Now you see it, now you don’t: History as written by lions

At the time of writing this editorial, in September 2015, 872 people have been killed by police officers in the US since January 1st; statistics generated by The Counted project for the Guardian newspaper predict that the total number of deaths this year will be in the region of 1100 (http://www.theguardian. com). In the US, black people are twice as likely as their white counterparts to die as a result of contact with the police; deaths from shootings by other civilians add to the toll. The deaths of Michael Brown, Eric Garner, Sandra Bland, Trayvon Martin and the many others commemorated in the ‘hashtag’ #BlackLivesMatter are testament to how dangerous it can to be to live as a black person in the US. The legacy of slavery lingers on in persistent inequality and poverty among many of America’s black communities. Despite all the effort put into gaining civil rights, it seems that, in some areas, little has really changed (Theroux 2015).

Media attention to inequality, oppression and indeed death itself is often transient and can be fickle. Some (but by no means many) Black deaths, such as that of Michael Brown are reported in the international news media alongside interviews with distraught family members, friends or local pundits (http:// mappingpoliceviolence.org/unarmed/). As Rafeef Ziadah (2011) has pointed out in her poem, responding to media attention in such situations requires skill in fitting 'into sound bites and word limits' and the ability to comply with media demands to 'just give us a story, a human story ……. We just want to tell people about you and your people so give us a human story'. Trying to convey important points when faced with such strictures is an impossibility, which she sums up in 'today, my body was a TV'd massacre'.
Once the stories are gathered attention wanes and the media moves on. More black people are killed but their deaths receive less attention.
By contrast, at the same time as we were compiling this issue, the world seemed to erupt in condemnation of a white American dentist, who killed a lion in Zimbabwe for no other reason than that he could do so; he killed for 'sport'. In most societies, activities such as this are no longer seen as praiseworthy. As the old African proverb has it, 'when lions write history, hunters will not be seen as heroes' and here was a first class exemplar: a poor non-literate animal, unable to defend itself against the most deadly predator on the planet -a human with a gun. Moreover, the predator was a white man with a gun, on the borders of the former Rhodesia, and thus a figure that invited both scorn as a symbol of colonialism, and admiration from others who still think it is their right to kill for pleasure rather than necessity. The ensuing storm brought forth a third stream of protest. Not surprisingly, indeed quite understandably, African Americans felt that the deaths of their fellows should remain firmly in the public eye. They were just as, if not more newsworthy than the late, lamented lion. No doubt a lot of people felt sorry for the lion but the deaths of so many African Americans deserve more concern and compassion rather than avoidance; they also require urgent action if the tide of deaths is to be reversed.
Garnering support and lobbying for such action is not easy even in this era of internet-fuelled social media, where costs are low and the speed of spread is staggeringly fast. Inequality in access to the internet and the levers of awareness and pressure compound other forms of disadvantage. If this was not the case why would there be a need for groups such as Avaaz (www.avaaz.org) and '38 Degrees' (www.facebook.com/peoplepowerchange), whose mission is to champion less popular causes such as the plight of refugees and the environment?
As a journal, Diversity and Equality in Health and Care does not campaign for any group or to seek to privilege any one strand of equality over another. We do not, frankly, subscribe to the theory of a hierarchy of oppressions. If you are oppressed or discriminated against because of any characteristics or membership of any grouping, then that is unjust. Equality of esteem, opportunity and access should be universal human rights, though we accept that they are rarely achieved in practice and often opposed or made more difficult because of a lack of will, evidence of effect or of effective remedies. Research into interventions that may address those inequalities is still required and here we note a further form of inequality with some marginalised groups receiving more attention, and attracting more funding, than others.
Research is only part of the story. The outcomes of research must be translated into evidence that carries weight, into educational materials to upskill practitioners, and into knowledge that is regarded as essential and central to policy and practice. For that, this journal exists and, in the process, we shall continue to argue that more diversity is better! Indeed, a recent study revealed that genetic diversity -the less related one's parents or ancestors are -is associated with higher educational attainment and height, and better lung capacity (Joshi et al. 2015).
What we would like to underline, in this editorial, is that not all inequalities are as visible as others and that discrimination may be unseen, or based on markers that are unspoken or invisible to others. Whiteness itself is a blunt category -many sub-groups, including the Irish, as noted by Fazil et al's study in this issue, do not share the experience of the majority. Some differences, as highlighted in this issue by Mary Dawood's Practitioner's Blog, are unseen physical attributes or impairments such as deafness. However, as the title of her piece, a reference to a very moving play by Mark Medoff, the film version of which starred William Hurt, indicates, those who live in the world of the Deaf are yet people of worth with their own stories, pride and values and deserving of appropriate services and care. Other distinctions may also be invisible and almost impossible to assess, such as family membership or social class, which may well be one of the privileges that we are urged to check but can also be a source of inequality if one does not have the right heritage to draw upon. Sexual orientation, a frequent theme of papers in this journal, is another largely invisible marker of difference, to say nothing of the trials of those who transition between genders. As frequent studies and new data highlight in this issue's Knowledgeshare, the distinction between male and female has many consequences for health and service provision, usually, it must be said, in the same detrimental direction for women. That said, we must acknowledge that in one respect, in their less common role as 'carers', men may be neglected or overlooked by service provision (http://men-care.org/). It is nevertheless curious, if people really do not discriminate, and systems are designed to meet all needs equally, that whenever inequalities are measured across a spectrum of domains, as, for example, in the annual patient experience surveys of the NHS, and many other user monitoring exercises, there are few categories where the balance of 'benefit' and 'less good results' are equally divided between groups.

