Being Seen by the Doctor: A Meditation on Power, Institutional Racism, and Medical Ethics

Racism against racialized migrants in healthcare in Europe: a scoping review

BACKGROUND

Racism is frequently mentioned as a social determinant of migrants' health and a barrier to health services. However, in the European context, racism and its impact on racialized migrants' access to healthcare is remarkably under-researched. This scoping review makes a first step toward filling this void by mapping the existing literature on racial and ethnic discrimination against racialized migrants in healthcare in Europe, identifying evidence gaps, and offering recommendations for future research on this topic.

METHODS

Following PRISMA guidelines, four databases were searched for empirical studies published in English between 1992 and 2022. Studies were included if they report findings on manifestations, experiences and/or impacts of racial or ethnic discrimination against racialized migrants in a healthcare setting in a European country. They were summarized by study characteristics (geographical scope, study design, research question and measures) and research findings were synthesized.

RESULTS

Out of 2365 initial hits, 1724 records were included in the title/abstract-screening, 87 records in the full text-screening, and 38 records in the data extraction. For many country and healthcare contexts, evidence on racism in healthcare is lacking. Most studies apply an explorative qualitative research design; comparability and generalizability of research results are low. Our analysis furthermore shows a near-exclusive research focus on racism on the interpersonal level as compared to institutional and structural levels. Our synthesis of study results identifies three interrelated ways in which racism manifests in and impacts migrants' healthcare: 1) general anti-migration bias, 2) health- and healthcare-related prejudice, and 3) differential medical treatment.

CONCLUSIONS

Our review underscores how racism reinforces inequities in healthcare access and quality for racialized migrants. It also highlights the need for more research on racism in Europe across a greater scope of country contexts, healthcare settings and migrant/racialized categories in order to understand specific forms of racism and capture race as a context-contingent social construct. It is critical that future research includes the consideration of individual-level racism as embedded in racism on institutional and structural levels. Methods and insights from other disciplines may help to critically examine concepts in light of underlying historical, sociopolitical and socioeconomic processes and structures, and to improve methods for researching racialization and racism in healthcare.

Picturing sanity, in black and white

This speculative work grapples with a riddle: if white supremacy is noxious, and if it is inescapable, is apparent black health, black sanity, in fact healthy? In order to help the reader appropriately appreciate the feat that is black sanity, I begin with a treatment of Fyodor Dostoevsky's literary character, Mr Golyadkin. I go on to extend my claim that Golyadkin's ill health or lack of sanity can be understood in terms of the violation of the norms of sociality, onto Antonin Artaud. Dostoevsky and Artaud therefore provide case studies with which it is possible to begin to develop an outline of the bounds and mechanics of white sanity. I juxtapose this outline to readings from a selection of works by African writers-Bessie Head, Véronique Tadjo and Dambudzo Marechera. This culminates in an interrogation of Franz Fanon's metaphorisation of disability. I grapple especially with the ethical and existential implications of his understanding of black amputation. The conclusion that I eventually reach is another riddle, which may or may not amount to a restatement of the riddle with which I begin.

Shapeshifters, systems thinking and settler colonial logic: Expanding the framework of analysis of Indigenous health equity

