Medicine and Labour Chapter 11 Medicine and Racism

All of us who have been brought up in a racist culture are racist and we will not start to combat that racism until we understand it. That statement inevitably offends and angers, quite rightly, for it is not true that all of us go round burning down mosques, pushing blacks off pavements or advertising jobs as ‘only Christian graduates of British medical schools need apply’ (hoping that second generation West Indians take the message as it was meant rather than literally). Nor is it even true that all of us do those things covertly – consciously downgrading our perceptions of black people but politely not mentioning it. What is true is that those of us who are neither overtly nor covertly racist are unconsciously racist.

Unconscious Racism

To illustrate what I mean by unconscious racism let me give some examples:

Two candidates are being considered for a place at medical school. One has been educated at Eton and has A level grades B, B and B. The second has been educated at a inner-city school and has grades B, B and C. If we assume that the two have competed on equal terms and that the former shows the greater academic potential we are, in fact, discriminating against inner-city, lower social class applicants, black or white. There is a fine line between positive action, which accounts for past disadvantage when using past achievement as a predictor of future success, and tokenism, which divides people into categories and allocates them quotas. To choose a black Old Etonian rather than a white one to maintain ‘racial balance’ would be tokenism. To add half a grade to the A level performances of those who had struggled against disadvan­tage would be positive action.

An Appointments Committee is considering two well qua­lified candidates for a medical post. One of them comes with excellent references from Prof X at the local teaching hospital. The other seems to lack teaching hospital experience, having worked entirely in peripheral hospitals. He also took three attempts to get his Membership, which the first candidate passed at the first attempt. The second candidate, who is black, seems a nice bloke, very able and perfectly capable of doing the job. The committee would like to appoint him, but concludes that it would be unfair on the first candidate who, on paper, clearly has a better curriculum vitae.

The reason that the second candidate failed to get a job in a teaching hospital was that he was black. The reason that he failed to pass his Membership at the first attempt was that in the peripheral hospital he was overworked, without time to study and without the teaching programmes which Prof X arranges for all his junior staff. If our well-meaning, liberal, fair, totally unprejudiced Appointments Committee does not take that into account it merely perpetuates the system. In this example the appointment is, in fact, influenced more by the racism of past appointments committees than by the fairness of the current one.

A hospital with a large Asian population in its catchment area fails to provide any Asian food on its menus, fails to make any interpreter facilities available and commissions an ‘out-reach’ health education campaign which prints its posters only in English.

Unconscious racism, therefore, has two main com­ponents. One is to fail to take account of past disadvantage and compensate for it. The other is to assume the existence of a uniform, i.e. English, culture. It can easily co-exist with other forms of unconscious discrimination, such as uncon­scious sexism or unconscious discrimination against working-class people.

British society is particularly susceptible to unconscious discrimination because of the strong sense of tightness’ that attaches to social norms in matters of ‘taste’ (which gives a false sense of uniformity to society) coupled with a tendency to treat deviancy by repressive tolerance.

The Appointments Committee which would freely accept a candidate with a black skin and a ‘cultured accent’ (itself a value-laden term) or a Bradford accent but reject one who sounded as if she actually had links with her subcontinent of origin would be carrying on a long tradition of discriminating through criteria which are irrelevant to, but closely associated with, the disadvantage one intends to avoid. The existence of a few people who fall into the disadvantaged group, but do not fall foul of the criteria, is essential to the preservation of this myth and such individuals may well encounter positive approval and advancement, which they will be expected to repay by pointing out how it is possible to advance on merit, just as they did. The most liberal of individuals can fall into the trap of accepting those stereotypes.

Racism in the NHS

In concentrating upon unconscious racism at the start of this chapter I would not wish to give the impression that the NHS is so advanced and liberal an institution that it is only unconscious racism which is a problem, and that overt and covert racism have already been banished. That is not the case. Health workers at all grades suffer from both forms of racism.

Since this book is concerned with the medical profession I will look in some detail at the effect of racism on black doctors. However other groups of health workers suffer similar problems.

West Indian nurses have complained of a failure to recognise West Indian GCE examinations. Young Moslem women find entrance to nursing blocked by a failure to respect their religious obligation to cover their legs: trousers are definitely not an acceptable component of nurse uniforms. Black nurses are frequently directed into the lower-status SEN courses even when they qualify for SRN courses and there is frequently quite overt discrimination against black nurses in relation to promotion.

