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FAQs
Racism at work - a crime in anyone’s language” 1 The Civil Rights Act 1964 remains of the greatest achievements in United States (US) history. It had implications internationally, making racial discrimination illegal, but its effectiveness in the employment domain remains contestable 2. The worldwide existence of workplace racism has attracted controversy and this is drawn out by psychiatry’s attempt to understand the nature of the problem 3. Discrimination at work, based on a person’s race, comes in different guises and can have negative consequences on both individuals and organisations 1. Despite legislation to protect individuals substantial progress needs to be made to eradicate the problem.
What is racism?
The Civil Rights Act 1964 remains of the greatest achievements in United States (US) history. It had implications internationally, making racial discrimination illegal, but its effectiveness in the employment domain remains contestable 2. The worldwide existence of workplace racism has attracted controversy and this is drawn out by psychiatry’s attempt to understand the nature of the problem 3. Discrimination at work, based on a person’s race, comes in different guises and can have negative consequences on both individuals and organisations 1. Despite legislation to protect individuals substantial progress needs to be made to eradicate the problem.
What is racism?
The concepts of “race”, “ethnicity” and “racism” are explained in figure 1.
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Figure 1: Definition of race, ethnicity and racism 4, 5 |
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Race |
The group a person belongs to as a result of a mix of physical features, ancestry, and geographical origins, as identified by others or, increasingly, as self-identified. The importance of social factors in the creation and perpetuation of racial categories has led to a broadening of the concept to include social and political heritage, making its usage similar to ethnicity. Race and ethnicity are increasingly used synonymously. |
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Ethnicity |
The group you belong to as a result of a mix of cultural factors that include language, diet, religion, ancestry, and race. |
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Racism |
A belief that some races or ethnic groups are superior to others, used to devise and justify actions that create inequality between racial groups. |
Racism is a social process associated with “overt and covert forceful establishment and maintenance of power by one social group over another” 3.
Racism can be seen as a misuse of power and, even today, power relations are signified by subtle cultural rules that perpetuate racial inequality 6.
What are the origins of racism?
That some races are superior to others has origins from the 19th century 5. The history of racism has stimulated considerable debate in understanding racism.
Racism may have origins in experiences derived from, what is known in analytical psychology as, the collective and personal unconscious. The personal unconscious arises from the lifetime experiences of the individual.
This is distinct from the “collective unconscious” which psychiatrist Carl Jung described to represent a form of the unconscious common to mankind as a whole and originating in the inherited structure of the brain 7. This contains inherited primitive cultural and racial elements. Both the personal and collective unconscious, made from our individual and ancestral experiences respectively, may account for the manifestation of racism in society today.
In recent times the experience of overt racial bigotry and prejudice is seldom seen 8. Nevertheless, discrimination against members of a social group may persist because it is so deeply entrenched within society, by the personal and collective unconscious, that it becomes the automatic response even when no conscious intent is present 9. “Everyday discrimination” is the discreet, pervasive discriminatory acts experienced by stigmatized groups on a daily basis 10, and highlights the modern perspective that racism is subtle.
“Like a virus that has mutated, racism has evolved into a new form that is difficult to recognize and harder to combat” 8
As blatant forms of racism become extinguished, particularly in the current climate of political correctness, unconscious racial biases in subtle forms, known as ambivalent or modern racism 10, are appearing. This has been referred to as aversive racism occurring in people who possess strong egalitarian values, and who believe they are not prejudiced, but have negative racial feelings and beliefs that they are unaware of 8. These feelings and beliefs are rooted in the normal psychological processes of social categorization, satisfaction of basic needs for power and control, and socio-cultural influences 8. The ambivalence involving positive and negative feelings creates a psychological tension that leads to an inconsistent pattern in their behaviour 8.
The cumulative effects of unpredictable and seemingly trivial behaviour such as avoidance of ethnic minorities, closed and unfriendly verbal and non-verbal communication, and failure to provide assistance, is more damaging 10. Apparently harmless interactions, including racist assumptions and questioning about where somebody is from, also convey messages about marginality and not belonging 11. This subtle racism may contribute to the racism perceived by minority groups in higher status professions and organizations.
