Book
Acknowledgements
Contents
Introduction
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
Chapter 10
Chapter 11
Index
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INTERNAL COLONIALISM - II
HEALTH AND OTHER SCHEMES TARGETING BLACK PEOPLE IN BRITAIN
The health of black people
GENERAL REMARKS. MORBIDITY AND MORTALITY
‘Issues in Race and Education’(1) had this to say, in 1983, about health care delivery to Britain’s racial minorities:
“In a racist society, society’s response to the health problems of minority group members is likely to be racist. There are differences of degree, of course. The National Front uses health issues in an overtly aggressive and propagandist way. The state, in patrolling its borders at Heathrow, uses health as a means of intimidating new arrivals and barring entry to Britain. The medical profession makes erroneous and damaging assumptions based on notions of cultural superiority and ignorance: less vindictive in motivation, perhaps, but not necessarily less damaging, in effect, on the victim”.
Over the years, since the first large post-war waves of immigration, Britain’s racial minorities have not been absorbed into the native working class, but have continued, instead, to remain as a reserve army of labour, an underclass, in a state of persisting social, economic and political internal colonialism. In this the experience of black people in Britain has been different from that of other ethnic groups who have made their homes in Britain, such as the Jews, the French Hugenots and, latterly, the Poles, other East Europeans and the Hungarians. Although some would view racial subordination and exploitation in economic class terms, race and racism cannot be explained fully through class analysis. It is through the model of internal colonialism that caste and racism, ethnicity, culture and economic exploitation can be integrated into an overall conceptual scheme (2).
Racist oppression is akin to national oppression and cannot be viewed simplistically and wholly in terms of the class struggle, although it interrelates with it. As ‘OCTOBER’ puts it (3):
“The conjuncture of class struggle can no longer validly be analysed or understood by looking at the internal economic workings or social formations of a specific society but must be studied at the global level of the imperialist system. Defining racism in terms of the function performed for the domestic imperialist economy loses sight of the fact that racism developed as, and still remains, the ideological concomitant of imperialism’s oppression of nations. For national minority people in this imperialist society, racial oppression is the highest and most vicious form of national oppression”. The model of internal colonialism, further, includes the common historical experiences that are shared by Britain’s subjugated racial minorities. Classical colonialism and racism developed out of the same historical situation and reflected a common world economic and power stratification. Despite the variation in political and social structure, classical colonialism and internal colonialism developed out of a similar set of technological, cultural and power relations. There is a common process of social oppression characterizing the racial patterns in the two contexts. Colonialisation involves a relationship whereby members of the colonised group are administered by representatives of the dominant power and managed and manipulated by outsiders in terms of ethnic status. An important component of colonialism is racism.
Blauner(4) defines racism as a principle of social domination by which a group seen as inferior or different in terms of alleged biological characteristics, is exploited, controlled, and oppressed socially and psychically by a superordinate group. In his first analysis of the inner city ghettos, Clark(5) saw the ghettos as the consequence of the imposition of external power and the institutionalization of powerlessness and described them as social, political, educational and economic colonies within which subject peoples are confined, victims of the greed, cruelty, insensitivity, guilt and fear of their masters. Clark went on to describe the inner city ghetto, moreover, as a powerless colony whose divided political leadership was short-sighted and dependent upon the larger political power structure. Its social origins are financially precarious and dependent upon sources of support outside the community. Programmes and policies are very often supervised and determined by individuals who do not live in the community.
Speaking of the American inner city ghettos, Marable(6) had this to say:
“The scientific justification for the gradual eradication of ‘marginal’ ethnic groups has been growing for two decades...............What is qualitatively new about the current period is that the racist/capitalist state has proceeded down a public policy road which would inevitably involve the complete obliteration of the entire Black reserve army of labour and sections of the Black working class........(Market economics) must, if it intends to succeed, place the onerous burden of unemployment on the shoulders of the poor so securely that the middle to upper income groups will not protest in the vicious suppression of this stratum.
“Unlike classical fascism, (new Rightism) must pursue its policies without publicly attacking Blacks............What white people have never fully understood
-but what the black can never forget - is that white society is deeply implicated in the (inner city) ghetto. White institutions created it, white institutions maintain it, and white society condones it........With....the political collapse of white liberalism, the direction of the political economy and social hierarchy is veering toward a kind of subtle apocalypse which promises to obliterate the lowest stratum of the (racial) poor......The genocidal logic of the situation could demand, in the not too distant future, the rejection of the ghetto’s right to survival in the new capitalist order. Without gas chambers or pogroms, the dark ghetto’s economic and social institutions might be destroyed, and many of its residents would simply cease to exist”.
One is reminded of the near total disintegration of the black community in Britain itself, within two generations of Emancipation, a fact that has already been referred to, in Chapter 2.
The racial minorities in Britain are over-represented in the working class (partly as a result of downward social mobility). The 1981 Labour Force Survey (Central Statistical Office, 1983) demonstrated, in addition, high rates of unemployment for minorities from the New Commonwealth and Pakistan. In the post World War II expansion of the British economy, these immigrants came to fill the gaps in the labour market caused by the upward movement of the indigenous (white) workers themselves. With the contraction in the economy that began in the late sixties, the jobs of the immigrants (i.e. the reserve army of labour) were the first to be declared redundant.
In its evidence to the Royal Commission on the National Health Service in 1977, the Community Relations Commission, London, the statutory body which was the predecessor of the Commission for Racial Equality, London, said that: “......the 1971 Census shows that nearly three-quarters of the ethnic minority population is concentrated in one-third of the census enumeration districts, in which they constitute over one-fifth of the total population. When these (highest) 10% of enumeration districts are compared with others on indicators of deprivation, it is found that they contain nearly three times the mean, for Great Britain, of households who share or lack hot water, twice as many who share or lack a bath, nearly three times as many living at a density of over 1.5 persons per room (the statutory overcrowding level) and nearly four times as many households lacking exclusive use of all basic amenities”.
The multiple disadvantages suffered by racial minorities in Britain are reflected even in the few statistics that have been published on the health status of black people in the country. Studies of the mortality of (black) immigrants(7) show high figures for deaths from the stress related illnesses and diseases associated with social disadvantage and deprivation.
Mortality from tuberculosis is higher in immigrants from the Indian subcontinent, but surveys have shown that there is strong evidence that the majority acquired the disease as a result of the poor and overcrowded housing conditions in Britain’s inner cities (8). Tuberculosis is the illness per se of social misery. Mortality ratios for hypertension and stroke are strikingly high in immigrants from the Caribbean and Africa with a four to six fold increase in hypertension and a two fold increase in stroke. To a lesser extent, the mortality from these conditions is also high in Indian immigrants. This difference is much greater than the social class differences in England and Wales. Among immigrants from Africa, hypertension is particularly common among the Africans, with ischaemic heart disease common among the Indians (9). Mortality from diabetes is high among immigrants born in the Caribbean and in the Indian sub-continent. Among the latter, ethnic Indians have much higher mortality ratios than the ethnic British born in India. There is a suggestion that the mortality ratio for diabetes is also high for immigrants from Africa.
Whilst maternal mortality is low in England and Wales, a high maternal mortality is observed in immigrants from Africa, the Caribbean and, to a lesser extent, the Indian sub-continent. Department of Health and Social Security (DHSS) reports suggest that a majority of these deaths are avoidable. Accidents and violence are major causes of death, particularly at younger ages, and mortality from these causes is high in almost all immigrant groups. There are high death rates from motor vehicle accidents and from fire. Mortality from nephritis and chronic infections of the kidney are high in immigrants from the Caribbean, Africa and the Indian sub-continent (10). Balarajan et al.(ll) showed that, in immigrants to England and Wales from the Indian sub-continent, the observed mortality due to infective and parasitic diseases, endocrine diseases (notably diabetes), diseases of the circulatory system (notably ischaemic heart disease and cerebro-vascular disease, in males) and diseases of the digestive system (notably cirrhosis of the liver) exceeded the expected mortality.
