John Barnes and the Iceberg

I first told this story at an action learning set meeting with other Knowledge Mobilisation Research Fellows (KMRFs). Most recently I told it at a workshop at the Health Services Research UK symposium in Nottingham.  Another KMRF Vicky Ward has blogged about this workshop.

Something I’ve been trying to do as part of my fellowship is to find a simple way to explain the links between ethnicity and health.  The links are complex and contested with people working in this field, be they academics, NHS staff or activists, having many different perspectives on these links.

I was attracted to the creative means used by some of the other KMRFs in their projects, for example serious play with Lego, forum theatre and the use of images to describe themes from qualitative data.  But I couldn’t work out how to use such methods to portray the complicated ideas I’m interested in.   Nevertheless, the idea of trying to do something along these lines stayed at the back of mind.

Then I was at a conference where someone from Leeds GATE (a third sector organisation working with people from Gypsy and Traveller communities) talked about and shared a map they have produced to depict the ways in which many people from Gypsy and Traveller communities access NHS services.  They used the metaphor of roads, bridges and tunnels and these were depicted clearly and engagingly in their illustrated map: an illustration that seems to work as a way of describing a complex inequality in a way that people actually experiencing that inequality, NHS staff and policy makers can all relate to.

So maybe I could do something similar around ethnicity and health?

Later I was delivering a new equality and diversity training session I’ve developed for CCG staff.  One of the teaching resources I use is an article that John Barnes (a black football player) wrote for the Guardian newspaper in 2013. In it he argues that the overt racism in football that was much reported on at the time (Russian fans throwing bananas at a Black British player and the much debated case of a White British footballer who’d been heard verbally abusing a Black British player on the pitch and whether he should be fined or not) is only the tip of the iceberg and that the real problem is the hidden, systemic discrimination that contributes to reduced opportunities for Black British people, the lack of Black football players who go on to become top coaches or managers and the fact that many Black British people don’t reach their intellectual or professional potential.  He also describes the more subtle, and often not talked about, stereotyping of Black people and the disproportionate numbers of Black British people who are runners, footballers or singers.

Barnes’ argument seems to me very relevant to the situation in the NHS where the focus of much Equality and Diversity training and work has been on “tip of the iceberg” individual acts of discrimination rather than on reducing the effects of less obvious and more multi-faceted systemic inequalities. The first time I’d led this training session it became clear in the discussion that some participants hadn’t understood the points Barnes was making.  So, I found myself standing at the flipchart having drawn an iceberg with its tip showing above the waves, eliciting from the group what is above and what is below the water line and writing phrases like verbal abuse and deliberate discrimination on the tip of the iceberg and then on the much larger part of the iceberg below the water, writing poverty, lack of interpreters, stereotyping, organisational culture, inconsistent application of processes and mistrust.

I was able to return back to this drawing throughout the session, explaining that the Public Sector Equality Duty requires us to reduce the inequalities that are caused by many of the factors that are hidden beneath the sea and that to identify those inequalities we need to gather together and consider various pieces of information, for example service usage data, demographic information, feedback from patients and research evidence.

So this metaphor has actually helped me to introduce the concept and practice of knowledge mobilisation too.