• behaviour
• capability
• clinical leadership
• health system
• organisational effectiveness

The purpose of this paper is to use personal narrative along with available data, to shed some light on system blindness and its inter-related structural racism.

I would like to start by reflecting on my journey. I started as an International Medical Graduate (IMG) in the UK over a decade ago.

Each person including IMGs has a unique experience in the healthcare workplace. For me it all started with a comment made by ‘my referee’ following 6 months of a clinical attachment in a busy medical ward. They reported concerns about my communication skills which they thought were driven by strong Franco-Arabic accent and culture. Their statement opened my eyes to the bias that I was going to face as I immersed myself into the UK health system.

Having experienced initially non training and then training grades, I came across several explicit oppressive attitudes, equally by white and non-white fellows: ‘all the troubles, are coming from this lady’s country’, a comment made by an Asian colleague during the Arab Spring. He was talking to a patient about me, as I was assisting him with a chest drain. Being Muslim of North African heritage was associated with violence in my registrar’s eyes. ‘We are treating you differently because you’re behaving differently’, a comment made by a supervisor when I asked why I was being treated differently to my colleagues.

As a trainee, while I experienced less explicit racist comments, I observed more implicit bias. I have more than doubled the standard years in training for childcare reason. Over the last decade I observed my white colleagues being supported to progress academically and professionally. They received better payments, they have had better access to research with higher chances of a successful grant application, higher chances to get the best rotations in training and higher chances to have consultants’ posts in teaching hospitals (of course they have to go through a process of application and interview, just to tick the box of Equality Diversify and Inclusion). Women of colour like me, must patiently wait at the back of queue for opportunity, and continue to work much harder to demonstrate their potential. Over the years I learned that waiting at the back of queue is not always bad. It helped to me observe, learn, grow, and notably reflect on people and system patterns, appreciate my own values; and be kind to myself. At the back of queue, I came across some of the kindest colleagues, with exceptional integrity, who helped me to deliver my potential.

My personal experience is only a drop in the ocean of systematic racism exposed over the last few years.

The first year of the COVID-19 pandemic exposed a racial gap with higher rate of mortality in minority ethnic groups patients and healthcare workers (HCWs) alike.1–4

Several reports emerging over the last few years made it overwhelmingly clear that ethnic minority communities experience poor healthcare outcomes across all range of services, mostly in mental health and maternity.5

Notably the NHS Workforce Race Equality Standard report included sobering and unsurprising figures. While almost quarter of the National Health Service (NHS) workforce are from minority ethnic groups, this group still experience higher rate of harassments (from staff and patients), higher rates of referral for disciplinary actions and fewer opportunities for career progression compared with their white peers.6 Further grievous evidence has emerged highlighting the growing structural racism in health research.7

These reports make a case for radical action on racial inequity across the whole system. The first step of this action is to admit that equity does not exist in healthcare; and in health research. Whether you are a patient, HCW or researcher you will suffer the adverse impact of being different. But before we jump to recommendation/solutions let’s spend more time understanding the problem first: why are minority ethnic groups, patients and staff alike, likely to suffer the consequence of being different?

Let’s go back to my referee comment about my communication skills: the stigma that communication is not good enough because of my strong Franco-Arabic accent and culture.

He clearly saw me and judged me through his cultural lens.

He had no concerns about my professionalism, but there must be a reason that made my referee feel uncomfortable with my accent and my culture. He must have felt that I was acting or behaving outside ‘the norms’.

How dare a woman of Tunisian heritage talk and behave differently outside ‘the norms’? My cultural behaviour and my accent appeared strange. I had the wrong language, skin colour and culture…

Experiencing race-based microaggressions by white and Asian colleagues over the years, taught me that racism is beyond white vs non white issue; and there is a need to understand racial disparities in a more granular way.

The way we interact with each other’s as humans is defined by patterns which shape how we experience and react to being with different people.

As Humans, we are profoundly social creatures, and we can be part of multiple systems or contexts at the same time: family, nations, community, faith groups, organisation.

The way we interact as human is not only individual to individual, but we are also people in context.8 Yet, as human we are vulnerable to context or system blindness. Our failure to recognise each other’s contexts, can be costly for individual and damaging for organisation. It causes distress, destroy relationships and creates divide in organisations.8

In a blind system, we feel that how we see and interact with different people is the right thing to do and is a true reflection of reality. In a blind system, we engage blindly with a set of patterns, repetitive experiences and behaviour, that become the ‘norm’ and define our relationships. Whoever looks different and behaves differently is potentially invisible in blind system. The moment they become prominent and visible, they are automatically excluded, because ‘realistically’ the normal reaction with different ‘outsiders’ is to dominate, oppress and suppress. Even if these ‘outsiders’ manage to change their language, the way they dress, their manners, they remain different in a structurally blind system.

People in blind systems are reflexive and less reflective. They reflexively experience discomfort with different people. They reflexively undermine different people’s potential to perform well compared with ‘normal’ peers. People of colour are seen as a danger in a dominant culture. In system sight, however, people reflect and develop self-awareness of the patterns that define their relationships, and behaviour. In system sight, people can change and adapt their patterns, because they care about each other.

Despite the general scepticism of changing deep-seated attitudes. We are experiencing a ‘Kairos moment’ and an opportunity for change. We need system sight, where we don’t reflexively exclude ‘the other’ for example, person of colour, a LGTB, a Muslim, Jewish… we need system sight, where looking different is no longer exceptional to the normal but part of normal.

To facilitate this mindset shift, we need a leadership that enables challenge to oppressive behaviour. For example, a person valuing others’ differences, needs to feel safe to step up and challenge racist behaviour; and comfortable to speak up. Rather than observing, they need to join ‘the others’ in facing an oppressive system. Yet, there is a risk of challenging deeply held beliefs. Regardless of the outcomes of this experience, the best reward of mobilising and organising people to actively engage in challenging racist attitudes, is to bring people together.

Along with psychological safety and enabling people to speak up and challenge racism, we need leadership that create an environment where people can relate and connect with each other. Creating a work environment that enable people to regularly meet, and get to know one another’s histories, cultures, families etc… We need an environment that enable people to connect as equals on a routine basis.

An organisation that facilitates connecting with one another on an ongoing basis, and working on mutually meaningful projects, enables individuals to experience their commonalities as well as their differences; and will increase the chances to achieve its full potential.

How about ‘the other outsiders’, what role can they play to address structural racism apart from criticising the insiders?

Victims of racism tend to criticise. Taking responsibility to deliver the truth, they aim to expose the culprit insiders and hold them into account. Racism victims do not feel they belong to the failing system. It is ultimately the insider’s job to take responsibility of the system failure. The culprit insiders must accept the message and heal the damaged system. Using reflexive response, insiders will try to resist the message. They feel misunderstood and embarrassed. They struggle with emotions, and struggle to admit and justify failure in front of the critical courageous victims of racism.

One thing we need to realise in this situation, is that oppressors and victims are human of the same system. Humans are not angels and can be toxic. What differentiates between humans, is self-awareness and realisation of their toxic trait, and their impact on our relationship throughout the life course.

Victims of racism need to play role in addressing system failure, by pointing out the insider blindness, while insiders will probably resist and resent, using the right narrative they will ultimately convene and collaborate to resolve the conflict. Building healthy relationships is the only way to heal failing organisations and increase their ability to achieve its’ full potential through the lens of system sight.

Inequality and structural racism are entrenching all aspects of health system from clinical to academic research, adversely impacting on workforce, patients’ and organisations’ abilities to achieve their full potentials. Healing the imperfect organisation, require all parties input. We need to move to system sight underpinned by connectedness and healthier relationships.