In the late seventies, long after primary immigration from the New Commonwealth had ceased (the Immigration Act of 1971 had seen to this), the British ruling class were, nonetheless, paranoid about what they felt was a threat of Britain being, in the words of future Prime Minister Margaret Thatcher, “swamped” by increasing numbers of black people. It is not surprising, therefore, that the state and its servants have directed most study and research on that aspect of immigrant health which permits easy penetration into, and surveillance over, the immigrant family. It is also that aspect of health which has to do with the immigrant family at its most vulnerable. This is the research in, and study of, immigrant perinatal and maternal morbidity and mortality.
In an analysis of ethnic influence on stillbirths and infant mortality in Bradford, England, during the period 1975-1981(12), large differences in mortality between the Asian and non-Asian population were found. There was an excess mortality associated with congenital abnormality in the Asian population. In this analysis, it was discovered that there was a mortality rate associated with congenital abnormality of 12.4 per 1000 total births in the Asian population compared with a figure of 4.8 per 1000 in the non-Asian population.
In an analysis of ethnic differences in perinatal statistics carried out at the Dudley Road Hospital Maternity Department in Birmingham, England(13), it was found that, although a high proportion of Indian mothers fell into the low risk group based on age and parity, they, nonetheless, had the highest stillbirth and perinatal mortality rates (15.1 and 27.5 / 1000 respectively as compared to rates of 8.2 and 13.5 / 1000 respectively in Europeans). Congenital malformation rates were highest in the Pakistani and Bangladeshi groups (29.6/1000 and 32.6/1000 as compared with 21.6/1000 for Europeans). The authors concluded that the ethnic origin of the mother was apparently an important factor in perinatal mortality.
In a report on ante-natal services in the West Birmingham area, which includes the Dudley Road Hospital Maternity Department, the West Birmingham Community Health Council(14) stated that some Asian women were very unhappy both with their own personal care as well as with other aspects of care, and several disturbing references were made to hospital clinic staff “shouting” at non-English speaking women. The report goes on to quote a Pakistan-born woman whose baby was later born dead and who had this to say about the hospital’s antenatal clinic and maternity department:
“The nurses do not treat the patient properly, they shout at you and say, “Why did you get pregnant again?” After you have the baby, they don’t help you. They shouted at me when I was pregnant last time (with previous baby) and say I should not have a baby due to my diabetes - but I know I only get diabetes during pregnancy. As I have said before, the nurse and the doctor shout at me and treat me like dirt”.
In a further report from the English Midlands County of Leicestershire (15), it was shown that Asian patients had a significant excess risk of perinatal death (one and a half times) when social class, parity, height, legitimacy, and the general practitioner’s qualifications were taken into account. Lumb et al.(16) showed that the perinatal mortality rate for Asian babies born in Bradford during the five years 1974-78 was persistently higher than for babies born to United Kingdom mothers (32/1000 for Indian/Pakistani babies as compared to 21/1000 for English babies). In a report from London on the perinatal mortality rates of babies who were delivered at St Thomas’s Hospital, it was stated that the perinatal mortality rate in the West Indian population was significantly higher (between 1.4 to 4.3 times higher) than in the United Kingdom white population. The report went on to say that the excess West Indian perinatal mortality could not be explained completely by differences in the proportions of stillbirths and early neonatal deaths, nor by the distribution of deaths by parity, maternal death, or social class.
The explanations given by the medical establishment for the higher perinatal figures in Asians and West Indians vary from alleged deficiencies in the community health services and in the life-styles of immigrants, through cultural, religious and social differences, to poor uptake of ante-natal services by the racial minorities, and the vegetarian diets of some of them. No mention is made of the racism of the medical and nursing staff that is the cause of the poor uptake of health services; instead, Asians are expected to accept and utilize the existing facilities (17).
The Court report strongly criticised the country’s failure to maintain statistical parity in infant mortality with other countries and especially with France, Sweden and Japan, but then went on only to speak vaguely of the need for better services.(18)
Patton, the Medical Officer for the London Borough of Haringey (one with a large black population) in an article in 1978 (19) suggested that even when reasonable community health services were offered, as shown by the success of the native English mothers with their babies, there were some immigrant groups that were likely to fall behind; but as opportunities for care and appreciation of the baby by its own mother increase, so does the prospect for survival. In a fit of nationalistic fervour, he went on, “Good maternal care has helped our species to survive through centuries of war, famine and disease”. He reflected that the mother’s nationality could be an indication of the life-style of her immigrant group and the effect of that life-style on the quality of her maternal care. Patton went on to discuss differences in life-style without any reference to the social and economic context in which ‘immigrant’ groups have to live and bring up their families.
As Torkington states(20), when describing the situation in an inner city area in Liverpool: “......the experience of black people within the National Health Service and, particularly, in the Liverpool area is the result of a complex of discriminatory factors ranging from race, class and sex, to cultural differences, geographical location, etc. But in our view, the overriding factor in the overall experience of racial minorities is racism within and outside the health service”.
The placing of blame on the individual or the culture of origin, now well known as the strategy of ‘victim-blaming’ is another form of social control employed by the British state. In this scenario, the state is relieved of the onus for action to correct the situation. The responsibility to take the necessary measures is transferred to the individual thus absolving the state of any obligation in terms of financial expenditure or changes in the social and economic structures.
Referring to the futility of many aspects of the Government’s health education programmes, Donovan(21) had this to say: “People do not perceive that their traditional diets and family patterns are primary causes of their ill-health -the actions of the state and the class system are much more obviously involved”. Writing in 1984, Johnson(22) stated that the significant issue of racism, both in practice and in society, had not been seriously analysed in the mainstream of professional literature. There was little recognition of the significance of racism and the role of ‘overseas’ or ethnic minority medical staff for the health care of Britain’s ethnic minorities.
Torkington(23) describes an incident that illustrates this point. During 1981-82, the Merseyside Chinese Community Service employed a bilingual nurse and, in the six months following this, there were 213 requests for interpretation for visits to hospitals, clinics, health centres and surgeries. The Chinese Community Service recommended the appointment of a Chinese-speaking general practitioner to be based in Nelson Street, an area with a large Chinese population. An application from a Chinese doctor, however, was rejected by the Family Practitioner Committee.
STATE SPONSORED HEALTH CAMPAIGNS AND SCHEMES AIMED AT THE RACIAL MINORITIES
As a service (and as an employer, many would add) the NHS has never catered to the multi-racial society that Britain is today (24). Health authorities claim that their inaction is the result of a lack of resources and, instead, finance ‘soft’ areas of health care such as the production of health education leaflets in association with publicity campaigns like, for example, the Anti-Rickets Campaign and the Asian Mother and Baby Campaign, which are of little value to ethnic populations, but which serve the purpose of diverting attention from the deeply entrenched racism at all levels within the health service itself. Furthermore, a considerable amount of resources is expended in maintaining the machinations that are necessary to perpetuate, conceal and legitimate the racism in the caring services.
Three such campaigns which have been canvassed within the NHS in the last few years will now be described for the purpose of illustrating the convoluted workings of a racist system. They are the Anti-Rickets Campaign, the Asian Mother and Baby Campaigns and the advocacy-interpreter schemes. These schemes/campaigns play a further role in that they offer employment to de-skilled black health workers; the deskilling of black workers is an important aspect of the underdevelopment of Britain’s black internal colony.
