bad people who are prejudiced, that would not If it is only bad people who are prejudiced, that would not have such a strong effect. Most people would not wish to have such a strong effect. Most people would not wish to imitate them — and so, such prejudices would not have imitate them — and so, such prejudices would not have much effect — except in exceptional times. It is the much effect — except in exceptional times. It is the prejudices of good people that are so dangerous.prejudices of good people that are so dangerous.

Vikram Seth. A suitable boy. London: Phoenix, 1993.

““What happened to the medical profession of What happened to the medical profession of Germany is stern testimony to the fact that Germany is stern testimony to the fact that acceptance of or even silence before anti-acceptance of or even silence before anti-semitism and the rest of the trappings of semitism and the rest of the trappings of racism....can lead to the dishonour and crime in racism....can lead to the dishonour and crime in which the entire medical profession of a country which the entire medical profession of a country must in the last analysis be considered an must in the last analysis be considered an accomplice.”accomplice.”

Andrew C IvyStatement In: Mitsherlich A, Mielke F.Doctors of infancy: the story of the nazi medical crimes.New York. Schuman.1949: xii-xiii