Does racism exist in Irish healthcare? According to practitioners and students alike, the answer is an unequivocal 'yes'. The point, however, is that racism takes different forms. Often it is down to what is called unconscious bias. Sometimes, however, it is far more in-your-face – in every sense of that phrase.

Patients come first: this ethos is instilled in the minds of every healthcare worker. It is a guiding principle for the vast majority of those working in the healthcare sector.

For healthcare workers of colour, however, that essential ethical position can sometimes become a cross to bear, when patients turn abusive or act in an unintentionally racist way.

Anecdotally, we had heard that young students of colour, completing their internship programmes in the country’s healthcare system during the coronavirus crisis, were badly treated and made to feel inadequate.

Could this be true? The only way to find out was to speak to pharmacy and nursing students about their individual experiences of workplace racism. We also talked to a Paediatrician from Pakistan to see if prejudice based on race and skin colour extends to those writing the prescriptions.

You Look French To Me!

The issue was brought to the attention of Hot Press when we spotted an article by Aaron Koay (pictured), a final year Pharmacy student in Trinity College Dublin (TCD), published in the student publication Trinity News. It outlined Koay’s experience, and that of other students of colour, in Ireland.

A thought-provoking piece, it was also published in the IPU Review, Ireland’s official pharmacy publication.

A shock of black hair covers Koay’s forehead. Naturally shy, he wears a tiny, hoop earring in his left ear and a dimple appears on his right cheek when he smiles.

An overachiever in his home country of Malaysia, he was offered a scholarship to study in a western country. He chose Ireland, having weighed his options carefully. “I thought Australia and New Zealand were too close to home. I wanted to study in Europe," he said.

Racism, he had heard, was raging in the UK.

His on-campus experiences have mostly been pleasant, though he confesses that he tried hard to suppress his accent.

“When I first came here, I was always trying to fit in, and not make myself stand out,” he told me.

Aaron is Koay’s Anglo-Saxon name. Most Asian students have one: it makes living abroad easier for them. Koay cites an American study which recently revealed that CVs sent out under Anglo-Saxon names have a 50 per cent higher chance of being selected by employers than those sent out under African or Asian names.

In many cases, researchers say, it is unconscious bias rather than racism which prompts employers to stick to what sounds familiar.

One time on campus, a woman asked Koay if he understood English, merely because he paused a few seconds before answering her question.

“I was like, yes, I’m a student here,” he said.

Koay speaks fluent English. By now, however, coming to the end of his work placement programme at a pharmacy in Dublin, he is used to people questioning his mastery of the language.

“Can I get someone who actually speaks English,” one patient at the pharmacy recently jeered.

“I’m from Malaysia, but ethnicity-wise I’m Chinese like my grandparents were Chinese,” he explained. “Chinese is one of the major ethnicities in Malaysia. And people would just assume that I speak Chinese. As it happens I do, but I can't start talking to you in French saying, 'you look French to me’.

“When I said it to someone, she just kind of laughed. A lot of people say, 'Oh, they're just trying to be friendly’.”

Another Pharmacy student, Aghogho Atiyota – a former Ethnic Minorities officer at Trinity – told Hot Press that he has seen students of colour struggling to book and organise cultural events.

Aghogho, who is of African descent, also made the point that course modules are focused on diseases prevalent among Caucasians, like ‘skin cancer and liver disease’. The effect, he observed, is that he's being trained in how to serve white people.

“I want to be informed about ethnicity and backgrounds and their links to various diseases,” he said, “not just learning about liver disease and skin cancer which mostly affects Caucasians.”

Coronavirus Racism

The coronavirus was first identified in the Chinese city of Wuhan. Bigots across the world, now blame Chinese people for the health crisis, and in practice this fresh hostility towards Chinese people extends to all Asians. As Koay points out, some refer to all Asian people as Chinese.

US President Donald Trump has also frequently referred to the coronavirus as the ‘Chinese virus’, fanning the flames of racial divisions. Later he justified his choice of words to reporters, saying that he meant to debunk conspiracy theories that suggested that the American military was the source of the outbreak.

With that as background, Russel Jeung, a professor of Asian-American studies at San Francisco State University,set up a website dedicated to documenting incidents of hate crime against Asian-Americans during the coronavirus crisis.

There have been over 14,000 reports of Asian people being spat on, hit or shouted at – and accused of carrying the virus – since the pandemic started.

Koay revealed that he had been scared to wear a mask. He had read accounts of attacks on mask-wearing Asians. The young pharmacy student is also critical of western media, accusing newsrooms of covering the crisis thorough a lens of ‘white bias’.

The prime minister of New Zealand, Jacinda Ardern, he said, has been extensively praised for managing the crisis seamlessly. Her Taiwanese counterpart Tsai Ing-Wen – another female leader – successfully dealt with the epidemic back in May, but received very little media coverage.

“It’s like there is this big gap in the world’s map,” he said. “It’s like something missing from it, you know what I mean?”

