Address by A. Sivanandan to the King’s Fund’s Consultation for Black health workers following the NHS and Community Care Act (1990), which began the dismantling of the National Health Service. (Race & Class, 34/4, April 1993)
I was not sure, when I was first asked to speak to you today, of what use I could be to you in your deliberations, what contribution I could make. For you, after all, are the people who deal (in one way or another) with the everyday problems of health care, you are the experts, the people on the ground.
But the more I delved into the literature on the subject, not least in the papers and proceedings of conferences that the King’s Fund itself has already been involved in, the more I became aware that there were two things missing from the study of the subject – or, if they were there, they were there as aspects of the problem you were studying and not informing the study of the subject itself.
One was the way in which the health of Black people was understood and the other was the way in which the term Black was understood, or, rather, not understood.
My talk, therefore, is concerned with these two aspects: (a) the meaning of health to Black people: what does health mean in a racist society, a society that, in stereotyping Black people, stereotypes their health? and (b) the meaning of Black to health people: what does Black mean in terms of the fight against racism in this country, and how does it apply to the administration of health under the new dispensation?
Unless we get that right, we are not going to get our battle lines right. Unless we see Black people’s health as a fight for resources, a fight for correct diagnosis, a fight for correct treatment and care – as a fight for Black people and, therefore, for society as a whole — we will end up by being the servitors of our own servitude, mere instruments (in a PR exercise) in the Tory strategy of marketing health and denigrating care.
To take my first point first. What does health care mean in a society where racism is endemic, where health itself is sick unto racism? What does the study of the health of Black people involve in such a society?
Hitherto, the way that the subject of Black people has generally been approached has been from the point of view of health, as an aspect of health, a question of health – health subdivided by Black. Health and care and everything that goes with them (diagnosis, prognosis, treatment, medication, etc.) are givens within which you look at the Black condition; they are the given frame of reference, which need not be questioned, which need not themselves be screened for racism.
But, in a racist society, in a society where everything is coloured by anti-black bias, it is important-and, I would say, primarily important — that we look at the impact of that bias on the frame of reference itself, if we are not to carry that bias through to the study of the problem. We need to look at the impact of that bias in the disciplines through which we diagnose disease if we are not to carry that bias through to treatment and cure. In other words, if the tools with which we analyse a problem, diagnose a disease, are themselves biased, the problem, the disease, becomes that much more compounded and the solution, treatment, that much more irrelevant, harmful and dangerous.
You have only to look at the whole field of psychiatry to see how diagnosis, mis-diagnosis, based on racial stereotypes has proved fatal. We at the IRR have recently published a book about Black deaths in custody, and a number of these, we found, arose from ‘sectioning’ young African-Caribbeans under the Mental Health Act and/or diagnosing them as schizophrenics.
And both these arise from a double set of racial stereotyping: (a) that young Blacks who react to racial oppression by being defiant of authority or, like the Rastas, refuse to recognise it, are mental and should be sectioned, and (b) that young Blacks who are so sectioned are often suffering from schizophrenia – for African-Caribbeans are, genetically or because of West Indian family and/or child-rearing patterns or some cultural or ethnic deficit, prone to schizophrenia.
Take the case of Richard ‘Cartoon Campbell, a 19-year-old Rastafarian who was arrested for allegedly breaking into a sports shop. When taken into custody, he refused to give his name or to be finger printed, and claimed in court that he had been ‘framed’ by the police. Such defiance and refusal to recognise those in authority as a matter of principle is commonplace among Rastafarians. But the magistrates referred him for psychiatric reports. He was diagnosed as schizophrenic, because of ‘socially inappropriate behaviour’ (which included references to the starving of Africa and looking out of the window when being spoken to). At Ashford, where he was on remand, he was given major tranquillisers. He went on hunger strike and became very weak. Officials, who deemed him to be a dangerous and mentally sick man, preferred to keep him at the remand centre rather than take up the offer from a local hospital that he recover on a medical ward. A decision was made to force-feed him and, five days later, he was found dead in his cell where he had choked in the night.
