Growing up rich in poverty-stricken Malawi, I wanted for nothing. A white female, I was unhindered by lack of money, lack of education, language barriers, violence, poor health, gender, ethnicity, or religion, and I was somewhat aware of this privilege. I attended excellent schools, was loved by my family, and, as the crowning jewel of my secondary education, attained a place at a British medical school where I was confronted with and shocked by poverty in the UK. I sought to understand inequality here, where it seemed there was the means for universal prosperity. This took me to prisons, brothels, centres for impoverished families, and onto kerbstones with the homeless.
In prison, I met torturers and murderers, but never someone whose story didn’t make sense. I wonder if I had grown up sexually abused in a care home, with a father who ‘taught me to box’ before I could walk, whether I too would join a gang, or be unable to express my emotions. One in 20 children in Britain have been sexually abused, with a third never reporting it.1 Sexual abuse is associated with increased welfare dependency, criminal activity, and substance abuse, and decreased employment prospects.1,2
I wonder if I came from a neighbourhood where a tiff between friends ended with stabbings whether I would have carried knives too, and ended up behind bars before finishing school. Violent crime is characteristic of deprived neighbourhoods in wealthy states, where there is greater felt need to defend the comparatively little people perceive themselves to have.3
I wonder if my family had struggled due to my parents’ drug habit whether I too would have turned to dealing and taking drugs to escape mentally, and survive financially. Poverty is linked to substance abuse, and dealing to neighbourhoods with poor employment prospects and parental drug abuse.3
With women experiencing homelessness I’ve asked myself whether I too would have lost hope and reverted to alcohol or heroin when I found myself traumatised, alone, and pregnant, lacking support, education, or a home. I think I’d have found the easiest way to support habits was to engage in sex work too, or made a beeline back to prison to find headspace. As prison populations grow and sentences shorten, effective reintegration into society has dwindled, creating the ‘revolving door’ effect, with high re-offending rates.4
WE ARE THE PRIVILEGED FEW
I realised that injustice is totally outside my personal experience. Only 4.1% of medical students come from the most disadvantaged fifth of society nationally, and >50% come from the most privileged (>25% have attended private schools).5 Most of us didn’t come to medical school because we know anything personally about inequality.
Inequality, however, is at the heart of medicine because deprived and vulnerable families are more likely to be unwell.3 We, as privileged individuals, are educated scientifically in health and then have the task of enabling more vulnerable others to benefit from this and achieve wellness. The reality of this dichotomy is that, in my experience, medical students do not understand patients who are vulnerable, and so there is a human tendency to mock.
I saw a presentation about endocarditis recently. Students chose to act out a homeless man’s history. The inaccuracy of the caricature revealed astounding ignorance. Laughing, they described how he ‘lived in a shed’ by choice and injected meth ‘for kicks’; from their privileged perspective they considered his decisions and situation laughable. Laughing off difficult situations is a coping mechanism, but this was mocking what they couldn’t understand. Later someone remarked that they ‘wouldn’t take a cup of tea’ from a patient on a home visit, because of the ‘state of the place’. A cup of tea, the universal symbol of hospitality — rejected.
Britain is the fifth most unequal society in Europe. A fifth of the population and a third of children live in poverty (despite their parents being employed), food bank utilisation is increasing, and 44% of the nation’s wealth belongs to the top 10%. Poverty has become the national norm.6
Most of us will never experience such injustice, or fight to survive as vulnerable patients do. I have realised the importance of understanding enough to truly empathise, and I believe it is this that enables effective communication. We cannot view through the lens of our own norms. Preventive lifestyle interventions are integral, and so is our ability to communicate with patients in a relevant way. The medical profession globally attracts the privileged, so if any communication is to be effective, and any intervention successful, we must educate ourselves, not mock. In doing this, we enable our position of immense privilege to be beneficial to others, which I believe is among the ultimate responsibilities of a doctor.
- © British Journal of General Practice 2019