Academic Highlights: Pathways forward

Besson (2021) Confronting whiteness and decolonising global health institutions

by Hiwot Getu

Drawing on two of the Lancet Series ‘Confronting the consequences of racism, xenophobia, and discrimination on health and health-care systems’ key principles aimed at confronting the consequences of racism, xenophobia and discrimination (the need for decolonisation and increased diversity and inclusion within global health systems) this review looks at Besson’s perspectives piece ‘Confronting whiteness and decolonising global health institutions'. Besson challenges the general lack of tangible anti-racism efforts within global health institutions.  They advise that, to achieve meaningful decolonisation of global health and accompanying equality, diversity, and inclusion (EDI), that surpass the surface level, a collective awareness of the role that power and the social construction of whiteness plays, within contemporary global health architecture, is required by all global health personnel. 

Besson's excavation of the deeper layers of 'power' and 'the social construction of whiteness', informed by critical colonial discourse, highlights power and whiteness as historically conditioned and inextricably linked; a dual force which persists to influence contemporary global health. The residual impact of historically rooted racial hierarchy, in which the social construction of whiteness is '...the neutral and best way of being human...' is observed present in the functioning of global health institutions, affecting components of social justice, including knowledge co-production, ‘agency for non-white people’, equal resource allocation and equitable healthcare delivery.  

The contemporary global health setting is mechanised by Western codification and Western cultural superiority, due to the historic naturalisation of whiteness as ‘normal’ and the racial marking of other groups and cultures as divergent and inferior. Besson advises that this phenomenon is adversely shaping and limiting the scope for equality, diversity, and inclusion in global health, resulting in static and false stereotypes of race and ethnicity which steer contemporary research priorities. Such stereotypes stigmatise racial health disparities experienced by minoritised people and culminate in discriminatory healthcare responses which problematise minoritised cultures as the source and cause of health issues experienced. 

Barriers to knowledge co-production appear evident. Besson highlights a reality within global health academia, whereby the influence to conform to ‘the unexamined promotion of a set of sociocultural competencies…’, ‘perceived proximity to whiteness…’, and ‘…the myth of Black exceptionalism…’ can determine the advancement of minoritised scholars, at the cost of denying and excluding multicultural heritage. This serves to misconstrue the right to knowledge co-production and equality, diversity, and inclusion as conditional, characterised by a superficial depth which can be ‘weaponised as proof of good intentions’, and ‘…evidence of progress…’ by institutions. Besson notes the interdependency between the fear to address racism, due to potential backlash, and Western denial and fragility within global health institutions. 

Against a canvas of ‘racial unconsciousness’ within the global health setting, the historical social construct of whiteness continues to manifest under its guise of ‘invisibility’, impacting vast areas of contemporary global health. The end of Besson’s perspectives piece appears resolved with a solution that, decolonising global health will only be possible if all people ‘… “free” ourselves from the idea of the innate superiority of western culture and research paradigms’. 

Alsan, Marcella, Owen Garrick, and Grant Graziani. 2019. "Does Diversity Matter for Health? Experimental Evidence from Oakland." American Economic Review, 109 (12): 4071-4111.

By Rachel Ibikunle

In the United States, male African Americans are thought to live on average 4.5  fewer years than non-Hispanic White men - the shortest life expectancy of all ethnic groups. The underlying reasons are multifactorial but up to 60% of the gap in life expectancy between Black and White men is due to chronic diseases. Preventative screening is an effective way of reducing the risk of developing chronic diseases. Subsequently, at least part of the mortality disparity is due to the underutilisation of preventative health care services. 

Prompted by this data, Alsan et al’s study aimed to assess the impact of the doctor’s race on the uptake of preventative services among African American men in Oakland, California. 1,300 black men were recruited from 20 barbershops and two flea markets, where they completed a baseline questionnaire. All participants were given a voucher to use at the clinic to receive health screening. For the purposes of this study, a clinic was set up and 14 both Black and White doctors were recruited. All doctors were otherwise balanced in age, experience, and medical school rank.

The study proceeded in two stages at the clinic. At stage one, participants (in private) learnt of their randomly assigned doctor via a tablet showing both a photo and text. The participants were then provided with the choice between four services: Body Mass Index measurement, blood pressure measurement, diabetes screening and cholesterol screening. In the second stage, the participants had a consultation with their randomly assigned doctor. At this point, participants had the opportunity to change their choices of preventative services. The study showed that at stage one, there was no difference in uptake of the four preventative services between those assigned to a Black doctor and those assigned to a non-Black doctor. However, at stage two, participants assigned to a Black doctor were much more likely to choose all of the preventative services, than those assigned to a non-Black doctor. The findings suggest Black doctors could reduce the Black-White gap in cardiovascular mortality amongst men by 19%.

The glucose and cholesterol screening were more invasive services than the other two services as they required a blood test and the authors felt they required a higher level of trust in the doctor. Interestingly, uptake of also increased for those assigned to Black doctors.

There are limitations to this study as there are many potential biases. Although the participants and doctors were not told that the study was focusing on ethnic concordance, they were told it was to improve the uptake of preventative services in men, which may have impacted on the results. Participants who were more positive about screening services at study outset, may have chosen to take part. 

Moreover, the participants who attended the clinic, it could be argued had different ‘health seeking behaviour’ which could have skewed the overall results as they were noted to have been more likely to be unemployed, have significantly lower self-reported health, were less likely to have a primary care physician, and were more likely to have visited the emergency room than those who did not attend the clinic. 

It is also important to note that these results were seen within a controlled research environment and within preventative services, so it would be important for future efforts to observe if the same effect is seen in a standard setting and with curative services. 

The study provides important insight into one possible way of increasing the uptake of preventative services as a means of reducing the subsequent ill health and reduced life expectancy of African American men compared to their White counterparts. Physicians in the US are predominantly White, and so offering ethnically concordant care to serve the diverse population, and those individuals who may want this, is not currently a feasible option. These findings provoke conversations about the wider issue of diversity in graduate education and the workforce, as well as ensuring services are set up to be culturally appropriate to meet the needs of the population in both concordant and discordant patient/doctor relationships. These efforts will help progress towards health equity.