{"id":1032,"date":"2025-11-26T07:00:34","date_gmt":"2025-11-26T07:00:34","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmjleader\/?p=1032"},"modified":"2025-11-21T11:58:10","modified_gmt":"2025-11-21T11:58:10","slug":"leading-from-the-imperial-core-medicine-listening-and-solidarity-by-guddi-singh","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmjleader\/2025\/11\/26\/leading-from-the-imperial-core-medicine-listening-and-solidarity-by-guddi-singh\/","title":{"rendered":"Leading from the Imperial Core: Medicine, Listening and Solidarity. By Guddi Singh"},"content":{"rendered":"

\u201cNot everything that is faced can be changed, but nothing can be changed until it is faced\u201d<\/em> [1]. James Baldwin, the Black American writer and civil-rights essayist, captures why the truth about healthcare is heavy \u2014 and clarifying.<\/p>\n

Those of us in clinical and organisational leadership are used to carrying targets, safety metrics and workforce crises. It is tempting to believe that if we just work harder within the system, we can fix it.<\/p>\n

But some truths sit upstream of any dashboard. They are about who<\/em> our systems were designed around, whose<\/em> risks are considered acceptable, and whose<\/em> lives are quietly treated as less valuable. Facing those truths is uncomfortable. It might also be the most important leadership work we do.<\/p>\n

The comforting story of \u201cthe good doctor\u201d<\/strong><\/p>\n

Medicine trains us to see ourselves as good people doing our best in a difficult world. When things go wrong, we look first to individual failings or resource gaps. The system may be \u201cstressed\u201d, but rarely is it described as unjust.<\/p>\n

Global health colleagues have challenged that story for years<\/a>. They remind us that health systems \u2014 including our own \u2014 were built through empire, slavery, industrialisation and racial capitalism. The benefits and harms of those histories were not evenly distributed, and they still aren\u2019t.<\/p>\n

If you work in the NHS or another well-resourced system in the global North, you work in what some scholars call the imperial core<\/em><\/a>: countries that have long benefited from global extraction and still hold disproportionate power over capital, data and knowledge.<\/p>\n

That does not make us villains. But it means our systems are not neutral. They reflect decisions in which some groups have always had more protection and more room for error. Leaders who cling to the \u201cgood doctor\u201d story \u2014 we are doing our best, leave the politics at the door<\/em> \u2014 risk guarding the status quo.<\/p>\n

Listening as a leadership act, not a soft skill<\/strong><\/p>\n

One of the most radical things we can do as leaders is to change who we listen to, and what we treat as \u201creal\u201d knowledge<\/a>.<\/p>\n

Patients, families, nurses, porters, reception staff, junior doctors, migrant colleagues, Black and Brown staff who are routinely overlooked or disciplined more harshly \u2014 none are voiceless. They are often unheard<\/em>.<\/p>\n

Global health scholar, Seye Abimbola, describes the \u201cforeign gaze\u201d in academic publishing<\/a>: work written to impress distant gatekeepers rather than serve the communities being described. A similar gaze shows up in leadership. We make decisions shaped by regulators, reputational risk and political optics, rather than by the lived analysis of those most exposed to harm.<\/p>\n

Listening as an ethical practice means:<\/p>\n

    \n
  1. Treating repeated patterns of harm \u2014 such as disproportionate disciplinary action or worse outcomes \u2014 as system messages, not anomalies.<\/li>\n
  2. Believing people the first time they tell us what the system is doing to them, even when it unsettles our sense of fairness.<\/li>\n<\/ol>\n

    This is not about \u201chearing all perspectives equally\u201d. It is about weighting the voices of those historically ignored.<\/p>\n

    Using privilege without re-centring ourselves<\/strong><\/p>\n

    For many of us, the word privilege<\/em> still triggers a defensive reflex: I work hard. I\u2019m exhausted.<\/em><\/p>\n

    But privilege in healthcare leadership is not about ease. It is about how the system responds to us.<\/p>\n

    Leaders are more likely to be believed, given the benefit of the doubt, and able to shape agendas. We hold access to rooms, budgets and journals others do not.<\/p>\n

    The question is not guilt. The question is: what do we do with the power we already have?<\/p>\n

    In a recent BMJ Global Health<\/em> editorial, Mark Shrime calls for \u201cprioritarian scholarship\u201d<\/a> \u2014 work that deliberately centres those who are worst off. Leadership can borrow that lens.<\/p>\n

    Prioritarian leadership would mean:<\/p>\n

      \n
    1. Designing decision-making around those most affected. <\/strong>If you change outpatient access, are service users genuinely present \u2014 or only their data?<\/li>\n
    2. Shaping metrics that reveal structural harm. <\/strong>Overall improvement can mask widening inequities. A prioritarian lens asks first: what is happening to those at the sharpest edge?<\/em><\/li>\n
    3. Taking more personal risk so others can take less. <\/strong>Speaking up about racism or bullying carries different consequences for a junior migrant nurse than for a medical director. Leaders can choose to absorb the fallout.<\/li>\n<\/ol>\n

      This is not heroism. It is simply using the insulation we already have to create more safety for those who don\u2019t.<\/p>\n

      What this means for leadership culture<\/strong><\/p>\n

      If we take seriously the idea that we are leading from the imperial core, a few implications follow.<\/p>\n

      First, we must stop pretending health systems are merely technical machines. They are moral and political projects. Decisions about who waits, who gets seen and who is believed are value-laden, even when wrapped in neutral language.<\/p>\n

      Second, we need to be honest about how our own careers have been supported by structures that disadvantage others. Many of us trained in institutions easier to access if you were wealthy, white or already connected. Our publication records may owe as much to precarious colleagues\u2019 labour as to our own brilliance. Facing this is not self-flagellation; it is part of redistributing opportunity.<\/p>\n

      Finally, we must move from statements to practice. Most organisations now have EDI strategies. Fewer have:<\/p>\n