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Of those on the receiving end of racism, few will display the forbearance and resilience of a Nelson Mandela1. For most the net effect is an unhealthy mixture of emotions including frustration, anger and despondency; an unlucky few suffer physical injury or death. Racial bigotry and prejudice is a challenge for multicultural societies the world over, but in Britain, with its large ethnic-minority population (almost 6% and likely to increase), the challenge is particularly acute2. A 1997 Policy Studies Institute survey revealed that 25% of white people admitted to some prejudice against minority ethnic people3, and of even greater concern is the evidence of deep-seated racism in institutions such as the police4. In medicine, research has consistently shown disparities between the health experiences of ethnic-white and ethnic-minority groups5 but the existence of racial discrimination within the profession is less well acknowledged. A report from the King's Fund, Racism in Medicine, summarizes the evidence that British medicine systematically discriminates against its ethnic-minority workforce6.
The obstacles begin at medical school entry and re-emerge at various points in a medical career7. For example, in certain specialties many non-white clinicians encounter a ‘glass ceiling’ beyond which promotion is impossible; and the consequence is that some are forced into a less competitive specialty. So, the National Health Service suffers a double loss: one specialty is deprived of individuals with strong motivation, while another gains members whose enthusiasm may be low8. Two decades after the matter of racism was first highlighted9, there has been little obvious progress in improving the race-relations record of medicine in the UK9. What steps must the medical profession now take? Outlined below are some of the initiatives that I believe require urgent consideration.
First and foremost, the medical profession must take stock of the mounting evidence of racism in the health sector. The National Health Service, to its credit, has begun this process10,11. Medical schools, the Royal Colleges, hospital trusts and primary care groups need to engage in a similar programme of introspection (in conjunction with representatives of national and local ethnic minority groups if necessary), to determine how best to bring about equal opportunities within their organizations.
Crucial to progress is a suitably informed workforce. Therefore the principles and practice of transcultural medicine should be incorporated in undergraduate and postgraduate curricula. Courses in which students explore the notion of racism are already offered by some medical schools and could be emulated by others. For example, from genetics, students learn that homogeneous races do not exist; from anthropology (the very discipline founded on the nature of race), that a racial taxonomy is no longer valid; from sociology, the contribution of social Darwinism to the ethnocentric paradigm that underlies institutional racism12. Students should also explore the strengths and weaknesses of strategies already employed to tackle racism in healthcare—for example, the promotion of integration, adoption of colour-blind policies, positive discrimination.
What about selection procedures? We know that, among applicants to medical schools, individuals with foreign names have been at a disadvantage13,14, that coloured staff are underrepresented in senior clinical posts15 and that discrimination exists in the allocation of NHS distinction awards16. One of the hallmarks of a healthy organization is that it welcomes and applauds whistle-blowers; the despicable treatment of Professor Joe Collier, who first exposed systematic discriminatory practice in medical school selection procedures, must never be repeated17. Rather, we need to create confidential channels of communication where staff with concerns are welcomed and valued. Thanks to the work of Collier and others, there has been some progress towards greater equality in recruitment practices; most NHS institutions have adopted equal-opportunities policies. But practice is not synonymous with policy, and the next move is to develop explicit selection criteria that can be tested in terms of the ethnicity of successful candidates. If voluntary measures fail, league tables may prove necessary18.
Another issue is the racial harassment of NHS staff. Within nursing, two-thirds of ethnic-minority staff said they had experienced racial harassment from patients; and, in the same survey, one-third of respondents reported harassment by colleagues and managers19. Anecdotal evidence suggests that the picture is no different in medicine7. The Government has committed itself to eradicating such harassment from the NHS20, but success will depend on the creation of a workplace ethos in which victims are positively encouraged to seek redress, through the law if necessary.
In both scientific and moral terms, racism should be alien to medicine. The National Health Service, largest employer of ethnic-minority people in Europe, should be a leader in the struggle against it.
I am in receipt of a NHS R&D National Primary Care award.