Racism in medicine Institutional racism and the medical profession

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Racism in medicineInstitutional racism and the
medical profession

• Aneez Esmail
• University of Manchester

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Black and ethnic minority communities are not
getting the services that they are entitled
to the institutional racism that is
responsible for this is a disgrace and a
festering abscess which is at present a blot upon
the good name of the NHS. The Bennett
Inquiry April 2004
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Institutional racism Institutional racism is
the collective failure of an organisation to
provide an appropriate and professional service
to people because of their colour, culture or
ethnic origin. It can be seen or detected in
processes, attitudes and behaviour which amount
to discrimination through unwitting prejudice,
ignorance, thoughtlessness and racist
stereotyping, which disadvantage minority ethnic
people Sir William McPherson in the Stephen
Lawrence Inquiry 1999
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What is the evidence ?The professional legacy

• Applications to medical school
• Examinations
• Getting a job
• Career progression and promotion
• Remuneration
• Complaints and suspensions

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Medical School Selection

• Ethnic minority applicants disadvantaged
• McManus et al 1989
• Esmail et al 1995
• McManus et al 1998

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Getting a Job

• Controlled trial using identical CVs with
  English and Asian names
• White candidates twice as likely to be
  shortlisted compared to Asians
• Esmail and Everington BMJ 1993306691
• Esmail and Everington BMJ 19973141619
• Less than 10 of trusts carried out equal
  opportunities monitoring

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Getting 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)

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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)

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Complaints

• Overrepresentation of doctors from ethnic
  minorities in cases brought before the GMC
• Esmail and Everington BMJ 19943081374
• Ethnic minority doctors 6 times more likely to be
  charged with offences compared to white doctors
• Complete lack of transparency in process

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Offences with which doctors were charged
BMJ 1994308 1374
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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
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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
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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)

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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 1998316193-195)
• White consultants nearly 2 times more likely to
  receive discretionary points (4 times more likely
  if higher awards considered)

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Discretionary 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)

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The professional response

• Its all out there
• My best friends are black
• We are professionals we dont discriminate
• How can we many of us are black anyway

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If it is only bad people who are prejudiced,
that would not have such a strong effect. Most
people would not wish to imitate them and so,
such prejudices would not have much effect
except in exceptional times. It is the prejudices
of good people that are so dangerous. Vikram
Seth. A suitable boy. London Phoenix, 1993.
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What happened to the medical profession of
Germany is stern testimony to the fact that
acceptance of or even silence before
anti-semitism and the rest of the trappings of
racism....can lead to the dishonour and crime in
which the entire medical profession of a country
must in the last analysis be considered an
accomplice.
Andrew C Ivy Statement In Mitsherlich A, Mielke
F. Doctors of infancy the story of the nazi
medical crimes. New York. Schuman. 1949 xii-xiii