Christine Ekechi: How do we start a conversation about racism in medicine?

Tackling racism in medicine can only come about with honest conversations. Christine Ekechi suggests we can start that journey in three ways

It is impossible for any healthcare professional to have escaped recent world events and the dawning focus on race and health outcomes. Whether one fully understands the concerns, indignation, and outrage about racism in the UK or not, what is inescapable is the disparity in health outcomes for people from Black, Asian, and other minority ethnic (BAME) backgrounds.

Inequality exists in almost every part of health. Mental health, cancer, or indeed maternal mortality are just a few examples of areas where people from BAME groups experience poorer outcomes. The revelation of covid-19’s disproportionate impact on BAME groups was of no surprise to those of us who’ve spent their careers explaining that racism, bias, and prejudice are often the root cause of persisting health disparities. Since the MBRRACE report on maternal mortality was published in November 2019, I have worked with the Royal College of Obstetricians and Gynaecologists to explore how race and racism contribute to the difference in health outcomes for BAME women. As such, I should find it easy to discuss race and racism with colleagues.

In reality, it is difficult. What I experience is a wall of awkwardness. People’s unwillingness to consider that medicine may operate within a framework that is inherently disadvantageous to people of a different skin colour closes conversations before they have begun. Personal insecurities and overall fragility have meant that conversations about racism are often perceived as an accusation of racism against individuals or as criticism of all that is good within our healthcare system. 

Conversations with colleagues on racism and medicine are frequently ill informed due to an absence of knowledge about slavery, British colonialist history, structural racism, and indeed the reality of the everyday lives of the patients we look after. A junior doctor took my position as a consultant within a large teaching hospital as an example of the gender and racial equality he believed existed throughout medicine. It struck me as lacking a true understanding of the imbalance in outcomes not only for his patients, but also for the colleagues he worked alongside. 

Easier conversations are those instigated by colleagues themselves. Another junior doctor, realising the discrimination perpetuated against Black women within her feminist academic group, explained the slow realisation she’d had of the privilege afforded by her race. Through this lens, we were able to openly explore the structural racism that existed inside and outside of medicine. It was a revelation for her and a sobering experience for me.

We have seen the difficulty in talking about and acknowledging racism, but it is not impossible. Educators know that education is most effective when learners are willing to learn. The truth, however, is that the work to understand racism in medicine rests with non-BAME healthcare professionals and leaders, and not with me or any other BAME healthcare worker. Change can only come about with honest conversations and we can start that journey in three ways.

Firstly, the history of racism in medicine is shamefully absent within our medical curriculum. Without it, there can be no understanding of the structural racism that permeates our daily interactions with patients and conversations around this issue are bound to fail. What does structural racism mean? Why are Black women offered less pain relief in labour? Why are Black men more likely to be sectioned under the Mental Health Act? What does this say about our pervading beliefs about the value of Black people? Understanding the historical context behind unequal health systems is the first step towards conversations that are free of defensiveness and embarrassment. 

Secondly, it is imperative to understand that racial equality education is not an exercise to satisfy mandatory training requirements, but a core skill central to the delivery of equal, safe, and excellent care. We must recognise the link between racism and poor health outcomes for BAME groups. Pointing to increased rates of pre-existing health conditions ignores the racial drivers behind these statistics, and satisfies people who do not wish to have the harder conversations, nor consider the difficult solutions needed to close the inequality health gap. The works of Michael Marmot and David Williams should be mandatory reading for all in healthcare.

Finally, challenging closed mindsets and limited discourse can only be effective when BAME healthcare professionals occupy positions of leadership. Diversity of thought and true understanding can only occur when diversity exists within the corridors of power.

These past weeks have made many of us recall either our own personal experiences of racism or how we have contributed to racism within our society. Racism is not an affliction confined to certain countries or areas of our civil life. It is around us everywhere, including medicine. Hospital trusts have rushed to release statements to state their stand against racism, but it is not enough. Healthcare providers must create settings that encourage a culture of learning, conversation, and acceptance. 

We have talked the talk these past few weeks. Now we must commit to talking and learning as we walk that walk. 

Christine Ekechi is a consultant obstetrician and gynaecologist at Imperial College Healthcare NHS Trust in London and RCOG spokesperson for racial equality. Twitter @DrEkechi

Competing interests: None declared.