Code of Conduct for Patients

Back at the pharmacy, it is distressing that some people try to avoid dealing with Koay or ignore him as soon as his white colleagues appear.

“I was talking to a patient the other day,” Koay recounted. “Everything went well. I was talking about the prescription, I was like, ‘do you need all these items’ whatever. You know, my [white] colleague had been on her lunch break –and as soon as she came out, they started talking to her. I was like, okay, they don’t need me anymore.”

Koay said the internship was his first time facing the Irish public, away from Trinity’s multicultural ‘bubble’. Asked if he might refuse service to a patient who treats him with prejudice, he shook his head.

The Code of Conduct for pharmacists says that practitioners have a responsibility not to allow their ‘personal views’ to get in the way of care. “Always put the patient first,” it states “and make their health and safety your primary focus. Make sure patients’ needs are recognised, assessed and responded to and that their dignity is preserved and their values respected.”

Koay is hoping that relevant bodies will now draw a parallel code of conduct for patients, which would ensure that healthcare workers are not faced with racial prejudice.

Darragh O’Loughlin, the General Secretary of Irish Pharmacy Union (IPU), told Hot Press that pharmacists also deserve to have their dignity preserved. It is, he added, up to the HSE to draw a code of conduct for patients.

“Racism is inexcusable in all circumstances,” Darragh said, “and pharmacists and other health professionals, like all workers, are entitled to practise their profession and live their lives free from harassment, aggression and abusive or threatening behaviour.”

Joanne Kissane, Director and National Co-ordinator of Affiliation for Pharmacy Practice Experimental Learning (APPEL), which oversees the placement of pharmacy students in Ireland, told Hot Press that the organisation works to ensure that all trainers are ‘accredited’ and supportive.

“The APPEL team implements an extensive quality assurance contact programme of support and engagement throughout each placement,” she said, “where both students and their Trainers are contacted on multiple occasions throughout each placement. Issues raised are comprehensively addressed as part of this programme.

“APPEL does not condone racism or discrimination against students at any point during their college experience, including their learning placements.”

When the Patient Becomes the Bully

Damilola (Dammy) Olaniyi and Temi Adefeko, are two Irish nursing students of African background, attending TCD. They are finishing their placement programme at a hospital during the health crisis.

Both of them have experienced racism and sexual harassment on a more or less daily basis.

Adefeko, an ever-smiling young woman with long black hair, whose mother also worked in the healthcare sector, said one patient hit her in the chest and called her the N-word.

"But the care still has to be given. It has to be done," she said. “I got boxed in the chest by someone who told me ‘don’t touch me, Blackie’. I used to get upset, but you get to a stage where you just kind of give up, you’re like: ‘whatever’.”

Most of the racial abuse, they admit, comes from patients with dementia or people grappling with alcohol addiction. Adefeko and Olaniyi believe that when extreme prejudice is manifested in people with dementia, it reveals a suppressed racism, which is unleashed due to the brain's decreased ability to control behaviour.

“People just brush it off,” Olaniyi smiled, “saying ‘Oh, that’s just dementia speaking’. It’s weird because the implication is that they weren’t racist before, and now they suddenly are.”

Adefeko said that one patient being treated for alcohol addiction kept probing her as to why she was living in Ireland.

“She was like, ‘You came here because there was a war in your country? Are you an asylum seeker?’ which I’m not, we just migrated here,” she said. “And she was like, ‘If you touch me, I’m going to scream’.”

Olaniyi said some patients also ask to touch her hair, an experience that makes her feel self-conscious and ‘othered’.

Sexual aggression is also a serious issue. "I'm just basically desensitised to all of it," Olaniyi said.

"My breasts have been literally grabbed,” Adefako recounted, “and the patient said, 'hop on to the bed with me'. It's usually old men who have done it. But the care still has to be given."

Olaniyi recalled dressing a man who then asked for a kiss. Even in sexual harassment, there is an element of racism.

Adefeko once refused a man’s sexual advances only to hear him whisper under his breath, ‘All right, you’re just a black nurse’.”

Not Our Job to Educate White People?

After the killing of George Floyd in America and the subsequent worldwide reckoning over race, both young nurses felt the weight of people’s eyes on them. Some of their white friends reached out, asking for education.

“It’s really not our job to educate white people,” Adefeko said. "When this whole thing started, I was in the staff room, and people started bringing it into conversation 'Did you see George Floyd? Did you see it? It was horrible, wasn't it?' And they were all looking at me to add to the conversation.”

Black people in Ireland have told their stories, the young women said. They now want only to be treated equally with every other Irish citizen. On the face of it, it is a simple request.

Adefeko and Olaniyi added that the seemingly innocuous question 'Where are you from' often turns toxic: for them, it is always followed by, ‘No, where are you really from’? Sometimes, it’s the small things that hurt the most.

"I think people need to educate themselves about microaggression,” Olaniyi said. “If a policy was made around addressing that it would be very helpful."

