The blank page
I’ve been thinking that I should write something related to our dialogue on race for a while, but not really known how to start. A very patient and good friend has suggested that perhaps I could write about white privilege, which is of course something which should be in my sphere of awareness as a white person. Taking the plunge and putting words to paper as someone with no personal experience of racism, and as an individual who has no expertise in the area, has seemed a little daunting, if even a little insulting to those who have spent years researching racism, and to those who have lived with racism as part of their life. But the ability to stare at this blank page, begin to write a few words, cross it out, and walk away, is, in a way, an example of that privilege. I don’t have to think about race, I don’t have to frame my own life through that specific window, and I don’t have to make the effort to do any reading or try to write something on this as a topic. But for those who have experienced racism, this isn’t a ‘topic’: it is life. It therefore seems that no matter how inexperienced I am or lacking in the right words, if we want to truly share in that life with our colleagues and loved ones while promoting good care for our patients, it shouldn’t matter how clumsy the words feel if we accept that there are effects of such privilege which we would personally wish were otherwise.
What is white privilege?
There are various definitions of white privilege, but a quick Wikipedia search suggests it as “implicit or systemic advantages that people who are deemed white have relative to people who are not deemed white; it is the absence of suspicion and other negative reactions that white people experience”(Wikipedia ascribes this definition to Neville et al 2001) (1). Of course there are those who debate whether this concept really exists, or whether by focusing our attention on difference, this only seeks to further drive division in society or promotes some sort of self-fulfilling prophecy of disadvantage for future generations. Only last week, conservative MP Kemi Badenoch suggested in parliament that teachers who present white privilege as fact rather than a “contested political idea” should be considered to be breaking the law, and that the (until now) previously less widely discussed concept of ‘critical race theory’ is “an ideology that sees my blackness as victimhood and their whiteness as oppression” (2). These comments came in the context of a debate during Black History Month but on a background of increasingly polarised conversations and the view that the Black Lives Matter movement is ultimately too “political”. There is also criticism of the concept of white privilege within the anti-racist movement itself where it has been argued that by focusing on ‘privilege-checking’ at an individual level alone, this ignores wider systemic change needed to produce a more equal society: Momtaza Mehri writes that “the language of white privilege obscures systemic inequality by reducing it to individual actors” (3). But setting aside whether we believe that such concepts should be taught in British schools (I’m personally sure that if we gave teachers the correct resources, matters surrounding racism could be taught sensitively), or whether we believe that systemic political structures and policy decisions as well as individual behaviour have an impact on how we see race in our society (I personally believe that they do), all it takes is to consider the definition of white privilege to see how easy it might be to deny its existence by those that would prefer it didn’t exist.
In her bestselling book, Reni Eddo-Lodge explains that “it’s so difficult to describe an absence. And white privilege is an absence of the negative consequences of racism…reminding white people that their experience is not the norm for the rest of us. It is of course much easier to identify when you don’t have it, and I watch as an outsider to the insularity of whiteness”(4). For a white person to see an absence of suspicion and other negative reactions in their own experience might seem difficult: how could we be conscious of something which hasn’t happened to us? If we think of one definition of simple privilege itself as “an advantage that only one person or group of people has, usually because of their position or because they are rich”(5), it is easy to reflect on how those who possess greater material wealth than those who do not, have an advantage in society. It is even imaginable that those with privilege defined by material wealth might be able to look at others and see their own privilege because after all who can deny the existence of material possessions. But this does not mean that some with privilege see what they lack: the absence of feeling hungry, the absence of worrying about being able to afford school uniforms and the absence of worry about finding enough work for the week can only be seen by those with privilege if they are looking for it. This does not mean that those with privilege might not have been discriminated against on other grounds, or that they do not have other worries or struggles, but simply that these worries will not be determined by financial concerns (unless we count worrying about losing that wealth or being taken advantage of because of being wealthy!) So part of seeing, is actively looking for something which we lack and surely has to begin at the point of listening to those who have not experienced those absences.
How can it harm us to look?