THE ANTI-RICKETS CAMPAIGN
This is an illustration of how the British state re-invented the wheel in regard to ethnic minority health care. In 1965, an article in the Scottish Medical Journal(25) drew attention to the high incidence of rickets in Pakistani children in Glasgow, where rickets had been rife in native children in the pre-World War II years, but had been eradicated as a result of preventive health measures and improved overall living conditions in the post war years. In the late thirties, attempts to eradicate the disease by campaigns to educate the public towards better eating habits and to raise the level of awareness to the high incidence of rickets did not bear much fruit and so the government, at the beginning of the war, took to fortifying with vitamin D such foods as dried milk, cereals and margarine. Parents were encouraged to give young children supplemental vitamin D, and rickets as well as its ‘adult’ form, osteomalacia, was virtually eradicated in Britain.
Vitamin D is necessary together with calcium and other essential nutrients for normal bone formation. Rickets is due to insufficient Vitamin D which results from an inadequate diet or insufficient exposure to sunlight. Because of the lack of Vitamin D, the absorption of calcium (and phosphorus) from the food in the small intestine is reduced. Calcium is not deposited in bones and the calcium that is already present in the bones may be withdrawn. The growth disc at the growing end of a bone produces abundant cartilage but this cannot be converted to bone. Bone formation and bone growth are reduced and the soft bones bend. The adult form of rickets is called osteomalacia (literally ‘bone-wasting’) and, in this condition, there is a loss of calcium from the bones due to an absolute or relative lack of vitamin D or calcium. It may follow pregnancy or gross malnutrition. Natural foods rich in vitamin D are eggs, diary products and fish.
In the late fifties and early sixties, rickets and its adult counterpart, osteomalacia, began to be diagnosed with increasing frequency. It was also felt that there was a high incidence of the sub-clinical forms of the two diseases that could cause low-grade ill-health. The state’s response to this must be seen in the context of societal relations in Britain in the seventies and eighties. Although, in the post-war period, black people in Britain had been resisting racism as early as 1954 (26), when in a small street of terraced houses in Camden Town, West Indians fought back against racist thugs throwing petrol bombs, whilst the police remained largely indifferent, resistance against institutional and state racism sharpened in the sixties and seventies culminating in the nationwide rebellions of 1981.
To soften the impact of its own racism, the state employed a ‘carrot and stick’ approach to the black community in the imperialist heartland. The ‘carrot’ was a new feeble Race Relations Act with the avowed aim of securing rights for black people, although with institutional racism in the judiciary, tribunals and every other sector of human endeavour, the outcome has been anything but equal for Britain’s black population. The ‘stick’ was a series of, increasingly racist Immigration Acts aimed at legalising and perpetuating the second class status of the black British. This was reinforced by the institutionalization of a whole series of racist practices in employment, health and education that was to incarcerate whole communities in an underclass.
With black people increasingly resisting their oppressors, the state, now anxious to present a human face showing a caring concern, came out with a series of interventions in the health sector. Alas for the state, the response from its black citizens has been increasingly critical.
The Anti-Rickets Campaign was launched by the Department of Health and Social Security (DHSS) in February 1981 ostensibly to deal with the problem of rickets (and osteomalacia) in the Asian community; it completely ignored the smaller, but nonetheless definite, increase in the incidence of the disease amongst the white population, especially amongst the white elderly. The campaign literature declared that the high incidence of rickets among Asians was due to their lifestyle and their inadequate diet, ignoring again the fact that the average Asian diet more closely approximates the ideal diet than the average British diet does.
The reason why white youngsters do not get rickets is because some of the regular constituents of their diet (e.g. margarine) are fortified with vitamin D, and margarine is not eaten, to any great extent, by many Asians. When it was suggested to the DHSS that a common constituent of the Asian diet (e.g. chappati flour) be fortified with vitamin D, the DHSS rejected the proposition (27), arguing, speciously, that there would be a risk of overdosage.
The Anti-Rickets Campaign literature also stated that the long dresses of Asian women prevented the sun from reaching their skins and thus decreased the amount of vitamin D synthesized in the body from precursors in the skin. The reality of the situation is that many Asians living in high-rise blocks of flats do not see much of the sun, are prevented from walking about freely in the open because of the very real fear of racist attacks, and often sit at home with the curtains drawn so as not to attract the attention of fascist thugs. After all, it was Lloyd-George, a former British Prime Minister, who, describing the dank and overcrowded slum conditions amongst which many of the industrial working class lived, said that “while the sun never sets on the British Empire, it also never rises on many a working class home”.
All that is needed to prevent rickets and osteomalacia in Asians is the addition of a small, safe, and easily calculated amount of vitamin D to the Asian diet (e.g. chappati flour) and then give supplemental doses, as indicated, to the high-risk groups e.g. children and lactating mothers. After all, this is what happens within the white community in Britain. But the whole Anti-Rickets Campaign gave the British state the opportunity, or, at least, so it is thought, of pathologising Asians and their culture (especially the Asian diet, Asian mothers and Asian clothes) by portraying these as somewhat inadequate and in need of being rescued by caring white institutions and concerned white professionals. The whole scheme backfired on the DHSS as Asian organisations were quick to point out the multiple fallacies in the DHSS’s arguments. In the face of hostility from the Asian community, the scheme soon fizzled out.
THE ASIAN MOTHER AND BABY CAMPAIGN-SECOND CLASS HEALTH CARE FOR ASIANS
The relatively high perinatal mortality amongst the black communities in Britain gave the state the opportunity for a second bite at the cherry. It is well known that because of the racist attitudes of health service personnel there is a poor uptake of services by the black communities and this poor uptake extends to certain ante-natal services. The state decided to intervene a second time in Asian health care with a further propaganda campaign.
The Asian Mother and Baby Campaign (the A M and B Campaign) was nicknamed the “son of the anti-rickets campaign” by civil servants in the Department of Health and Social Security (DHSS). The government’s stated reason for launching the Asian Mother and Baby Campaign was to facilitate communication between Asian mothers and health service personnel. The increasingly serious racial discrimination in the employment of black health workers, sanctioned, by default, through the indifference of Parliament and the government and by the racism of the Industrial Tribunals and of the judiciary, had seriously depleted the National Health Service of skilled black workers by the early 1980s. This has been discussed at some length in a previous chapter. This campaign was intended to counter increasingly vocal charges of racism in both employment and service provision in the health service, and to do this by introducing a new black contribution at the lowest level in the staffing hierarchy of the NHS. This new black contribution was composed of ‘linkworkers’.
The Asian Mother and Baby Campaign was launched in Birmingham in December 1984, by the then Minister for Health, Kenneth Clarke, with 11 linkworkers working in ante-natal clinics and hospitals in Birmingham. At the outset plans were made for similar schemes of linkworkers to be launched in Leicester, Bradford, Blackburn and Bolton, areas with large Asian populations.
An early leaflet from the Campaign(28) declared that its aims are to publicise, and improve the accessibility of, ante-natal care for Asian women. The Campaign, whose headquarters are at ‘Save the Children Fund’ offices, is a partnership between the government, ‘Save the Children Fund’, the Health Education Council (now reconstituted as the Health Education Authority and under increasing government control) and the health authorities. The linkwork scheme was described as a new approach towards attempting to break down the communication barriers between Asian mothers and health professionals in ante-natal clinics. Although there were already a small number of linkwork schemes in operation, the Asian Mother and Baby Campaign scheme was admittedly the first to be funded by central government. The founding of the Campaign, it was stated, was taken as a clear recognition of the problems created by the language and cultural barriers between health professionals and Asian mothers.
