Black or White - Racism in the healthcare sector

Do you know the Chibo shelf, the one with all the packaged coffees? When I was out shopping the other day, I stood in front of it with the intention of buying a coffee. One type of coffee caught my eye: BlackWhite. And all of a sudden Michael came to mind. Michael Jackson and his song Black or white. As the saying goes: "it's no matter if you're black or white". Michael, I have to disagree with you though - it's been more than 30 years since this song came out. Nothing has changed. A sad realization that the coffee shelf brought me.

"We experience discrimination and everyday racism in Germany." - Noah Sow describes this as a clear fact in her 2007 book "Deutschland schwarz-weiß" (Germany black and white). The BIPoC group in particular (BIPoC is the abbreviation for Black, Indigenous, People of Color) is severely disadvantaged in Germany. The reason for this disadvantage lies in discrimination and everyday racism, which is experienced and experienced differently depending on the area of life. BIPoC are victims of insults, violence, exclusion, humiliation and ignorance on a daily basis.

My personal experiences reflect this. My children are bullied or insulted at school or in sport because of the color of their skin. I myself know the omnipresent rejection in everyday activities - taking the bus, going for a walk, visiting the immigration office, shopping, looking for an apartment - even going to the seaside to relax - all of this takes place under the impression that you are not wanted as a person. Insults such as the "N-word" or "the black man" don't end with me as a person, but also extend to the people closest to me. For example, my (white) partner was often called an "N-whore" - in the middle of the subway. She was also asked whether she had adopted these exotic-looking children - particularly nice when shopping at the checkout at Penny.

These experiences influence the entire self, shape and reduce self-esteem and put people under constant tension.

This stigmatization has existed for generations.In human history, black-skinnedpeople have long been seen as "not equal" to white people. Clear evidence of this was slavery in the south of the USA from the 16th to 19th century. This is taught in schools in many African countries, but in a way that already creates a false image of Europe in African minds. Right from the start, African migrants feel inferior to white society in most life situations. This certainly has its roots in the colonization of African countries (see Seukwa 2006), from which many people still bear psychological wounds today. Racism is an attitude that is largely based on prejudice. At least those people who think and live in a racist way have a real justification for their attitude. They have never been to Africa, nor do they maintain close contact with fellow Africans in this country.

After Georges Floyd's death in the USA in 2020, Africa called for an emergency meeting within the UN. After his violent death in Minneapolis at the hands of a police officer, black people, people of color and allies protested against racism across the US under "#BlackLivesMatter". Despite the coronavirus pandemic, the movement quickly spread across almost the entire globe. According to a statement by Dieudonné Désiré Sougouri, Ambassador of Burkina Faso, "people of African descent around the world experience discrimination and racism and are hindered and destroyed in their lives and in their success in life as a result."
 

BIPoC also experience racism and discrimination in the healthcare sector. Here in particular, it is absolutely intolerable, affecting people in particularly vulnerable life situations.

I am writing this article as a private person and from a professional perspective. I want to sensitizepeople - colleagues, practitioners, doctors, decision-makers, BIPoC - simply all people - simply all people. Because "racism is not a one-off experience, but the sum of all experiences that a person has over and over again" - "It is a privilege to be able to inform yourself about racism instead of experiencing it yourself" (Amina Touré, Green politician, 3rd Vice-President of the State Parliament, SH).

Research

There are over one million people of African descent living in Germany, who are also the main group affected by acts of racism and discrimination. All the terms and concepts summarized under BIPoC are political self-designations. This means that they arose from resistance and still stand for the struggles against these oppressions and for more equality.

In order to find out whether and how racism and discrimination take place in the healthcare system, it is necessary to interview the affected group of people themselves, as experiences and experiences only lead to real study evidence from the perspective of those affected.

In contrast to the USA, UK, Australia and New Zealand, there have been no systematic studies on racism in medicine in Germany to date (cf. Wendhorn, 2021). This article is based in particular on the findings of the Afrozensus study (2020), the Positive Voice 2.0 (2020), an article by Dr. Mathias Wendeborn 2020 and the results of the Mitest study (cf. RKI2017a). The experiences, expertise, analyses and reflections of Black people and experts from the sources of knowledge in this article are also included. The research by Dr. Amma Yeboah (Yeboah, 2017) and the analyses and reports by Dr. Marco Leitzke (Enquetekommission des Thüringer Landtags, 2019) on racism in healthcare were fundamental for the qualitative survey in the Afrozensus.

