Shortlisted Essay - 2020: A year of reflection, resilience and reform
On 25th May 2020, the video of George Floyd’s killing drew fresh attention to
the violence that Black people disproportionately suffer at the hands of the
police, igniting a cascade of protests across the world, and bringing the Black
Lives Matter movement back to the fore. For many in the Black community,
this was a solitary example of the countless Black lives lost at the hands of
the police every year. However, the egregious nature of the killing obliged
those outside of the Black community to take notice, opening the door for a
renewed discussion about the systemic racism and unconscious biases that
remain pervasive in many Western institutions to this day.
The death of George Floyd came almost four months after another public
health emergency of international concern was declared by the World Health
Organisation. The COVID-19 pandemic, which, to date, has claimed over one
million lives worldwide, served to illuminate another significant public health
concern: the extent of racial disparities in healthcare outcomes, which have
also been longstanding in many Western nations. Soon after the virus took
hold in the UK, it became apparent that Black people were dying at a much
higher rate than their White counterparts. This finding was made explicit in
Public Health England’s inquiry into disparities in the risk and outcomes of
COVID-19, 1 in which Black men in the UK were found to be 4.2 times more
likely to die from COVID-19 than White men, a finding that is likely
attributable, at least in part, to the healthcare inequities that afflict many Black
people in our society. Indeed, many of the NHS healthcare workers who died
from the virus were also Black men and women, further highlighting the
ubiquitous nature of these injustices. Even in their place of work, Black people
were not protected, resulting in the needless deaths of many who had worked
tirelessly to save the lives of others.
In spite of the many tragedies that have befallen the Black community this
year, the world has been reminded of that which Black people possess:
resilience. We have displayed indomitable strength, both as individuals and as
a community, and indeed, the world has taken notice. Through peaceful
protest, powerful speech and persuasive written word, we have made our
voices heard, and have continued to speak truth to power, even after the
myriad of black squares faded from our social media feeds.
So how can this strength translate into our practice as healthcare
professionals? Esteemed Jamaican physician and activist, Dr Harold Moody,
wrote in 1932: “[We must] identify ourselves with the masses and make their inaudible cry
our own.”
As Black African and Caribbean doctors practicing here in the UK, we are in a
position to raise up the voices that often go unheard in society, allowing their
voices to ring among those which often overpower the conversation.
Countless studies have identified how an individual’s Blackness can affect the
care they receive, either through implicit bias, or ill-conceived assumptions
about Black people’s bodies. It is therefore our role as representatives of the
Black community within this system, to highlight these shortcomings, and
push for a much needed and vastly overdue change.
Systemic reform is vital for the equitable treatment of Black people within our
healthcare system, yet, this change cannot occur without those who have an
understanding of the nuanced complexity of implicit bias having a seat at the
table. After years of independent inquiries into race being conducted by those
outside of the community, this year has seen important changes to this
precedent. Professor Kevin Fenton of Public Health England, who is of
Jamaican descent, headed the inquiry into the racial disparities in COVID-19
outcomes, and the Royal College of Obstetricians & Gynaecology (RCOG)
Race Equality Taskforce is being co-chaired by Dr Christine Ekechi, a
prominent Obstetrician and Gynaecologist of Black African descent – two
huge steps in the right direction.
While these taskforces operate at a national level, we can each do our part to
shed light on these important issues locally – at our universities, in our places
of work, and within the communities in which we live. An example of how such
efforts can be transformative is the FIVEXMORE campaign, which was
created by two Black women, Tinuke and Clo, to highlight the degree of
internal healthcare inequity in the UK. Through a number of successful
campaigns that raised the profile of this important movement, this
organisation is now working alongside the RCOG Race Equality Taskforce in
order to examine and address the racial disparities in maternal healthcare
outcomes that were highlighted by the MBRRACE-UK report. Their story is a
testament to what can be achieved with true determination, and serves as an
example of how change can come from consistency and perseverance.
While much of 2020 has been characterised by adversity, I remain
encouraged by the strides that have been made by many inspirational people
of African and Caribbean descent during this difficult year. We can all learn
from their actions, and approach our work with the knowledge that we can all
make a difference, no matter how small we deem those differences to be.
Even starting the conversation is a worthy action, as change cannot come
without the wider acknowledgement of these issues within our society.