Does racism exist in healthcare organisations?
“American Medical Association apologizes for racism in medicine” (10th July 2008) 12.
This admission by the American Medical Association, of racial discriminatory practices against African-American physicians, reflects the recognition of racism in other western countries.
In the United Kingdom (UK) racism has been revealed in public institutions such as the metropolitan police 13 and widely reported in the nursing profession 14,15 within the National Health Service (NHS). Trevor Phillips, chairman of the Equality and Human Rights Commission, referred to the “snowy peaks of the NHS” 16 with a large number of ethnic minorities at the base. Less than 10% of senior managers and 1% of chief executives are from ethnic minority background 17.
There is a “glass ceiling” 18 preventing promotion and black and minority ethnic (BME) managers feel they have to work twice as hard and have twice as many qualifications to succeed 19.
Since 2000, after a survey commissioned by Department of Health (DOH) reported that half of front-line NHS BME staff had been victims of racial harassment in the previous 12 months 20, reports of racism in healthcare have increased. In 2001 a Kings Fund report, “Racism in Medicine” 21, generated powerful debate after finding that bullying and discrimination were a daily fact of life for black and Asian doctors. Then in 2003 a British Medical Association (BMA) survey revealed that in ethnic minority doctors, who form nearly one third of the NHS workforce 22, more than 80 per cent believed that their ethnicity had a negative effect on their career advancement 23. In 2004 the Royal College of Psychiatrists accepted that racism existed in the NHS and in their own institution 24.
How does racism manifest itself in medicine?
“Discrimination can appear to be hidden when it is institutionalized, although it is not usually hidden from the person who is subjected to it” 3
Institutional racism is “the collective failure of an organization to provide an appropriate and professional service to people because of their colour, culture and ethnic origin” 13. Health disparities among patients have been widely linked to racially biased discriminatory health practices 25, 26, 27 but how do structures, processes, and values within an organization discriminate against those working in the medical profession?
There is considerable evidence to indicate that discriminatory practices against doctors evolved from medical school. For instance racial discrimination has operated at the time when students applied to study medicine 19, 28, through short-listing based on whether applications had Asian or English names 29, 30, and with downgrading of non-English names by computer 31. Discrimination has also been reported during medical school in the US and Canada 11. UK ethnic minority medical students also perform poorly in examinations compared to white students 32, 33 although the lack of evidence of explicit discrimination may suggest the involvement of more subtle communication styles and cultural differences 33.
If the problems at medical school are accountable by racial organisational processes it is not surprising that discriminatory practices persist after qualification (figure 2)
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Figure 2: How BME doctors may experience racism 17, 19, 34, 35, 36 |
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Bullying and harassment |
More likely to experience bullying and harassment. |
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Recruitment and career advancement |
More likely to be over-represented in junior grades. Reduced promotion and career advancement also seen in relation to academic careers. Underrepresented in senior leadership positions. |
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Disciplinary hearings |
Over-represented at disciplinary hearings with nearly a third of complaints coming form other health professionals. |
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Disciplinary action and dismissals |
Six times more likely to be disciplined e.g. in 2006 two thirds of the 54 doctors struck off in UK had trained outside UK. |
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Reward systems |
Disadvantaged in the allocation of discretionary grants and NHS distinction awards. |
What are the consequences of racism in healthcare?
“Racial discrimination damages both those discriminated against and those doing the discriminating” 37
The cost of workplace racism is that it acts as a chronic and acute stressor on the individual with a range of consequences (figure 3):
“Racial fatigue” characterizes the potential emotional and psychological sequelae of feeling isolated in a work environment in which race regularly influences behaviour but is consistently ignored and nobody wants to discuss it (“racial silence”) 40.
Racism may be underreported for the same reasons seen with workplace bullying: fear of making matters worse, belief that nothing will be done, concerns regarding confidentiality, fear of victimization, and concern about being labelled as a troublemaker 41. In addition the individual may fear being regarded as having a “chip on one’s shoulder”.