There are very few black NHS administrators and clerical workers, but at the level of unskilled ancillary staff we come, of course, to the ‘traditional’ roles of black people. However ancillary staff had better not ‘get uppity’ or they might be privatised as a punishment for their militancy, (Privatisation of NHS ancillary services predominantly affects the lowest grades of staff, in which most black health workers (apart from doctors) are to be found.) or even deported, as in the case of the Filipino workers. (In the early 1980s many Filipino workers in the health service in London were deported, sometimes for failure to declare ‘relevant’ facts on their applications for entry even though they claimed never to have been asked the relevant questions.) Amidst such overt racism it may be thought idiosyncratic to have opened this chapter with a description of unconscious racism amongst liberal members of professional appointments committees.

So far as patients are concerned, however, unconscious racism may well be the more serious problem. The inadequacy of interpreter services can block access to the health service for large sectors of the community. Failure to take account of Asian diets in the training of dieticians and doctors can interfere with the advice given to diabetics and other patients with needs for dietary advice. Failure to provide Moslem food in hospitals can cause real hardship. Failure to take proper account of differences between the norms of behaviour of different cultures can cause misdiagnosis of psychiatric illness.

Overseas Doctors – the Evidence

It is impossible to work in the medical profession and not know that it is a racist profession. For at least ten years after qualifying hospital doctors are in competition with each other for a succession of jobs on short-term contracts. They know that when a short list is being drawn up white doctors who are suitable receive precedence over blank doctors and that black doctors are appointed only when there is no suitable white applicant. They concede this when they discuss the competitiveness of a job by the number of white applicants. They discuss the merits of a hospital by the proportion of its staff who are white. They know that the best black medical senior registrars (and a black doctor needs to be good to make it that far) are advised to become geriatricians and that many black doctors work as associate specialists who, if they were white, would find consultant posts. They know all this, and they take it for granted, and they still manage to feel indignant when they are told that the profession is racist.

Those who do not work so close to the system, and therefore need statistical information to form their understanding of the experience of overseas doctors will find such evidence in a book by David Smith. (Overseas Doctors in the National Health Service, Policy Studies Institute, 1980)

In answer to the question, ‘Suppose that two doctors with comparable qualifications and experience, one of them coloured and overseas-qualified, the other white and British-qualified, apply for the same hospital job in England. In this situation, what do you think will be the chances of the two applicants?’ only about one doctor in twenty thought the two applicants would have equal chances, whilst over a third thought the overseas doctor would be rejected slightly more often and about half thought the overseas doctor would be rejected much more often. There were only slight differences between GPs and hospital doctors and between British-qualified and overseas-qualified doctors, in their responses to this question, except that those overseas doctors who thought discrimination would occur were more likely to categorise it as severe. The proportion of doctors who thought discrimination would occur was 86 per cent in both British-qualified and overseas-qualified doctors, but amongst British-qualified doctors the proportion who said the white doctor would be chosen ‘much more often’ was 48 per cent whereas amongst overseas doctors it was 56 per cent.

In a sample of hospital doctors aged between 28 and 54, standardised to a notional age distribution so as to account for differences of age between white and overseas doctors in the sample, almost half of British qualified doctors were consultants compared with less than a fifth of overseas-qualified, whereas over a third of overseas doctors were senior house officers or house officers (the most junior grades) as opposed to about a tenth of British doctors. Two thirds of overseas doctors occupied the most junior three grades of house officer, SHO and Registrar, as opposed to about a third of British doctors.

Statistically, however, this distribution could be partially explained by differences in language ability. All the doctors in the sample were given a language test and amongst high-scoring doctors there was very little difference in grades between British and overseas doctors. Amongst medium-scoring doctors there was a difference, with 29 per cent of the British-qualified being consultants compared with 7 per cent of the overseas-qualified. Amongst the poor-scoring doctors comparisons could not be made since too few British doctors achieved poor scores.

This suggests that three groups of overseas doctors can be identified, based on language ability. Amongst those whose English is very good even by British standards, there is little discrimination relative to British doctors of the same linguistic standard. Obviously this group of doctors has no real com­munication problem, and their command of English as a foreign or second language is excellent, yet they still suffer exclusion. Amongst those whose command of English falls below the standards of the native population there is created a proletariat of overseas doctors drifting from one junior job to another with no real career prospects.