We still have a long way to go in the pursuit of equality, not only for us as
Black doctors operating within the British healthcare system, but also for our
patients within the Black community, who we hope to serve. But as Dr Martin
Robison Delany, one of America’s first Harvard-educated Black physicians,
once wrote:“Our elevation must be the result of self-efforts and work of our own hands.
No other human power can accomplish it. If we but determine it shall be so, it
will be so.”
Written By Dr Melanie Etti, Clinical Research Fellow in Microbiology,
(Reference List Included)
Shortlisted Essay
The year 2020 has been another pivotal year in the history of African and Caribbean people.
As a diaspora, we have felt a collective frustration as we have watched the cumulative
failures towards our community be unveiled in plain sight to the world. In the realm of
healthcare, the horrifying statistics of the fivefold increase in maternal mortality during
childbirth, and the fourfold increase of death as a result of Covid-19 in comparison to our
white counterparts have been laid bare for all to see. It has been instilled in us, as training
healthcare professionals, that our patients should always be our first priority. We have been
taught to provide care in ways which aim to minimise harm and act with the best interests
of the patient at heart. From these statistics, we are able to conclude that we are currently
operating within a system, designed in theory to be impartial but in actuality, operating in
bias. Given the gross disparities in healthcare outcomes, it raises the question of the
effectiveness of our medical practice in relation to black individuals.
Although it has the potential to be overwhelming, we cannot and should not let ourselves
be paralysed by despair when faced with the enormity of the challenge ahead. These
statistics, shocking as they may be, allow us all to have baseline objective measures. Which,
moving forward, have the potential to serve as valuable reference points, allowing for the
impartial and tangible evaluation of the effectiveness of any future actionable points.
They remind us that there is a fundamental shift in mindset needed, as comfort and
familiarity, though good at times, also have the potential to be the biggest enemies of
progress.
Operating from the perspective of guilt never has and never will be sustainable way to
achieve long lasting change. Habits can be extremely hard to break, and granted although
complacency at this stage is inexcusable, the dismantling and rebuilding of these systemic
failures is not something that we can expect to happen overnight. It is therefore essential
moving forward, to realise that every step taken towards revolutionising our delivery of
healthcare is all part of the cycle of committing to change, regardless of the frustratingly
slow and agonizing pace that seems to be associated with it.
According to the General Medical Council’s Good Medical Practice guidance, we should
treat both our colleagues and our patients fairly and without discrimination.
However, when the issue of racism is broken down, we are able to see that it permeates
into every facet of the lives of those experiencing it, both from the perspective of African
and Caribbean healthcare professionals to the perspective of patients on the receiving end
of our care. With an increasingly diversifying population, we cannot afford to be operating
within systems where these biases go unchecked as it has the potential to endanger lives.
It is crucial for us to be working within teams that are receptive to change, and who are
willing to work collaboratively to help bring about a long-lasting change for the future. As a
collective, we often operate within spaces where there are legitimate concerns of being
unduly punished or ostracised by our colleagues when speaking out on racial issues.
Therefore, cultures within workplaces and institutions need to be re-shaped to ensure that
we do not feel more comfortable in biting our tongues for the sake other’s comfort than we
do speaking out and taking a stand against the racism we face. There needs to be an
emphasis on continuous re-evaluating and reflection and also, a firm rejection of the idea
that there is a limit to the amount of change, growth or learning that can occur.
In conclusion, we need to realise and accept the fact that historical amnesia has led us to
where we are by ignoring the very problem which keeps poking its head out in various
shapes and forms. In order to obtain any further growth, we cannot let that carry on, as it is
a hindrance which creates self-sustaining barriers. Medical institutions hold the power to
put actions and policies into place to ensure that we are educating ourselves holistically for
the equal benefit of every patient. As a collective, we also have the ability to hold them
responsible through the process of lobbying for the change we want to see.
It must be ensured that we are giving and creating spaces for those who are wholeheartedly
invested in the cause, making room for constructive dialogue and speaking up to hold
people and institutions accountable for their actions. As people from African-Caribbean
backgrounds we can offer insights into our experiences. We should, therefore, be at the
forefront of the consultation and solution generating process to help tackle the most
pressing issues facing our communities. Additionally, we should hold solace in the fact the
we are a truly resilient community. Our collective effort in generating and mobilising the
power that we have for our betterment is nothing short of phenomenal. Silence sometimes
has the ability to lull us into false senses of security, so as long as we keep speaking out and
speaking up, we should know that there will be people willing to listen.
