Book review, Divided: Racism, medicine and why we need to decolonise healthcare by Annabel Sowemimo
Reflecting on her own positionality as a patient, NHS sexual and reproductive health doctor, activist and academic, Annabel Sowemimo’s Divided is an eye-opening exploration of race and health.
Written during the Covid-19 pandemic, when the urgency of racial inequalities in health became impossible to deny, Sowemimo argues that it is crucial to understand the deep colonial history of modern medicine in order to move towards achieving more equitable health outcomes. She takes the reader on an honest and revealing journey of the history of eugenics, race science and colonialism to examine topics such as mental health, the justice system, global aid, education, and medical technology today.
Through this rich exploration, Sowemimo shows how racially marginalised groups have faced perpetual neglect and abuse at the hands of White people who, due to colonialism, were deemed the main creators of medical knowledge. Unsurprisingly, this has led to a deep distrust of healthcare systems, which are often seen as White spaces. In turn, White people are also viewed as the gold standard of what is ‘normal’; single measurements to correct for ‘Blackness’ have been embedded into medical practice, generalising across genetically diverse Black populations, and ignoring mixed ancestry. She includes multiple examples: spirometry uses race adjustments thus ignoring multiple factors which can impact lung function; pulse oximetry produces falsely high readings of blood oxygen levels for darker skinned people; skin redness is used as a sign of inflammation, which is harder to see on darker skin types; kidney function scores (eGFR) correct for Black patients by a factor of 1.2. She argues that reducing race to a simple binary equation against a ‘standard’ is harmful, and crucially, is not even the standard for the global majority.
The chapter on education within medicine provides particularly useful suggestions for moving forward. Every time we see implementation of a race correction, Sowemimo argues we should examine what evidence it is based on, whether it is justifiable, and how and if it is worsening existing racial inequalities. She also encourages integration of different racial groups within medical schools, to build trust and develop an inclusive, well-rounded group of professionals to deliver better healthcare. As so much of healthcare research is generated in the Global North, deciding what is included in the health curriculum and how to educate a new generation of healthcare providers is also vital to challenging the status quo, particularly because what is taught in the UK is hugely impactful on how people’s health is managed over the world. Education on the structural determinants of health, continuing to challenge our institutions, question their relationship with the Global South and build reciprocal funding arrangements to ensure we create spaces for them to share their expertise and knowledge, are fundamental.
A key takeaway from Divided is that we all have a choice: we can ignore the clear evidence of racial injustice in healthcare, or we can change. She asks readers to advocate for the health of others, as we would wish our own health to be advocated for.