Cultural Diversity, Ethnicity and Racial issues in Managing

End-Stage Renal Disease in UK

A personal perspective based on my experiences

Culminating in a presentation at the UK EDTNA-ERCA Conference, Birmingham, 2003

 by Professor Ram Gokal

 

Background – my early days in Rhodesia 1945-1967

I was born in Southern Rhodesia (now Zimbabwe), which until it gained independence in 1980, was a British colony with partial self-rule rights; it was an apartheid system in all but name. My parents had emigrated there from India. There were three races: white, brown and black – the whites were ‘superior’ and ruled the other races and all laws ‘favoured’ them. There were segregated/designated areas for the ‘lower’ races for living/housing, schooling, shopping, entertainment, and restaurants. Blacks had to have an ID pass to travel out of their area. Growing up under these conditions was not easy and this also applied to education. In spite of these severe restraints, a group of us Asian students did manage to get excellent results in high school (‘O’ and ‘A’ levels)  and gained entry into university at UCRN (University College of Rhodesia & Nyasaland), the only multi-racial educational institution in the country.

So I was very sensitive to racial prejudice and could ’sense’ anything racial.

In 1967, despite my brown colour, I managed to successfully compete against six other short-listed white candidates and win a Rhodes Scholarship to Oxford University, UK. This was hailed as a major achievement and a breakthrough!

Oxford University 1967-1970

Coming to Oxford was like `nirvana`- so free, friendly, and welcoming. It took some getting used to – the new non-racial environment and also the weather! I experienced no problems of a racial nature in the Oxford community (which always had many overseas students that were not white. I regarded the Rhodesia experience as a ‘nightmare’ and focused on getting qualified as a doctor.

 Medical training as a nephrologist 1970-1980

After qualification, I was fortunate to secure without any problems highly rated training posts in Oxford and London . I continued my training in nephrology, during which I was acutely aware of the limited dialysis facilities, and was  seeing patients ‘turned away’ –painful but unavoidable given the resources we had. At Newcastle under David Kerr, my training was going extremely well and it became time to apply for a consultant post. That experience was a rude awakening and I realised that the racial issues were prevalent (though ‘hidden’) in the higher echelons of the medical establishment, in the community and at appointments committees. Here is my personal experience.

Consultant experience – before and after appointment

When I was applying for a consultant post in 1979, we faced big problems! The ‘we’ refers to Jo Adu (of Ghanaian origin- black), Ramesh Naik (also an Asian from Rhodesia – brown) and myself (brown). We were all highly qualified, well trained with good research publications. At a series of interviews, there were always four short-listed candidates – the three of us,  and one other – who was white. In interviews  at Royal Free, Leeds (twice), Birmingham , and Bristol  we three came second and the ‘white’ candidate was always   appointed! It was painful and the RCP reps on the committees were clear and open about the prejudices we were having to endure. I have no doubt that this was ‘racial’: a member of one   appointment committee was reported to say ‘our predominantly white community and patients will never accept a non-white consultant’ This was taking me back to the early Rhodesian days, and was even more painful, because  this racialist attitude was like an ‘undercurrent’ – still evidently prevalent and surfaced when it mattered. How prevalent was this in medical circles and society at large?

 Then we came to an interview in Manchester and there were only the three of us  left –   and I fitted the bill because of my PD experience. Jo got the next job in Birmingham and Ramesh in Reading. This just highlights the issues at that time. The obvious question in my mind: was – ‘Is this prejudice also reflected in patient selection?’ Whilst there were limited facilities to take patients on for RRT  , was the selection biased in favour of those who were young, fit  and racially/ethnically appropriate (i.e. white)?

There were two incidents after my appointment in Manchester when this became most apparent.

