Lectures BMJ ‘Born Equal - Racism in Medicine

Lectures

BMJ ‘Born Equal - Racism in Medicine’ Lecture

In this lecture on the process of putting together the British Medical Journal (BMJ) ‘Born Equal-Racism in Medicine’ issue, Zosia Kmietowicz (news editor), Navjoyt Ladher (head of education) and Juliet Dobson (opinion and bmj.com editor) discussed the dilemmas they encountered whilst compiling articles for the journal and the steps they took to resolve them in order to publish and shed light on the experiences of doctors and patients from minority ethnic backgrounds and how little progress has been made in combating racism and prejudice within medicine.

With the senior editor team responding positively once the idea of an issue dedicated to the topic was proposed, the team invited guest editors Victor Adebowale (chair of the NHS Confederation, crossbench member of the House of Lords, former NHS board member) and Mala Rao (senior clinical fellow at Imperial College London and medical adviser to NHS England’s workforce race equality, both of whom have been extremely vocal in their calls to hold the healthcare system accountable for the racism that is perpetuated within it. In this way, every decision that was made would be well-informed from all angles with advice from the most influential voices. With this in mind, they engaged in many conversations surrounding the various ethical dilemmas. One such dilemma they faced was naming the prejudice experienced by doctors and patients from minority ethnic backgrounds from various areas of the medical sphere, be that medical schools, the NHS and/or regulators etc. This question, the editors explained, was quickly resolved with a unanimous decision that there should be no hesitancy to call it what it is - racism. However, what dominated the majority of discussions was the collective terms to be used within the issue. During the lecture, the speakers pinpointed the various collective terms that were brought up in the meetings and their reasoning for their conclusion, which was to use the term ‘ethnic minority’ , ensuring that specificity is maintained throughout i.e. avoiding use of umbrella terms as much as possible. Some of the terms that were mentioned included Black and Minority Ethnic (BME); Black, Asian and Minority Ethnic (BAME); Person of Colour (POC); Black, Indigenous and People of Colour (BIPOC); non-White and ethnic minority. Collective terms such as

these mask specificities and individual details, which are vital to comprehend when discussing the impacts of ethnicity within medicine. To illustrate this point, Zosia Kmietowicz brought up the very topical example of COVID-19, reasoning that during the first wave, the poorest outcomes were seen in those of a South Asian background, particularly individuals with familial roots in Pakistan and Bangladesh and by using collective terms such as BAME, these crucial details will be lost and therefore effective action cannot be taken to minimise the disproportionate impact on the aforementioned groups. Moreover, acronyms such as BAME and BME are UK specific and accessibility is a key factor of the language used within the journal. Not only are they UK specific, however, even within the UK, studies have found that out of 300 people only a couple had a vague understanding of what the terms stood for. Kmietowicz went on to explain that the media is also beginning to recognise this with The Sun tweeting that they would no longer be using the term BAME declaring it “outdated” and saying it “obscures important differences between ethnic groups” on 5th March 2021. Using this language would have therefore made the journal inaccessible and would have ultimately minimised the impact of the content within it.

Another factor that had to be taken into consideration were the opinion pieces. An overwhelming number of pieces were submitted and deciding which to publish proved to be a difficult task, not only because of the sheer volume but also because of the process of distinguishing which would have the most impact and relevance. Among those submissions were many pieces targeting religious discrimination, which although highly important and impactful were not as relevant to the issue. Others, although descriptive and emotive, were not productive and analytical pieces and so were also deemed unsuitable for this particular issue. Within the topic of opinion pieces also lies the issue of the contributors. The BMJ editors originally decided not to ask for contributions from their two regular weekly columnists, both of whom are White but were encouraged by Adebowale (one of the aforementioned guest editors) to allow them to write their weekly column suggesting that this issue should feature voices from all backgrounds. The editors went on to explain the range of feedback they received and the discussions this generated. One of the aforementioned columnists had taken to twitter to ask for advice and guidance on their piece. They were originally applauded for their initiative, however later received backlash for using others’ experiences and ideas and publish them as their own. The shift in response to this piece can be attributed to a range of factors whether it be the political climate or another factor entirely, but it was an interesting point nonetheless.

