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ss nucleus - winter 1999,  Racism in Medicine?

Racism in Medicine?

In light of the Lawrence Inquiry, Ranti Atijosan investigates racism in medicine

The Lawrence Inquiry

The report of the Lawrence Inquiry, published earlier this year, has brought the issue of racism in Britain today to the forefront of discussion.[1] In their investigation of the racist murder of Stephen Lawrence, a black London teenager, in April 1993, the London Metropolitan Police failed to investigate the murder adequately and implemented their policies in a discriminatory way.

In the wake of the report, which charges the force with 'institutionalised racism', there have been accusations of racism within a number of other British institutions and professions - including the National Health Service (NHS). Although allegations of racial discrimination within the NHS are not new, doctors, like police, have taken offence at this 'slur' upon their profession.


Much of the continuing debate over racism is clouded by a misunderstanding of terms. Racism in general terms consists of 'conduct or words or practices which disadvantage or advantage people because of their colour, culture, or ethnic origin.' [1] Institutional racism, in contrast with individual racism, is defined by the Lawrence Inquiry as follows:

'Institutional racism originates in the operation of established and respected forces in the society. It relies on the active and pervasive operation of anti-black attitudes and practices. A sense of superior group position prevails: whites are 'better' than blacks and therefore blacks should be subordinated to whites. This is a racist attitude and it permeates society on both the individual and institutional level, covertly or overtly.'

Racism in Medicine

At present at least one in 18 of Britain's population is black or from an ethnic minority, with an estimated one in four doctors practising in the UK having qualified overseas. We therefore live in a multicultural society both in terms of the patients we treat and the colleagues with whom we study and practise.

Research shows, however, that ethnic minority doctors fare worse than their white colleagues at all levels in the profession.

1. Discrimination in selection procedures

Over ten years ago, Joe Collier, a doctor at a London teaching hospital, notified the Commission for Racial Equality about computer software being used in the student admissions process of his medical school that discriminated against ethnic minority candidates. This programme gave a lowered computer generated score for candidates with non-Caucasian names. As a result he was 'vilified and ostracised'.[2] The problem of racism within the medical profession has improved leaps and bounds since then; however, it is still a long way from being solved.

White applicants to medical school are twice as likely to win places as suitably qualified black and Asian candidates[3,4] and out of 25 medical schools there has never been an undergraduate or postgraduate dean from an ethnic minority group.

2. Discrimination in career opportunities

Research in 1993 showed that the chance of obtaining a first SHO post is significantly less for doctors with Asian as opposed to Anglo-Saxon names, despite equivalent curriculum vitae.[5] An identical study in 1997 showed only slight improvement and there was still a marked difference between the proportion of white (52%) and Asian applicants (36%) being short-listed.[6]

Other studies have highlighted that white consultants are three times more likely than others to receive merit awards[7] and Asian doctors are six times more likely than white doctors to be disciplined by the General Medical Council (GMC). The advisory board of the British Medical Journal has only one ethnic minority doctor.

3. Discrimination in disciplinary procedures

The 1996 PSI study Handling Complaints Against Doctors, which was commissioned by the GMC, found that 29% of complaints made to the GMC were against overseas qualified doctors. However following a screening process that passes complaints onto the preliminary proceedings committee the figure rose to half. By the time it reached the professional conduct committee, 58% of all cases involved doctors who qualified overseas. The study concluded that while there was no evidence of 'overt discrimination…an absence of bias cannot be demonstrated beyond all reasonable doubt'.[8]

Dr Aneez Esmail is a Manchester GP who has been at the forefront of exposing inequalities within medicine. He points out that if you look at cases that are based on hard evidence, like improper prescribing, there is no difference between the number of white and ethnic minorities being accused. However when there is a discretionary aspect, such as a failure to visit or indecent behaviour, differences crop up. 'Ethnic minority doctors get accused of indecent behaviour but white doctors get accused of improper relationships. It is like saying ethnic minority doctors are unable to form a relationship with their patients, even an improper one.'[9]