When it comes to young Black men, little attempt is made to seek the cause of a patient’s behaviour in his particular history or the anomie visited on him by a racist society. Instead, the illness that may have been caused by the individuals inability to bear the brutal brunt of racism is further compounded by the racism implicit in the diagnosis and cure. Racial diagnosis overrides clinical diagnosis, and the patient, so far from getting the care he needs, is even further entered into a syndrome of uncaring from which his illness first sought escape. Racist stereotypes which British culture finds a laugh on the Jim Davidson and Bernard Manning shows are no laughing matter in Broadmoor and Ashworth.
How much of psychiatry is, ipso facto, biased against African Caribbeans? How much of maternity and post-natal care is biased against Asians? How does racism get refracted through the disciplines to treatment and cure? Because there is no such thing as pure medicine, only applied medicine, the disciplines through which we look at problems of health amongst Black people should themselves be voided of racist bias before they can be of any use to Black people.
But this, in turn, would require us to look at the outlying organisations, structures, bureaucracies that surround and predicate the way in which such disciplines are taught and applied, the way in which the health and care of Black people are treated.
And this, of course, leads to the even wider question of the social pathology of the diseases in which Black people are caught. By this, I mean the stresses, the pressures, the illnesses conditioned by unemployment, bad housing, poor schooling. Nor am I talking of the Black middle class, people like you and me, who are comparatively well off, but of the denizens of our inner cities who have been locked up and forgotten in Thatcher’s benighted Britain, and only become visible when they break out of their impossible lives and burn their own places down.
Black health, therefore, is not an isolate that can be studied and remedied on its own terms. It’s also tied up with the social and economic conditions, themselves determined no little by racism, in which Black people live.
Asthma in Tower Hamlets adjoining the docklands is not an Asian disease, but something that has been brought about by the destruction of their environs for the construction of yuppiedom. In another part of the East End, a hospital found that Asian mothers often did not turn up for long-awaited appointments for their deaf children. It was assumed that these mothers were too uncaring, too much part of peasant culture to appreciate the value of a specialist and modern equipment. But the reality was that these mothers lived on council estates where the incidence of racial violence was so high that they dared not leave their flats unattended for even a few minutes, let alone spend a day at hospital. Any attempt to look at Black health, therefore, must go beyond the narrow confines of specialisation of health and medicine and take on a much more challenging and holistic perspective.
If my first approach to the subject, then, is from the perspective of health, my second and complementary approach is from the perspective of Black. And it is absolutely important to get this right because, more and more, the health of Black people is being understood in ethnic and cultural terms – in terms of people’s origins (despite the fact that they have now lived here for over a generation) and not in terms of: (a) how those origins –cultural, ethnic – have themselves been traduced and transformed by British racism; (b) how that racism itself has traduced and transformed the original ethnic diseases’; and (c) how racism throws up its own illnesses, both physical (such as asthma, dermatitis and hearing loss, deriving from ‘black’ working conditions) and mental (such as depression and breakdown, deriving from racial harassment).
A Black perspective is not just an ethnic perspective or a cultural perspective, but an anti-racist perspective. And it derives not from some abstract academic definition, but from the living struggles of African-Caribbean and Asian working people in this country, in the 1960s and 1970s, against an undifferentiated and brutal racism. And it denotes a common unity against a common oppression, forged in a culture of resistance and producing a sense of community.
Some of you, I am sure, are familiar with that history, but it might be useful to recap some of its high points to see what perspectives we can bring from it to our understanding of what constitutes Black health.
We were brought here, as you know, to do the low-paid, menial, dirty work that white people no longer wanted, or had, to do in Britain’s post-war reconstruction. But it was our labour that was wanted and not us. So we created a whole Black infrastructure of our own to meet the needs of Black settlers who were excluded by racism both from statutory services and from the labour movement. For example, we set up our own Black churches, our own Black workers’ organisations which first held their meetings in barbers’ shops and works’ lavatories, our own Saturday and supplementary schools to offset the racism of the schooling system which bussed our children out of their neighbourhood and relegated them to ESN schools (schools for the educationally subnormal).