It may be noted at this point that the Royal College of Obstetricians and Gynaecologists includes within its member­ship examination a question in which candidates are asked to write an essay which will be marked for style and use of English and not for content. White doctors in the specialty sometimes describe this as the ‘wog stopper’.

Another explanation for the junior grades of overseas doctors could be that many overseas doctors come to this country only for training posts and then return home. Although this was corrected for by the age-standardisation it must be borne in mind that the ‘high flyers’ of the overseas doctors would return home quickly whereas the high flyers of the indigenous population would instead be promoted quickly.

To test definitively the question of whether discrimination occurred, Smith constructed a table showing the grades of hospital doctors who had obtained their Membership or Fel­lowship of the appropriate Royal College and who scored 21 to 29 on his language test (the score range corresponding to that degree of command of English which obtained amongst British-qualified doctors), standardising for age.

Within this group, 63 per cent of British-qualified doctors were consultants as against 38 per cent of overseas-qualified, and 41 per cenMof overseas qualified doctors were SHOs or registrars as against 18 per cent of British-qualified doctors.

Overseas doctors were also less likely to work in the pre­stigious teaching districts. For example, amongst overseas-qualified doctors with Membership or Fellowship under a third worked in a teaching district, compared with half of British-qualified doctors.

Surprisingly, there was no significant difference between British- and overseas-qualified doctors of the same grade in the amount of time they had available for study.

Overseas doctors were more likely to be found in low-status specialties and less likely to be in their first choice specialty. This makes the delayed career progress observed even more significant, since doctors in these specialties would normally expect more rapid career progress.

Readers who are interested in exploring this question in more detail would be well advised to read Smith’s book. Suffice it to say that his findings support the accusation that the profession exploits and discriminates against its black members.

The Role of Medical Racism in the Medical Career Structure

The basic feature of the medical career structure is the large imbalance between the number of consultants and the number of doctors in junior grades. Doctors are not expected (or indeed allowed) to stay indefinitely in junior grades, which are all seen as training grades, designed to prepare them to become consultants. However there are about two ‘training grade’ posts for every consultant post, despite the fact that doctors spend about three times as long in the consultant grade as they do training for it. This means that there are six times as many junior posts as can be sustained by the career structure and five doctors in every six must, for one reason or another, quit the system.

There are three main ways out from the system – into general practice, into motherhood and abroad. Future general pracititioners provide a ready source of doctors for the most junior grades of house officer and SHO, but it is still impossible to staff all the SHO posts with doctors spending only the two to three years required for general-practice training in those grades. The balance is made up partly by black doctors. It is also partly made up by white doctors who are embarking on a programme of specialist training which they will not in fact complete because too many would-be specialists are chasing too few jobs and so some will fall off the ladder and convert to a general-practice career late, thereby spending longer in the hospital service than they need have done.

The situation is even worse at the next grade up – the registrar grade. Here the supply of people gaining hospital experience intentionally before entering general practice has completely dried up. The surplus posts must be occupied entirely by black doctors or by doctors who have been duped into a career which they will not complete.

The structure which provides consultants with a retinue to do their routine work for them is therefore sustained by the exploitation of three groups of doctors – black doctors who will quit the system to go home, women who will quit the system to become mothers and dupes who will spend several years and a considerable amount of emotional and intellectual energy in training for a career which in fact will be denied to them.

It is not necessary that the departure of any of these groups of doctors should be voluntary. The system of short-term contracts ensures that when doctors become ‘time expired’ they can simply be disposed of.

It is in this context that we can see the roles of the three groups of overseas doctors that can be discerned from David Smith’s statistics, and also from observation. Doctors of poor linguistic ability form a reserve pool which can make good the shortage of SHOs. Doctors whose linguistic ability is up to average British standards, but not excellent, are allowed to climb the career ladder as far as the registrar grade, but are still discriminated against when they try to go further. Thoroughly Anglicised doctors, with excellent standards of English even by British standards, are allowed to progress further to consultant posts (although not prestigious ones), thereby concealing the racism of the structure and forming an overseas-doctor elite to whom concessions can be made whenever it is necessary to defuse tension amongst the exploited.