In this issue
We open this issue with two guest editorials, returning to a topic that we have not discussed for some time (see Uddin 2006)the question of forced marriage as a form of domestic violence. Let us be clear about what this means. Forced marriage is the forcing of two people into an intimate relationship, including sexual relations, against their will. Our two guest editorials approach this issue from different perspectives. Ashraf explains some of the cultural context for the practice of forced marriage, highlights the family and community aspects, and identifies who is most commonly at risk. She then presents useful practical advice and guidance for health professionals who may encounter patients who are being or who have been forced into marriage. She emphasises the importance of being open about the subject and not sidestepping the issue with excuses about not interfering in cultural matters. Health professionals need to be alert to the possibility of forced marriage because, in their encounter with an individual patient, they, the professional may be the only source of help.
Sargent's editorial reviews the legal aspects of forced marriage and clarifies the position of this in English law. Clearly there will be implications for all the processes relating to domestic violence and partners, although we have yet to hear of forced or arranged same-sex marriages, which may require a reinterpretation of the Forced Marriage Act (2007). It is evident from her review that there are multiple protections against forced marriage but the current legislation remains mixed and confusing, not least in failing to provide scope for annulment beyond a very narrow time window. As with other forms of domestic abuse, it may well take some time for victims to feel confident to appeal for help or reveal their situation and while the perpetrators may be subject to prosecution we need to think how best to provide victims with remedies.
We commend these two editorials together as forming another valuable tool for self-education and continuing professional development.
We return to the theme of inequality in our first research paper, Fazil et al. (2015) present evidence of inequalities in cancer treatment and in particular, their relationship to communication practices. Their paper also shows how attention to cultural heritage and understanding can lead to improved outcomes. The value of bilingual community cultural advocates is highlighted, as a positive intervention. We note other elements of good practice in this paper, including the methodology employed to collect the data and the process of respondent validation or feedback to the communities researched. Good practice should imbue all research as well as being supported by it.
In our second paper George et al. (2015) add to our small but growing collection of systematic reviews in the field and explore the much-touted value of training in cultural competence, including clarifying just what this might mean in practice. There is a huge literature mostly advocating cultural competence training (CCT) or one of its variants without really exploring its content, defining its implementation, or evaluating its effects. It is necessary to avoid the risk of reifying notions of culture, concretising stereotypes, or treating culture as an unchanging entity. Diversity, as George et al. suggest, and we would also argue, is more than just another word for 'race', 'ethnicity', or 'inequality'. This paper provides a much needed synthesis which hopefully will enable moves towards agreed definitions and approaches and evaluation research that can demonstrate effects in practice and on outcomes. There is, however, evidently plenty of scope to improve pre-professional-practice 'formation' training as well as in-service learning in these respects.
In our practice paper Islam et al. shift the focus from treatment and outcomes, to involvement in care, which itself can lead to better outcomes both for those treated, and those taking part as they learn and transmit information about specific conditions and their treatment. In terms of end of life care and cancer, the term 'palliative care' is, for most BME communities, not well known or understood. The study reported in this issue has made an appreciable impact on this gap in Leicester, UK (see also http://www.loros.co.uk/education-training-research/research/ diversity/ ). Contrary to some expectations, it proved possible to obtain volunteers from the main BME groups in the city. This required sensitive bespoke training and support. Recruiting and retaining volunteers in any context is not easy, and the paper is frank about the problems experienced, which should prove helpful for others attempting similar schemes -which we hope will be many. This process of using community peer volunteers has been found effective in other fields and locations (Morjaria-Keval & Johnson 2006). This paper is commended to our readers as an alternative intervention to be considered wherever services complain that 'we are open but They (who-ever they may be) won't come'. We note that while it may be true that the word 'volunteer' might be absent from many South Asian and other languages, the English also have no easy translation for the Hindi/Punjabi word 'sewa' -sometimes translated as 'selfless service'.
Finally, our CPD feature is now under new management. Dr Qulsom Fazil of the University of Birmingham Medical School and a new member of our Editorial Board has kindly agreed to take this on: please send any contribution for this feature to her at q.a.fazil@bham.ac.uk. The CPD series is designed to complement our research and development-focused articles, and provide readers with accessible ways to improve their practice. If required to submit returns to appraisal processes, each of these exercises should be reckoned to count towards at least an hour's training and reflection, and should be submitted in portfolios with evidence of any reading around or impact on professional practice arising from that exposure. In this issue, we are pleased to link this CPD feature, which refers to a continuing debate in other papers published by us and also to the Practitioner's Blog by Mary Dawood on the needs of deaf service users. If you would like to contribute to the Blog feature please contact Mary at mary.dawood@imperial.nhs.uk.
To this we add, as ever, our Knowledgeshare feature, in which a great deal of additional new evidence is presented regarding aspects on inequality, and some examples of better practice or initiatives to reduce inequality. Contributions to this feature should be sent to Dr Nicky Hudson at nhudson@dmu.ac.uk. Knowledgeshare -along with all the paid for research articlesis open to all readers in the Open Access process. This, we hope, will assist authors to recognise that their work will be supported, and read by more people, through the linkage of research and practice with education and personal professional development.