I remember being in a lot of pain during childbirth with my precious daughter. I had chosen and practiced meditation, so did not ask for pain relief until I was admitted for an emergency c-section. The midwife said to the consultant, “don’t’ worry she’s got a high pain tolerance.” Quite understandably focussed on other things, I never considered the throw-away comment. However, now, when I consider some of the misconceptions and stereotypes about pain thresholds in ethnic minority women, I feel anger and frustration.
It is well documented that people of an ethnic heritage often experience barriers to accessing health care, including mental health services. Whilst there is a plethora of evidence to support this, I am staggered when I am party to conversation with people who do not understand why we are still talking about ethnic health care inequalities.
Whilst poor socioeconomic status explains some of the health disadvantage experienced by many minority ethnic groups, it is far from the whole story. Interventions aimed at countering socioeconomic disadvantage in general – such as the early years investments advocated by the Marmot Review – may do little to improve the circumstances of minority ethnic people while structures of racist discrimination persist into later life.
Moreover, the effects of racism and social determinants of health are deeply intertwined. Racism both shapes social determinants of health and has its own effect on the health of ethnic minorities. It is a social construct that uses nationality, ethnicity or other markers of social difference to maintain, capture and justify the differential access to power and resources in society. Therefore, to understand race and health, we must understand the role of ethnicity and racism within modern societies. It is those everyday acts of interpersonal discrimination, implicit biases, cultural and structural racism that will, over time, lead to worse health outcomes, including higher rates of chronic diseases and lower life expectancy.
High wealth countries such as the UK have a very well-documented legacy of slavery, imperialism and colonialism. It is nonsensical to me therefore when questioned about the legitimacy of equality work. Surely, only someone with privilege would utter such words.
Let me take this one step further. What if you are from the Black LGBTQ+ community? What impact does this intersectionality represent in reality?
Health inequalities are commonly defined as differences in health status or in the distribution of health determinants between different population groups that are unjust and avoidable. Did you know that LGBTQ+ people experience disproportionate behavioural health struggles such as depression, anxiety, post-traumatic stress, substance use and suicidality, often in response to external and internalized stressors produced by an oppressive environment? Black LGBTQ+ people not only face these same mental health struggles, but their mental health symptoms may be further exacerbated and at times caused by structural forces such as racism, ethnocentrism and poverty. And as a racially marginalized people, they already face biased policies and systems as they try to gain access to housing, jobs, places of leisure and health care.
It is harrowing to learn that as Black people, their attempts to schedule a mental health visit with a new provider is less likely to be responded to! Further, access to culturally and racially competent mental health care is limited for Black LGBTQ+ people, with an existing mental health workforce that is predominantly white and insufficiently trained to conduct mental health sessions when topics of oppression and privilege are integral. Half of Black, Asian and minority ethnic LGBTQ+ people (51%) have experienced discrimination or poor treatment from others in their local LGBT community because of their ethnicity. Black, Asian and minority ethnic LGBTQ+ people are faced with the challenge of integrating two aspects of their identity, both of which are disparaged; many Black, Asian and minority ethnic LGBTQ+ people experience dissonance between their cultural/religious and sexual identity. Some feel pressure to minimise their cultural identity in LGBTQ+ spaces and their sexual identity in Black, Asian and minority ethnic environments.
I fear that the journey to social and racial justice will be a long and painful one. We must each take responsibility for what we think, feel and believe; question why we feel that way and, more importantly, speak out and act when that injustice is right in front of our eyes. Running away from or denying the truth does not change it being the truth. We must take an honest and critical inventory of the messages and ideas we have been taught over our lifespans, which are laced with implicit and explicit biases, be it racism, anti-LGBTQ+ prejudice, etc. We must examine our day-to-day behaviours that may contribute to the oppression of Black LGBTQ+ people. We must resist any inclination to conclude that we are already competent and doing good work, even if we are ourselves Black, LGBTQ+ or both. To commit to serving Black LGBTQ+ people is to examine our views and behaviours each day, and to view this examination as an ongoing process that never ends. No longer can we sit with perilous indifference.
We must evolve our health service in terms of our values, processes and who is involved in defining and redefining our culture. In serving Black LGBTQ+ patients, we must reframe the misconception to see to them as “at risk” and instead see them as “at promise” for a future of good health and well-being anchored in their own resilience and supported by our abilities as staff, providers and institutions to provide services to contribute to their resilience.
The 2015 National Institute of Economic and Social Research (NIESR) report found that the existing evidence base points to LGBT people being more dissatisfied with health services in comparison to those who are not LGBT. This was supported by a further report in 2016 which found that many health care managers and teams did not consider tackling ethnic health care inequalities to be part and parcel of their job.So, it begs the question, whose ‘job’ is it?
Notes
Ahmad, W and Bradby, H (2007) ‘Locating ethnicity and health: exploring concepts and contexts’, Sociology of Health & Illness, 29, 6, pp.795–810. http://wrap.warwick.ac.uk/633/1/WRAP_Bradby_Locating_ethnicity.pdf
Nazroo, J Y (2014) ‘Ethnic inequalities in health: addressing a significant gap in current evidence and policy’, in ‘“If you could do one thing...” Nine local actions to reduce health inequalities’, British Academy: London
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Karla Parker is Head of Business Improvement within the Emergency and Elective Care Improvement team at NHS England and NHS Improvement. She has spent most of her career working in senior operational business roles within various public and private sector organisations including the media, education, the NHS, and social care. Karla is the Secretary of Haringey Borough Women’s FC, where she played, captained for 13 years and managed. She owns a residential property development business as well recently taking on a new role as a fragrance distributor with her 12-year-old daughter. Karla is passionate about nurturing the skills of children and young people and volunteers as a mentor.
In her spare time, Karla likes to write on her blog, experiment with new recipes to varying levels of success and keep fit.
Racism and inequity is a public health crisis. Thank you so much Karla for this post!