A personal perspective on cultural diversity, ethnicity, and racial issues in managing end-stage renal disease in the UK, and on experiences of bias and discrimination.
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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!
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.
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.
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 appointed. It was painful, and the Royal College of Physicians representatives 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 racist attitude was like an undercurrent, surfacing 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. 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?’ There were limited facilities to take patients on for RRT then. Was the selection biased in favour of those who were not just young and fit, but also on whether they were perceived to be racially/ethnically appropriate (i.e. white)?
There were two incidents after my appointment in Manchester when this became most apparent.
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 1980s was precarious (mainly because of the lack of in-centre haemodialysis 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.
I collated evidence published 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 slides can be viewed here – (pdf 1.1 Mb) Gokal 2003 Culture ethics race
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.
Included in an addendum to the lecture presentation (slides 41-50), are summaries of later key publications, from 2012 to 2022.
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. First posted 2023
Last Updated on September 11, 2024 by neilturn