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Discrimination within the UK’s healthcare system could be one of the reasons south Asian people are disproportionately affected by coronavirus, doctors have said.
South Asian women, in particular, have been known to complain about being dismissed by doctors who claim they are suffering from the so-called “Mrs Bibi syndrome”, also known as “Begum syndrome”.
Derived after the common south Asian surnames “Bibi” and “Begum”, it refers to an imagined condition where south Asian women are said to exaggerate their health complaints despite showing few objective signs of ill health.
This “medical racism” can make patients reluctant to open up to doctors and lead to neglect of health conditions, putting them more at risk from coronavirus.
Research by Public Health England has suggested people of Bangladeshi ethnicity were twice as likely to die as those who are white British.
A separate study showed south Asian people had a 19% higher chance of dying in hospital in the UK from Covid-19 than white people.
Researchers say that risk is partly due to high levels of diabetes in the south Asian population.
Statistics such as these have not come as any surprise to Prof Sunny Singh – the creative writing and English literature lecturer hasn’t seen a doctor or visited a surgery in the UK in 15 years. “I do not trust the NHS,” she said.
Instead, she goes to India to get full medical checks or Skypes with her doctor in India to get prescription medicine.
Her decision to eschew healthcare in Britain stems from early experiences of doctors here who “ignored or dismissed” her concerns. It’s an experience that many people from Black, Asian and minority ethnic (BAME) communities can relate to – especially women.
Although often passed off as casual “banter”, racist and sexist stereotyping that “brown women complain about pain a lot” has the potential for very real health consequences. If her grievances are being dismissed as being exaggerated or fabricated, then her doctor risks misdiagnosing or overlooking a genuine problem.
“I’ve been told that because I’m South Asian I’m a hypochondriac,” Singh told HuffPost UK. “It’s happened on multiple occasions.”
Dr Harun Khan, who has previously written about the stereotype, says the problem is in part due to the class disparity between doctors and patients. A 2016 report in the British Medical Journal found only 4% of doctors in the UK came from working-class backgrounds.
“This clear difference between ‘us and them’ on the wards creates a space for discriminatory stereotypes, targeting solely BAME patients, to exist,” he said.
Khan describes a moment when a senior doctor mockingly referred to this “syndrome” while describing a patient – the woman was then discovered to have an acute finding on her CT scan which required elective surgery.
He said he had only ever heard this syndrome being referred to in a derisive way, adding: “It’s more common than you think.”
“If someone is coming with a bias or perception of you before you’ve even presented yourself, it inherently impacts the doctor-patient relationship,” he said. “From the patient’s point of view, it can be quite dehumanising to not be listened to.
Dr Salman Waqar, a research fellow at Oxford University’s Nuffield Department of Primary Care Health Sciences, agrees “there are issues around preconceived ideas of health professionals and their patient’s presentations – we all have them.
“BAME patients do also report poor satisfaction with their GPs compared to white patients,” he told HuffPost UK.
These experiences can exacerbate “acculturative stresses” that come from being part of an ethnic minority community and that are “probably exacerbated by the intersection with gender and faith, especially for Muslim women.”
“When you add to that this narrative of ‘othering’ minorities that we have all internalised, it’s highly likely that south Asian women from unprivileged backgrounds and in poor health will be on the back foot to begin with.”
Gender and language can also play a factor in creating this “dissonance”, where a vulnerable patient may struggle to articulate and advocate for herself to a physician.
“This is particularly true however in chronic pain – where this Bibi/Begum Syndrome originates from, of all over body aches in a middle-aged south Asian woman,” Waqar added.
He argues the inequalities of higher rates of diabetes, heart disease and conditions that put a person at greater risk of coronavirus are “to a large degree socially patterned, rather than as a result of a genetic disposition”.
“If patients feel like their practitioners have not listened to them they will be reluctant to open up,” he continued. “And in relation to Covid-19, there certainly are pockets of the population who are scared about seeing anyone.”