Finally, as a society, humankind has progressed in mind boggling ways over the course of
centuries. So just imagine what would be in store for the future if everyone, regardless of
race or socioeconomic background, was given all the opportunities they needed to fulfil
their full potential.
Written By Naa Amua Quaye, Cardiff University School of Medicine
(Reference List Included)
Shortlisted Essay: A REFLECTION ON HOW THE EVENTS OF 2020 HAVE AFFECTED THE AFRICAN AND CARIBBEAN COMMUNITY AND HOW UNDERSTANDING THIS IMPACT CAN IMPROVE OUR FUTURE MEDICAL PRACTICE
The events of 2020 have uncovered the true fragility of our society. A global
standstill imposed by COVID-19 and the insurgence of the Black Lives Matter (BLM)
movement have sparked economic crises, social unrest and interpersonal conflict
across the globe. Although systemic racism in the UK is inherently covert in nature,
the death of George Floyd publicised the chronic, racial injustice that exists in the US
and simultaneously has unveiled the racial inequality that still exists in the UK. The
African and Caribbean community, and people of colour in general, have endured
the synergistic effects of COVID-19 and racial inequality, thus have been
disproportionately affected by the events of this year. Nevertheless, in the face of
adversity, we must continue to reflect, learn and grow. I believe that 2020 has given
us the tools to scrutinize the so called ‘meritocratic’ systems that we live in; the
systems that supposedly advocate for equality and freedom yet feign ‘colour-
blindness’ when race is mentioned. In this essay, I summarise my main learning
points from this year. Although these are my own personal reflections, I recognise
the importance of being honest and open to encourage further discussion, so I hope
these can be of use to anyone else wanting to join this railroad to justice.
1. Racism is about effect, not intent
As a mixed-race woman, I believed that racism was about intent, thus ‘good’ people
could not be racist. I was disillusioned by the events of 2020. Reni Eddo-Lodge
writes ‘We tell ourselves that racism is about moral values, when instead it is about
the survival strategy of systemic power.’ in her book, About Race 1 . Here, she
acknowledges that racism is a far deeper issue than individual prejudice; instead, it
is entrenched in the fabric of society and functions to preserve a power imbalance
that exclusively disadvantages people of colour. We have to ask ourselves: why do
Black Caribbean school children consistently perform lower than their white
counterparts 2 ? Why are Black Caribbeans 3.8x more likely to be arrested and 3.7x
more likely to be detained under the Mental Health Act than their white
counterparts 2 ? To put it into perspective, Black Caribbeans make up only 1.1% of the
population in England and Wales 2 . Nonetheless, in 2018/19 black people were
almost 10 times more likely to be stopped and searched 2 . Akala posits that we live in
a society where it is cheaper to send a young person to Eton than it is to incarcerate
them, thus the current inequality is an issue of priority rather than resource. 3 Though
this is not new information, it is imperative that we challenge these statistics and the
structures that perpetuate them.
2. Racial inequality exists in healthcare.
A powerful article by Olamide Dada summarises just a small part of the racial
inequality that exists in the NHS 3 . Despite advocating for justice, non-maleficence
and benevolence, we can clearly see that medicine is not exempt. Olamide outlines
the disparity in the level of care received by black and white patients alike, and the
shocking fact that 95% of the medical professionals that died in the first month of
COVID-19 were black and ethnic minority. These statistics become relatively
unsurprising when we examine the foundations of modern medicine. We are victims
of selective academic omission; from the presentation of dermatological conditions
and life-threatening skin colour changes on darker skin, to J. Marion Sims and his
disturbing contribution to the field of gynaecology. Acknowledgement of this history
is vital. Encouragingly, the events of 2020 have begun to initiate measure to
diversify the medical curriculum and provide student-led EDI workshops.
Additionally, a greater awareness of the challenges that people of colour face will
allow for interventions to be made to negate the inequalities in healthcare.
