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Racism in medicine
Institutional racism and the medical
profession
Aneez Esmail
University of Manchester
Black and ethnic minority
communities are not getting the services
that they are entitled to…
‘… the institutional racism that is
responsible for this is a disgrace and a
festering abscess which is at present a
blot upon the good name of the NHS.’
The Bennett Inquiry – April 2004
Institutional racism
‘Institutional racism is the collective failure of an
organisation to provide an appropriate and
professional service to people because of their colour,
culture or ethnic origin. It can be seen or detected in
processes, attitudes and behaviour which amount to
discrimination through unwitting prejudice, ignorance,
thoughtlessness and racist stereotyping, which
disadvantage minority ethnic people’
Sir William McPherson in the Stephen Lawrence Inquiry 1999
What is the evidence ?
The professional legacy
• Applications to medical school
• Examinations
• Getting a job
– Career progression and promotion
• Remuneration
• Complaints and suspensions
Medical School Selection
• Ethnic minority applicants disadvantaged
– McManus et al 1989
– Esmail et al 1995
– McManus et al 1998
Getting a Job
• Controlled trial using identical CV’s with
English and Asian names
• White candidates twice as likely to be
shortlisted compared to Asians
» Esmail and Everington BMJ 1993;306:691
» Esmail and Everington BMJ 1997;314:1619
• Less than 10% of trusts carried out equal
opportunities monitoring
Getting a job - Career progress
• 66% of medical workforce is white but
80% of all consultant appointments are
taken by white doctors (DoH 2000)
• 42% of white doctors shortlisted for
consultant appointments (12% successful)
but only 28% (6% successful)of ethnic
minority doctors shortlisted (CRE 1996)
Getting stuck in a job
• 66% of staff grade doctors and 65% of
associate specialist grades qualified
overseas (DoH 2001)
• 44% of all locums qualified in South Asia
or West Africa. 70% of long term locums
qualified overseas(Audit Commission 1995)
• In nearly 80% of trusts surveyed, one or
more locums employed for more than 12
months (Atherton and Murray 2001)
Complaints
• Overrepresentation of doctors from ethnic
minorities in cases brought before the
GMC
• Esmail and Everington BMJ 1994;308:1374
• Ethnic minority doctors 6 times more likely
to be charged with offences compared to
white doctors
• Complete lack of transparency in process
Offences with which doctors were
charged
Offence
EM
White
OR
Improper
relationships
Indecent
behaviour
Disregard of
responsibility to
patients
3
19
0.7
(0.2-2.5)
19
7
12.4
(4.9-32)
97
48
9.2
(6-13)
BMJ 1994;308: 1374
‘Thus in the three studies conducted over a period of nine
years, the PSI found unexplained differences in the treatment
by the GMC of overseas qualifiers as compared with UK
qualifiers; the overseas qualifiers were more severely dealt
with. This may or may not indicate that there is racial bias
within the GMC….. It ought to be possible to refute a
suggestion of bias if it can be demonstrated that decisions are
taken according to objective criteria and by the consistent
application of established standards. Professor Allen has
repeatedly advised the GMC that it will be unable to refute the
allegations of racial bias unless and until it develops objective
standards and criteria….. without such standards and criteria,
the GMC will be unable to satisfy the public that it is
complying with its duty to protect patients.’
Dame Janet Smith – The Shipman Inquiry
Racism objectifies and makes a person into a thing and a
thing by definition has no capacity for human
relationships….
The unique complexity of a human being cannot be summed up
and reduced by the colour of the skin. The patient who feels
understood and cared for, who felt taken seriously and respected
was less likely to be assaultative than one who felt rejected,
powerless, despised, put down or dismissed.
Frantz Fanon
Suspensions
• Mainly anecdotal
• Almost a third of ethnic minority staff
experienced bullying and
harassment(Positively Diverse, DoH 2001)
• 45% of black and asian doctors reported
being bullied at work compared with 34%
of white doctors (Quine 2002)
Distinction and Discretionary
Awards
• 5.4% of distinction awards held by ethnic
minorities (22% of all consultants) ACDA 2000
• White consultants 3.5 times more likely to
obtain award (Esmail et al BMJ 1998;316:193-195)
• White consultants nearly 2 times more
likely to receive discretionary points (4
times more likely if higher awards
considered)
Discretionary points
“Such a high level of subjectivity is
anathema to the successful application of
equal opportunity guidelines since it works
to the disadvantage of ethnic minorities,
both in operation and perception… This
case falls into the worst category of racial
discrimination against a senior medical
professional” (Dr M Nasr v. Salisbury NHS Trust)
The professional response
• It’s all ‘out there’
• My best friends are black
• ‘We are professionals – we don’t
discriminate’
• How can we – ‘many of us are black
anyway’
If it is only bad people who are prejudiced, that would not
have such a strong effect. Most people would not wish to
imitate them — and so, such prejudices would not have
much effect — except in exceptional times. It is the
prejudices of good people that are so dangerous.
Vikram Seth. A suitable boy. London: Phoenix, 1993.
“What happened to the medical profession of
Germany is stern testimony to the fact that
acceptance of or even silence before antisemitism and the rest of the trappings of
racism....can lead to the dishonour and crime in
which the entire medical profession of a country
must in the last analysis be considered an
accomplice.”
Andrew C Ivy
Statement In: Mitsherlich A, Mielke F.
Doctors of infancy: the story of the nazi
medical crimes.
New York. Schuman.
1949: xii-xiii