Aware of the reduction, through racist practices, in the number of skilled black health workers in the National Health Service over the previous decade, the Campaign claimed that linkworkers in each area have to be far more than interpreters. They have to be active facilitators between health professionals and patients, bridging language differences, interpreting non-verbal signals, and attempting to allay any anxieties and apprehensions that the mother may have. It was hoped to help improve service delivery to mothers, and to relieve the ‘frustrations’ felt by many health professionals. Training would comprise theory (given by the Campaign’s trainers themselves) followed by practical training to be given by health professionals. The training programme would cover communication skills; the background and working of the National Health Service, including the maternity services; self-awareness in relation to the role of the linkworker; and race awareness training (for black health workers). A code of conduct defined the boundaries of the linkworkers’ responsibi1ities.
Much valuable information has been left out of the Campaign’s voluminous literature. There has not been a single word on the widely acknowledged racism in the health services. As Torkington says, “........the overriding factor in the overall experience of the racial minorities is racism within and outside the health services” (29). Furthermore, these linkworkers, who are Asian, are poorly paid; their pay is only slightly better than what their (unemployment) supplementary benefit would be. They are usually recruited from the ranks of the unemployed and they are given temporary, although possibly renewable, contracts. (The Campaign’s Asian director herself moved to the Asian Mother and Baby Campaign from the Anti-Rickets Campaign when that all but fizzled out.) All this is hardly calculated to give the linkworker a sense of job security or even job satisfaction as she, together with the Asian patients she hopes to help, from a position of insecurity, poverty and powerlessness, daily faces the powerful, the knowledgeable, the wealthy, the self-assured and the racist.
Black organisations have repeatedly stated that the way to help overcome “the problems created by the language and cultural barriers between health professionals and Asian mothers” (to use the Campaign’s own words) is certainly not to exclude skilled black workers from all levels of the health service, and then to introduce, at the lowest level of the health service, a new black dimension, consisting of underpaid, unqualified, insecure, health service ‘domestics’, to compensate for the former.
The current status of the campaign is that it is being promoted in low key as the Department of Health and Social Security takes note of the opposition to it from Asian organisations. The Campaign has been criticised by a committee of the Council of the London Borough of Brent, and events to promote it have been picketed by representatives of Asian organisations in London. In answer to queries from the public, the Health Education Council/Authority, one of the promoters of the Campaign, says that it no longer keeps any promotional literature on the Campaign.
HEALTH ADVOCACY SCHEMES
These schemes are locally based and promoted by certain Community Health Councils (CHCs). The Community Health Councils were constituted after the 1975 reorganisation of the National Health Service in response to criticisms that the NHS was undemocratically managed by health service administrators. It was intended that the CHC should function as a locally based consumer watchdog in regard to the local health authority. The CHC itself is not democratically elected; instead, its members are chosen partly by the local authorities in the area of the health authority and partly by local voluntary organisations. It does not have any formal power, only the right to be consulted on the operations of the local health authority. In practice, most CHCs have only a limited impact on the health service locally and what was hoped would be an influential and vocal consumer watchdog “has evolved into a system of licensed health campaigners employed by the NHS” (30).
The health advocacy scheme is in many respects similar to the Asian Mother and Baby Campaign which it preceded and has now partly superseded. It says nothing about the exclusion of skilled black workers from the NHS, but vigorously promotes the admission of unqualified, unskilled, low-paid, temporarily hired and often part-time racial minority workers into the lowest ranks of the health service. Not surprisingly, the CHC that most fiercely supports the health advocacy scheme, and this support is often voiced in the less conservative sections of the medical press, is the City and Hackney Community Health Council (C and H CHC), the consumers’ ‘watchdog’ for the City and Hackney Health Authority. This health authority serves the City of London, the centre of British finance imperialism, as well as the neighbouring London Borough of Hackney, the most deprived borough in all England. This health authority also manages the, by now, infamous St Bartholomew’s Hospital (founded 1123), the racism of which is known throughout the land(31) and where generations of medical students, were told “White children are born; black children are bred” (32).
The City and Hackney Community Health Council’s (C and H CHC’s) own advocacy scheme is called the Multi-Ethnic Women’s Health Project (MEWHP). According to its sponsors (in 1984), this project is an extension of the C and H CHC’s work into the non-English speaking community, and also into patient advocacy for individual users of the maternity services(33). In 1985, the C and H CHC declared that, although the project was developed to work with non-English speaking women, it was obvious to them, from the experience that had been developed in this one area, that the principles could be extended to other groups of users of the health service (34).
The C and H CHC states that it had been concerned, since 1979, about the way that ante-natal care was being delivered and, in particular, the manner in which the needs of non-English speaking women were being met, and wondered as to how the services might be improved. The C and H CHC felt that their inability to present their problems and their lack of knowledge of the system made these women particularly vulnerable to bad care. The C and H CHC thought that the options open to it in regard to this problem were:
- Formalising and improving the list of volunteer interpreters from amongst the staff.
- The employment of interpreters.
- The employment of staff from the relevant ethnic groups.
- The employment of (unskilled) health workers to work as patient advocates, offering their help to patients as they come to hospital.
The C and H CHC rejected the first three options and plumped for the fourth (35). The reason given by its secretary was that the C and H CHC had taken on as a model the patient representative scheme in the inner-city ghettos of the United States. The scheme in Hackney would, according to the C and H CHC, employ local women (from the racial minorities, who had not been trained) as health workers - whose job it would be to “speak up” for women who were unable to speak up for themselves, to advise women on the options of care available to them and to negotiate with the doctors, midwives, appointment clerks and catering staff on their behalf (36).
When the project was commenced at the Mothers’ Hospital in Hackney, (white) hostility to the scheme was taken out on the multi-ethnic workers as the presenters of the patients requests, and had racial overtones (37).This was the predictable outcome to schemes of this nature that had been foretold by black organisations. How a group of low-paid, intimidated, unskilled, untrained racial minority persons could, as the C and H CHC expects, “speak up” for their fellow women against powerful white professionals and other skilled employees in a situation saturated with racism is something that continues to astonish black organisations in East London.
During the year, 1985-86, despite repeated requests from representatives of black organisations on Hackney Council’s health committees, the City and Hackney Health Authority (and, indeed, the borough’s health consumer watchdog, the C and H CHC), were unable to supply a simple ethnic breakdown (a head count) of the health authority’s workforce, contrary to the DHSS directive ( HC (78) 36 ), dated October 1978, and still current, and the Commission of Racial Equality’s Code of Practice (approved by Parliament in 1984). These figures, if they had been made known, would have confirmed the health authority’s racist employment practices referred to.
ATTEMPTING TO CONTROL THE FERTILITY OF BLACK WOMEN
In the late seventies, the British state was obsessed with the ‘numbers game’, viz., calculating the number of black people already resident in this country and, from this, attempting to work out figures projected for the end of the century using unreliable and suspect methods of calculation. Mrs Margaret Thatcher, leader of the Parliamentary Opposition and later Prime Minister, voiced the feelings of many on the Right when she said in 1977: “The British character has done so much for democracy in the world that if people feel that they are going to be rather swamped by those (black immigrants) coming in, then they are going to become rather hostile”.
But the state was even more obsessed with the fertility of the black women already in Britain. Stories abounded in the media on the alleged excess utilization of maternity beds by black women and on the supposedly large size of immigrant families. It was felt that something had to be done to reduce the fertility of those women already in the country. Large numbers of different leaflets in various Asian languages were produced urging families to have fewer children. Black women were offered abortions and sterilization much more readily than white women (38).
Gould(39) believes that sterilization has long been regarded by some in Britain as “a proper means for preventing the birth of children, who, though not perhaps unwanted, would possibly be second-raters, particularly in the matter of their intellectual capacity, and who would thus be ‘a burden on society, and who, even more importantly, would themselves give birth to inferior citizens, and so contribute to the erosion of the quality of the ‘genetic pool’, or the excellence of the human race....”. Gould goes on: “.........(if) allowed to proceed unchecked, the progenitiveness of the unfit will lead us all to destruction. Adolf Hitler was wedded to this idea”.
