Racial equality in mental healthcare
In a recent study from the USA, it was reported that healthcare professionals use disproportionately high negative terms to describe black patients’ behaviours in comparison with white counterparts (Special Report: Racism and Inequities in Health Care for Black Americans).
Written by Dinesh Bhugra
Studying electronic health records of over 18,000 patients, researchers found that over half (56%) of the cases indicated that stereotypes of race and gender persisted. Three-fifth of patients were black and they were 2.54 times more likely to be described with one or more negative descriptions in the electronic health records compared with white patients. Although the data was collected from a single centre and in the middle of the pandemic, the negative connotations allocated to black patients are striking.
In some ways this is a surprising finding and in others it is not. When I first started training in the late 1970s, often patients were described by their physical appearance and behaviour. Case notes would describe patients as ‘this pleasant overweight lady’ or using terms such as ‘NFN’ (‘Normal for Norfolk’), which were used routinely and nobody ever thought that these could be seen as derogatory. As decades passed attitudes changed and our entries in case notes changed too, with no personal descriptions. But the description of black and ethnic minority patients are still tinged with stereotypes.
Numerous studies from the UK (and the USA) since the 1960s have demonstrated higher rates of psychiatric disorders in ethnic minority populations but also stigma and discrimination faced by these communities, which delays help-seeking and consequently leads to worse outcomes. Although some progress has been made in recognising racism and dealing with it in the work place and in service provision, there is a long way to go. Even with the pandemic raging, more black individuals were being stopped and parties in council flats were being disrupted and fined, whereas London’s SW1 was buzzing.
Racism is endemic in many institutions and simply arranging more training sessions to get rid of it is not enough. There have been endless books, papers and lectures on unconscious bias and how to reduce it, so why does it still persist?
We know that each of us carries at least one if not more prejudices – whether about sexual orientation, religion, diagnostic categories, race, ethnic minority status, or any other factor. Individuals often tend to place their own culture on a pedestal and look down upon other cultures. Why should this be so?
There are a number of explanations, but perhaps most important in my view is the issue of ‘otherism’. We create the other to justify, understand, recognise and differentiate our own identity. This makes it difficult, but certainly not impossible, to get rid of unconscious biases.
When a poor white man says that he does not have white privilege, is he both right and wrong because it depends upon where privilege comes from? It is probably a result of economic status, education, specific university or club but it also comes from a history of power and its inherent expectations.
People from ethnic minorities may have different ways of expressing distress and accordingly seeking help from different sources. It is incumbent upon the NHS and social services to ensure that community link workers, culture brokers and mediators are appointed to ensure authentic dialogue can exist between communities and mental health service providers. That is the only way things are going to change for the better and less stigmatising words be used.
Dinesh Bhugra is a trustee of SANE, and is the former president of the World Psychiatric Association and the Royal College of Psychiatrists