3. Introspection is paramount
Ignorance is forgivable, but apathy is unacceptable. We must identify the gaps in
our knowledge, critique our innate, unconscious biases and self-reflect. We must
recognise the insidious influence of the media; though it has been pivotal in the
propagation of the BLM movement, we must not forget the condemnation of BLM
protestors and the unsubstantial attribution of the (inevitable) second peak of
COVID-19 to the movement. Again, this is not novel; the depiction of the black man
as an inferior, aggressive and animalistic creature was popularised by Birth of a
Nation (1915) and still very much exists today, though arguably more covertly. A pertinent barrier to change arises from the rhetoric that we live in a post-racial
society in which personal success is awarded solely on merit. This narrative cleverly
functions to negate the experiences of people of colour and attribute their relative
disadvantage to character-driven personal failings rather than unfair structures
descended from a legacy of slavery. The ‘If it ain’t broke, don’t fix it’ mindset is
inherently flawed if one doesn’t take time to consider whether their experiences even
qualify them to comment on the integrity of the system. Reni Eddo-Lodge describes
how the challenges that disabled people face due to the inaccessibility of the public
transport system only became visible to her once she was forced to use the stairs to
transport her bike as part of her daily commute 4 . It is this kind of awakening that is
the precursor to change.
What can we do as healthcare professionals? We must use our platform to raise
awareness of racial inequality; through service evaluations, workshops and open
discussion. We can engage in outreach programmes like Melanin Medics - the
epitome of positive action – which demonstrate the benefit of sharing knowledge and
experiences within the African and Caribbean community. And, as humans? We
should treasure any privilege we may have as it will be an important tool in our
toolbox. Then, we must expand our toolbox by acquiring knowledge and listening to
lived experiences. Finally, we must use these tools to make change. Individual
change doesn’t have to be big. Instead, the compound effect of small changes will
amass and will crack this power imbalance and permanently abolish the fossils of
slavery.
Written By Sarah Venning, Cardiff University School of Medicine
(Reference List Included)
Shortlisted Essay: Systemic Racism in UK Healthcare – Highlights from the Covid-19 Pandemic
1. COVID-19 - Trends in the UK’s African-Caribbean Communities
Since its arrival in the UK, COVID-19 seemed to be taking its toll, disproportionately, on non-white ethnic majority (NWEM) communities – with the rates and risk of death in the UK’s African-Caribbean communities (ACCs) being the highest. The Table 1 data – from the Office of National Statistics (ONS) (2020) – estimated that, between 2 March and 15 May 2020, COVID-19-related mortality rates in black males and females were disproportionately higher relative to males and females of other ethnic groups – as high as 2.9 and 2.3, respectively – after adjusting for age. The data in Table 2 compares the mortality rates of different ethnic groups as an odds ratio in relation to the reference (white ethnic) group. Presented here are two sets of data for various ethnic groups, by sex, from the same period: age-adjusted and fully adjusted (Table 2). The fully adjusted data represents a calculation that takes into account socioeconomic, demographic, and geographic characteristics. The trend displayed by this data is similar to that seen in the age-adjusted columns: both black males and females had experienced the highest death rates – 2.0 and 1.4, respectively – when compared to the white ethnic male and female populations (ONS, 2020).
Table 1: Age-standardised COVID-19-related mortality rate per 100,000, in males and females by ethnicity – based on data between 2 March 2020 and 15 May 2020 – retrieved from the Office of National Statistics (2020). The highest COVID-19-related mortality rates were observed in both black male and female groups, with the second highest rates associated with Bangladeshi and Pakistani males and females. Age adjustment is important considering that the strong association between COVID-19-related deaths and age had become evident during the initial emergence of the disease. With this in mind, and considering that different ethnic groups display different age distributions, standardising estimates with regards to age had increased data validity. The classification ‘Other’ includes Asian other, Arab and Other Ethnic Group categories.
Table 2: UK Mortality rates, displayed as odds ratios, in NWEM groups, by sex, when compared to the white ethnic population; based on data between 2 March 2020 and 15 May 2020 – retrieved from the Office of National Statistics (2020). The white ethnic population were used as a reference group because this is the ethnicity with the largest population in England and Wales. The classification ‘Other’ includes Asian other, Arab and Other Ethnic Group categories.
Two conclusions are inferable when comparing the age-adjusted with the fully-adjusted data in Table 2: 1) that additional unaccounted-for-factors had contributed to the increased risk of COIVD-19-realted death among the African-Caribbean population in England and Wales; and 2) that, given the marked differences between the two categories in both male and female subsets, socioeconomic, demographic and geographic characteristics had accounted for at least some portion of the mortality rates observed. A more recently published analysis by ONS gave consideration to the contribution of comorbidity – determined using both the 2011 Consensus and the 2017 NHS hospital episodes statistics (HES) – to the mortality rates observed across ethnic groups (ONS, 2020). This analysis purports a strong association between mental health illness and COVID-19-related mortality, relative to other comorbidities; with the prevalence rates of mental health illness being notably higher in Black Caribbean males and females (ONS, 2020).