Depo-Provera is an injectable long acting contraceptive and is given every three months. Banned in the United States, it is widely used in the Third World. It has been suggested that half of all prescriptions for Depo-Provera in Britain were made out for black women (40). British gynaecologists feel that Asian women are not subject to press publicity and are, therefore, much more receptive to Depo-Provera than women who have been subject to the adverse publicity about it. At the time when it was widely prescribed for black women, gynaecologists were otherwise recommending it only for short term interim contraception, for example before vasectomy becomes effective or after rubella vaccination. Its side effects are heavy bleeding, especially when given to women in the immediate puerperium; ‘transient’ infertility and irregular menstrual cycles may occur after discontinuation of treatment. Some studies have demonstrated an increased incidence of cancer of the neck of the womb. Black people are of the opinion that the use of Depo-Provera fits into the pattern of the British state’s plans for increasingly co-opting the caring services into a corporatist strategy for the exercise of social control.
THE INCREASING USE OF HEALTH CARE IN SOCIAL CONTROL:THE 1982 HEALTH REGULATIONS
New health regulations came into effect in October 1982 and taken together with the 1981 Nationality Act and other institutional practices will further incarcerate black people in the status of second class citizens. The new health regulations permit free health care only to those who are ‘ordinarily resident’ in the United Kingdom, and residency tests may be imposed, in this regard, on patients in the NHS. Some black people are excluded from free treatment on the grounds that they are not ordinarily resident in the United Kingdom. As Mrs Gwyneth Dunwoody, a one time Labour Party spokesperson on health, said, in a speech in the House of Commons, on 6 July 1982 “The immigrant community in this country nay be forgiven for regarding this as yet another extension of internal immigration controls”.
The Manchester Law Centre reported: “........the only way (the new health regulations) can be enforced is by investigating the immigration history of everyone who applies for treatment - precisely to see if they are “ordinarily resident” in the United Kingdom” The Centre states its belief that the health services are implicate in the abuse of black people, not only those black people who are temporarily or permanently living here, but also those who intend, for one reason or another, to come to Britain (41).
As people can be prevented on health grounds from coming into this country, the question of health is used as an excuse for immigration control. There is now a direct link between the Home Office and (via the Department of Health and Social Security) local hospitals. The hospitals use the link to find out whether a patient is “ordinarily resident” and, therefore, entitled to free treatment, and the Home Office may get to know if a person is here legally or not, and, if not, that person could be deported. The Manchester Law Centre report cites examples of persons ordinarily resident in the U.K. not only being refused NHS services, of one kind or another, purely on racial grounds, but also, in other cases, being subjected to the most blatant racist abuse by NHS personnel (42).
THE ROLE OF HEALTH IN IMMIGRATION CONTROL
In the health control of immigration, some members of the medical profession were not acting as doctors in the sense that they were not providing care or treatment but, instead, were solely involved in the enforcement of immigration control. In addition to doctors working as Medical Inspectors at ports of entry in Britain, some medical persons abroad in the immigrants’ home countries were requested to act as Medical Referees and to subject people to medical examination before departure. Even if persons abroad have been cleared by the medical referees there, they can still be stopped by the medical inspectors here in Britain. The relevant regulations here are the DHSS Circulars, ‘Advice to Medical Referees in Connection with Immigration from the Commonwealth and Pakistan’ and ‘Instructions to Medical Inspectors DHSS Circular A/12/22’. The remit of the medical referee or medical inspector is to determine whether an intending entrant is likely to become a liability on the state. Blocks to entry into Britain can arise with senility, mental abnormality, or conduct disorder (e.g. alcoholism, drug addiction, or sexual deviation).
On 1 February 1979, ‘The Guardian’ reported that vaginal examinations (‘virginity tests’) were being performed on some Asian women entering Britain. The reason for this, said the Home Office, was that proof that a woman was not a bona fide virgin would show that she was not really a fiancee and was lying in order to gain entry into the country. The following is an account of the degradation inflicted, on a 35-year old Indian woman, on her arrival at Heathrow Airport, as told by herself:
“I was sent, for a medical examination, by immigration officials. A woman told me to take all my clothes off. I was given nothing to cover myself with - no dressing gown or blanket, although I had asked for one. I waited like that for twenty minutes. Then a male doctor came in. I asked to be seen by a lady doctor, but they said “No”. I was most reluctant to have the examination, but I did not know whether that was normal practice here. So I signed the consent form. I was frightened that otherwise they would send me back.
“The doctor was wearing rubber gloves and took some medicine out of a tube and put it on some cotton wool and inserted it into me. He said he was deciding whether I was pregnant now, or had been pregnant before. I said that he could see that without doing anything to me.
“I have been feeling very bad mentally ever since. I was very embarrassed and upset. I had never had a gynaecological examination before”.(43)
Government ministers then admitted that such examinations had been carried out in the past. The Home Secretary told Parliament that immigration officers had on occasion asked the medical inspector for his opinion as to whether a passenger had borne children (44). However, the examination of passengers to establish whether or not they had borne children or had had sexual relations was discontinued and appropriate instructions were issued to entrance clearance officers at posts overseas. Information as to how often such examinations had taken place, and who had authorized them and at what level, though, was not forthcoming (45).
Following this, the government asked its Chief Medical Officer at the Department of Health and Social Security, Sir Henry Yellowlees, to investigate the subject of gynaecological examinations for administrative purposes by the Immigration Service at Heathrow Airport. In his report “The Medical Examination of Immigrants”(46), Sir Henry skirted the question of ‘virginity tests’ and instead argued for stricter controls on immigration to prevent the entry of those who might endanger the health of other persons, or “for medical reasons, place an undue load on the public purse”. The report dealt with ‘virginity tests’ in only one paragraph, stating that Home Office instructions, that they be discontinued, were being followed. An Asian woman who first revealed that ‘virginity tests’ were being carried out at Heathrow Airport was then offered financial compensation by the Home Office on the condition that she would not sue.
In addition, ‘The Guardian’ of 8 February 1979 stated that X-ray examination for administrative purposes, i.e. for age estimation, itself a most dubious procedure, was being carried out by medical referees on the Indian sub-continent. Women in Bangladesh were being X-rayed to determine age and identity and, in one instance, reported ‘The Guardian’, a pregnant woman had been X-rayed. In Western countries, such an examination would only be carried out under the most dire medical necessity.
Following these revelations, instructions were issued in October 1979 that bone X-rays should not be used in assessing the age of adults, but only of those under the age of 21. However, in its Appendix I, para. 5, the Yellowlees report concluded that the use of X-rays of the bony skeleton provided a useful, fairly accurate and acceptably safe way of estimating the age of children when it is important to do so. In 1982, the Home Secretary announced that the use of X-rays to determine age were being discontinued on the grounds that they were unlikely to provide more accurate evidence of age than the assessment of physical characteristics (47). In the final year of their use, nearly 700 children had been X-rayed on the Indian sub-continent (48). However, X-rays for other non-medical purposes are still being performed indiscriminately.
Medicine has, as we have seen, served as a form of internal immigration control in other ways. In 1976, nearly 200 Asian women attending a Leicester ante-natal clinic were asked to produce their passports; one woman who refused to do so was refused treatment. After protests, the practice was halted. In 1979, though, the Department of Health and Social Security issued a circular entitled ‘Gatecrashers’ which advised health authorities that they had a part to play in ensuring that “the principle of eligibility” for treatment was adhered to and that only those who were “ordinarily resident” in Britain were eligible for free NHS treatment. If hospital staff doubted a patient’s eligibility for treatment, they could properly ask for further evidence, including passports, to enable them to resolve the doubt, although this had to be done sensitively (49). In 1982, the government introduced a scheme for charging ‘oversea visitors’ who sought treatment under the health service, justifying this move by claiming that the system of free treatment in the NHS was being abused by people from overseas, although there was, in fact, no evidence of such abuse. In practice it is only those patients who are black or with foreign-sounding names who are subject to questioning as to their eligibility for treatment.