4. Discrimination in appointments

The bias against ethnic minorities is manifest in other areas of the health service. A survey of membership of Health Authorities showed that in 1992 there were no ethnic minority chairpersons of Regional Health Authorities and just 1.4% of other members were from ethnic minorities.[10] A 1993 BMJ editorial stated: 'That NHS boards do not reflect the racial composition of their local communities is unsurprising, given that people from ethnic minorities are rarely appointed to public positions. Recruitment is likely to follow the well-established pattern of recruiting in one's own image and those responsible for these appointments are usually white'.[11] Hence, it is not surprising that while more than 26% of hospital doctors at the time were from ethnic minorities, they made up only 5% of the Consultant committee, 4% of the General Medical Council and 1% of the BMA Council.[12]

5. Discrimination in diagnosis

Further bias can be seen in the way that patients are dealt with. Afro-Caribbeans are three to six times more likely to have schizophrenia diagnosed than white people and are over-represented among patients compulsorily detained in psychiatric hospitals, despite the fact that levels of schizophrenia in the West Indies are much lower.

According to one study, when the intervals between the onset of angina symptoms and consultation for coronary angiography are compared, patients of Indian origin (matched for age and extent of disease) are seen later than white patients.

As stated in a recent BMA news review, 'There are so many different aspects to racism in the NHS. Part of the problem with doctors is just that very old, established systems are exclusive, and ethnic minorities appear to be more excluded than others.'[10]

The Bible and race

Whilst there have been Christians throughout history who have been guilty of racism, the Bible teaches that there is no hierarchy of races.

The image of God, which gives humankind its special dignity, is bestowed equally on all human beings (Gn 1:27) - and Adam and Eve, symbolising the entire human race, are together given the mandate to 'fill the earth and subdue it' (Gn 1:28). Likewise the whole human race is subject to the effects of the Fall as a consequence of rebellion against God (Gen 3:22,23).

According to the Bible, the different 'nations' (or rather 'people-groups' - not to be confused with 'nation states' which are often multiracial in composition) originated after the flood at the time of the tower of Babel (Gn 11:1-9). Up until this time the whole world had a common language (11:1) but after Babel, God confused their languages so that they could no longer understand each other. Human beings were scattered over the whole earth (11:8,9) 'according to their lines of descent, within their nations' (10:32). God then determined for each nation 'the times set for them, and the exact places where they should live' (Rom 17:26).

God's choice of Israel as his chosen people was not because of any particular merit or superiority on their part (see Dt 7:7,8). Their special status was because they were to be the means by which God was to bring 'salvation to the ends of the earth' (Is 49:6) through the death and resurrection of Jesus Christ. God's plan from the beginning was to 'gather all nations and tongues' to 'come and see (his) glory' (Is 66:18).

This is why the picture in Revelation of God's saved people is one of 'a great multitude from every nation, tribe, people and language' (Rev 7:9). God 'accepts men from every nation who fear him and do what is right' (Acts 10:34, 35).

These principles underlie Paul's teaching that in Christ 'there is no Greek or Jew, circumcised or uncircumcised, barbarian, Scythian, slave or free' (Col 3:11).

Whilst it is true that as a consequence of sin we live in a world where some races dominate others (just as men dominate women - see Gn 3:16 & 9:24), the standard for God's people is to have the attitude of God himself - treating all races as equal.

The Bible tells us that God 'loves the alien (immigrant)' (Dt 10:18). 'This is the basis of his command 'The alien living with you must be treated as one of your native-born. Love him as yourself…' (Lv 19:34). The people of Israel were forbidden to oppress and mistreat immigrants living with them (Ex 23:9). Justice was not to be perverted (Dt 24:17,18).

Miriam, the sister of Moses, was struck for seven days with leprosy for rebelling against Moses because she was unhappy with his marrying an Ethiopian woman (Nu 12). Jesus' parable of the good Samaritan shows how the love of God crosses racial boundaries (Lk 10:25-37) and in the story of the sheep and the goats giving help to 'strangers' was a mark of righteousness (Mt 25:31-46).

The fundamental reason that God's people must treat aliens with respect is that God's people are themselves 'aliens and strangers' on earth (Heb 11:13; 1 Pet 2:11).

How should we respond?

Armed with the knowledge of what God expects, what should we do?