Trust is absolutely critical in a doctor-patient relationship. If a patient feels like she is not being heard or understood, she may very well choose to avoid seeing doctors altogether – like Singh.
Her experiences with doctors in the UK were “infuriating” and “frustrating”. “Mostly it’s just fury,” she said. “Come on, I should just be able to get proper medical care without dealing with this kind of stupidity.”
“It’s the kind of thing you have to wind yourself mentally up to go down to the surgery to get a check-up, to work up the emotional energy for that potential for bullshit.
“I just don’t have the energy.”
She admitted the pandemic had left her “slightly concerned”. “I’m thinking now: what do I do if I get sick? I just do not trust the NHS.”
Dr Fizzah Ali, a neurology doctor who has also written about the “syndrome”, says that while “conscious bias is not compatible with a career in medicine”, the casual clinical stereotype can cause unconscious bias in doctors which could lead to missed diagnoses, delayed treatment and preventable unwanted outcomes.
In the US, implicit bias has led to African American women being less likely to be referred for invasive cardiac procedures despite being at an increased statistical risk of cardiovascular disease.
“These unrecognised biases and associations can alter our perceptions and behaviour,” Ali told HuffPost UK. “It could potentially affect clinical decision making.”
“Medical racism is not an unknown phenomenon,” said Singh, who has tweeted about the subject on several occasions. “It’s not just doctors who deal with it, it’s about medical research and practice.”
The impact of that on south Asian women, she says, is “huge”. “It’s everything from as major as reproductive health to something as small as vitamin D supplements – it’s part and parcel of healthcare in the UK.”
She points to the studies linking coronavirus deaths to high levels of diabetes, hypertension and heart disease – conditions that people with south Asian backgrounds are at higher risk of developing.
“Part of that must be a genetic propensity,” she said. “The rest is to do with our lack of access to healthcare and racism.”
An official PHE inquiry suggested racism and discrimination were some of the “root causes” to these high death rates from coronavirus in BAME people.
The PHE report described the relationship between ethnicity and health as “complex and likely to be the result of a combination of factors”, including that BAME communities are more likely to live in urban areas, in multigenerational households, in poorer and deprived areas, and occupy key worker roles that expose them to higher risk of Covid-19.
“The unequal impact of Covid-19 on BAME communities may be explained by a number of factors ranging from social and economic inequalities, racism, discrimination and stigma, occupational risk, inequalities in the prevalence of conditions that increase the severity of disease including obesity, diabetes, hypertension and asthma,” the report concluded.
The truth is not one single factor can explain why south Asian people are almost 20% more likely to die of coronavirus in hospital than white people.
Ali, Khan and Waqar all agree we need to look beyond the current pandemic and focus on the structural barriers of racism within our healthcare system.
“Being aware of these biases is the starter, but what I think is more powerful and effective than [for example] doing unconscious bias training, is having an inclusive healthcare system and a culture of practice that is looking to co-produce and be person-centric,” Waqar said.
“If you look outside coronavirus, it’s about poorer outcomes in relation to health and barriers to accessing healthcare for ethnic minorities,” Ali said.
“It’s about the marginalisation of women patients and women of colour. It’s about why Black women are five times as likely as to die in childbirth than white women, and Asian women twice as likely to die.”
“The disproportionate Covid-19 deaths is related to the impact of structural racism on ethnic and racial minority communities, so we need to be talking about structural racism,” said Khan. “It’s a much broader conversation.
“Why are Black and brown people more likely to die? Why are they in poverty? What structures do we have in our society that exacerbate these class disparities that affect healthcare provision?” he asked.
For Singh, she plans to continue to fly abroad for her healthcare. “I trust medical care in India more,” she said, acknowledging her privilege of having that option.
“It isn’t just me – we know women aren’t being taken seriously when they come in, women of colour even less.”
She continued: “Racism is baked into the system; it’s baked into medicine.
“When you really start looking at the bigger picture – it isn’t the virus that is killing south Asians. It’s medical racism.”