The "Afrozensus" is the first comprehensive study to look at the realities of life, perspectives and experiences of discrimination of black, African and Afro-diasporic people in Germany. In the form of an online survey of over 6000 people, it was possible to collect a sufficiently large amount of data and thus compile a representative sample. The education and empowerment project Each One Teach One (EOTO) e.V., together with Citizens For Europe (CFE) gUG and funded by the Federal Anti-Discrimination Agency, conducted a survey in the form of interviews and focus group surveys with experts from the health and education sectors.

The report provides a comprehensive picture of how the respondents assess their lives in Germany and what expectations they have of society and politics. In this way, one of the youngest population groups in Germany is finally gaining the visibility as a group that is necessary for better representation of their interests.The analysis of the results - especially in the health sector - aims to show structural racism and its consequences on the one hand, andto formulate recommendations for action to improve healthcare for BIPoC through participatory reflection on the other. In order to capture the experiences of discrimination of Black, African and Afro-diasporic people in Germany in a complex and multi-layered way, experiences within 14 central areas of life were surveyed.

Across all areas of life, the combination consisting of the characteristics "racist reasons / 'ethnic origin'" and "skin color" was mentioned most frequently (433 mentions). The second most common combination of characteristics is "having been discriminated against for racist reasons / 'ethnic origin'", "skin color" and "gender" (200 responses).

This multiple or multidimensional discrimination predominantly affects BIPoC, i.e. black, non-white people or people of color. They experience discrimination based on racist ascriptions (Positive Voices 2.0, 2020).

Of the 79 people who identify as black, non-white or people of color ((B)PoC), 34% state that they have been verbally harassed once or several times. In each case, 22% have the impression that family members have made discriminatory remarks or gossiped because of their (alleged) migration background or because the person is (B)PoC and have avoided healthcare services once or several times because they were afraid of possible discrimination. Fear of using healthcare services was reported by 18% of respondents.

Based on the results of the Afrozensus online survey, concrete measures are proposed to reduce racial discrimination and to protect and promote people of African origin in Germany.

Healthcare system

The analysis of the results of the Afrozensus study reveals interesting findings, particularly in the healthcare sector. According to the study, 14.7% of respondents have already experienced racism and discrimination in the health and care sector.

• Two thirds of Afrozensus respondents (66.7% of n = 2108) state that their doctor does not take their complaints seriously. Almost every 10th person (9.5%) stated that this situation occurs "very often".
• 62.0% of Afro-census respondents (n = 819) state that their experiences of racism are not taken seriously and questioned during psychotherapy.
• Almost 3 in 10 (28.4 %) of 2051 Afro-census respondents with experiences of discrimination in the area of "health and care" state that they have experienced discrimination there in the last two years in relation to their "name[s]", among other things Having experienced discrimination
• In the focus groups, doctors described how, due to the racist attribution of "Mediterranean syndrome", also known as "Morbus Mediterraneus" [G], the misjudgement of pain expression and pain sensation often leads to delays in diagnosis and misdiagnosis.
• "Poor medical care" is rated by 4 out of 10 respondents (43.4% of n = 3931) as a rather big or big problem for the Black communities.

Statements by respondents reflect their feelings through their behavior in relation to health-securing or promoting behavior:

