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I always know someone is going to say something racist when they start a sentence with, “I’m not racist, but …” Nobody likes to think they would ever discriminate against someone based on the colour of their skin – and some people seem increasingly uncomfortable about acknowledging that such discrimination exists at all in the world. Yet we are now seeing a backlash from certain political groups against diversity initiatives, including from Kemi Badenoch who wants to do away with “DEI bureaucracy”, and Nigel Farage who promises to get rid of “woke” council roles such as those involved in increasing diversity, equity and inclusion.
Whatever your political views, no one wants debates to be lost in emotion rather than based on the evidence. So it is helpful to come back to facts about race and how it affects people’s lives. And as new Guardian reporting on racial inequalities in pain relief reveals, when it comes to healthcare, the evidence is overwhelming: race and ethnicity are associated with differences in the quality of care people receive and, ultimately, in their health outcomes. Regardless of whether anyone is being racist, it is clear that some people receive worse healthcare because of their racial or ethnic background.
Take maternal care: women from Black and Asian backgrounds are less likely than their white counterparts to receive an epidural while giving birth. And this isn’t because they don’t ask for one. They ask and are ignored. New research finds that Black women are stereotyped as having “thick skin” and being able to tolerate pain, while Asian women are seen as “princesses” who are over-demanding and judged for not tolerating even a small amount of pain.
Experts call this the “ethnicity pain gap”. They have found that the colour of your skin seems to inform whether you are offered pain relief in all areas of healthcare, not just during childbirth. Take cancer treatment: patients from Black, south Asian and mixed ethnic backgrounds received fewer and lower doses of pain-relieving medications than people from white backgrounds, even after controlling for patient age, cancer type, health condition, deprivation and other variables that could affect that decision.
There have been numerous studies on these inequalities and I could go on and on, but instead, can we all accept the strong evidence that there’s a link between someone’s skin colour, their patient journey and their health outcome? But having consensus about a problem is only a first step. What can be done about it? I don’t think calling people racist generally helps to address these kinds of inequalities; it can lead to defensiveness and reluctance to change. Here’s what we know so far about interventions that do make a difference.
First, within healthcare, what gets measured gets prioritised and improved. Healthcare organisations routinely monitor waiting times, infection rates, mortality outcomes and more. Racial and ethnic disparity data needs to be routinely collected and shared transparently across an organisation with accountability for what that data shows.
Second, awareness-raising for all staff of our unconscious biases can help. That is, certain beliefs we carry that affect how we treat others (that we might not even be aware of). For example, some healthcare settings have introduced training for medical professionals to dispel myths such as that Black patients have a higher pain tolerance, or that Asian people have a lower one.
Third, whenever possible, medical care should follow standardised clinical pathways that reduce individual bias in medical decisions. Checklists, protocols and objective criteria on care – for example, when a woman can access an epidural during birth – take away the unconscious (or conscious) bias that can set in at key decision points. Of course, individual judgment is important in medical care, but having the same processes for everyone can make healthcare fairer all round.
Finally, leadership from the top matters in recognising the ethnicity pain gap and making it a priority across an organisation. If leaders don’t care about an issue, it disappears. It’s about changing the entire culture of an organisation to say: this matters and we’re committed to improvement.
Again, none of this is about accusing individual staff of racism. Most people working in healthcare genuinely want to provide the best care possible, but we can see that within delivery and care individuals are being treated differently, and the data points to a clear pattern of racial and ethnic differences. Acknowledging the data and evidence is the first step in collectively working towards solutions.
Being American, I think of Martin Luther King Jr, who had a dream that one day people would “not be judged by the colour of their skin, but by the content of their character”. Medicine should be the same: patients should receive the same high-quality care regardless of the colour of their skin. It’s not political correctness or being woke to say this. It’s simply good healthcare and good practice.
On a final note – as someone with darker skin, who was raised in Miami to immigrant parents from India, who was often read as Hispanic, and who then migrated to Britain and now lives in Scotland, I think my skin colour is the most superficial thing about me, and about others. Our skin might be brown, Black, white or some shade of any of those because, over thousands of years, our ancestors evolved different amounts of melanin (which gives our skin colour) depending on how much sunlight they were exposed to, balancing protection from UV light with the body’s need for vitamin D. In short, the biological differences between ethnic populations are tiny compared with the genetic similarities we all share.
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