Although medical controls on immigrants have been part of the country’s system of immigration control, their significance lies in their role of providing further legitimation for the system. Medical controls give the impression of being based on the scientific judgement of objective facts rather than on mere political considerations. A British Medical Association (BMA) campaign based on its report, ‘The Medical Examination of Immigrants’ (50), argued that the purpose of the medical examination was two-foldmedical (to minimise the spread of infection) and economic (to prevent a drain on the state welfare and health services). It is clear from the BMA report that its authors were as much influenced by racism and economic arguments as they were by health considerations. Comparing British immigration policies with those of other countries, the BMA report went on: “Immigrants to the United States, Australia and New Zealand are, for the most part, of European stock. They are, on the whole, drawn from the more literate and developed countries of the world” (Para. 29) whilst, on the other hand, a policy of free entry for Commonwealth citizens carried obvious health risks to the indigenous population (Para. 125), forgetting that the Commonwealth immigrants were coming from countries that had, until recently, been ruled and progressively underdeveloped by an imperial Britain. The increasing use of medical controls and arguments opened the door to the use of medical techniques in situations where health was not in question, but for reasons that were administrative and political.
As Gordon states: “The issue of medical controls also raises the question of the relationship of the state to the medical profession and to medicine. As we have seen, the British Medical Association was a strong advocate of medical controls and played an important role, not just in the pressure it brought to bear on the government, but also in the effect it had on public opinion in that it supported, wittingly or not, arguments which had been put forward by racists, and supported them with a considerable weight of professional expertise. Medical science was consequently increasingly used both as a justification for the control of immigration and as a means of administering control” (51).
Raising important questions of ethics for doctors, the government’s Chief Medical Officer stated that a doctor working for the immigration service was acting as an agent of the service and was in a similar position to doctors employed as police surgeons or occupational physicians. Medical techniques and expertise are, in these situations, put to uses which are not medical at all, but administrative and political. In the present context of internal immigration controls in Britain, medical checks and medical techniques will be used not just to keep black people out of the country, but also, through deportations, to get rid of those already in the country.
As the Manchester Law Centre puts it, black people were encouraged to come here as workers to build the welfare state. However, as soon as they attempted to become consumers of the welfare state, demands surfaced to exclude them, and these demands were supported by the construction of a series of myths aiming to demonstrate that the immigrants were bringing disease and an alien way of life into the country (52).
PSYCHIATRY IN THE SERVICE OF THE STATE
The deep roots of racist thinking in the history of the disciplines concerned with human behaviour ensured a major role for psychiatry in perpetuating and reinforcing racist attitudes and practices in British institutions. With the institutionalization of racism, the oppression of black people was consolidated in every social substructure (53). Although the crude and blatant forms of racism in psychiatry have gone out of fashion, more subtle and sinister forms have surfaced. Whilst in the past, psychiatry focussed on individuals, its liberal practitioners have now transferred the onus for the pathology onto the individual’s culture. So, if previously the blacks and their genes were the problem, the liberal psychiatrists now view black culture as pathological (54). With the bias in the provision of mental health services to different ethnic groups in Britain, ethnic patients have been turning to private medical practitioners (55). However, Afro-Caribbean males are more likely to be admitted to psychiatric hospitals (56). Afro-Caribbean patients are twice as likely as whites to be detained involuntarily in hospital under Section 136 of the Mental Health Act 1959 (57).
A similar situation pertains to Asian-born patients in psychiatric hospitals in Britain. Black patients are more likely, than whites, to refer themselves to hospital as emergencies, but to default on booked attendances. They are also more likely to see a black member of the psychiatric team, to see a junior doctor, or to receive potent pharmacotherapy or electro-convulsive therapy, and they are less likely, than white patients, to see a senior member of the psychiatric team or to receive individual or group psychotherapy.(58)
Studies on black people usually focus on what is abnormal in their lives. This distortion is ubiquitous in the social and behavioural sciences. After living for two years amongst blacks in the United States, a Swedish anthropologist had this to say of the portrayal of blacks by white professionals: “........the image of the ghetto dweller becomes one of failure and impotence. It tells little about how he goes about life from day to day, coping with the people around him and with the problems in his mind” (59).
Thomas and Silien suggest that this lopsided emphasis on pathology, even when motivated by sympathy, results in dehumanization. Seen as a ‘victim’, the black man appears in the literature as a patient, a parolee, or a petitioner for aid, rarely as a rounded human being. It is not surprising, therefore, that the black community is fed up with being constantly researched by investigators who can see only the deforming marks of oppression (60).
Ellison adds that, although these sociological formulae are drawn from life, they do not define the complexity of life in the community. Besides the ruggedness of life, the hardship and the poverty, there is something subjective, wilful and “complexly and compellingly human” that white society and sociologists ignore and deny(61). Although poverty, poor housing and poor schooling have disastrous effects on the black community, it would be wrong to assume that black people are overwhelmed by the destructive influences of a racist society.
Ethnocentric attitudes in psychiatry result in incorrect diagnoses and the inappropriate disposition of black patients. The criteria for psychiatric diagnosis and classification are often taught in an abstract, generalised fashion that omits cultural considerations. It is more likely that as psychiatrists take more of an interest in the social experience of racial minority patients, the diagnosis of schizophrenia will become less common and be replaced by that of ‘situational reaction’.
In the sixties, a shift of emphasis and outlook occurred in psychiatry. “Culturally deprived” became a code term for poor blacks, and poverty was discussed as if it were a personal trait rather than a social condition As emphasis is placed, on the psychological characteristics of the poor individual himself, there is a redirection of concern from overcoming the objective circumstances of poverty (which would be impossible in a capitalist society) to altering the attributes of people who are poor.
Implicit, in the concept of ‘cultural deprivation’, is the cult of ‘cultural inferiority’. Kenneth Clark wrote that just as those who proposed the earlier racial inferiority theories were invariably members of the dominant racial groups who themselves believed that their groups were superior so it is that those who now proppose the cultural deprivation theory are members of the privileged groups (62).
This ‘deficit model’ was explained by Bernstein, who found that class differences in modes of communication create dissimilarities between the cognitive functionings of poor and of privileged children. The low class family uses “restricted” language codes, whereas the middle class family uses elaborated structures. The restricted pattern is described as stereotyped and repetitive. The middle class child, on the other hand, is able to communicate more flexibly and precisely (63). McVicker Hunt declared that children in poor families lacked opportunities “to develop cognitive skills underlying competence with language and numbers"(64). The preoccupation with psychological deprivation detracts from those hardships that the poor are encumbered with, and that call for correction. Birch and Gusson have demonstrated the impact of poor health, nutrition and poverty on school failure and the intellectual potential of children. The same homes that lack toys and, games are the homes in which hunger and disease abound (65).
Many of the ideas that abound about the black family and its “tangle of pathology” have been imported from the United States. The Moynihan Report, “The Negro Family: The Case for National Action”, was issued by the U. S. Department of Labour in 1965. It compared the “approaching complete breakdown” of Negro families with the maintenance of a high degree of stability that obtains in white families. The false assumptions implicit in this report are, firstly, the concept that the white family is homogenous; and, secondly, that the “white family” whatever that means, is necessarily the model by which other families are judged.
The high divorce and illegitimacy rates do not support the concept that the “white family” is a “stable” unit. The Black Health Workers’ and Patients’ Group of London suggest that the concept of the “black family” is used to divide generations and to hold up one community as a negative reference point for another. The image and ideology of the bourgeois nuclear family is again held up as the universal and standard norm. British institutions compare the inward looking, “strong” Asian family with its arranged marriages, with the Afro-Caribbean family and its “lack of heritage”, now subject to endless pressure (66).