There may be barriers to seeking understanding of how racism affects people with whom we live and work. The beliefs that things are not as bad now as once they were, that people should be judged on their individual merits rather than being defined by a group identity, and the view that identity politics and ‘culture wars’ are destroying democracy can all be used as reasons to avoid examining the impact of racism within our society. Fear of saying the wrong thing, difficulty in knowing whether an individual would want to speak about the topic or lack of awareness can all prevent a conversation being opened on an individual level. But ignoring the conversation completely means that this inevitably confines the matter of racism to not being spoken of at all. So how do we start that conversation? Thinking of the experiences of my own friends and colleagues, it doesn’t take me long to come up with a short list of some of their experiences of explicit racism that I have never had to encounter:
-I was never called a “paki” in the primary school playground but got told off for fighting back
-I never had a couple in a café move a table away from me and tell me that I could “go home now” the morning after the Brexit vote
-I have never been asked by a patient or family member if they could have a different doctor because they didn’t like the colour of my skin
-I have never had a medical student challenge me during a teaching session as to correct medical terminology because “we do not use that phrase in this country” despite being medically correct and in a senior position
-I have never been surrounded by three policeman and asked what my purpose was when sitting on a bench outside the medical school library waiting for lectures after someone reported me for looking suspicious
These instances probably don’t count as actively looking for something which I have not experienced as I have been lucky enough that my friends have shared these experiences with me. Even spending time with people of a different ethnicity does not always mean that I have an understanding of how my own race might confer some privilege. For example, I would never have thought to change the route of my evening walk because of being worried about how the colour of my skin would be interpreted, and I have never had to worry about forgetting shampoo when staying in a hotel because the products which are provided are not suitable for my hair. These latter experiences were those of my good and patient friend, but it is only when we have framed a conversation in terms of race that I would know about these experiences. I can only think of one instance where spending time with someone of a different skin colour alone has allowed me to immediately consider how whiteness might have an advantage: I have never been stopped by police on entry to the UK but witnessed it more than once when travelling with my Asian husband to be. So if it is difficult to be aware of privilege, then one way to increase that awareness surely has to include having a conversation with those with whom we work and those who we love about race.
But if having conversation is the vehicle to learn about such experiences, how does then being aware change outcomes?
The medical context-impact on colleagues and impact on patients
In his report “the snowy white peaks of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England”, Kline (2014) examines the impact of staff and Board diversity on the effectiveness of healthcare provision and how this relates to patient experience (6). The report highlights the absence of black and ethnic minority staff from senior roles within the NHS including at trust board level. This absence is disproportionate to the number of BME staff working within the organisation as a whole and number of BME patients living in the communities which the NHS seeks to serve. Kline comments on the lack of improvement and in many cases, decreasing representation at senior levels since 2008, but also on how this section of the workforce is “the most undervalued and least rewarded section of the NHS workforce” in more general terms where nationally, BME applicants were 3.48 times less likely to be appointed than their white counterparts despite meeting requirements demonstrated by being shortlisted. More specific analysis of London’s workforce found that BME NHS staff were “disproportionately found in lower grades”, were “treated less favourably in recruitment, promotion, incremental and performance awards and bonus payments”; were “more likely to experience bullying and harassment”; and were “more likely to face disciplinary action or be reported to professional regulators.” (The fact that there have been relative increases in BME representation at board level since 2014 (7) is not the end of the story given these numbers still fall short as a proportion of the total BME NHS workforce and given ongoing evidence of experiences of discrimination which BME staff report (8).)
Kline explicitly links these findings to the negative effect on NHS organisations, but also on patients, citing five ways that discrimination against black and ethnic minority staff can result in losing out for everyone. For example, “if BME staff are treated unfairly then it is likely to have an impact on morale, absenteeism, productivity and turnover” and that research shows that “the workplace treatment of BME staff is a very good barometer of the climate of respect and care for all within NHS trusts and correlates with patient experience” (6). Kline reports that there is a link between workplace team diversity and innovation even at board level, highlighting the possibility of missing out on harnessing the full potential of an organisation. Placing such observations in the context of the Francis report and the need for better leadership to create “a culture in which staff are more valued”(6) and also evidence which repeatedly shows that there are greater health inequalities for patients from BME backgrounds shows how urgent and important these findings are.
