What can we do about racism in medicine?
“Change means growth and growth can be painful. But we sharpen self-definition by exposing the self in work and struggle together with those we define as different from ourselves, although sharing the same goals.”
I grew up in Kent, in South East England in the 1970s and 80s. I didn’t meet anyone who wasn’t white until I was about 12 or 13 years old. My only exposure to black people was in National Geographic magazines where they were an exotic curiosity or occasionally on television where I remember children’s TV Play School presenter Floella Benjamin and decathlete Daley Thompson. It was normal when I was growing up to hear adults refer to black people as ‘Wogs’ or ‘Coons’. I remember coming to London once with my dad to watch a Rugby match and seeing a Black man on the underground and remember pointing to his stereo and saying to my dad, “look at that man’s ‘wog-box’” and my dad being cross with me and pushing me back onto the train. I felt betrayed because this is what he used to say and now it seemed that there was something wrong with it. I also remember teasing a black boy at Judo club with racist names. I must have been about 6 or 7 years old. I remember him being upset and attacking me, but I don’t remember anyone telling me off or racism ever being mentioned. I don’t think I even thought about racism until I was a teenager.
The death of George Floyd was an inflection point, forcing many of us to confront the question, “What should we be doing about racism?”
Robin Di’Angelo’s answer to this question is, “What has enabled you, as a white person, to live your entire life without having to answer that question before? How were you able to ignore or avoid even having to think about it until now?”
She argues that the problem is not one of racist people behaving badly in a tolerant culture, but a racist culture that conditions people to act and think in racist ways. You need to think and act counter-culturally to overcome racism. As Malcolm X put it, “You can either be racist or anti-racist, there is no space in-between where you can be ‘non-racist’”. Framing racism as a cultural issue makes us all complicit.
So, this month, I ran a session about racism and medicine at work[DG1] . It was set up as a tutorial for two physician associate students and two GP trainees. I also invited our reception manager (a Black man) and a patient (a woman with a Black Caribbean father and a White mother).
Little preparation was required. I told the people coming that the subject of the session (a trainee tutorial) was racism in medicine and that it would last 90 minutes. We found a room that was big enough and well ventilated enough to meet safely in a time of Coronavirus[DG2] . I chose to facilitate the session and explained that we were going to begin with a personal story. The only rule was that in responding to peoples’ stories [DG3] we were only allowed to ask questions about facts, feelings or interpretations, but we were not allowed to offer any opinions or interpretations of our own. While we had called the session ‘Racism in medicine’ we made little mention of medicine. Racism has similarities with illness and disease. Disease is defined by people in authority. You might consider yourself to be suffering, but it is not a disease unless a doctor says it is. Illness is what patients experience: the ways symptoms impact on functioning, relationships and social interactions. To understand a disease, for example Diabetes, you need to know about the pathology and the impact on people’s lives. To understand racism you need to understand facts and figures as well as the everyday experiences of people affected by racism. At our session there were no experts deciding whether something counted as racism. We were there to understand racism as lived experience.
I had not consciously designed the session with the following in mind, but these are some of the things we achieved.
- No hierarchies. Nobody in the room claimed to have any greater expertise in racism than anybody else. We were bringing our stories and our skills as listeners.
- Epistemic justice. This combines narrative justice and hermeneutic justice. Narrative justice is when accounts that tend to be unheard, ignored or dismissed are invited, listened to, and taken seriously. Hermeneutic justice is when interpretations that tend to be unheard, ignored or dismissed are invited, listened to, and taken seriously.
- Bearing witness. Bearing witness to suffering is uncomfortable for the witness. Whenever we listen to stories of racism, we should expect to feel uncomfortable.
- No shame. This is not a place for White shame. My story concerned a young child who grew up ignorant. Once I found out what racism was, I changed my behaviour.
- Time to think. Tightly structured sessions that are full of activity can stop people thinking deeply because participants are focused on achieving tasks and keeping to time. I did not know where the session would go and wanted to leave time for discussion.
1970s Britain was a great deal more racist than it is today, but the stories the other people in the room shared, revealed that racism is still very present today; in schools, universities, GP surgeries (including our own), the streets of Hackney, medical school, online – everywhere. Di-Angelo was vindicated, racism is systemic. It was an experiential learning session – we acted with humility, curiosity and empathy. The stories are confidential, but one I can share.
For years, one of receptionists has received more complaints than any of the others. The complaints are about her attitude, about being given the wrong information, about being unhelpful, just about everything and anything. We have to apologies and respond to the written complaints and have supported her and given her additional training. In the middle of March this year, we had to close the doors of the practice and patients had to call before coming in. Overnight and without precedent patients stopped coming to the reception desk. Since then she has had no complaints. And she has taken more calls than any of the other receptionists. Since patients stopped seeing her as a Muslim woman with a headscarf they stopped complaining. The sudden cessation of face to face contact at the reception desk was a natural experiment that helped demonstrate one way that racism operates.
In response to the session, Andre our reception manager said,
“I’ve never been asked by a white person about my personal experiences as a black man
I quickly realised that I have supressed feelings about my past/present experiences.
I want to make you understand that we have been conditioned to think that nothing will be done about systemic racism so we just keep calm, carry on and play our position!
This session made me feel very empowered and gained my trust. This enabled me to share my stories with you (as a white man), without fear of judgement &consequence”
Sharon, who came to share a patient perspective said,
“Thank you Dr T for inviting me; some powerful thoughts & thank you Andre for maintaining my faith in my black brothers.
Of course anger, frustration & confusion is paramount when your voice, your history & culture is constantly ignored & ridiculed. Who put the chip on my shoulder…?
Education, Empathy & Respect are a pretty good prescription! Thank you, the more we discuss & learn the less pain to endure.
Years of having to stay quiet & ignore the horrid side of our British History very frustrating! I think our Society as well as the rest of the world finally accept that 400years of slavery simply won’t go away or be forgotten”.
All the practice staff have been buzzing about the session. Other receptionists and clinicians have asked to come to the next session, and I have spoken to other patients about it. For years we have been trying to tackle overt racism – taking action when people are racially abusive, but now we have found a way to do something about systemic racism. The session cannot stand alone, and it must be repeated regularly. But it is an important start.
 DiAngeloo R. White Fragility: Why it’s so hard for White people to talk about race. Beacon Press 2018
 Mendenhall. E. Rethinking Diabetes: Entanglements with Trauma, Poverty and HIV. Cornell University Press 2019