BLACK PSYCHIATRISTS
As psychiatry in Britain is a low prestige speciality, there are large numbers of junior psychiatrists from the racial minorities in the National Health Service psychiatric units and institutions. The opposite obtains in the U.S. where psychiatry is a fairly popular, and, more importantly, well-paying speciality. In 1975, in Britain, 19.1% of all consultants in mental illness in the NHS were from the racial minorities; in the U.S., in 1971, only 1% of all psychiatrists were black, (at 11.0%, the percentage of blacks in the U.S. population is double that of the non-European racial minority population in Britain). At the same time, the percentage of racial minorities at the registrar level of training in Britain (corresponding to the mid-residency training level in the U.S.) was 64.1%, whereas, in the U.S., the number of blacks in psychiatric training comprised only 2% of the total. (Blacks in the U.S. comprise more than 90% of the non-European racial minority population.) In Britain, the overwhelming majority of racial minority psychiatric consultants and juniors, in the NHS, are of Asian origin (67).
Racism operates in the staffing procedures in psychiatry as in the other specialities within the NHS, although not to the same extent, because of the unpopularity of psychiatry, as a speciality, with white British doctors. Even so, as the figures quoted above show, relatively few of those racial minority doctors who commence training in psychiatry finally end up in the permanent position of a consultant in a National Health Service hospital. On top of this, racial minority doctors are more concentrated in the even more unpopular speciality of mental handicap, and in less prestigious, service-orientated, non-teaching district hospitals. The pass rate of racial minority doctors in the psychiatrists’ specialist exams is half that of white doctors (68). As is the case with every other institution in British society, racism is reflected not only in the practice of psychiatry but also in the very manner in which the speciality is structured: white consultants, Asian junior doctors, black nurses and black domestics.
SOCIOBIOLOGY (the study of human social behaviour in biological terms)
As the little Englanders of post-Imperial, post-industrial Britain withdraw into the nationalist laager, there has evolved the new racism, a racism that depends on sociobiology and pseudoscience to justify and support calls for the repatriation of black people, even those that were born in the country, and for keeping Britain white. According to the new racism, there is an inherited predisposition for the members of any one racial group to unite against, and be antagonistic towards, members of any other racial group. Pseudoscience, in combination with a populist appeal referring to the alleged sentiments of “the ordinary person” and “the people of England”, is utilised to provide an intellectual justification for the new racism. Claims are made about human nature, that, for example, it is natural to bond together with those of a similar kind (69).
Barker adds that it is the use of the concept of instincts which gives the new racism the appearance of scientific validity in the context of particular aspects of biology, ethology and sociology (70). He then goes on to quote Robert Ardrey, a popularizer of the scientific claims of certain students of the science of human races, and a neo-Darwinist: “The biological nation..........is a social group containing at least two mature males which holds as an exclusive possession a continuous area of space, which isolates itself from others of its kind through outward antagonism, and which through its defence of its social territory achieves leadership, co-operation and a capacity for concerted action”. In his revolutionary theory of natural selection, Darwin postulated that organisms selectively survived through processes involving better adaptation to the enviroment in which they lived. These organisms then passed on the characteristics responsible for better survival in their genes to their offspring Over periods spread over millions of years, these changes accumulated, producing new and evolving species. These ideas do not, of course, take into account the concept and existence of society, in the context of which exists forms of co-operative behaviour as well as competition for resources.
By emphasizing theories of human nature and instincts, moreover, the new racism maintains that people react to societal situations in a manner pre-determined by their natures, and thus helps to defuse charges of prejudice and racism. What unites people of one kind is a shared way of life which brings them together in a nation. A shared way of life includes language, customs, beliefs, and feelings which add up to a shared culture. As black people are different, they do not share a way of life with white people and, therefore, cannot be part of the British nation.
The new racism defines human nature and instinct as not just bringing together people of the same ‘kind’, but also as making them hostile and antagonistic to others who they feel are different. Implicit in this argument is the notion that white society and culture is not just different from others, but superior to them. Although those who propagate the theories that go to make the new racism would deny, firstly, that they support racism, and, secondly, that there is such a phenomenon as institutionalised racism, the net effect of their pronouncements is to perpetuate state racism and to bring the fascist thugs out onto the streets.
RACE, CLASS AND HEALTH
From the data obtained from mortality and morbidity studies, together with that from local authorities and the education service, the inescapable conclusion is that the oppression of racial minorities could not be solely the result of their economically inferior class position. Racism is a product of class society, although race operates as an independent factor, and is not confined within the limits of economically based class relations.
The enforced incarceration of racial minorities within the lower socio-economic strata is the result of institutionalised racism and to consider separately the effects of class, e.g. education and technical skills, is wholly inappropriate. Racism has an effect separate from that of class and which is responsible for the greater oppression of racial minorities. This has been called the ‘double oppression of race and class’. Racism embodies categorically distinct political and social mechanisms (71).
The motivation for capitalism is profit and the accumulation of more capital. This is obtained through the exploitation of the worker, when the employer pays the worker less than the value of what he produces and keeps the rest, called the ‘surplus value’. In the process of superexploitation, such as obtains with racial minority workers in a racist society or with workers in the economically dependent peripheral capitalist countries of the Third World, massive profits are accumulated by capitalist employers (or the state) and by the multinational (transnational) corporations.
The disastrous results on the health of the worker is a reflection of the degree of exploitation of his labour and of the investment (or lack of it) in facilities for his health care.
In a racist society, differential pay for racial minorities is the cause, as well as the result, of inferior education, housing and social services. The health of these workers is further jeopardised through occupational diseases and accidents and more hours of work at greater intensity. The commodities produced by the need to maximise profit, and consumed in the ghetto, promote disease. The relations of class and race in a capitalist society produces physical and emotional violence at all levels. Racism lowers the standard of living of all workers and, although it is more intensely felt by the racial minorities, its quantitative effect is greatest on the majority working class. Racism is an essential element of the social relations of production in this country; it heightens the contradiction between labour and capital and throws into sharp relief the disease-producing character of the capitalist mode of production. Another contradiction is the promotion of mass disease among the workers: disease which is unnecessary, preventable and man-made.
Cooper et al(72) allege that at this period of intense structural crisis in the worldwide capitalist system, a necessary concomitant will be the tightening of political restrictions and an increased reliance on direct force as the primary means of social control. Racism, they suggest, will be the cutting edge of these developments. Far from a trend towards improved health care, there will be a move toward the other face of modern capitalism, fascism. The everyday treatment of minorities serves as a model for the institution of fascism, by making the use of violence by the state, and the conditions of superexploitation, acceptable. These conditions are proto-fascist and become generalised during periods of economic crises.
Finally, Cooper et al. conclude that the pervasive impact of these social and economic determinants of ill-health makes it imperative that a mass-based, multi-racial, militant social movement be developed to redress the injury to public health engendered by racism and to prevent the growth of the fascist movement. For the present, the single most important determinant of a person’s life chances is his race.
PROFESSIONAL DOMINANCE IN THE NATIONAL HEALTH SERVICE
Historically, health care delivery in Britain has been concerned more with the privileges of the medical profession than with the needs of patients. The entrenchment of professional privilege and hegemony is ensured by the manner in which medical education itself is organised, with the selection of medical students being guided by socioeconomic criteria rather than by academic qualifications.