This structure eases the career experiences of British graduates, since fewer dupes are needed if blacks and women are available in sufficient supply. It is interesting that the proportion of women in medical school was allowed to increase at the very time that an increase in medical school throughput threatened to bring about self-sufficiency in doctors, and hence to expose British doctors to experiences previously reserved for blacks. It is also interesting that concern at the imbalance of the career structure began to be expressed at the same time, again because British doctors began to enter a part of the system from which they had previously been protected by the black cushion. The package of solutions called for by the BMA included cuts in medical school throughput, sponsorship schemes to attract black doctors and repatriation provisions to remove them from the system when they were no longer needed.

Overseas Doctors – the Campaign

The Overseas Doctors’ Association was founded in the aftermath of the Merrison Report on medical education which cast doubts on the competence of overseas doctors. This particularly angered overseas doctors, a group of whom launched the Overseas Doctors’ Association. The BMA reacted angrily to the formation of the organisation, accusing it of dividing the profession and dismissing it as a mere fringe organisation.

For about two years the ODA remained a rather low-key organisation with only a few hundred members. However in 1977 it raised its campaigning profile very considerably, attacking the exploitation of overseas doctors and the way that the leadership of the profession gave token sympathy but denigrated the efforts of the overseas doctors. By 1979 its membership had increased to 600 members, and it won several seats on the General Medical Council. A major press campaign was launched.

The BMA’s response was to emphasise its own role as the representative of all doctors. Overseas doctors who held office in the BMA (especially the unpopular, powerless, but apparently prestigious office of Divisional Secretary) were invited to write articles for BMA publications and for the medical press, and were given prominence in reports of conferences. The BMA had recognised a threat.

When an organisation reaches this stage of its development the objective of the BMA is to prevent its disturbing the unity of the profession. The BMA will therefore seek to attract it to work within the BMA structure and will make token concessions to divide the radical and conservative sections of the organisation, in the hope of co-opting the latter and isolating the former.

This battle was now to take place in the ODA. The radical elements were led by Krishna Korlipara, a dynamic Bolton GP with a flair for publicity, a good business mind and a powerful commitment to the underdog.

Korlipara became General Secretary of the ODA. He recognised that the Association would, by its very nature, contain more established doctors than non-established, and that it must not neglect the floating locum medical proletariat. He also recognised the need for publicity and the need to attract members by providing services.

Under his leadership the ODA grew to a membership of several thousand. However by the early 1980s the medical press was reporting divisions within the ODA leadership about Korlipara’s aggressive style, and by 1982 Korlipara no longer really had control of the organisation and many of his ideas were blocked, although this was concealed to some extent by his role as the ODA’s chief publicist. The opposition to Korlipara was already coalescing and by 1984 was to be strong enough to achieve a constitutional change preventing his seeking a further term as General Secretary and then to defeat him electorally (amidst angry scenes at the ODA AGM) in his bid to win the office of Chairman.

In 1982 this opposition was still beneath the surface. The BMA, however, began to adopt a much more friendly attitude to the ODA, consulting it regularly, and emphasising the importance of overseas doctors within the BMA.

The floating locum proletariat had never entered the ODA in large numbers and was not in a position to become involved in either the ODA or the medico-political machinery. Korlipara’s faction, although composed of established doctors every bit as much as its rival, sought to champion the underdog but was now in eclipse. The stage was set for the BMA to reassert control by the process of bringing the ODA out of the cold. The ODA was not to be told that coming out of the cold meant stepping into the fire.

The ODA began to occupy a place as a powerful pressure group in the profession. As it did so the more conservative elements, now in the ascendancy in the factional struggle, began to argue that it was unwise to rock the boat lest the new-found power be lost.

By 1983 therefore it must have seemed to the medical establishment that the problem of overseas doctors had been solved. The ODA had been absorbed into the fringes of the establishment and no longer played a divisive role. A black medical establishment, secure in career posts and only mildly discriminated against, had been created, controlled the ODA and provided black faces for BMA and Royal College conferences – even for offices on the edge of power. The more exploited sectors of the black medical community could be contained by the black medical establishment’s control of the ODA and by the use of a rhetoric of realism.