The final point of significance was the question of how to keep the conversation going beyond the special issue with the most enlightening topics breached in the lecture being the extent to which racism is present at medical schools, the implications this could have on future medical advancements such as within the realms of AI and how the shifts in politics leads to further disparity within the medical profession e.g. after Brexit there was an

exponential increase in attendance of Eastern European doctors to support groups. All of which are discussed at length within the journal itself, which can be accessed at https://www.bmj.com/racism-in-medicine.

To end with, the panelists provided some reading recommendations, which I have included below for your interest:

Medical Apartheid - Harriet Washington

Political Determinants of Health - Daniel Dawes

The Immortal Life of Henrietta Lacks Rachel Skloot

Overall, this lecture was highly valuable. The perspective of journal editors was one that I, personally, had neglected to consider when reading pieces from medical journals, however is something that is worth reviewing. Moreover, gaining an insight into the process of creating a journal with the purpose of maximum impact, reach, and accessibility is interesting to keep in mind, especially while actually reading the pieces and recognising the impacts of this on its language, contributor and content. One final note. Combating racism in medicine will not only improve outcomes for patients, however will have enormous implications on the medical practitioners and wider society. It is a conversation that, as the editors highlighted, should not be limited to “special issues” , however, should be at the forefront of discussions about the healthcare system.

References:

Rojin Zahaki LVI-16

Kmietowicz, Z., Ladher, N. and Dobson, J., 2021. BMJ ‘Born Equal-racism in medicine’ .

Zamila Bunglawala (2019). Please, don’t call me BAME or BME! - Civil Service. [online] Blog.gov.uk. Available at: https:// civilservice.blog.gov.uk/ 2019/07/08/ please-dont-call-me -bame-or-bme/ [Accessed Mar. 2021].

Bmj.com. (2021). Racism in medicine | The BMJ. [online] Available at: https://www.bmj.com/racism-in-medicine [Accessed Mar. 2021].

Who thinks about ‘Doctors in Distress’?

I recently attended a virtual webinar by Dame Clare Gerada where she spoke about the charity, Doctors in Distress. Alongside this, she mentions the book, Beneath The White Coat: doctors, their minds and mental health. This book talks in great detail about doctors’ mental health. I feel really strongly about discussing the importance of managing mental health and I feel that it isn’t discussed enough in a scientific, social or political setting. Since Year 8 the idea of questioning if doctors take care of us, who takes care of doctors has been deep within my mind. I had previously worked on a presentation about it with my friend, which ultimately led to the basis of my EPQ title.

My main aim for my EPQ is to investigate what systems are in place or can be put in place to assess the mental health of a medical practitioner. I use the word ‘assess’ broadly, less of judging a doctor’s mental health but more in a way to see if they need extra support or someone to talk to. The Doctors in Distress charity is exactly that; a place where medical practitioners can attend group sessions and a form of psychological PPE (personal protective equipment) is provided. The word PPE is usually used to describe physical equipment e.g. masks, gloves, hazmat suits so I found it intriguing that Dame Gerada used it to describe something that affects us both physically and mentally. She is right of course, mental health illnesses and problems affect us in more ways than one. Especially during COVID-19, now is the time to think even more deeply about the people taking care of us, all front-line medical workers.

To provide some more information about what Doctors in Distress entails, here is the basis and principle upon which it was founded by Amandip Sidhu. The Doctors in Distress charity was inspired by a tragic case of a cardiologist doctor who passed in November 2018. He experienced what is commonly referred to as ‘burn out’ and felt he had only one way to escape the suffering. The founder of the charity passed ownership to Dame Clare Gerada who has helped expand its influence and community. The charity’s aim is to raise awareness of the value of medical professionals' health and well-being.

"IT WILL TAKE TIME AND THERE IS

MUCH TO ACCOMPLISH BUT WE

BELIEVE THE RIGHT THING TO DO

IS TO HELP THOSE THAT CARE

FOR US ALL. " - Amandip Sidhu

I chose to write this article to share my experience of this virtual talk that I attended, as well as raise awareness of the importance of mental health and how common it really is. Especially for a high intensity, stress filled environment that doctors and other medical practitioners work in, managing mental health is crucial. It can be the breaking point of so many young doctors. I want to expand the awareness about how common mental illness is, how people manage it, what the causes might be and how people can help?