The word ‘microaggression’ was first used by Dr Chester M. Pierce, a professor of Education and Psychiatry at Harvard University, in the 1970s.

However, the recent popularity of the term is attributed to the work of Dr Derald W. Sue, a psychology professor at Columbia University. In a 2007 academic article, he broke down the word into three categories: microassaults, microinsults and microinvalidations.

Dr Sue also wrote a book on the subject called Microaggressions in Everyday Life: Race, Gender, and Sexual Orientation.

A tone-deaf inquiry regarding someone's ethnicity is considered to be a micro-aggression. A conversation about a foreigner’s ability to speak English without an ‘accent’ can be as well.

The Reality of State Racism

For Mohsin Kamal (pictured, below), a Paediatrician recruited from Pakistan to serve in the Irish healthcare sector, racism is embedded in the system.

Dr Kamal, who works in a Dublin hospital, told Hot Press that – bizarrely – the current laws exclude him from up-skilling from the rank of a medical registrar to the position of consultancy. Year after year, Dr Kamal trains students who will rapidly move up the medical ladder, in a way to that his nationality disallows.

“My most difficult thing to overcome was being born in Trinidad,” V.S. Naipaul, a Nobel Laureate in Literature once said.

Dr Kamal, who is personally warm and calm, said he couldn’t agree more.

“I’m doing research,” he said. “I’m doing clinics, I’m doing presentations, I’m teaching the students, but I’m not equal. It doesn’t make any sense to me, I don’t know how it makes sense to them. I think it’s just because I was born in Pakistan, that’s the only reason I can think of.”

According to a 2019 medical workforce report, non-European graduates comprise about 43 per cent of the current HSE NCHD workforce. Yet equal training opportunities are not available to them.

The World Health Organisation (WHO), urges countries to "observe fair recruitment practices and ensure equality of treatment of migrant and domestically trained health personnel."

Dr Kamal said he is proud that he has gained a wealth of knowledge while working in the Irish healthcare sector, but what he describes as the ‘systemic discrimination’ within the HSE frustrates him.

Training spots, he said, are offered based on candidates' nationalities rather than their professional fluency and academic qualifications. Meritocracy is non-existent, he said.

Migrant doctors already seeing patients are also required to repeat English language exams when seeking training opportunities, like when they apply for Basic Specialist Training (BST).

The UK authorities, with all their reputation for racism, Dr Kamal said, provide equal training opportunities for doctors, regardless of their nationalities.

"The NHS has acknowledged the importance of doctors, and they are accommodating them very well,” Dr Kamal said. “They have changed their laws to give equal training opportunities to everyone – and for doctors training is very important. It makes us better doctors, but it also puts you in a position that you can be a consultant at some stage."

Dr Kamal and many non-European doctors within the HSE are asking the State to quash discriminatory laws that prevent them from applying for BST and other forms of up-skilling.

When asked might he leave Ireland for the UK, Dr Kamal said that his daughter has grown used to the country, and he doesn’t want to uproot her.

Dr Kamal is also on a Stamp 1 visa, which means he needs to renew his permission to stay in Ireland every six months.

“It’s very stressful,” he offered. “It’s even hard to get a visa appointment online.”

The new Minister for Justice, Helen McEntee TD, recently announced that non-European immigrants living in Dublin can now renew their permissions to stay in the country online by uploading the relevant documents via the Irish Immigration and Naturalisation Services (INIS) website.

Dr Kamal is hoping that the new minister will also grant long-term visas to essential workers like himself.

“I have never experienced racism from patients,” he stated. “But the Irish healthcare system discriminates against non-European doctors.”

It is, it seems, as simple – and as crude – as that.

• ENDS

WHY IS RACISM NOT MENTIONED?

The HSE has a policy against workplace harassment. But the charge is made by student nurses, Dammy Olaniyi and Temi Adefeko, that it fails to acknowledge the existence of racism.

The official counter-view is that incidences of racism are covered, even if the word is not employed.

“The HSE is committed to creating a safe environment within which to work or to be treated,” a spokesperson told Hot Press. “The HSE does not tolerate verbal or physical harassment in any form by employees, service users, members of the public or others.”

The emphasis is placed on the phrase ‘in any form’.

The HSE’s policy document on the Prevention and Management of Work-Related Aggression and Violence is 21 pages long. However, the word racism doesn’t occur even once there.

“The Health Service Executive,” it states, “has adopted the EU definition of work-related aggression and violence as: ‘Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health’.”

The HSE also has a Dignity at Work policy whose aim is to ensure an environment that is “free from all forms of bullying, sexual harassment and harassment.”

It points out that workplace harassment and bullying can hamper “employee morale and can result in absenteeism, stress-related illnesses and higher turnover of staff.”

“The Dignity at Work policy,” it says, “covers sexual harassment and harassment as outlawed by the Employment Equality Acts 1998 to 2008 and workplace bullying and reflects the experiences of both employers and union representatives in dealing with complaints of bullying and harassment.”

Still, no mention of the word racism, Adefeko and Olaniyi say.