Published: 13 December 2022
Professor Mala Rao OBE established the Ethnicity and Health Unit, under the Department of Primary Care and Public Health, at Imperial College London and NIHR ARC Northwest London to apply an evidence-based approach to addressing ethnic health inequalities. In this blog she explores the scale of the problem in the research arena and issues a rallying call for action.
When my recent copy of the British Medical Journal (BMJ) arrived in the post I was struck by the picture on the cover. It showed two ladders, with a woman climbing each. One was a white woman, halfway up her ladder; the other, a woman of colour, hardly on the first rung. The cover headline was ‘Tackling the race gap in health research’.
Not only had the analysis I led on this topic ‘Tackling racism in UK health research’, been published but its conclusions were captured by this powerful image in a way my narrative analysis could not. It summarised the inequalities, as well as the personal career journeys, of so many people of colour, including me.
Bold ambitions to change public health
I came to the UK fresh out of medical school in India, in pursuit of postgraduate training. Although my undergraduate years were punctuated by many scientific advances in medical care, it was the scope of public health, to systematically eradicate infectious diseases, that impressed me most.
Bitten by the public health bug, full of enthusiasm and curiosity and with a huge appetite and energy for learning, I set out to gain the further knowledge and skills necessary to become a leader in this research area. Did I achieve my ambition? In short, no; and the reasons why have become clear only years later.
A diverse health and care service
The NHS has a highly ethnically diverse workforce, just over 42% (of 283,663 licensed doctors in the UK) of its medical workforce are from an ethnic minority background and internationally recruited staff have been central to its service delivery since its launch in 1948. Despite heavy reliance on these staff, substantial evidence shows they are likely to experience racism and discrimination and have poorer experiences and opportunities throughout their careers.
Ethnic minority doctors in the NHS include those who are UK medical graduates as well as international medical graduates (IMGs). Evidence highlights there is a hierarchy in terms of performance across dimensions ranging from pass rates in exams and assessments, to levels of pay and representation in leadership roles, with white UK graduates showing the best results, ethnic minority UK graduates showing the next best results and IMGs - demonstrating the poorest measures of performance.
Investigating health inequalities
Evidence of these inequalities lay buried until NHS England launched a Workforce Race Equality Strategy in 2015. Since then this strategy has stimulated significant action. The first priority was a collection of evidence of race inequalities in the NHS workforce. Key outputs are the publication of the NHS Workforce Race Equality Standard and the Medical Workforce Race Equality Standard and actions to address the many dimensions of ethnic inequalities in the NHS workforce.
The arena of academic health research has been much slower to identify, acknowledge and react to these issues. It was not until the seismic events of 2020, the emergence of disproportionate impacts of the COVID-19 pandemic on ethnic minority populations and health care staff, and the resurgence of the Black Lives Matter movement that the health research community acknowledged the need to examine its own dismal record.
Racism in health research
Our 2022 analysis of racism in UK health research brought together, for the first time, the considerable evidence of systemic barriers to ethnic equality across UK health research, in its commissioning, implementation, assessment and publication. We found racism in universities is pervasive and often silently accepted and normalised. Evidence ranged from the racial harassment of ethnic minority medical students, and ethnic minority academics facing a lower likelihood of securing a research grant, to lower levels of representation in leadership positions. Recent reviews undertaken by the major research commissioning and funding organisations in the UK, such as UK Research and Innovation (UKRI), Wellcome Trust and NIHR confirm these differentials in funding and opportunity.
NIHR has moved beyond the initial step of measuring equality and diversity across its research infrastructure and has delivered an EDI Strategy that states its central operating principle for inclusion is to:
“…develop researchers from multiple disciplines, specialisms, geographies and backgrounds, and work to address barriers to career progression arising from characteristics such as sex, race or disability.”
Commitments such as this remain rare in the sector and deserve to be acknowledged. Perhaps the most concerning aspects of this continuing indifference to the inequalities are the underrepresentation of ethnic minority patients and communities in research, as was starkly exposed during the pandemic, and underinvestment in research to address the disproportionately greater burden of ill health in these populations. The Research Excellence Framework (REF), too, appears to pay little more than lip service to the issue of equality and our most influential medical journals acknowledge their complicity and need to play their part in addressing the challenge.
Time for action
A 2021 independent review to address discrimination and advance anti-racism at the London School of Hygiene and Tropical Medicine revealed striking findings. Students of colour do not have equitable experiences or opportunities to progress, staff of colour continue to be underrepresented at senior academic levels, and the institution continues to be shaped by its deeply racist colonial legacy. Little wonder, then, that this woman of colour, an alumnus twice over, received little encouragement to pursue her goals all those decades ago.
Academia must no longer accept the race gap in health research which has gone unnoticed and unresolved for decades. Shaping a healthier society requires health and care researchers to build an equity-based research agenda which welcomes diversity and inclusion to develop a better mix of ideas, greater innovation and enterprise.
We have gone past the point of recognising and acknowledging a problem exists. It is time for all of us in the research community to act, and act decisively.
Mala Rao established the Ethnicity and Health Unit, under the Department of Primary Care and Public Health, at Imperial College London and NIHR ARC Northwest London. Its key objectives are to carry out research where there are gaps and to translate research evidence into action and positive change.
Successes include work on:ethnicity, equality and equity that takes an in-country and global perspective
- launching the NHS’s first comprehensive induction programme for International Medical Graduates recruited to work in the UK
- early research among people from ethnic minority backgrounds exploring hesitancy to participate in clinical trials research
- editing a special issue of the International Review of Psychiatry on mental health and wellbeing and the climate crisis.