Evaluating Values by Rageshri Dhairyawan

As medical leaders, we are encouraged to think about our values. The Faculty of Medical Leadership and management standards for medical professionals are guided by values espoused in the Seven Principles of Public Life, which include integrity and accountability. But who and what we value is just as important as our personal values.  And ideally, our espoused values should match our enacted values, so that what we do matches what we say we want to do.

With regards to the health outcomes of Black, Asian and minority ethnic groups, despite our good intentions, there may be a gap between our espoused and enacted values. The health inequalities faced by these groups, which have been so conspicuously highlighted by COVID-19, existed well before this current pandemic and are present in many areas of health. I list some examples here, which make for uncomfortable reading.

In comparison to White British people in the UK:

  • Black women are 5x more likely to die in pregnancy.
  • Black men are twice as likely to be diagnosed with prostate cancer and proportionately more die of it.
  • Black people are more likely to have severe mental health symptoms, but less likely to receive treatment for them.
  • South Asian and Black people are 3-5x more likely to start dialysis.
  • South Asian and Black people are 3-5x more likely to be diagnosed with Type 2 Diabetes.
  • Black people are more likely to have hypertension.
  • Black people are more likely to be diagnosed with asthma.
  • Women from minority ethnic communities are more likely to have never had a cervical smear.
  • 74% heterosexual people receiving HIV care in the UK in 2018 were from minority ethnic communities and the highest rate of late diagnosis (the most important predictor of HIV-related illness and death) was in heterosexual Black men.
  • Rates of sexually transmitted infections are highest in Black communities especially Black Caribbean. This was first reported with regards to gonorrhoea rates in the late 1950’s.

These disparities limit life expectancy and quality of life for many Black, Asian and minority ethnic people in the UK. These disparities are so pervasive and longstanding, there is an urgent need to change our approach. In the BMJ’s recent Racism in Medicine issue, Salway et al report that minority ethnic groups are “poorly served in the NHS with care being patchy, stigmatising and rarely culturally sensitive, and that there are gaps in national data leading to inadequate evidence on how to meet the health needs of these groups” 1.

Can a healthcare system in which the disparities listed above exist over decades be said to be valuing all human life equally? Perhaps in answering that question, we need to consider the allocation of resources for funding; how much money is being put into understanding and addressing these inequalities? And furthermore what type of evidence do we value in building our understanding?

An example of how differently evidence may be valued is the Public Health England COVID-19 Report. The government has been widely criticised for delaying publication of the section reporting the findings of thousands of stakeholder interviews. However, several senior clinicians commented on social media that this was not a concern, as the more important epidemiological data had already been released. In fact findings from the interviews leaked in the press have pointed to a possible cause of the inequalities (structural racism and discrimination) and have also made recommendations on how to protect groups going forwards, two things the original report did not include. This highlights the value of researching the lived experiences of people affected by health inequalities, to understand the complex mechanisms that lead to them.

This is not a rare example. A recent report from the United States found that Black scientists were less likely to receive research funding than their White counterparts, due to the fact that they were more likely to propose studies in community research including health disparities and patient focused interventions. Reviewers showed a preference for research topics that “tend to have methodologies that are highly controlled with very precise outcomes” suggesting research rooted in communities (and led by researchers who may be from those communities) is not valued to the same degree as other types of research 2. Similarly in the UK, through stakeholder workshops, Salway et al found that “there was a lack of evidence on the health of ethnic minority communities here due to a lack of demand for evidence from policy makers and limited visibility of this field in leading medical journals.” They also noted “limited competence and confidence among researchers and low representation of ethnic minority researchers within academia also contributed. Participants also thought that charities and social science funding streams were more ready to fund such research than National Institute for Health Research” 1.

This all suggests that we do not value the voices of our patients as important sources of evidence. This is contrary to perceived best clinical practice, where taking a thorough history and listening to our patients is an essential part of reaching a diagnosis.

So what can we do to ensure our enacted values match those we espouse? To start, I suggest that widening representation in clinical and academic leadership at different levels showing we value the opinions of our Black, Asian and minority ethnic colleagues, may improve this. We must also value community voices as a vital source of knowledge through participatory research. Allocating funding and resources to this may lead to interventions that are more effective at addressing ethnic health inequalities, than our past endeavours.

The COVID-19 pandemic and worldwide Black Lives Matters protests sparked by the killing of George Floyd have highlighted the layers of structural racism that many Black, Asian and minority ethnic people face in our society. This is an opportune time to act on deep-seated racial health inequalities, which will otherwise become more entrenched if there continues to be a gap between what we say we value, and what we actually value. Listening to, and valuing the voices of those most disadvantaged in our society is an essential part of this.

References

  1. Salway S, Holman D, Lee C, McGowan V, Ben-Shlomo Y, Saxena S et al. Transforming the health system for the UK’s multiethnic population BMJ 2020; 368 :m268 doi: https://doi.org/10.1136/bmj.m268
  2. Hoppe TA, Litovitz A, Willis KA, Meseroll RD, Perkins MJ et al. Topic choice contributes to the lower rate of NIH awards to African-American/black scientists. Science Advances 9 Oct 2019. DOI: 10.1126/sciadv.aaw7238 

Dr Rageshri Dhairyawan

Dr Rageshri Dhairyawan is a Consultant in Sexual Health and HIV Medicine at Barts Health NHS Trust, London and a Honorary Senior Lecturer at Queen Mary University of London. Her work focuses on improving care for marginalised populations living with HIV. She is an elected trustee of the British HIV Association and SWIFT women which focuses on women living with HIV. She also sits on the medical board of NAZ, a charity specialising in the sexual health of ethnic minority communities.

Declaration of interests

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.

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