The situation, however, was far from stable. The black medical establishment was neither as stupid nor as cynical as might have been assumed, nor were the concessions that had been made to it enough to secure its undying loyalty to the BMA. There was always the possibility therefore that it would respond positively rather than defensively to any emerging pressure from its constituents.

That pressure was likely to emerge as the increasing medical school throughput made it necessary to solve the staffing equations in a context of British self-sufficiency of doctors. This inevitably raised the spectre of repatriation of the reserve army of exploited overseas doctors in the more junior grades.

Repatriation was brought to prominence in medical politics by two events. One was the approach, in February 1984, of the fifth anniversary of the revised Medical Act. Overseas doctors who entered this country since that Act hold a form of registration called ‘limited registration’, which expires after five years. Within those five years it can be converted to ‘full registration’ only if the doctor makes a certain progress, essentially amounting to progress into specialist training. The prospect therefore arose that from February 1984 onwards registrations would start to lapse, excluding doctors from medical employment.

Repatriation was also raised by the idea of the overseas doctors’ sponsorship scheme. This was an idea for allowing doctors to come from overseas to a properly organised training scheme which would allow them to attain certain specific training objectives, such as a British postgraduate qua­lification, and then return home. The ODA, and also many well-meaning British doctors, welcomed the scheme as a way of improving the lot of overseas doctors who would come to this  country for an organised programme of experience and training instead of being subjected to exploitation within the vagaries of the short-term contract system. The scheme was also attractive as a solution to the manpower equations. It would be possible to reduce medical school throughput, bring the career structure into balance, and fill the vacancies in the consultant’s retinue with doctors off the sponsorship scheme. It would allow the country to discard the dangerous idea of self-sufficiency of doctors which threatened the career structure with the de­mands of disappointed and articulate British doctors, cut its medical schools and go on staffing its hospitals with blacks just as it always had, but in a more organised and benevolent way.

The problem in the perfect solution was that there was no guarantee that these blacks would not stay on and compete with British doctors for career posts when their sponsorship scheme was over. The BMA, therefore, could only accept the scheme if there were guarantees that the doctors concerned would go home when they completed it. Many of the scheme’s benevolent supporters accepted this as an unfortunate constraint that they would have to tolerate in order to win support. The ODA, however, was horrified at the idea of repatriation.

At the ARM in Dundee the scheme was approved, including this element. Repatriation was, indeed, attacked by only two speakers, both of them from the white left. Overseas doctors did not oppose the scheme in the ARM, although the ODA made statements of opposition outside.

In 1985 the government created new immigration controls for doctors which prevent overseas doctors spending more than five years in this country, and therefore permit implementation of the sponsorship scheme, complete with repatriation. Proposals agreed between the government and the BMA in 1986 – the Hayhoe Report – build on this by introducing jobs reserved for overs%as doctors.

The BMA further antagonised overseas doctors when procedural sharp practice was used to shuffle off the Dundee agenda an MPU-sponsored motion on racism in medicine. Overseas doctors were furious.

Further pressure built up on the ODA in the autumn of 1983 when an unregistered Argentinian doctor, working as Director of a health care pressure group, launched the National Association for Ethnic Minority Doctors (NAEMD), in direct competition with the ODA.

This move aroused bitter opposition and was taken against the advice of the MPU, but in retrospect can be seen to have brought to the fore tensions that were present but unexpressed.

NAEMD was an overtly anti-racist organisation with a radical perspective. It appealed to the more exploited sectors of the black medical community. It collapsed after a few months, but not before the ODA had become more radical in response. In June 1985, following the anger that surrounded Korlipara’s defeat in the ODA, a new breakaway organisation was launched, the Overseas Doctors Federation.

The MPU also launched a campaign against racism in medicine early in 1984 and relations between the MPU and the ODA improved considerably as the ODA found it necessary to step back from its role in the establishment.

In the mid-1980s, therefore, the relationship between black doctors and the BMA is unfreezing, dissatisfaction is emerging, and the ODA faces a challenge to its position. It is too early to predict how this situation will develop, or in what form the unity of the profession will again be negotiated.

Race and Health — Issues and Ideology

Over recent years there has been a growing debate about the special health problems of black communities. Amidst growing recognition of these problems two ideological standpoints can be perceived – the establishment position which sees the problems as resulting from the culture of the ethnic minority groups, and the radical position which sees the problem as being the racism of British society. The radical position views the establishment position as victim-blaming, whilst the establishment position views the radical position as being a politicisation of a technical health problem.