• "My doctor doesn't take my complaints seriously." (n = 2108)
• "I often don't feel like making appointments with doctors or visiting new practices because I want to avoid unpleasant, discriminatory experiences. I have also been consciously researching doctors who are Black or of Color for a long time in order to avoid the experiences described above." (Interviews: patients from the Afrozensus study).
• "Most white therapists and psychologists are not sensitive to and/or reproduce anti-Black racism experiences. Therefore, like many other BIPOC [G] individuals, I feel the need to be in treatment with BIPOC therapists and psychologists who are sensitive to my experience as a Black person. However, since there is a) a general lack of these and b) only very few are covered by health insurance, I refrained from therapeutic treatment for a long time when I could no longer pay for [...] therapy with a Black therapist on my own (€75 per session)." (Interviews: patients, Afrozensus).
• "To be able to do treatment properly at all, you have to understand everything that is said. So language also plays a big role." (Focus group: doctors)
• "Both [by] doctors and medical assistants, my being black is repeatedly commented on and addressed in various contexts. It's often the question of where I come from, whether I was born and grew up in Germany. Doctors have often explained my state of health by saying that 'this is often the case with people from Africa'. A white gynecologist compared my skin color to that of her German-Moroccan son, who has the same beautiful mocha skin as me. It also happens again and again that doctors, after asking about my origin, talk about their trips to Africa." (Interviews: patients)
• "There needs to be more research and support in Germany, we are just as much a part of society as everyone else." (Interviews: nursing staff)

Muslim respondents (77.1 % of n = 118) were significantly more likely to state that they had been discriminated against in the area of "health and care" in the last two years than non-Muslim respondents (63.1 % of n = 2392). The group difference is 14.0 percentage points. Respondents with personal and/or family experience of flight (72.0 % of n = 389) stated with +10.7 percentage points more frequently that they had been discriminated against in contact with the area of "health and care" in the last two years than respondents without experience of flight (61.3 % of n = 2060).

More differentiated research approaches also generally point to the lack of discussion of racism and discrimination in mental health care and psychotherapeutic practice in Germany (Kluge et al., 2020; Sequeira, 2015; Velho, 2011). This in turn raises the question of how the content of the curriculum for training or studies in the medical field is structured and what content is made available to learners.

"Only if students become aware of this can we prevent doctors being unleashed on patients with such internalized stereotypes or, conversely, patients being unleashed on doctors."

All of these phenomena lead to the social exclusion (Huster/Boeckh/Mogge-Grotjahn 2008) of individuals and are part of the everyday lives of many migrants.

Health with a focus on HIV

Overall, discrimination in the healthcare sector was shocking in the Positive Voices 2.0 study: "One in 10 people in the interview stated that they were asked inappropriate questions in places where they receive their HIV treatment and that their file was specially marked. Also in HIV-related healthcare services, 8% experienced treatment at separate appointments or avoidance of physical contact (Positive Voice 2.0, 2020).

In Germany, almost every third new HIV diagnosis concerns a person who has immigrated. In addition, the MiTest study (see RKI 2017a) found that migrants still do not have equal access to testing services compared to the majority German population. In practice, barriers to access can be found, for example, in limited treatment options for positive HIV status and/or in restrictive factors such as unregulated residence status, lack of health insurance, language barriers and financial limitations. Other important barriers are stigmatization and experiences of racism or other aspects caused by the migration process, but also a lack of basic services such as language and cultural mediation. (Cf. Dr. Ulrich Marcus / RKI).

Stigmatization has a long history, especially in relation to infection and contracting a sexually transmitted infection (STI) or contracting sexual diseases. HIV is a primary sexually transmitted infection worldwide. In most cultures around the world, HIV is seen as a contamination of the body (Ouedraogo 2005: 36), similar to the plague or syphilis in the 18th century. Along with this, the infected person is blamed for the disease, for their "misbehavior" in a certain situation.

The infection is therefore not acquired by chance, it is actively acquired (Sontag, Susan: Aids und seine Metaphern, Munich 1989: 34 ff.). With regard to HIV/Aids, the stigma is doubly occupied with the fear of death and illness and the morally charged topic of sexuality in all its facets. In addition, in many countries of the world there is ignorance about HIV, which depends on people's level of education (Hella von Unger: Versteckspiel mit dem Virus 1999:15).

Ultimately, the stigma surrounding HIV/AIDS is the result of the multiple moral and cultural taboos and the resulting silence. Black migrants not only have to face the stigma of their HIV infection, but also that of their skin color. Ultimately, it is society that defines the stigma and adds further attributions or devaluations, so that the stigma multiplies (Unger von and Nagel 2009 in DAH- Life + Magazin: 6).