But how does this link to white privilege?
How can those at an individual level affect these statistics and how might they effect change? How might having an awareness of the advantage of being white translate into any positive action? I think some of the answer might be in what we perceive racism to be and how it is perpetuated: one would hope that all of us working in paediatrics would be against racism in principle, but would all of us recognise it when it is not in its most overt form? Kline reminds us of the Macpherson report which defined institutional racism as “the collective failure of an organisation to provide an appropriate and professional service to people because of their colour, culture, or ethnic origin”(6). But by focusing on a collective response alone, we can seek to be absolved of our individual responsibility if we do not also consider the next sentence: “It can be seen or detected in processes, attitudes and behaviour which amount to discrimination through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage minority ethnic people”. It is the attitudes and behaviour that we practice ourselves, and how we perceive and react to the attitude and behaviour of others which has to be the place to start. Even for those of us who have no influence on who is chosen for the Trust board, we do have influence over how we interact with our colleagues, friends and patients. Although systems of hierarchy still remain within medicine, even those at a junior level should be able to challenge what they see as discrimination if the appropriate channels are put in place. Such channels might even be initiated by having conversations such as these. But it is not as simple as just trying to be nice.
The blank page revisited
A personal lack of experience without seeking out the history of another’s experience may result in blissful ignorance. Simply learning about that history without trying to consider the underlying contributing systemic factors might result in lack of change, but unless we make a move to at least begin to listen to that experience, we will never define racism as a problem to begin with. Without seeing that problem, no change can occur. The blank page will remain white. I know I’ve not got everything right in these conversations so far, but I think I’m obliged to at least continue to try.
1. https://en.wikipedia.org/wiki/White_privilege (Neville, H., Worthington, R., Spanierman, L. (2001). Race, Power, and Multicultural Counseling Psychology: Understanding White Privilege and Color Blind Racial Attitudes. In Ponterotto, J., Casas, M, Suzuki, L, and Alexander, C. (Eds) Handbook of Multicultural Counseling, Thousand Oaks, CA: SAGE.
2. Wood V. Teachers presenting white privilege as fact are breaking the law, minster warns. Independent online, Wednesday 21stOcotber 2020. Available at: https://www.independent.co.uk/news/uk/politics/kemi-badenoch-black-history-month-white-privilege-black-lives-matter-b1189547.html
3. Mehri M. Anti-racism requires so much more than ‘checking your privilege’. Guardian online, Tuesday 7th July 2020. Available at: https://www.theguardian.com/commentisfree/2020/jul/07/anti-racism-checking-privilege-anti-blackness
4. Eddo-Lodge R. What is white privilege? In: Why I’m no longer talking to white people about race. Eddo-Lodge R. Bloomsbury publishing 2018. p.86.
5. Cambridge dictionary online: available at: https://dictionary.cambridge.org/dictionary/english/privilege
6. Kline R. The snowy white peaks of the NHS: a survey of discrimination in governance and leadership and the potential impact on patient care in London and England. Middlesex University Research Repository 2014. Available online at: https://www.england.nhs.uk/wp-content/uploads/2014/08/edc7-0514.pdf
7. NHS workforce race equality standard: 2019 data analysis for NHS trusts. NHS England 2020. Available at: https://www.england.nhs.uk/wp-content/uploads/2020/01/wres-2019-data-report.pdf
8. ‘A long way to go’: ethnic minority staff share their stories. Kings Fund July 2020. Available at: https://features.kingsfund.org.uk/2020/07/ethnic-minority-nhs-staff-racism-discrimination/
Please note-I have used the term BME in this post acknowledging that there are a range of views about whether this is a useful term or not. My decision was based on its use in the Kline report with the understanding that it can be criticised as a term of reference: this could be the subject of another post!
I would love to hear your views on your own experiences as paediatricians: what do you think about the concept of white privilege, what barriers are there to communication in our hospitals and how might things change? Do you have something on the topic of health inequalities or experiences that you would like to share? All comments and criticism are welcome.