This article first appeared in Volume 54, Issue 1 of our print edition of Index on Censorship, titled The forgotten patients: Lost voices in the global healthcare system, published on 11 April 2025. Read more about the issue here.

For those regularly subjected to racial discrimination, it can be exhausting to encourage people without this firsthand experience to see things from their perspective. Convincing others that certain behaviours or attitudes are harmful can be frustrating, difficult and ultimately lead to hostility – and nowhere more so than within large organisations, where prejudice may be deeply embedded.

The National Health Service (NHS) is one of the UK’s most loved and largest institutions, employing more people than any other organisation in the country. But, as a result, it is not exempt from societal issues.

Institutional racism within the NHS, impacting both staff and patients, has been well documented. A report compiled last year by Middlesex University and the charity Brap found that “racial prejudice remains embedded in the health service despite initiatives to remove it”.

The NHS has failed to “provide a safe and effective means for listening to and dealing with concerns” raised by Black and minority ethnic (BME) staff, and it noted a “culture of avoidance, defensiveness or minimisation of the issue from their employer if they did so”.

Nearly three-quarters of UK- trained staff had complained of race discrimination, according to the study. A survey commissioned by the membership body NHS Confederation in 2022 also reported that more than half of its surveyed BME NHS leaders had considered leaving in the three years beforehand as a result of racist treatment they had experienced while doing their jobs. Black patients also often find their concerns ignored by healthcare professionals, with potentially deadly consequences.

Dr Annabel Sowemimo, a doctor of sexual and reproductive health and author of the book Divided: Racism, Medicine and Why We Need to Decolonise Healthcare, has spent many years facing and exploring this prejudice, and has seen her own concerns ignored as both a patient and a practitioner. Speaking to Index, she told a story from her time as a junior doctor working in the paediatric accident and emergency department, when a Somali child came in experiencing abdominal pain but with “atypical symptoms”. An experienced nurse said the child needed to go home with antibiotics, as they had a urinary tract infection. But Sowemimo was not convinced by this diagnosis.

“I saw the patient and I said, ‘I don’t really think that this child has an UTI’,” she said. “The dad didn’t really speak great English so it was difficult to communicate.” Ultimately, the child was diagnosed with severe appendicitis and needed surgery. “If they had not had surgery [the appendix] probably would have ruptured – that’s what the surgeon said to me,” Sowemimo added. “It was really hard, because I was a really junior doctor, I had been in the department for only a few weeks, and the nurse was quite senior and I didn’t want to be seen to be going against what she said.”

Sowemimo, who is from a Nigerian background, believes that a combination of cultural bias from staff and culturally influenced self-censorship by patients can play a collective role in misdiagnoses. “I don’t think that nurse was being racist, but there were certain things that made this child more vulnerable,” she said. “Culturally, I think the child had probably been raised in an environment like mine.

“I would, as a kid, never make a scene in public because my Nigerian parents just wouldn’t stand for that kind of thing. So sometimes, if I was uncomfortable, even around adults, I’d just hold that energy in, whereas other children could probably express that more.”

Sowemimo believes that self-silencing can be particularly pervasive among Black patients, who may have fears around their expressions of pain or discomfort being construed as “aggression” by healthcare professionals. “We change our behaviour,” she said. “We’re worried about being seen as ‘angry, Black women’ in particular. So even if I am in pain, I’m not going to feel comfortable yelling and writhing around. It doesn’t mean that I’m [less] in pain [than] the next person, just that I’m acutely aware that sometimes things get misread.”

A misguided belief that Black women “exaggerate” their symptoms has also proven to be fatal, and nowhere more so than in maternity care. Black women in the UK are nearly four times more likely to die in pregnancy and childbirth than their white counterparts. In 2023, an investigation into the death of a pregnant Black woman in Liverpool found “cultural and ethnic bias” played a part in her late diagnosis and death. Hospital staff had neglected to take some observations because she was “being difficult”, according to comments in her medical notes. This delayed her diagnosis and treatment and led to her baby dying, and then to her own death two days later.