Experience also shows that some refugees in some federal states are still tested for HIV without their consent. in 2017, for example, the State AIDS Commission in North Rhine-Westphalia (NRW) positioned itself against this in a recommendation on the care of HIV-positive refugees - "Clarification that HIV diagnostics is not a routine part of the initial examination of asylum seekers according to the decree of the Ministry of the Interior and Municipal Affairs of NRW on the accommodation of asylum seekers" (cf. Arbeitsgemeinschaft AIDS-Prävention - NRW).

For migrants with black skin color, however, there is not only the stigma of their HIV infection, but also the racism they face in Germany, i.e. the multidimensional discrimination (see DAH- Positive Stimmen 2.0 - 2020). Both stigmas bring with them prejudices that are even mutually dependent and complementary. Africans are labeled as incompetent or stupid people or even asevil and are often identified with the image of the carrier of disease. And to quote Zimbarco (2007:3) "This is why we reject the "other" as strange and dangerous, because we don't know it, and yet it gives us a thrill to hear about people's sexual excesses and moral violations.".

"Today, people with HIV can live, love and work like everyone else. For many, the social consequences of HIV infection are more serious than the health consequences. The majority of respondents to the "Positive Voices 2.0" study continue to face discrimination, exclusion and devaluation in their everyday lives.Social development is slower than medical development," says Matthias Kuske, project coordinator at DAH, summarizing the results. Most people in Germany live well with their HIV infection - in the sample of the online survey, 90% agree with this statement. Thanks to the good treatment options, three quarters of those surveyed feel that their health is not or only slightly restricted. however, 95% report at least one discriminatory experience in the last 12 months due to HIV. 52% state that their lives are affected by prejudices regarding HIV infection.

"I feel more discriminated against because I have black skin, but there is still a lot to be done about HIV. Many people ask me directly about HIV because I am black." Peer-to-peer survey, question 78

"It is always difficult to recognize why I am discriminated against. During the interview, I realized that I experience the most discrimination because of my skin color. People see that immediately, HIV doesn't." Peer-to-peer interview, question 78.

Racism and its consequences

Racism leads to psychological, emotional and physical impairments. Racism is a violation of human rights. It can lead to problems in the use of health services, among other things:

• Avoidance, that is, BIPoC avoiding healthcare
• Cancellation and delay of treatment or therapy
• Extra effort for black people, as they seem to have to justify themselves a lot
• Mental stress

"In other words, survival or existence in the system is accompanied by very, very massive psychological and physical [consequences], but also in terms of professional development." (Expert interview: Black experiences in the healthcare sector)

The neglect of sensitization of the staff employed seems particularly serious here. Appropriate training and awareness-raising programs for the various professions must find a place and be established. Especially with the knowledge of the health consequences that experiences of racism and discrimination have on a person's mental health in particular, it is essential to focus on this.

Summary

According to the UN Convention on Human Rights, health is a human right (Article 25, UN Charter of Human Rights) and according to Art. 2 para. 2 of the Basic Law, which Germany undertakes to guarantee with the welfare state principle (Article 20 para. 1 of the Basic Law). "A necessary prerequisite for ensuring health protection is non-discriminatory access to medical and nursing infrastructure and services, which, in addition to medical and therapeutic treatment, also include medicines and medical devices" (Bartig et al., 2021).

No one should be excluded from using healthcare services. Unfortunately, some marginalized groups (Dr. Wendorn, 2021) or BiPoC are strongly affected by discrimination and racism. Observations show that some BiPoC fall out of the insurance system. Migrants without valid residence papers and/or health insurance are systematically excluded.

The studies analyzed in the selected studies illustrate the urgent need, but also the great potential of conscious, planned action to push back anti-Black racism and to strengthen Black, African and Afro-diasporic communities in Germany.

The specialist discourse on the health effects of racism in general and anti-Black racism in particular is not yet fully developed in Germany, and the necessary reforms in the health sector are still in their infancy. Here, the qualitative research of the Afrozensus in particular is providing important impetus for necessary changes (Afrozenszus 2020).

All actors in society, especially decision-makers in politics and administration, but also our own communities and our own organizations, networks and activists, must be concerned with advancing this research and thus creating better living conditions for BIPoC in Germany.