The medical schools have demonstrated a distinct bias in the selection of the country’s future doctors. For example, a Royal Commission reported that, in 1961, whilst social classes 1 and 2 made up 18.3% of the general population, and social classes 3, 4 and 5 made up 81.7%, 68.9% of final year medical students were drawn from social classes 1 and 2, and 31.1% were drawn from social classes 3, 4 and 5 put together. In 1966, the proportion of students from social classes 1 and 2 had risen to 75.7%, whilst those from social classes 3, 4 and 5 had fallen to 24.2%. It was alleged that part of the reason for this was the operation of pre-entry selection factors (73). The report went on to state that the students from lower class backgrounds had a consistently superior academic performance at medical school in contrast to their colleagues from the upper social classes. It was also shown that 78.3% of those applying for entry to medical school from a state-financed school were rejected as compared to 20.5% from privately financed schools, although the rejected applicants from state schools were as well, if not better, qualified than those from private schools (74). 21% of medical students in Britain have a medical father. In 1961, under-graduates from social classes 1 and 2 made up 59% of the total university population in Britain (75).
It would appear, therefore, that the actions of medical school selection panels are consistent with wider attitudes in society at large, i.e. in keeping with the wishes of the ruling class. Robson states that medical school selection panels play an active
role in the maintenance of social gradients between the medical profession and the majority of its clientele (76).
The Royal College of Surgeons of England in its evidence to the Royal Commission on Doctors’ and Dentists’ Remuneration in 1958 had this to say:
“............. there has always been a nucleus in medical schools of students from cultured homes............This nucleus has been responsible for the continued high social prestige of the profession as a whole and for the maintenance of medicine as a learned profession. Medicine would lose immeasurably if the proportion of such students in the future were to be reduced in favour of the precocious children who qualify for subsidies from local authorities and the state purely on examination results”.
In 1984, with Guy’s Hospital Medical School still continuing to maintain a student intake consisting of a high proportion from social classes 1 and 2, the following ‘jokes’ were printed in a students’ society magazine that was published in aid of charity:
- A Pakistani goes to his doctor, saying, “Dacta, I have vite patch on top my head”.“Here take this”, says the doctor, handing him a large bottle of thick brown liquid.The Pakistani returns a week later, completely cured. “Tell me, Dacta, vat is miraklecure?”.
“Well”, replied the doctor, “it was shit - I thought you needed topping up!”
- "How do you stop a wog (a black person) from drowning?”
“Take your foot off his head!”
- “Why do wogs smell?”
“ So that blind people can hate them too”.
- Sign in a gynaecologist’s waiting room:
The doctor at your cervix today is Dr Schwartz” (‘Schwartz’ means ‘black’ in German).
The editor of the London Asian weekly that exposed these obscenities went on to describe them as “intolerably racist” and stated: “...........it is clear that the writers’ minds run mostly on a perverted kind of sex, excreta, various bodily odours and effluvia, and a schoolboyish concept of childbirth and ‘titillating’ animality. Can it be true that the writers and readers are such ostensibly responsible and mature people as future doctors and surgeons training at such a renowned teaching hospital as Guy’s? Is this what caring for sick bodies breeds - a prurient salacity?” The local Member of Parliament referred the matter to the Director of Public Prosecutions, though to no avail. A black local government councillor had the last word when she said, “I really do fear for the lives of black people in hospitals if this is the calibre of doctors this country is producing out of ratepayers’ money” (77).
Although blacks form a tiny proportion (about 3% - 4%) of the annual medical school intake, these are generally from abroad, mainly from the former colonies, and are not British blacks. The oversea blacks do not now have the right of permanent residence in the United Kingdom, and have to return to their home countries on the completion of their studies.
Once inside a medical school, the student becomes socialised into the professional world, albeit at the most junior of levels. Students assume a professional identity before they have accumulated professional knowledge (78). Such a situation is enhanced by the isolation, in the medical school and in the teaching hospital, from the general student world and, in a sense, from the patient himself. The process of professional socialization was summarised by Hill when he wrote that “the aim and object of medical education is to educate a student to become a member of the profession of medicine rather than a mere scientist or technologist” (79).
In the professional socialization which occurs during medical education, medical students are furnished with the values and ideals of their intended profession. The needs of patients become subordinated to the professional ethic and definitions, and patients become the means to a professional end. The profession is the professional’s prime concern (80).
The defence of the hegemony of the medical profession, the preservation of the dominant professional grouping’s own position, and the detraction from the basic right of all persons to adequate health care has been all part of a historical process which began with the squabbles between apothecaries and surgeons for the rights of medical practice, and, then, continued through the confrontations that characterized the first public health Act of 1848, the National Health Insurance Act of 1911, and the National Health Service Act of 1946, up to the present day. More importantly, the double standards of medical ethics is best illustrated by the professional codes of practice which disallow advertising by individual medical practitioners but permit advertising for private health insurance schemes. Whilst advertising by individual practitioners benefited members of the public in the sense that it informed them of the nature and extent of the medical services that were on offer, advertising for private health insurance, on the other hand, is beneficial to the dominant professional sector practising private medicine (81).
PROGRESS IN A MEDICAL CAREER
Writing in 1948 (82), Oswald Hall described how the members of the medical profession are heavily dependent on a set of formal institutions and informal organisations. The established specialists constitute the inner core of the profession. This functions to control appointments to the medical institutions, to exclude or penalise intruders, to distribute patients, and to enforce rules and control competition. Hall suggested that the influence of the inner core is crucially important in the careers of new recruits to medicine. In describing the four stages of a medical career, he further suggested that these were a set of adjustments to the inner core and to the institutions it influences. The four stages are:
- The generating of an ambition
- Gaining admittance to the medical institutions
- Acquiring a clientele (in the case of those in private practice) and fame
- Developing a set of informal relationships with colleagues which facilitates the above in some fashion.
Doctors tend to be recruited from the ranks and families of professioanl workers who possess the mechanisms not only for generating and nurturing the medical ambition, but also for constantly re-defing and re-directing that ambition. Although ambition is conceived to be a subjective matter, it is in the case of doctors, largely social in character.
Careers in medicine are largely made in hospitals which are themselves of a hierarchical nature. The hospitals are linked with the medical schools and research units and establishments, and these provide chains which aid the young aspirant to move along to the next level. The final appointments are not made on the basis of technical superiority, although the applicant must be technically proficient. At this level, personal factors and institutional acceptability play a part. The distinctive policies and unique history of the medical profession tend to exclude doctors with specified backgrounds and to encourage others. For fame, and a large private practice, a specialist is dependent on the active assistance of a group of colleagues. The specialist’s hospital connections facilitate the development of referral relationships between doctors.
The inner fraternity (the inner core) of the medical profession is made up of specialists who have access to, and dominate, the main hospital posts (83). It represents the integration of the distinctive lines of specialization in the hospital service and a method of organising the supply of services. The members of the inner core comprise a social group and, because of their close working relationships, similar educational and socio-economic backgrounds and common professional bonds, they are a fraternity. They operate, at all levels, mechanisms for both “incorporating the newcomer and repelling the unwanted intruder”. Moreover, “the group is sufficiently small to become a democracy of first names......Because it shows so many of the characteristics of the primary group and of the secret society, it has been labelled ‘the inner fraternity’ “. The subject has been further discussed by Gould (84). Hall concludes “......it would appear that specialised medicine is no longer an independent profession, a freelance occupation. It has become highly interdependent rather than independent, and it is carried on within the framework of an elaborate social machinery rather than within a freely competitive milieu”. Gould (85) describes how some of the less scrupulous consultants leave their competent ‘juniors’ to do much of the outpatient and ward work, and operating, which they ought to be tackling themselves. The juniors dare not complain since they depend heavily upon the goodwill and recommendations of their elders. Another perk for consultants in the National Health Service is the system of merit awards, which 60% of the consultants will be receiving by the time they retire.
The awards themselves are secret and the method of conferral, according to two top psychiatrists from London’s prestigious Tavistock Clinic, writing in the ‘British Medical Journal’, a pretty “sleazy arrangement” (86).
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