Diversity & Equality in Health and Care Open Access

As we began to compile this issue, we were buoyed by the news that the International Olympic Committee had decided that London should be the host city for the Olympic Games to be held in 2012. This held all sorts of emblems: belief in the power of the human spirit and that obstacles or hurdles can be overcome, and that people from all over the world can unite to celebrate human achievement. Very powerful indeed was the perception that London was ‘the world in one city’, and that the recognition of this fact, that people from all the societies of the world were, indeed are, already living together and would form a ready-made cosmopolitan spectator body for the Games, hadweighed heavily with those voting. Diversity, in the words of commentators, was its own strength and its own reward. However, within the sameweek, we experienced another event, which showed the other side of the coin, and the need for constant reaffirmation and rediscovery of the facts and requirements of living together in diversity: the explosion of devices on the London Underground and famous red buses. It is central to the philosophy of this journal that we emphatically reject any belief that violence brings about solutions in our disagreements with others. How each of us regards other people is central to our understanding of diversity and indeed the whole of our human existence. It is through genuine and peaceful engagement with others that we begin to make progress in mutual understanding, which is what we share and celebrate.

Some things are expressed in numbers, and others in words. Other people believe that only actions will suffice. We happen to believe that there is something ‘real’ which underpins our human existence, and which we are all, in words, figures, actions or pictures, striving to express, explore and celebrate or share. The events of whatwill now be termed 7/7, the explosion of bombs and subsequent activity in London, echoing those of 9/11 in New York and in other times and places across East Africa, South-East Asia and the ‘Middle East’, continue to echo. It requires an understanding and an appreciation of diversity for these events and conflicts to be resolved and it would be true hubris or impudence to assert that our journal was a key element in this. However, we make no apologies for attempting to do our bit – in numbers (quantitative), words (qualitative) and actions (knowledgeshare). In this issue we have tried to present a selection of thoughtful papers thatmaymove the debate forwards or inform and develop our readers’ ability to address these questions.

We begin with a guest editorial from Iain Graham, written from his base in Bournemouth, which is possibly Britain’s capital of international language schools. He discusses the concepts of globalisation and multiculturalism. In particular, he explores their meaning and implications for health and social care practitioners and especially for those in universities who seek to create a learning experience for these professions. As an educator, he relates these issues to professional skills and knowledge that must extend to incorporate an understanding of a range of cultures and social structures. Only then canwe recognise that, like Dr Johnson’s story of the washerwomen arguing across the street, we are all starting from different premises. This is not a simple task, and for the educator, the challenge is to persuade the learner to adopt lifelong learning strategies that embrace and positively seek out diversities. Only thus can we all avoid reproducing stereotypes. In the light of the importance of education, and in recognition that we are attracting a strong showing of papers in this area, we have added to our regular sections one specifically dedicated to carrying papers about this topic, to complement the focus on research, debate and practice.

The research papers in this issue represent attempts to dismantle stereotypes, challenging our views about other people. Since how we see is a key theme, it is appropriate to start with a paper from Birmingham by Vinette Cross and her colleagues, which examines the pervasive and preventable scourge of glaucoma. There is a well-known problem of raised blood pressure (hypertension) among people of African–Caribbean descent, although it is less well recognised that they are also subject to higher levels of blindness arising from raised pressure within the eye – glaucoma. Those most at risk, perhaps inevitably, are probably also the least well informed. This paper brings together knowledge from molecular genetics and community-based insights to tackle this issue. As with other conditions, people from black and minority ethnic communities present for treatment later and have consequently worse outcomes, partly because of their lack of access to relevant information and consequent misconceptions about what can be done. Visual impairment and even loss of sight may be accepted as inevitable and not something that can be treated or prevented. Cross and her colleagues ably demonstrate these health beliefs, how real people think and talk about disease, and how best to help them. Clearly, getting people to rethink their beliefs is the best way to change behaviour, but it is not easy. The vivid quotations presented here drive home that message and should enable us to move forwards in targeting health promotion in this field. (Incidentally, have you noticed the ethnic origins of people advertising eye care products?)