It is important first that we look at ourselves. It is easy to tell ourselves that we have no prejudice, be it racist or otherwise, within us. The word racism is an ugly word and understandably we do not like applying it to ourselves. The Bible tells us, however, that our hearts are deceitful and desperately wicked (Je 17:9), and therefore we need to be humbly prayerful, that God will show us if we have prejudices within us. If and when we find them, we need to confess them and repent of them.

Are we excluding people from our friendship groups on the basis of their culture or cultural behaviour and expression? Is our CMF group or Christian Union open and welcoming to people of different cultures and backgrounds?

We can also give tacit assent to racism by letting it go unchallenged. Racist jokes need to be pointed out for what they are. Ignorant attitudes need to be countered and discriminatory behaviour needs to be challenged. Racism and prejudice are often not seen as issues that can be dealt with in the CMF or CU, however there is no reason why we should not recognise and challenge these issues from a Christian point of view. Inviting a speaker to talk about racism within medicine may attract people to CMF who would often not normally come and also give opportunity for Christians to find out about an issue they often think is far removed from them.

Positive practice is also needed. We need to find out about the cultures of those around us: our friends, people in our CMF groups, our colleagues and people in our church. It can be interesting and fun to find out about foods, language, dress, country, or even worship style. At the same time we will diminish our prejudices as we begin to understand each other better. Our CMF groups and CU's can hold international evenings, as an introduction in Freshers' week, or even as a part of evangelistic outreach; thereby giving people a chance not only to come and hear the gospel, but also to come and find out about the new cultures in their midst.

Bringing change in society

Society is beginning to change. The BMA has now recognised the problem and its racial equality working party is taking an active role in the government's tackling racial harassment in the NHS initiative.

The GMC also seems serious about tackling its embarrassing statistics. Sir Donald Irvine, the GMC president, has suggested that revalidation could tackle the issue of racism.[10]

Dr Sam Everington, an East London GP, who has performed a number of studies into racism within the NHS, puts forward suggestions that applications should be anonymised for name and medical school. He believes that positive discrimination would be a mistake but suggests that:

'We need to celebrate difference and bring people together in recognising the positive aspects of cultures…'

He advocates the overhauling of recruitment panel information to ensure appointment is on grounds of merit:

'…human resources heads should be given a greater role in the process of selecting doctors to ensure peer selection does not degenerate into jobs for the boys'.[10]

Society is beginning to change but this is an issue where Christians need to set an example both individually and as a group. We have the standard which God has set for us. We should now live up to it so that society recognises and works towards that standard too. As a previous article in the Journal of the Christian Medical Fellowship asks; should not CMF be at the forefront of bringing God's standard of treating those of different race to the attention of the profession?

  1. Macpherson W. The Stephen Lawrence Inquiry. Report of an inquiry by Sir William Macpherson of Cluny. London: Stationery Office, 1999
  2. Collier J. Tackling Institutional Racism. BMJ 1999;318:679
  3. McManus IC, Richards P, Maitlis SL. Prospective study of the disadvantage of people from ethnic minority groups applying to medical schools in the United Kingdom. BMJ,1989;298:723-6
  4. McManus IC. Factors affecting likelihood of applicants being offered a place in the United Kingdom in 1996 and 1997:retrospective study. BMJ 1998; 317:1111-1117
  5. Esmail A, Everington S. Racial Discrimination against doctors from tethnic minorities. BMJ 1993; 306: 691-2.
  6. Esmail A, Everington S. Asian doctors are still being discriminated against. BMJ 1997;314:1619
  7. Esmail A, Everington S, Doyle H. Racial discrimination in the allocation of distinction awards? Analysis of award holders by type of award, specialty and region. BMJ 1998;316:193-195
  8. Allen I, Perkins E, Witherspoon S. The Handling of complaints against doctors. Report by the Policy Studies institute for the Racial Equality Group of the General Medical Council. London: Policy Studies Institue, 1996
  9. Wafer A. Racism on our own doorstep? BMA News Review 1999;26-27 (May)
  10. Jewson N, Mason D, Bourke H, Bracebridge C, Brosnan F, Milton K. Changes in ethnic minorities membership of Health Authorities (1989-1992). BMJ 1993;307:604-5
  11. Dillner L. Ethnic Composition of NHS Boards. BMJ 1993;307:1295-6
  12. BMA Report. Call for Action on Racial Discrimination in Medical Schools. BMJ 1993;307:134
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