Anti-Black Racism (ASR) should be viewed as a specific phenomenon and structural framework conditions for the empowerment of Black, African and Afro-diasporic people should be created. The data collected so far speaks for itself (Afrozensus 2020), as it shows the extent and forms of anti-Black racism (ASR) - especially in education and healthcare, two areas that are among the core tasks of public services. The fact that people of African origin are too often denied or hindered access to these existential goods due to racist discrimination should also be a wake-up call for politicians and administrators to take a firm stand against structural ASR. The necessary acquisition of competence for public institutions is not only required by law, but also a moral obligation (according to the politicians Dr. Pierrette Herzberger-Fofana and Dr. Karamba Diaby, from the Afrozensus 2020).

Additional topics such as anti-discrimination and racism-critical educational work for structural prevention should be integrated into the training and education programs of Deutsche Aidshilfe in the area of HIV/STI prevention work or the existing ones should be expanded. Intercultural and intersectional training and further training for association members should be disseminated and (bindingly) attended by employees. Intercultural openness and diversity can be disseminated.Because "racism and police violence are also a brutal daily reality for the majority of our communities and clients - be it in the area of sex work, imprisonment, addiction support or in the context of HIV. "

Participation and active involvement of (black) migrants - organizations and associations - in HIV prevention (cf. von Unger, Gangarova, 2011) should always be scientifically monitored and supported. Particular attention should be paid to fellow citizens who are excluded from the health sector, namely people without residence papers and/or health insurance, because prevention work is effective when everyone is on board (Ouedraogo, 2021).

The quality standards of Deutsche Aidshilfe (DAH) should be revised again and again. This is because migration is a cross-cutting issue in prevention work. All services are accessible to migrants. In addition, special services are aimed at migrant groups with special needs. The multidimensionality of people's identities and affiliations is always taken into account (see Gangarova, HIV-Prävention für/mit Migrant*innen, 2021). As a human rights organization, Deutsche Aidshilfe stands in solidarity with all Black people and People of Color who demonstrate against racist violence and discrimination. Its work also includes actively participating in and winning this fight against racism. Cooperation with its association members and anchoring the topic of anti-Black racism in structural prevention remain essential.

The analysis and discussion of the selected studies and articles, the increased number of podcasts (Deutschland 3000, Fair Bindung, Rassismus wirkt- wir zeigen, wie? Strukturelle Diskriminierung- wie Rassismus und Klassizismus zusammenhängen, Deutschland Funkt Kultur, etc.) on the subject of discrimination and racism reveal major challenges for the German healthcare system and migration policy.

As an organization that represents the interests of people with HIV, Deutsche Aidshilfe can contribute to achieving equality for the almost forgotten key group of BIPoC. This goal also forms the basis of the UN Decade for People of African Descent (2015-2024), which was proclaimed in 2014, because people of African descent in particular are still frequently exposed to racism, prejudice and discrimination.

The aim of this article is not to highlight the entire problem of racism at BIPoC in Germany, but rather to provide food for thought for practitioners, employees and decision-makers. Addressing racism, particularly in health and care, is long overdue and has been shamefully neglected to date. Structural racism is entrenched in this country and urgently needs to be dismantled so that society does not experience further divisions. Multidimensional discrimination and everyday anti-Black racism should be combated structurally, legally and socially in all its manifestations and other areas of life (education, labor market, housing, politics, etc.).

Combating racism in general and anti-Black racism in particular must not only be a task for the minority of those affected, but rather a task and duty for society as a whole.

Because one thing is clear: although there is no such thing as race (cf. Noah Sow), racism still exists.

"Think global, act local - respect belongs to all of us"

Omer Idrissa Ouedraogo

DAH specialist for migration, M.A. Psychology, M.A. Social Work, youth leader of intercultural youth encounters. Long-time employee of Aidshilfe Hamburg, former employee of the youth migration service, in Burkina Faso in the senior service of the social department.

"Encounters at eye level and respectful cooperation create real participation. Get involved and change the world."

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Wendeborn, Mathias (2021): Thoughts on racism in the German healthcare system - Pediatrician and adolescent doctor, Munich Chairman of REFUDOCS e. V, BAB 6