Such biases are endemic in many countries, and ethnic minorities faced higher mortality rates during the pandemic. Black American doctor Susan Moore documented on social media how her pain and requests for medicine were ignored when she was in hospital with Covid-19 in 2020. She said she was made to feel like a “drug addict” for requesting remdesivir, the antiviral drug used to treat Covid patients. She later died due to complications from the virus. In May 2020, the British Medical Association (BMA) reported that more than 90% of all doctors and consultants who had lost their lives from Covid- 19 up until that point had been from minority ethnic backgrounds.

Sowemimo believes that “biology” is weaponised in healthcare settings, with doctors and nurses often concluding that Black people are more likely to die from certain illnesses due to genetics. There are many complex factors that play into higher death rates, she said, including later diagnoses and a lack of clinical research.

“With some reproductive cancers or endometrial cancer, it seems that Black people present later, and with prostate cancer we have worse outcomes,” she said. “We’re trying to direct research towards these issues to actually work out what is going on, but ultimately [research isn’t funded] towards groups that are not seen as politically mobile, who are more disenfranchised and impoverished.

“Often, people keep telling you that it’s biological, that we’re all biologically flawed in some way, and this is making us more predisposed to all these things. I think that’s actually even more sinister – how people keep on pathologising Blackness rather than addressing the systemic problems that exist.”

Beyond the treatment of individuals, systemic issues around resource allocation “compound” the discrimination facing minority groups, she says. In what think-tank The King’s Fund refers to as the “inverse care law”, those who most need medical care are least likely to receive it. For example, people who live in the most deprived areas of England are twice as likely to wait more than a year for non-urgent treatment, and there are fewer GPs per patient in more deprived areas. BME people are over-represented in the most deprived areas, and are two to three times more likely to be living in persistent poverty.

Disparities in care are caused by complex societal problems that reach far beyond the realms of healthcare services alone. So changing the behaviour of NHS staff is only the first hurdle, and a high one at that. “I make this argument a lot in my work, that it’s really hard to change something that has been embedded for such a long time,” said Sowemimo. “And I think a key part of why we have a lot of these issues [is that] people are just not willing to change their practice.”

Broaching inappropriate behaviour can be difficult, given that most NHS staff have good intentions and want to help people. “People… feel like they’re underpaid, and they do work particularly altruistically,” Sowemimo said. “So telling them that they’re not being altruistic, that they might be being biased or discriminatory, people are going to [think that’s] quite rude.”

In recent years, there has been increasing political scepticism from the government surrounding the need to address inequalities in the NHS. In 2023, for example, the then health secretary Steve Barclay ordered the NHS to stop recruiting for roles by focusing on diversity and inclusion. Health equity commitments have also been discarded – the Maternity Disparities Taskforce set up under former Prime Minister Boris Johnson in 2022 met only twice in 2023 rather than the scheduled six times, and reported little progress.

But there is hope on the horizon: the current Labour government has committed to a Race Equality Act, which includes several provisions around improving healthcare outcomes for BME people, including closing maternal health gaps and improving diversity in clinical trial recruitment. However, the current geopolitical climate could reverse efforts. US president Donald Trump’s executive order banning diversity, equity and inclusion (DEI) programmes across the federal government may have a ripple effect for UK organisations, from which the public sector may not be exempt.

“There’s a lot of momentum around the push-back; we’re very much influenced by US politics,” Sowemimo said. Despite the hurdles, she isn’t going to stop banging the drum about healthcare inequalities. “I’ve always said that, sometimes, the work we’re doing is just to stand still,” she said. “It’s really hard when you’re in a time where you’re not actually fighting for progress, and no one’s going to say, ‘You’re the person that got that bill [or] that got these people their rights’. In fact, you just fought to make sure their rights weren’t removed.”