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Figure 3: Consequences of racism on an individual 1, 10, 38, 39 |
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Psychological |
Poor well-being. Loss of confidence. Humiliation. Low morale. Gives a sense of thwarted aspirations. |
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Physiological |
Increase blood pressure. Physical illness. |
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Behavioural |
Bad work performance. Require time off work. |
Organisations may also suffer with disharmony at work, high sickness levels, and resignation 1. In medicine this results in the “double loss” of a speciality losing highly motivated people and gaining those where enthusiasm may be low 19. In addition, victims of racial discrimination in healthcare may pursue legal action. In 2003 a surgeon won over £600,000 42 after being denied entry to the specialist registrar. Another surgeon successfully sued the BMA for more than £800,000 for racial discrimination after it failed to support his own claim against the DOH 43. In another case a UK trust paid £2.5m, including legal costs, for wrongful dismissal of a consultant obstetrician who was investigating discrimination 44.
What can be done if you are experiencing racism at work?
In the UK there is protection by legislation. It is unlawful to discriminate against anyone on racial grounds. The Race Relation Act 1976 defined three types of discrimination (direct, indirect, and victimization) 1, 45,. Following this was the setting up of the Commission for Racial Equality (CRE) in the UK to tackle racism and promote racial equality 45. The Race Relations Act 1976 has now been superseded by the Race Relations (amendment) Act 2000 46 that requires public bodies to eliminate discrimination, promote equal opportunities, and ensure good race relations. However legal processes are stressful and there are some steps you can take before pursuing this route (figure 4).
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Figure 4: Steps to take if you are a victim of racial discrimination 1 |
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Talk to colleagues and friends who may have suffered a similar problem because it helps to share a problem and trying to cope on your own can be particularly stressful. |
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Keep a diary of events of who said what, when, circumstances and any witnesses – this will give a vital record of the nature of the racism. |
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Find out whether your employer has specific rules about racism |
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at work or a grievance procedure you can use to raise a problem. |
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If you are in a union contact them to assist you with talking to management or approaching the perpetrator. |
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In the UK the Commission for Racial Equality is a national body that can help victims of racial discrimination. |
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Your local Citizens Advice Bureau or Law Centre may be able to help. |
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You may want to talk to a private law firm that specialises in discrimination issues. |
Recommendations and Conclusion
“The law may be just but its implementation is another matter” 47
Despite legislation and procedures, to address racism at work, healthcare organisations are slow in introducing and supporting the policies for race equality 18. Suits come to legal action, not for a lack of policy, but because of not being enforced 48. Practice is not synonymous with policy 19. Reinforcement of policies depends on the degree to which upper management understands discrimination and harassment 48. Although implementation of policies could be successful in combating overt racism this is not so for the covert form.
The covert form of racism, as in institutional racism where organisational processes are “unwittingly” enacted 13, suggests that racism is inevitable. Even people with strong motivations to avoid it are subject to automatic cognitive activation of stereotypes, which can unconsciously influence behaviour, making diversity training courses and non-discrimination policies relatively ineffective 10. Attending to, and encouraging the reporting of, the “softer” aspects of racism may be the key to establishing a true “positively diverse climate” 10. New forms of racism require new approaches (Figure 5)
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Figure 5: The STEEP model to approaching subtle racism in organisations 8 |
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Structured Support |
Visibly supported by senior management. |
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Training and Education |
Educate people about subtle bias and training to recognise it. |
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Experience |
Frequent and constructive interracial contact to decrease bias, enhance group cohesion, and increase productivity. |
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Personal Commitment |
Individuals must be committed to recognise and combat subtle racism. |
The most important part of the solution is education. Teaching on racism should be incorporated into the undergraduate and postgraduate curriculum 19. However of greater significance is recognising our own personal prejudices, at an early stage, so that prejudices we all harbour are challenged within ourselves.
“The hardest attitude to change is the one you don’t know you have” 8
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KEY POINTS – RACISM: |
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Is associated with power and superiority |
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Has evolved from an overt to a covert form |
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Is commonplace in healthcare organizations |
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Is manifested at each stage of a doctors career |
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Has implications for individuals and organizations |
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Can be partly dealt with through policies and legislation |
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Requires a new approach to eradicate the problem |
Useful UK online resources
Competing Interests: None Declared
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