Asian communities suffer high rates of rickets. The establishment response is that black diets are deficient in vitamin D and Asian women in purdah get insufficient sun. The solution is the adoption of a Westernised culture, but in the meantime vitamin drops can be issued to Asians. In contrast, the radical response is that rickets has always been endemic in this sun-deficient country in which the diet is low in vitamin D. That is why the British diet, which in many respects is less healthy than Asian diets, is fortified with vitamin D in bread and in margarine. We deny the same facility to those who eat Asian diets, and we should fortify chapatti flour and ghee as well. To deny the Asian community the food fortification service which we supply to the British population is racist.

West Indian communities suffer high rates of sickle cell anaemia, a genetic disease. The establishment view is that black people have genetic problems; it is necessary to do what we can do for them, but screening programmes would be prohibitively expensive. The radical response to the racist concept of genetic inferiority is to point out that every race has its genetic problems. The NHS arranges to cope with the genetic problems of the indigenous population, such as cystic fibrosis, but neglects the genetic problems of other races.

There is a high rate of diagnosis of psychiatric disorder amongst ethnic minority groups. The establishment position is to enquire into why there should be such a high rate of illness, while the communities themselves believe that the apparently high rate is due to misdiagnosis as a result of cultural misunderstanding and racism.

Asian patients don’t eat hospital food and their relatives bring food in for them. Bemused catering managers set out the position by saying something like, ‘Asians just won’t eat hospital meals. There is a bit of a problem with Moslems who don’t eat certain types of meat but there is always a meal on the menu which Moslems can eat, usually a cheese salad. It is a problem when their relatives bring food in to them, it causes so much litter.’ (Readers who think the establishment  attitude  described here  is  a caricature should look at early editions of The Times of 9 September 1983 in which the following report appeared under the headline ‘Hospital Curries’: ‘Asian meals are being served at Sandwell District General Hospital, West Midlands, in an attempt to stop patients’ relations bringing in curries from the local takeaway.’ We shouldn’t be too hard on Sandwell, however, who are doing the right thing, but for hopelessly patronising reasons. At least Asian communities now know how to move the hearts of catering managers who have not followed Sandwell’s example. ‘Usually a cheese salad’ is a direct quote from a statement made by a catering manager.)

The alternative perspective is that people have a right to expect food to their taste, especially if their taste is merely that of a significant section of the population.

Language difficulties cause a barrier to access to the health service for many communities. The establishment acknowl­edges the problem that so many Asian patients cannot speak English. A solution frequently suggested is that they should bring a relative with them who speaks English, their children, for example. The radical response is that it is absolutely appalling that so many health authorities do not employ interpreters for significant linguistic minorities in their district. It is quite unacceptable to expect people to discuss intimate medical problems through their children, relatives or friends.

There is a high incidence of TB in the Asian community. The debate runs as follows. ‘They pick it up in India. They will keep going back to visit relatives, and then of course they bring it back with them. We tried screening for it at ports and airports, but we didn’t pick any up because it was still at an early stage.’ The enlightened response is that TB broke out in this country when people congregated in cities and has been endemic ever since. The native population has acquired immunity over generations but when the Asian migrants arrive here from rural communities and are pushed into the overcrowded inner cities they suffer from the disease.

These two ways of looking at the same problems depend essentially on whether ethnic minority cultures are seen as legitimate subcultures within British society or as alien impositions to be destroyed by assimilation and adoption of the dominant culture.

The medical profession, on the whole, would accept the establishment position on all these issues. This was very evident when in 1983 the BMA Junior Members’ Forum was held on the subject of the health of ethnic minorities. The background to this Forum was that the Prince of Wales was President of the BMA for its 150th year. The BMA was deeply honoured by this, but was less pleased when he used his Presidency to ask the Association to look at the problems of disabled people, the health of ethnic minorities and the question of alternative medicine. Temporarily, this made the Prince of Wales the single most effective progressive force in medicine, and it would be wrong to ignore him in this book.

The 1983 Junior Members’ Forum was the BMA’s response to the second of these commands. The attitudes present in the Forum very much supported the establishment position. There was, for example, much more support for the idea of health education aimed at the Asian communities than there was for the provision of interpreters.