Despite increased attention in the health care field to the disparate health outcomes of Indigenous peoples, inequities persist. Analytical frameworks with the capacity to account for integrated systems analysis of power and domination are underrepresented yet vital to affecting change. Narratives represent Indigenous approaches to systems thinking, yet are often excluded from the literature on theorizing health systems. Recent theorizing in systems thinking provides a conceptual toolkit to interrogate health systems in a way that emphasizes ongoing histories of settler colonialism that underpin determinants of vulnerability, risks and poor health outcomes. Walby's (2007) approach to complexity theory provides an opportunity to re-orient the way health system researchers and practitioneers approach systems of domination in the context of Indigenous peoples' health, including viewing settler colonialism as a shapeshifter who abounds within the possibility of their environment and is a master of time and space. We explore the concepts of attunement and restraint in complexity theory and complex adaptive systems to better understand the movements of shapeshifters. Further, we demonstrate an application of Walby's framework to a narrative, using the highly publicized story of Brian Sinclair, an Indigenous man who died in a Winnipeg Emergency department. Noting how this approach accounts for settler colonial logics in health care system performance, we establish linkages between Walby's articulation of complexity and the fields of Indigenous and Settler Colonial Studies, anchoring this discussion in Indigenous ontology through the metaphor of shapeshifting. By focusing on the systems level, we elucidate the plethora of individual experiences as outcomes of settler colonialism played out within highly complex, adaptive social systems.

Ripple effects: integrating international medical graduates from refugee backgrounds into the health system in Australia

The field of ‘refugee health’ is generally understood in terms of the efforts of health professionals from a host country to provide care for humanitarian entrants. This paper attempts to undermine that idea, focusing instead on the service that health workers from refugee background communities are able to render, both to their own communities and to broader society, when barriers to their participation are made more equitable. The point of departure for this Practice paper is the 2019 pilot ‘Observership Program’ that was initiated by Mater Refugee Health in Brisbane, Australia. This was in response to, and in collaboration with, international medical graduates from refugee backgrounds. The two doctors who advocated for the programme had already independently embarked on a series of advocacy initiatives aimed at facilitating health workforce participation for members of their communities. In what follows we: outline the barriers to their medical registration and employment in Queensland, Australia; describe the process of setting up a 9-month clinical observership for two participants; and we reflect on the implications of the programme from a health policy and systems perspective. Ultimately, our contention is that because health systems are complex and adaptive, increased health workforce participation by members of marginalised communities has the potential to change the culture of the health system, making it more adept and responsive. Such, we propose, are the ‘ripple effects’ of addressing the obstacles to health workforce participation by members of refugee background communities.

Beyond biopolitics: the importance of the later work of Foucault to understand care practices of healthcare workers caring for undocumented migrants

Background

Undocumented migrants experience multiple institutional and legal barriers when trying to access healthcare services. Due to such limitations, healthcare workers often experience ethical dilemmas when caring for undocumented migrants. This article aims to understand how individual healthcare workers who regularly take care of undocumented migrants deal with these dilemmas in practice. So far, the role of healthcare workers in this context has mainly been theorized through the lens of biopolitics, conceiving of healthcare workers as merely obedient instruments of humanitarian government or gatekeeping.

Methods

Based on semi-structured, in-depth interviews and ethnographic observations with healthcare workers in Belgium, we explore how they ascribe meaning, reflect upon and give shape to care practices in relation to undocumented migrants. We use Foucault’s later work on care of the self to interpret the accounts given by the healthcare workers.

Results

Healthcare workers in clinical roles exercise a certain degree of freedom in relation to the existing limitations to healthcare access of undocumented migrants. They developed techniques such as purposefully being inattentive to the undocumented status of the migrants. They also try to master their affective responses and transform their bodily attitude towards undocumented patients. They perform practical mental exercises to remind themselves of their role or position in the wider healthcare system and about their commitment to treat all patients equally. These techniques and exercises are inspired by colleagues who function as role models, inspiring them to relate in an ethical way to limitations in healthcare access. The developed care practices sometimes reproduce, sometimes transform the legal and institutional limitations to care for undocumented migrants.

Conclusions

The findings nuance the biopolitical analysis regarding the role of healthcare workers in healthcare delivery to undocumented migrants that has been dominant so far. Theoretically this article provides a reconceptualization of healthcare ethics as care of the self, an ethical practice that is somewhat independent of the traditional professional ethics.

Trial Registration Medical ethics committee UZ Jette, Brussels, Belgium – Registration date: 18/05/2016 – Registration number: B.U.N. 143201628279.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00726-z.