Similarly, Nisha Dogra and her colleagues, in a local study of mental health among a particular cultural group, cast light upon the understanding of young people and their parents about mental health. Professionals, keen to involve the clients and their communities, too readily assume that everyone knows what they are talking about. Before you start to build, you must ensure a level basis of shared understanding of both the topic and the related terminology. Inequalities will persist until a few more people get down to basics, as in this research, and explore where the multiple communities of minority Britain are in their understanding of terms such as ‘mental illness’ and ‘mental health’, and whether parents and children share the same views and beliefs. Dogra’s interviews reveal quite clearly how much confusion there is about the nature and cause of mental illness, and how this may be seen as quite different from mental health. Researchers may talk glibly about holistic concepts and decry the medical model, but some at least of our clients would dearly love a biological explanation, or some way of seeing that there are interventions available that can ameliorate their conditions, rather than simply blaming external, untouchable and unexplainable stress. One of the key factors to emerge is the role of research in enabling and permitting discussion of these hidden things.

Samanta and colleagues have chosen to focus on a restricted area of disease, which nevertheless causes great pain for the individual and a significant burden for the NHS: rheumatoid arthritis. Using the traditional and well-established technique of systematic review, they reveal just how little research there has been in the UK that can assist policy and practice to address the needs of people from South Asian (or indeed, other minority ethnic) groups. It is not that the subject lacks a literature or that there is no interest in ethnicity. However, nearly all has focused on North American minorities (including ‘native American’ or American Indian groups), largely in an attempt to understand the nature and epidemiology of the disease. To meet the needs of UKminority populations requires lateral thinking and an effort to transfer knowledge from other sectors of health research. It seems that efforts of this type are beginning, but it remains hard to find good evaluation studies or reports of such activity in the conventional ‘peer-reviewed’ literature, which is where most systematic reviews begin and end their search. For minority concerns, new techniques may be required.

Before we can begin to build a jigsaw, we must take all the pieces out of the box, and turn them up into the light, to see the various colours, patterns and shapes that form the elements of the picture. Once we have assembled this we need to find ways of sharing this with others and, in the case of research, sharing what has been learned. In this issue we launch our new education sectionwith a paper by Ann Lawless and her colleagues who describe the process of curriculum change.

Australian medical schools have been making great strides to integrate models of diversity into their curricula. In this paper teachers from the primary care and medical education units of Adelaide describe how they have tried to encourage undergraduate medical students to discuss gender and culture, and recognise their impact on health.We note that for them gender means also recognising the peculiarities and stereotypes associated with the male: it is no more acceptable to ignore these than to ignore the specific requirements of females. Gender awareness, like cultural consciousness and race or ethnic monitoring, once promoted, can lead to a better distribution of new doctors across professional specialties, as well as to those doctors providing a better service to their users. To reach this point, however, requires a close and reflective look at the content of the curriculum. This is neither quick nor simple to achieve, and requires the input of an energetic and persistent individual. Once that has been done, some attractive ways must be found to engage the learners in the new ways of thinking. In the case of medical students, case histories are perfect vehicles. They will, however, require careful crafting to avoid creating or reinforcing stereotypes. This paper shows that it can be done.

Education is really about learning, and we can learn from debate. In this issue, we have three contributions that we felt merited that description. If we are going to have a good debate, it might be a good idea to know what racism is really all about, and where some of its ideas come from. Hitler was not the father of racism: it had many fathers, and probably many mothers as well, but he was certainly a major figure in its development. Further, his words and ideas still resonate down the corridors of history. Raj Bhopal has done us all a service by delving into those murky recesses and letting us see just what Hitler was saying and how it relates to modern debates about health and genomics. We have taken a few liberties to link his research to some further current debates.

We accept that many readers will find the words of Hitler and his devotees to be repugnant, but we believe, as did Florence Nightingale and some other scientists of hygiene, that sunlight is cleansing. The best way to destroy germs or demons is to expose them. Further, it is instructive to recognise that, then as now, the boundaries between ideas about blood, religion and culture were as flexible or muddled as suited the protagonists of separatism and ethnic cleanliness. Science and pseudo-science are wonderfully flexible weapons. Hopefully, those who read these pages will recognise their offspring and be able to refute them.