The term ‘burnout’ is often used when a doctor describes their mental illness.

Here is the definition; burnout is a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress.

Even Dame Clare Gerada expressed that she experienced burnout. It can be small or big but signifies a change from the normal routine. For example, one of her main principles that she constantly upheld was to always have curiosity about a patient. As soon as this is not present something is going wrong. How can one treat a patient you’re not interested or curious about? On one occasion she realised that she indeed had lost curiosity and she felt that something was different. This caused her to believe that she experienced burnout.

One of the key points that Dame Clare Gerada touches on is how challenging it is for a doctor to admit a change in their identity that has evolved over the years. She mentions how a doctor’s identity begins to form from medical school. Understandably, this is where their journey begins; the start of a lifetime to become a doctor. However, as this identity forms so early on, it would only become more concrete as they grow older and to change that identity would get even harder. For example, to go from doctor to patient. She suggests how this is one of the reasons doctors find it so hard to even admit they have a mental illness, let alone get help for one. Once you have obtained such significant training and respect for your position, admitting that you have an illness is extremely challenging.

Furthermore, when thinking about the frequency of mental illness we may have to consider the specialty. A statistic Dame Gerada touches up on is the fact that in recent years the number of paediatricians with mental health problems has risen significantly. Whereas, the figures that depict surgeons’ mental health problems is much lower. This could be because surgeons are more prone to handling high pressure situations, or it could equally be that they are more unwilling to report an illness. Why might this be? Does the specific work you do make way for an increase or decrease in likelihood of mental health problems? From what I can infer, different specialties handle varied situations and challenges. However, in the end each Individual is different and will handle a problem differently.

The main message that I discovered while researching this, is that doctors are human.

Having a mental health problem doesn’t mean that it is untreatable. With the right help you can get better over time. You can often help someone by talking to them, conversing through their problems. Just showing that you care and are there for them can help significantly. Doctors are incredibly skilled humans who can change the fate of life and death with their own hands, but still humans. Humans can get sick, they can also get better, but it is time to stop forgetting that doctors are human as well. We should notice and be aware of the fact that we might need to take care of the ones caring for us.

Angelina Kim LVI

The Theory of Natural Selection

English naturalist Charles Darwin had been working on the idea of natural selection for years, collecting research, making observations, and testing his hypothesis during a five-year voyage to study plants, animals, and fossils in South America and on islands in the Pacific. In 1859, he brought this idea to the attention of the world in his best-selling book, On the Origin of Species.

Natural selection is the process through which populations of living organisms adapt and change. Individuals in a population are naturally variable, meaning that they are all genetically different in some ways. This variation means that some individuals have traits better suited to the environment than others. Individuals with adaptive traits — traits that give them some advantage — are more likely to survive and reproduce. These individuals then pass the heritable traits on to their offspring. Over time, these advantageous traits become more common in the population and transmitted through generations. This process happens over many years and multiple generations. It is an ongoing process that leads to small changes throughout all species throughout several years. It can also lead to speciation, where one species gives rise to a new and distinctly different species; this is a process that drives evolution and helps to explain the diversity of life on Earth.

Darwin chose the name natural selection to contrast with “artificial selection, ” or selective breeding that is controlled by humans. He pointed to the pastime of pigeon breeding, a popular hobby in his day, as an example of artificial selection. By choosing which pigeons mated with others, hobbyists created distinct pigeon breeds, with fancy feathers or acrobatic flight, that were different from wild pigeons. He explained that a process much like artificial selection happened in nature, without any human intervention and claimed that natural selection explained how a wide variety of life forms developed over time from a singular common ancestor.

Before this theory was brought to light, scientists were under the impression that uniformitarianism (the idea that Earth has always changed in uniform ways and that the present is the key to the past) was the key to how evolution occurred. Several other theories had been discredited by whichever scientist had a more accurate and provable theory. The theory of uniformitarianism was what brought Charles Darwin to his conclusion of natural selection. Through the discovery of Darwin’s theory, scientists were able to better understand how species were able to evolve and become more suited to their environments over time, and light was shed on new leads for understanding humankind. After his theory was deemed to be true, scientists only then discovered DNA three years after. Several advances came about after Darwin proved his theory. Without the discovery of natural selection, these advances may not have been possible.

