‘Where are you really from?’ - Racism in Healthcare and How to Tackle It

During my work experience prior to medical school, I had an interaction with a patient that I think is universal to everyone in the health service who is of an ethnic minority. An elderly patient who was hard of hearing asked me where I was from. Upon replying, that I was from Nottingham in the UK, a White consultant bashfully explained that the patient likely meant ‘Where are you really from?’. Although recognising the undertones of this question, I replied that my parents are South African. The conversation then took a turn where the patient expressed disbelief that someone with ethnically brown skin can be African. I tentatively began to explain the origins of the Cape Malay people in South Africa and how they had come with the Dutch colonisers, as well as the immigration of Indian indentured labourers and businessmen. It was only later that I really pondered on this uncomfortable encounter and why my ethnic identity was the subject of interrogation in theatre. Ultimately, I had no blame for the elderly lady but I felt let down by the consultant who knew where the conversation was going and allowed it to run its course.

In a similar vein, during a placement in medical school, a White doctor who was consulting with a patient of Indian origin turned to me and asked if I was able to help translate. Apart from generalising the vast range of languages in India to my skin colour, it was also presumptuous to assume that someone of a certain ethnicity can speak a language. I dealt with the situation in a good nature and told the doctor that I could perhaps assist with Afrikaans but I don’t think that will be useful. Once again, I could see a degree of embarrassment in this doctors eyes but there was no real acknowledgment of what had occurred.

During medical school, there is an awful lot of facts and concepts to consume. It can lead to pattern recognition which is important in emergencies. However, simultaneously our critical thinking with regards to race, culture and how this pervades the health system is incredibly undeveloped.

The Black Lives Matter protests in 2020 after the murder of George Floyd sparked numerous conversations on race and identity. It was the first time I saw White colleagues and friends interested. During one discussion that I was a part of, a friend of mine said, “Why does it matter if my ancestors were racist when I am not?”. I replied that it represents two sides of the same coin. For you, it does not matter because the legacy of racism does not affect you, whilst for many others it still does.

One such case was the formulation of the dermatological handbook ‘Mind the Gap’ by medical student Malone Mukwende. Mukwende noticed the fundamental lack of medical teaching on dermatological conditions on darker skin tones, as a result he was inspired to fill this gap. Perhaps most famously, Bob Marley’s death from the rare skin cancer acral lentiginous melanoma resulted from a delayed diagnosis. “Mind the Gap” was a step in the right direction. It aimed to correct a past where darker skin tones were not valued. It made me wonder why it took so long.

During a placement in obstetrics, my supervising consultant shared with me the shocking figures that Black women are 3.7x more likely to die in child birth whilst Asian women are 1.8x more likely. This was found to stem from an absence of patient-centred care, poor communication, mistreatment of women and women-centred care not being the norm. A lack of quality healthcare translators and an absence of cultural sensitivity such as an awareness of the importance of the month of Ramadan (fasting) for Muslim women, highlights fundamental disparities in the way maternal care is provided. The voices of pregnant people of colour need to be heard.

Ultimately, these are only two examples in a sea of institutionalised racism that pervades the health system. The paper on maternal outcomes illustrates that task-centred care is a key component that leads to adverse outcomes. This clinical approach arises in medical school. There needs to be room for critical thought to challenge structural problems.

To combat this, it is essential to create open spaces where honest conversations can occur. This should occur in medical school. It is important to transcend embarrassment and recognise inherent faults that exist. More importantly, institutional racism will begin to be dismantled and health outcomes for all will be improved. This way, a new generation of health professionals will not hear the question ‘Where are you really from?’.