Understandably, there are some limitations to this data [e.g. the data was based on self-reported health and disability from the 2011 Census (ONS, 2020); this may have either underestimated or overestimated the data reported, due to the possibility of changes to ethnicity-related self-reporting within the past 9 years]; nevertheless, represented here are health inequalities – that is, avoidable differences in life expectancy, health, and/or wellbeing, between different groups of people, based on race, gender, socioeconomic status, or other differential categories – which are microcosmic of an inveterate psycho-societal phenomenon: systemic racism.
1. Lessons from COVID-19, Systemic Racism – The Need for Change
Due to its pervasion within the different strata of society’s functional systems, the contribution of systemic racism to health and wellbeing outcomes within ACCs is complex. As applied to Dahlgren and Whitehead’s (1991) Social Model of Health – Figure 1 – systemic racism has contributed to nearly all social and ecological health determinants affecting ACCs.
Figure 1: The role of systemic racism as applied to Dahlgren and Whitehead’s (1991) Social Model of Health. Systemic racism – defined here as the established adoption and implementation of racist ideology across the functional systems within a society – overlies the model’s general socioeconomic, cultural and environmental conditions; and thereby penetrates the downstream layers of categorical social and ecological determinants that contribute to health and wellbeing outcomes of the individual members of the ACC.
Necessary to address here is the disparity in death rates between black ethnic (along with other NWEM groups) and white ethnic healthcare staff; reported between March and April 2020, 95% of doctors that had died of COVID-19 were from NWEM groups, despite making up only 44% of medical staff; the same trend was observed among other healthcare professions (British Medical Association, 2020). It is logical that part of the death rate experienced by ACCs could be explained by the occupations held by black ethnic individuals – with higher proportions of black males and females in care worker and care worker roles (ONS, 2020). Yet, this does not explain the extreme disproportionality observed; and so it would be equally logical to suspect systemic racism as a redounding factor. However, whilst complex, the effects of systemic racism on ACC health and wellbeing outcomes can be tackled with an equally effective systematic approach by the UK’s healthcare sector.
Informing Current Practice through Improved Communication
The value of communication within the healthcare setting is apodictic; it allows for positive patient experiences – which are linked to improved clinical effectiveness and patient safety (Doyle et al., 2013). Notwithstanding this, effective communication can only be achieved once the barriers to communication have been expunged. As applied to ACCs, this would be evidenced by healthcare trusts engaging with the communities to address specific concerns and attitudes relating to health and wellbeing. Strategies such as workshops, surveys and focus groups – where all community members have the opportunity to participate, including ACC healthcare professionals – are possible ways to ensure this.
Data published by the Caribbean and African Health Network (CAHN), anent the impact of COVID-19 on the African-Caribbean community in Manchester, indicated numerous concerns that seemed common amongst community members, including: the discrimination faced by frontline workers; and the reluctance to use mainstream services caused by a lack of trust and cultural sensitivity (CAHN, 2020). These results are quite telling, and may very well be reflective of a recurring pattern of concerns across the UK’s ACCs; regardless, it is clear that a simple survey was able to yield valuable information from the community. Should this, along with the other engagement strategies mentioned, be implemented by local healthcare systems, the results could be used to tailor medical practice in a way that improves health outcomes in ACCs. What this sort of community engagement presents is an opportunity for both healthcare professionals and lay community members to learn from and inform one another of their experiences and expectations, breaking down the barriers to communication even further and establishing partnerships that are driven less-so by systemic bias.
Conclusion
Modern healthcare systems are expected to act as facilitators to the improvement and maintenance of health and wellbeing outcomes at the level of the individual, the local community, and nationally. However, the data presented throughout the COVID-19 pandemic brings to light the issue of health inequalities as a product of systemic racism – and the impact of such on the UK’s African-Caribbean communities (ACCs). However, this pandemic has provided a serendipitous opportunity for the healthcare sector to target engagement strategies, that may break down communication barriers and improve health and wellbeing outcomes for ACCs more wholly.
Written By Tariq Marsh-Henry, St George's University of London
(Reference List Included)