Medicine, as a profession, does not recruit equitably from the UK’s population. This matters because working-class young people do not have equal chances of becoming doctors. But it also matters how public health interventions are designed and delivered. All too often, health research, policy and practice are limited by unacknowledged social class biases.
A recent editorial in Science called for more diversity in research, noting that “Science has had enormous trouble building a workforce that reflects the public it serves”. Despite decades of widening access to higher education in the UK, this trouble persists. Working class young people remain far less likely to go to university, if they do go, they are less likely to go to elite universities, and far less likely to enter medicine as a profession. The reasons for this are complex, but systematic exclusions happen at every point in the process.
After entering elite universities, as Diane Reay’s work has shown, working-class students incur a higher burden in managing the disjuncture between habitus and field. In the US, Tania Jenkins unpicks the endless small decisions that reproduce hierarchies within medicine as the more socially-advantaged recruits are systematically favoured throughout selection and training pathways. Elites, she notes, learn to play the game early on to maintain advantages for their children. In the UK, one study of the specialty choices of trainee doctors noted that, overall, a whopping 89% of those entering training in 2013/4 (that is, those now in leadership positions) had parents with professional/managerial jobs.
Such evidence certainly undermines any faith in meritocracy. But does it matter for health policy and practice? Why does the narrow social class background of the clinician, the health researcher, or the health policy maker, matter for how we protect and promote the health of the public?
Lack of representativeness has far-reaching consequences. Diversity is essential to ensure that scientific ideas are challenged as they develop. It’s essential for ensuing that what we research and how those ideas get refined as ‘evidence’ for practice is not inadvertently biased by one particular set of perspectives. An example of what can happen when such biases are not challenged (cited in the Science editorial), is that of pulse oximeters to measure blood oxygen levels. As anthropologist Amy Thomas-Moran showed, their less effective performance for darker skins was an outcome of the ways in which racial biases in research are sedimented into practice over time.
In the UK, we might expect public health specialists to be more representative of the public than other professions. This is because it is less competitive than other training specialties; it increasingly includes non-medical professionals; and the move to local government in the UK should have rooted practice in locality and community. Demographic details of the UK’s public health workforce are difficult to find. However, the limited evidence suggests that public health is barely more socially representative than the wider profession: in the study of UK speciality training, 87% of recruits to primary care (which included public health trainees) were also from households where parents were in managerial or professional occupations. Another study found that Black candidates were 90% less likely to get onto training programmes than white candidates. Kazim Beebeejaun and Kerry Littleford draw on shortcomings of the COVID response to argue why this matters. Lack of diversity limits cultural competence to plan appropriate interventions, and it limits necessary innovation in systems thinking. Importantly, they also note the need for representation as value: a profession addressing health equity and social justice should espouse those values in its own profession.
A greater diversity of class background would offset the tendencies of public health to read off the preferences of the more affluent members of society as somehow inevitably healthier. Too often, health promotion initiatives are framed around middle-class choices of diet, transport or socialising, as if these are the ‘healthy choices’ that would be made if only constraints did not get in the way. The evidence base inadvertently reproduces middle-class values and assumptions. Too often, evaluations of policy initiatives fail to accommodate the trade-offs. Prioritising cycling in travel plans, for instance, might encourage active travel, but also contribute to the racialisation and gentrification documented by Mimi Sheller in Philadelphia. And all too often, public representatives are the only people in the room with authority to speak of working-class experience.
Relying on public participation to make up the diversity deficit is highly problematic. First, it is an unfair burden, for a small number of people to somehow represent all the missing perspectives. Second, it reinforces a deeply uncomfortable divide between professions and publics. Recruiting public members whose primary qualification is that they are not ‘professionals’ is hardly a solution to under-representation. It simply hardens the position of an expert, professional community as separate from ‘the public’ it serves. Rather than seeing public health as a problem for all of us, it can become a problem of ‘them’.
No profession can be a perfect demographic microcosm of the population it serves. But public health research and practice – and medicine generally – would benefit hugely from widening the social class base of its recruits. In the context of year on year cuts to the public health budget, a profession exhausted by pandemic management, and coping with yet another restructuring of national public health agencies, there may be few resources for the kinds of major outreach and support needed to expand recruitment to medicine as a whole and public health in particular. But a number of smaller adjustments might help in the short term, or help to offset the limitations of an unrepresentative profession. Better evidence on biases in recruitment to speciality training would be a start. A second move would be to learn more from the non-health directorates in local government, where there is perhaps a better track record of incorporating a greater range of experience and evidence. Third, a truly interdisciplinary approach to public health research needs strengthening, such that the evidence base is not still over-determined by a medicalised understanding of health. Finally, and importantly, before designing a research project or a programme, we all need to carefully consider how that would feel if we were the target, not the designer.