At different points in our forty-year struggle in Britain, different groups were at the forefront of exposing systemic racism and creating alternative services. In the earliest period, it was the Black political parties which ran our affairs, helped create Black media and Black resource centres in the community. During the 1970s, it was Black women’s groups which were at the forefront of the struggle, putting new issues which affected the Black family – such as health, contraception, internal immigration controls, treatment of psychiatric patients and prisoners – on the political agenda. It was then that the Black Health Workers’ and Patients’ Group was formed and a Black health bulletin created. Later in the 1970s, it was youth groups exposing fascist harassment and police violence which campaigned for the right to self-defence. (Of course, many of these gains were set back by government policies of, first, multi-culturalism in the late 1970s and, later, by the ethnic perspectives and so-called equal opportunities programmes ushered in after the Scarman Report on the 1981 uprisings.)
What, then, are the lessons that we can learn from that history? Firstly, we learn that a Black perspective is a holistic perspective which takes in the whole of society. Secondly, that a Black perspective is an anti-racist perspective and not a cultural or ethnic perspective. A Black perspective challenges a racist system, a cultural perspective finds accommodation within it. Finally, a Black perspective is a community perspective and not an individualistic one. Black unites, ethnicity divides.
How, then, from such a Black perspective, do we look at the changes taking place in the National Health Service and how do we meet the challenge? Let me touch on some of the more obvious changes that the present set-up poses to Black people and to working-class people as a whole.
For one thing, the whole language in which the new dispensation is cast is Tory-speak, market-speak. Providers, users, purchasers, consumers. It is the language of the market-place, the buyers’ and sellers’ language, denoting the language of money.
The one place in an individualistic, selfish, self-seeking society where people matter, where use value and not exchange value is paramount, is now being turned into an accountant’s playground.
How on earth can all consumers be grouped together? Already, the rich consumers are leaving and the poor consumers have no effective demand, no effective choice. If you have no money, no pull, no clout, you have no choice. You are an ineffectual consumer.
Besides, the word patient has a sense of obligation on the part of the doctor and of the hospital and promises a mutual relationship. What relationship has a consumer with a shopkeeper? Or a provider, as they now call it. Provider, what a horrible word. Words like ‘hospital’, “hospice’ carry a sense of hospitality, asylum, refuge, solace. Provider sounds like a service station for spare parts -except that providers who opt out, I suppose, can become department stores.
And not only is the language of service the language of the market place, but so is the notion of accountability. Accountability in the new set-up is not to patients, but to the Family Health Associations and, in the final analysis, to the accountants. You are accountable upwards, not downwards, which, of course, is Tory democracy. All of which gives a whole new meaning to the word accountability. Accountability: accountable to accountants.
I don’t know much about GPs and the targets’ for preventative medicine and screening procedures being set by the government, but I suspect that it will mean that GPs will begin to refuse to take on to their books patients from those groups which they think might stop them meeting their targets. And such market considerations will, in effect, turn passive prejudice into active discrimination. At the same time, this whole thing about ethnic monitoring of users, getting the ethnic low-down on patients (always suspect in a racist society), seems to me to be a marketing exercise, an exercise in market relations to facilitate ethnic markets which can only lead to an ethnicisation of health, a ghettoisation of disease.
Given such a set-up, it is inevitable that the government would want to develop a coterie of ethnic health workers and organisations, both statutory and voluntary, who will cover up the black holes in their scheme. And that I dare say is why some of your organisations are going to figure a little larger than life in their plans.
But British governments, of whatever hue, have always done this: set up buffering institutions, created a Black middle class to sell out the poor Blacks, set up whole tranches of Black experts, Black spokes people, as a PR exercise – hiving off Black expertise from the community in the process and leaving the community defenceless — dividing Blacks into cultural and ethnic groups and divesting them of the effective, meaningful choice that only community clout can restore.
And we must say ‘no’ to that. We must say ‘no’ to the cultural and ethnic interpretations of health which treat the symptoms and not the disease. The disease is racism. And Black is the scalpel we bring to the tumour, the cancer, of racism.
The question you Black health workers have to ask of yourselves, therefore, is are you Black first or professionals first? Are you Blacks who happen to be professionals or are you professionals who happen to be Black? A professional who happens to be Black is, at best, a mercenary on hire to his or her people, a Black who happens to be a professional is a soldier in the people’s army. The choice is yours.