• I was giving a talk to the NW Association of Physicians in 1982. There were over 100 consultants attending. I was talking on CAPD and how this could meet the short-fall in numbers as we were then not seeing the referrals from district general hospitals which we would expect given the known prevalence of ESRD. Most consultant present argued that they ‘never turned patients down and referred them all to the regional centres like ours’ . But one commented privately to me ‘that it is difficult to refer for dialysis those who have co-morbidities, the aged, and those with different ethnicity, culture and language’. Netar Mallick and I defended our case strongly. If each of the hundred DGH consultants who were at the meeting turned away 2-3 such patients a year, that would be another 300 per year we would be treating! It was a debate about referral practices, and about dealing with age-old prejudices. But also we needed to convince them we had the capacity to handle the load. We asked them to refer all patients, regardless of their clinical, social and cultural status and leave the tough decisions to us. Education was needed, and we did provide this to improve the situation – CAPD was a ‘saviour’.
• When Manchester became a leading renal centre, one often heard people talk of us as ‘that unit up north in “wogga wogga” land’. (wog – wily oriental gent – referring to me and Netar) – especially  from some nephrologists in the south of England. I think this was jealousy and our view was that our work, our programme and our results could  speak for themselves.

 Cultural Diversity, Ethnicity and Racial issues in Managing End-Stage Renal Disease in UK.

Was this experience reflected across  the UK? How did cultural, ethnic and racial issues affect the take on rate to other RRT programmes ? The situation in the early 1980’s was precarious (mainly because of the lack of in-centre HD facilities) and I am of the view that ethnic patients did ‘suffer’ this prejudice. There was also mass migration of people of different ethnicities into UK and Europe. My first experience of this migration was in 1972, when Idi Amin forcefully expelled all the Indians from Uganda – many settled in London and Leicester. During my career, I was fortunate to be able to dialogue with Asian patients as I spoke several necessary  languages (Gujarati, Hindi, Urdu and some Punjabi). This greatly facilitated my exchanges with patients and families, especially as I also understood the cultural and religious background.

Collation and presentation of evidence

1. I collated the available evidence published from 1980 to 2004 and  analysed the issues as I saw them. I presented this in an invited talk at the UK EDTNA-ERCA Conference in 2003 in the presence of the UK Minister of Health.  It was ‘well received’ by the Minister.

The abstract for the lecture  is below, and the lecture  can be viewed here. Lecture EDTNA Culture ethics race RGokal 2003

Abstract from 2003 lecture

Culture signifies the customs and way of life of a particular people and encompasses elements related to religion, language, customs, rituals, accepted behaviour and norms.   In the modern world multicultural communities have become more prominent;  because of increased movement of people for  political, economic and social reasons. These populations movements are superimposed on the diversity that already exists in individual countries.   This cultural “invasion” if tolerated and accepted, enhances the life of the people there but it also raises major issues of a social, racial and political nature.

In this context, major problems can arise when renal failure strikes. This is partly related to the professional carers being of the ‘host’ culture. The patient then has not only to battle with this disparity but also the vagaries and difficulties of the treatment for ESRD. In this situation interaction with people, who may have little or no knowledge of the cultural background of the patient can raise enormous difficulties and anxieties, which are undoubtedly going to impact on the quality of life and satisfaction with treatment.   Examples of patients with differing cultural backgrounds being disadvantaged in terms of dialysis access, as well transplantation are available.

Underlying all this, however, is one common goal that encompasses the way we manage these patients and impart treatment, no matter what cultural background they come from – the desire to improve  longevity  and  achieve an acceptable quality of life.  This involves a caring approach, a giving ethos, and imparting treatment with comfort, respect and patience.    We in this profession have a very privileged position being entrusted with the life-long care of these patients. It is for us to be able to incorporate the cultural differences, diverse as they may be, in imparting the best treatment we can. Even if we cannot understand the cultural background at least we can give therapy with compassion, love and caring and if we are able to achieve this, then the barriers of cultural differences can be surmounted and overcome to the advantage of the patient.   Cultural differences provide a challenge – but they can be used to foster better relationships and enrich the diversity of society.

 

 

2. Later publications 2012-2022

Included in an addendum to the presentation (slides 41-50), are summaries of later  key publications, from 2012 to 2022.

 

Finally..

There is no doubt, eighteen years after I retired from UK clinical practice that these issues have persisted, although they are now being addressed.

 

Ram Gokal

 

 

 

Last Updated on July 10, 2023 by John Feehally