Without analysing Blackness specifically, we cannot understand or defeat the anti-blackness that exists in the NHS, says Sahar Abdulrahman
The image of a police officer with his knee on the neck of a Black man for eight minutes and 46 seconds shocked many people, leading to a resurgence in the Black Lives Matter movement, which is continuing to reverberate globally. As we watched horrified, how many of us would acknowledge that what undoubtedly led to the death of George Floyd, systematic racism and implicit bias, is built into our very own NHS?
Although the term Black and minority ethnic (BME) is widely used to analyse race inequality, it is a term that can do more damage than good. This is not to negate the experiences of people from other ethnic minorities, but merely to illustrate that the Black experience—for patients and professionals—is a distinct one. Without analysing Blackness specifically, we cannot claim to want to understand or defeat the anti-blackness that exists in our sector.
The latest NHS workforce statistics, for instance, show that 55.6% of 119 597 medical staff are white. Yet if we categorise ethnic minorities as one entity, BME, we rather lazily fail to look at the breakdown of the remaining 44.4% of staff. This would show that Asian people make up 29.7% of the NHS’s medical staff, compared with 4.6% of Black medics.
Similar disparities are also evident when looking at medical school applications. Between 2007 and 2017, only 1950 Black students were admitted to the standard entry programme, compared with 14 865 Asian students. This more than sevenfold difference cannot be accounted for by our country’s demographics: people from Asian ethnic groups make up 7.5% of the population of England and Wales, and Black people make up 3.3%.
What differentiates the Black experience? Medicine has an exploitative history of using Black bodies for its advancement. The Sims’ speculum was named after an American physician who surgically experimented on enslaved Black women. The Tuskegee experiment saw hundreds of Black men left untreated with syphilis and uninformed of their diagnosis so that scientists could observe the effects. It led to the deaths of many of these men and the disease’s preventable spread to women and children—a scandal brought to light only in 1972 when the study was terminated. Sadly, these are just a few examples of medical advancement at the expense of Black lives.
This historic dehumanisation of Black bodies has left its legacy within modern medicine today. Even recent research, albeit with a limited sample, has demonstrated that among laypeople, medical students, and resident doctors, beliefs about Black people having thicker skin and higher pain thresholds still persist—assumptions which undoubtedly have their roots in colonial depictions of enslaved people as “animalistic” and “savage.”
But what has this got to do with Black people in Britain? Institutional racism in Britain is systemic and rooted in Britain’s colonial past. It is defined by the Macpherson report (1999) as the “collective failure of an organization to provide an appropriate service to people because of colour, seen in processes that amount to discrimination through prejudice, ignorance, and racist stereotyping which disadvantage minority ethnic people.” When systems are built around whiteness being accepted as the norm, it leads to the subsequent othering of non-white groups.
Whether it be in policing, housing, or healthcare, Black people’s outcomes are generally poorer. In the UK, compared with the white population, Black women are five times more likely to die in childbirth. The infant mortality rate for babies of mothers born in the Caribbean is almost two times greater than for mothers born in the UK. Black people are four times more likely than white people to be detained under the Mental Health Act, and 29% more likely to be forcibly restrained. How often are we as clinicians considering our own biases, and how our medical training through a white lens could have implications for our standards of care to Black patients?
My own experiences as a junior doctor are also cloaked in anti-blackness. Despite having a stethoscope around my neck and a large nametag, I am often automatically assumed to be a member of the nursing staff—by both patients and colleagues. A consultant colleague who is Black has been asked to transport samples, as staff believed he was a porter. I have seen patients attended to by Black consultants ask when the consultant would see them, mistaking them for juniors. As well as this, I have been told my braids, a common protective hair styling for afro-textured hair, were not professional by a clinical tutor.
These daily microaggressions are all too common for Black staff, and perpetuate the imposter syndrome phenomenon that comes with a lack of representation. Black non-medical staff make up only 1.2% of “very senior managers” in the NHS, compared with 92.9% white and 4.6% Asian staff. This lack of representation in managerial positions, and over-representation in patient facing roles, has been cited as a potential factor in the higher levels of covid-19 deaths among Black, as well as other ethnic minority, staff. But why are we missing from senior positions? What preconceived images of a leader do those employing at the top level have, and do they look like me?
In order to move forward, several changes need to occur. Firstly, as a profession that prides itself on evidence, it is disappointing that studies into racial disparities and implicit bias in healthcare remain scarce, with American research at the forefront. We should start to invest more in analysing this problem specifically in a UK context.
Implicit bias training is often hailed as the solution to institutional racism within the NHS. This alone is not enough to reform an entire system. Nonetheless, there is a deficit in both medical training and postgraduate teaching on implicit bias, which should be rectified.
Ultimately, what both Black patients and staff need is a healthcare system that is representative of them at every level, including higher managerial positions. Not just within the health service, but also in the wider community through scholarship, research, and teaching. We need to amplify Black voices, both when they belong to patients and colleagues, and start a dialogue going forward, steering away from blanket “BME” narratives and towards understanding the Black experience.
Sahar Abdulrahman is a foundation programme trainee currently practising within the West Midlands, with an interest in global health.
Competing interests: I have read and understood BMJ policy on declaration of interests and have nothing to declare.