A formidable pair -- cross and rushforth 327 (7411): 52 -- bmj career focus
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BMJ Career Focus 2003;327:52; doi:10.1136/bmj.327.7411.s52
A formidable pair Sam Everington and Aneez Esmail are a formidable and somewhat unlikely partnership. Progressive GPs in London's east end and Manchester respectively, they have been involved in a number of successful campaigns during their 20 year friendship. As Peter Cross and Bruno Rushforth discovered, an appetite for fighting just causes hasn't diminished over the decades Sam Everington
"I don't call this my surgery," says visionary GP, serial campaigner, and lapsed
barrister Sam Everington. We are in his Healthy Living Centre in London's east
end. The centre houses local artisans, including a stained glass window workshop, a sculptor, and carpenter. A park, which used to belong to the council and was always covered in dog droppings and used needles, has been leased to the centre. It has been transformed. Over 50 schoolchildren on school holidays are playing there. A semiformal football match, complete with supporters, is under way.
More equal choices give patients a better chance
"The healthy living centre is not just about physical health," explains Sam, "but also employment, education, creativity, environment, things critical to health and sometimes more important than Prozac. Using our first names is important. More equal choices give patients a better chance."
Sam's premedical career included welding in a Norwegian shipyard. His mother is Norwegian and has delivered meals on wheels for 50 years. His father is a barrister and Sam passed his law degree and bar finals simultaneously. While training to be a barrister he realised that he really wanted to be a doctor. He visited every medical school in the country, but finding a place at medical school proved difficult. In six months, while working in a pub, he sat and achieved grade As in Chemistry and Physics A levels and Biology O level. He studied at the Royal Free: "Many people regret that they haven't done other things because medicine is a lifetime vocation. Because I had done something else, medicine was a positive choice."
In 1987, Sam was working 120 hours a week: "Working long hours was dangerous. Most juniors thought it normal. Yet research had shown 50% of
junior doctors were emotionally disturbed," states Sam. He continues: "Christmas was approaching and I thought if they film people queuing for New Year's sales, they can film me sleeping outside the London Hospital." His 48 hour stunt attracted media interest: "When journalists realised it was to reduce our hours to 72 a week, when the rest of the country wanted a 36 hour week, they realised this was serious." Sam told journalists about a doctor who fell asleep during an operation and woke up on top of the patient.
Sam, with another doctor, took legal action against University College Hospital for making doctors work long hours and not ensuring their health and safety at work: "We spent the Easter bank holiday with television cameras following us, landing this writ on a hospital administrator. We took the campaign to the high court. The BMA said, 'You haven't asked our permission so why should we take it on?' " remembers Sam. They self financed the initial stages and won. The BMA backtracked and financed the campaign to the House of Lords, where a key principle of common law about working hours was set. "A BMA council meeting turned into an awful row. We were demanding legislation to control hours and a consultant was saying very aggressively, 'You'll pull the profession apart.' "
Sam campaigns with his friend and fellow GP, Aneez Esmail. "Aneez does most of the research. I do most of the media." They fought racial discrimination: "Aneez talked to a surgeon who said, 'Shortlisting is simple, I have two piles, Asian candidates and the others. Asian candidates go in the bin.' The profession said ethnic minority doctors don't get on because of the language or because they trained in India."
We. showed discrimination for what it was. As basic as a surname
This led them to do some research: "We sent fake job applications: identical except one had a typical Indian surname and one a typical English surname." Half way through their research, the pair were arrested by the fraud squad. "The Crown Prosecution Service dropped it like a hot potato," remembers
Sam. "We published our findings in the BMJ and showed discrimination for what it was. As basic as a surname."
When Sam and Aneez were arrested, the GMC wrote to them telling them their behaviour was unprofessional. "So we wrote back and asked why they weren't doing anything about the doctors doing the discrimination," says Sam. "They said they hadn't had any complaints. We investigated the GMC and found they were six times more likely to discipline ethnic minority doctors than white doctors and that ethnic minority doctors were disciplined for more serious offences than white doctors."
If you want to talk to a politician, talk through the media
Prospective campaigners take note: "Get early wins," says Sam. "Make whatever you do a success. Don't get bogged down in marches. If you want to talk to a politician, talk through the media. A local MP gets a bad story in a local newspaper. That gets their attention." It comes as a surprise that someone so anti-establishment has been a BMA council member for 12 years and was one of the nominees for chairman this year. "Being in the system can be helpful," explains Sam. "The BMA is one of the most powerful trade unions. Its access to key political circles is almost unrivalled."
Sam and Aneez were offered OBEs. Sam accepted but Aneez declined. "I desperately tried to persuade Aneez to accept. We will always have arguments about this." Sam explains that he accepted this award on his team's behalf for services to inner city primary care. What he has fought against matters, but this centre and his Stepney surgery may be his legacy. "If you ask patients what they want, they say things like 'let's have nicer chairs.' We say, 'We want to build a palace, are you going to come with us?' "
Aneez Esmail has been fighting racism in medicine for over 20 years. Working
with his friend and collaborator Sam Everington, they have exposed racial
discrimination in admission to medical schools, performance of ethnic minority students in exams, the allocation of distinction and discretionary point awards to doctors, and referrals to the General Medical Council (GMC).