An example of natural selection could be the distinction between polar bears and black bears. Although they are both from the same genetic make, they share very different heritable traits that make them suited for their environments. Polar bears are well adapted to the cold environments of Antarctica and do not fare well if they are placed somewhere that differs in temperature. A black bear, however, generally lives in warmer areas that experience four distinct seasons and hibernates during the winter months. A black bear could not survive if it was placed in an area that was cold year-round because it’s heritable traits are not designed

for that environment. This is an example of how one in the same population has branched off through the process of evolution and has become more adapted to the environments they are in, causing a new variation of species to be formed.

Although natural selection is one of the main driving forces of evolution, there are a few others that play a part as well. These factors are mutation, genetic drift, and gene flow. Mutations are changes in DNA that form genes. The mutation of genes is an important source of genetic variation within a population. Mutations can be random (for example, when replicating cells make an error while copying DNA), or happen as a result of exposure to something in the environment, like harmful chemicals or radiation. Mutations can be harmful, neutral, or sometimes helpful, resulting in a new, advantageous trait. When mutations occur in gametes, they can be passed onto offspring but they are one of the less common occurrences to happen in evolution. The previously mentioned example of polar bears and black bears is proof of genetic mutation. The most distinctive difference is the colour between the two: polar bears are white while black bears are black and other types of bears can be brown. Genetic drift is where certain advantageous traits do not carry on to the next generation and essentially die out. Gene flow is where certain heritable traits are shared between more than one variation of the same species. This process can lead to big changes fairly quick, unlike natural selection where changes occur at a slow prolonged pace. Once again, the example of polar bears and black bears could serve as a model for gene flow. They both share the same heritable traits of hunting, a trait needed to survive in both variations and environments.

If the environment changes rapidly, some species may not be able to adapt fast enough through natural selection. Through studying the fossil record, we know that many of the organisms that once lived on Earth are now extinct. An invasive species, a disease organism, a catastrophic environmental change, or a highly successful predator can all contribute to the extinction of species. Today, human actions such as overhunting and the destruction of habitats are the main cause of extinctions and seem to be occurring at a much faster rate today than they did in the past.

Despite the wealth of evidence from the fossil record, genetics and other fields of science, some people argue that evolution altogether is false. But all this information continues to support its validity and humans are one of the best manifestations of this theory. We have evolved into a very intelligent and intellectual population, who started as quite the opposite. Fossil "links" have also been found to support human evolution. In early 2018, a fossilized jaw and teeth found that are estimated to be up to 194,000 years old, making them at least 50,000 years older than modern human fossils previously found outside Africa. Through the process of natural selection, we have thrived and became an incredible population of many varieties. Evolution is happening all around us every day in every part of the world. Darwin was discredited for a long time even after he was dead by those who believed evolution was false and that God was the only factor behind the variations in species and how they change. Some now believe that God is the creator, and still, accept that natural selection plays a hand in the differentiation of species.

Charles Darwin was not the founder of evolution, but he did play a role in finding out how evolution occurs and what the

driving factors behind it were. If his theory had not been formed, how far would our knowledge of evolution have come? Maybe everyone would still believe in creationism or that uniformitarianism was the only process behind evolution. We have come a long way since those theories were first introduced, and we continue to move forward daily with advances in the topic.

References

All About Science, (2002). Darwin’s Theory of Evolution. Retrieved from https://www.darwins-theory-of-evolut ion.com/

Doc, T. (2015, November 24). Home. Retrieved from https://www.famousscientists.org/ev olution-theories-before-darwin/

Live Science Staff, (2007, August 15). Forces of Evolution. Retrieved from https://www.google.com/amp/s/amp.l ivescience.com/1796-forces-evolutio n.html World Transformation Movement. (1998). ‘Natural Selection’ allowed the human condition to be explained. Retrieved from https://www.humancondition.com/fre edom-expanded-book1-natural-Sele ction/?ref=adgrants-search _ biology& gclid=Cj0KCQjwov3nBRDFARIsANg sdoFRSuRTAHPOog_ghwVtuH _ 8t2 XOqKJq720ZPdulkQJOxP0NShnuE AaAginEALw _ wcB

Juliette Desbiez LVI