Annabel Sowemimo is an NHS doctor, a registrar in sexual and reproductive health, and an academic and broadcaster on the intersection of race and medicine. Her new book, Divided, began as a column on decolonising healthcare for gal-dem – an influential platform for writers of colour – which, sadly, recently closed. Those articles have led to this important and ambitious title, which seeks to educate readers about the racist origins of western medicine, asking for recognition of the mistreatment of patients in the past, and calling for a correction to systemic and institutionalised discriminatory practice.
She is refreshingly honest about the lack of easy answers and acknowledges her frustration. “Well, what do you suggest we do instead then?” as a master’s student asks in the epilogue. But Divided is a necessary book, and pertinent, if also of its time in that it reads as if much of it was written during the pandemic, fuelled by those terrifyingly pointed losses of BAME clinicians in spring 2020 (the first 20 NHS workers who died from the virus were non-white). It soon became obvious that BAME staff were disproportionately exposed and dying from the virus, at risk from the patients for whom they provided care. Sowemimo felt she “had to write the book” as no one could deny “that health inequalities and uneven power relations exist”.
It also feels, at least to me, another NHS doctor who was working full-time on the frontline during the pandemic, that it forced an improved understanding of the BAME contribution to healthcare, with acknowledgment of our heightened risk. Measures were put into place. There was some positive movement in clinical practise from 2020 to 2023, but Divided doesn’t really address this change. It’s possible that the author was working academically, rather than clinically, during that period and hadn’t seen this shift first-hand.
That does not diminish the value of her contribution. In her wide-ranging analysis of the hidden past, where medicine has failed people of colour, she tells the stories of those dehumanised, exhibited as curiosities and experimented upon, and exposes the debt that medicine owes to lives damaged and exploited. As a black medic training in London, who was subjected to micro-aggressions, she has incorporated her own stories into the account, and the sincerity of her intent is palpable. She is also honest about her privilege and her middle-class medical family; how this helped to give her a voice and to raise the concerns of others who have sought her help.
Divided deserves a large readership and will be useful to any patient who has questioned the basis of their treatment, and to any clinician who has followed prescribed protocol that distinguishes race without really understanding why. It provides much more than a salutary history lesson. Sowemimo is right to ask why poorer countries that contributed to vaccine production were unable to secure adequate vaccinations for their own population. She is right to ask why medical technologies have been programmed with discriminatory results, so that darker skin is not recognised. (Am I the only person to notice that automatic taps don’t work for brown hands?) When it comes to pulse oximetry, the finger-tip monitor that measures the oxygen level of the blood, such reduced accuracy could compromise patient care. And the metrics we use are also based on the white patient, from BMI to renal function. The term flesh-coloured, for a plaster or medication patch, is frequently for only one type of flesh.
Still, I find some of the clinical vignettes less useful to her thesis, not because they aren’t well told, but because I’m not convinced they are all race-related. She tells of the seven-year-old girl whom she appropriately diagnosed as probably having appendicitis, with the symptoms of peritonitic abdomen and raised inflammatory markers. This patient had been handed over to her as a probable urinary tract infection by the triage nurse. Sowemimo suggests that the nurse possibly got this wrong because the patient was black and quiet about her pain, but for me, as a doctor who did that same paediatric job in A&E, it is not my nurse’s responsibility to diagnose. Another example given is the dismissal of a black woman’s persistent pain for an abdominal pathology. Again, Sowemimo concludes this is because of race – but it could also be because the patient is a woman. Similar stories have been shared with me by female patients with depressing frequency, affecting all ages, races and classes. The intersection of race and gender in medical mistreatment and under-management is another uncomfortable truth, particularly when it comes to painful gynaecological conditions, such as endometriosis. Of course it would be a far bigger book if Sowemimo had to cover the complex intersectionality of gender and socioeconomics that compromises healthcare for the global majority – people of colour.
But Divided is a call to action; it helps us to understand the roots of racism and, indeed, sexism in medicine, and that there is no excuse for either. It is systemic, it is institutional and it is wrong. The individual doctor, looking at the patient in front of them, can take responsibility for righting what has been done poorly in the past – the under-treatment of pain symptoms in black women during childbirth; the over-diagnosis of schizophrenia in young black men.
In some areas, change is already happening. I was pleased that I didn’t recognise the tyrannical trope of the white middle-class consultant she describes in her training. Medicine in the NHS is diverse, and I have never been the only brown person in the room. Increasingly, my seniors have been ethnically diverse, too. As a medical school cohort, we openly mocked the “racist’s guide to medicine”, the unwritten charter that seemed to assume in exam questions that every middle-aged Asian man had diabetes, that every Muslim woman in a hijab had vitamin D deficiency, and every young black man had cannabis-induced psychosis.
There is still much work to be done and, as Sowemimo points out, simply increasing diversity in the health service isn’t enough if you’re working in a biased system. I gave up several hours of my time to participate in qualitative research for my trust about this, listing the challenges faced by our IMG (International Medical Graduate) trainees, and remember saying in frustration: “Why is it my job to educate you about race?”
I’m glad that someone as empathic and generous with her knowledge, research and experience as Sowemimo has made it hers.
Dr Roopa Farooki is an NHS internal medicine doctor and the author of Everything Is True: A Junior Doctor’s Story of Life, Death and Grief (Bloomsbury). She is an editor of Adda’s Healthy Communities collection, Remember to Rest, featuring healthcare stories from around the globe
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2023-04-10 06:00:00Z
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