"In my career, I've experienced a lot of discrimination," explains Aneez, "And I think I've become bolder in challenging it. But I don't believe that the majority of doctors are racist. Most of the people I know within medicine are good people, but they often work in institutions and structures that make them behave in a discriminating way."
Challenging these institutions has often brought Aneez up against powerful opponents: "I remember one senior member of the profession coming up to me when we had been critical of the GMC and telling me to go easy, that the medical establishment had a long memory. He was effectively telling me to back off if I didn't want my career to suffer. But he didn't realise that this was like a red rag to a bull."
I believe that institutional racism still exists within medicine—tackling these injustices still drives me
Aneez believes that his work with Sam has had a much wider impact than simply uncovering unfair practices within medicine. "Our work looking at the GMC is a good example of where we highlighted a problem with racism, but we also drew attention to issues about governance within the GMC—how they monitored and investigated complaints, the involvement of lay people, and the openness of the whole process." Aneez continues: "We found that there were disproportionately more ethnic minority doctors referred to the GMC. But my theory is not that they shouldn't be there, but that there are many other doctors who aren't from these groups who should be brought before the GMC. The old system was a sham, and ultimately it was patients who were harmed." Aneez believes that their research forced the GMC to implement more objective measures of how doctors are assessed when complaints are made against them.
Aneez and Sam first met in the 1980s when they were both active in the campaign to improve conditions for junior doctors. "People find it funny that we seem to be so different. Sam's worked within the medical establishment, sitting on the British Medical Association council and as a health adviser to the Labour party. He's the consummate politician. When I speak out some people think, 'He's just got a chip on his shoulder because he's Asian,' whereas Sam is seen as the reasonable white guy and that puts him in a better position to condemn discriminatory practices."
Medical Practitioners Union: or write to Carol English, National
Secretary, 33-37 Moreland Street, London EC1V 8HA. Tel: 020 7505 3265
Aneez grew up in Uganda, but his father was determined that his son should have an English education and so Aneez was sent to boarding school in Rugby. Then his father died suddenly and the family was expelled by Idi Amin, along with other Asian citizens. "I didn't do very well at Rugby," Aneez recalls with a smile. "But it did teach me how to fight. I was one of only a few kids from an ethnic minority and I had to learn how to stand up for myself."
Aneez continued to fight for what he believed in while at Sheffield University. "I was studying medicine, but got very involved with student politics. I helped organise protests and sit-ins against the university for trying to force huge fee increases on overseas students." He ended up in court, facing an injunction banning him from entering university premises. But the judge sided with Aneez and agreed that the students' actions were legal. The university authorities were forced to back down.
After medical school and house jobs Aneez began studying for membership of the Royal College of Physicians. "But I was just being asked to regurgitate facts" he recollects. "And I found that the whole process was numbing me. I felt in a cage, so I took an Open University course in health and disease and that opened up new horizons." After completing his general practitioner training, he took up a public health registrar post in London. But when his partner got a job in Manchester, Aneez thought about applying to the university department of general practice. "When I asked whether I should go for the job, my mentor said, 'Does it open more doors for you?' and that's how I now always look at new career opportunities. If the answer's 'yes' then I'll make the move, even if it seems a strange career path."
With the department also running a busy inner city GP practice, Aneez really enjoyed seeing patients again, which he could combine with his ongoing research. He became head of department and helped set up new services for refugees and drug users.
Despite challenging establishment practices for most of his career, last year Aneez was offered the OBE for his work helping disadvantaged groups. "It came totally out of the blue. I was very surprised, and yes it was an honour to be asked. But after some thought I decided not to accept it. It just doesn't seem right that in a modern society a public honours system should be based on the say-so of the Queen. As a British Asian, I also objected to the title: Order of the British Empire. Surely we can come up with a more appropriate name in the 21st century."
Aneez had another surprise in 2001, when he was asked to take on the role of medical adviser to the Shipman inquiry. He believes that his reputation was seen as an advantage: "Paradoxically, by standing outside of the medical establishment and as someone who's prepared to criticise the shortcomings of my own profession, I'm viewed by the government as independent and therefore useful."
I first met Aneez as a fellow volunteer on Manchester's healthcare mentoring project, which he helped set up to support children from local inner city schools interested in a career in the NHS. With a young family and his various commitments how does he fit it all in? "I think I'm good at
compartmentalising my life," he replies. "So I can work quite efficiently on
one project, then switch to another." He also believes in a healthy work-life
balance, "Don't let work take over, and don't ever forget that your family matters more than anything else."
So how can others get involved in similar campaigning work? "Be part of a group," says Aneez. "Or join a radical organisation like the Medical Practitioners Union [he was the president until November 2002]. It's important to be able to talk to other like minded radical doctors, so you can discuss and develop ideas on how to improve things." Aneez has certainly played his part in improving the lot of many, and he's not about to give up the struggle just yet: "I believe that institutional racism still exists within medicine—tackling these injustices still drives me."
Peter Cross, freelance journalist London Bruno Rushforth, fourth year medical student Manchester University, Manchester
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