Marc Colpaert’s paper, from a basis in officially trilingual,multicultural Belgium, explores deep thoughts about the nature and role of ‘diversity’, ‘self ’ and ‘other’. He explores, in a truly philosophical manner, the question of ethics, hospitality and culture in the aftermath of 9/11. Colpaert begins by considering the relationship between the hegemonic cultures of the West and Islam, and draws upon well-known philosophers, theologians and psychiatrists to begin a debate, which he, and we hope our readers, will find transformational. We cannot begin the process of transformation without considering where we are and how we stand in relation to others. In the process, we need to recognise that we too may experience pain and loss, but that should be a process familiar to allwho work in health and social care. We should therefore know how to help others and ourselves to come to terms with it. And thereby lies learning, in applying to ourselves what we expect of others.

Once we understand how we relate to others, we begin to know ourselves so much better and can move forward to new discoveries. But we need to learn to live with uncertainty, the unknown, and be prepared to be enriched thereby. The true hospitality lies in exchange, in reciprocity, not solely in giving. We can, Colpaert suggests, all be migrants or nomads, and undertake a migration of learning.

Culturally different non-migrant internal or national minorities can also be the objects of discrimination and exclusion. The paper by Iolo Madoc-Jones and Sarah Dubberley illustrates how bilingualism is not a simple matter. Indeed, the debate about the provision of language needs for health and social care in the UK has rarely considered bilingualism, which is a more appropriate approach for many than the usual refrain of ‘Why can’t they learn to speak English?’ or ‘Why can’t we have an interpreter?’. The Welsh, as the English find it hard to remember, are probably the largest territorially bounded linguistic minority in Europe. One in five of the population of Wales, in 2001, said they spoke Welsh. But their language has been maintained in secret, through religion, and against strong opposition: King Henry VIII banned its use in 1542 and it was only kept alive through Bibles and in chapels. The status of the language became debased, associated with immorality and barbarism; a plaint sometimes also heard from speakers of Sylhetti and Mirpuri, especially when they consider the relative prestige of the official state languages of Bangla and Urdu in Bangladesh and Pakistan respectively. The role, in other words, of language in maintaining identity cannot be denied. There are even terms or concepts that cannot be translated and others that encapsulate culture-bound health conditions or social structures: try explaining cul de sac to a Frenchman.

Naturally enough, this has particular resonance in mental health and, for older people, in rehabilitation and counselling work. Cognitive-behavioural therapy is highly dependent on the meaning of words. Consequently the monoglot practitioner is at a severe disadvantage, as is the patient he or she is supposed to be helping. But few health or social care workers have any awareness of the European Charter for Regional and Minority Languages or any training in these matters (for details, see https://conventions.coe.int/Treaty/EN/ Treaties/Html/148.htm). What is starkly revealed here is that this state of affairs exists even in a legally bilingual country such as Wales. All of this has resonance and a dreary familiarity to those championing the rights and needs of people whose background is non- English speaking. One hesitates to consider the needs of non-European language speakers in Wales. That said, neither should we forget that there are black and Asian Welsh speakers too.

There is, however, no end to the need for struggle: for evil to triumph, all that is necessary is for good (people) to do nothing. As this editorial was being concluded, people were gathering in Liverpool to mourn the explicitly racist murder of a young student, Anthony Walker. A string of speakers, including a Muslim imam and a Christian priest, council leaders and community representatives, stood up to say that no one, anywhere, should be killed for the colour of their skin or their membership of any religion. Unless we, health workers, academics and other believers in diversity, maintain that faith out loud and use our influence to ensure that society provides justice and equity in its health and social services, there are forces and groups who will seek to sow dissension and undo the gains of the past. Until that day, this journal will attempt to do its part by the provision of research, good practice evidence and debate to support that mission.