Dr Hadiza Bawa-Garba – Part 1: what does this case look like to medics?

Dr Hadiza Bawa-Garba, a paediatric specialty registrar, was struck off the specialist medical register a few days ago. Pulse, a GP magazine, provide a timeline for her case. In summary:

  • 18/2/11 – Jack Adcock, a 6 year-old boy, dies in Leicester Royal Infirmary of sepsis secondary to pneumonia whilst under the care of Dr Bawa-Garba.
  • 2/11/15 – Isabel Amaro, a Portuguese agency nurse involved in his care, is convicted of gross negligence manslaughter and is later struck off.
  • 4/11/15 – Dr Bawa-Garba is convicted of gross negligence manslaughter.
  • 29/11/16 – She applies to the Court of Appeal for “leave to appeal”; it refuses her application.
  • 13/6/17
    • She is suspended from the medical register for 12 months by the Medical Practitioners Tribunal Service (MPTS).
    • The MPTS reject an appeal from the General Medical Council (GMC) to strike her off the register.
  • 25/1/18 – She is struck off the medical register by the GMC following their appeal to the High Court.

Dr Bawa-Garba will no longer practise medicine in the UK.

Sources

I am neither a lawyer nor a paediatrician; my opinions are my own. Further, I do not have the transcript from the 2015 Crown Court trial – my sources for the original trial are the judgment from the 2016 Court of Appeal hearing. the Record of Determinations from the MPTS tribunal in February & June 2017 and the 2018 judgment from the High Court. I don’t have access to the coroner’s inquest.

54000 doctors is a website set up by Dr Chris Day, an Emergency Medicine trainee who fought a legal battle against Lewisham and Greenwich NHS Trust over whistleblowing. On it, is a letter concerning Dr Bawa-Garba’s case signed by four paediatricians and another doctor involved in the Child Death Review for a London Clinical Commissioning Group.

I have purposefully referred to this letter sparingly as I cannot easily verify the facts within it.

The story

Jack had a background of Down’s syndrome. He was on enalapril for a heart condition described as a “hole in the heart”. He also had a bowel abnormality. He was prone to chest infections. When well, he was a happy child who enjoyed playing with his sister.

10:15 am – Jack arrives at the Children’s Assessment Unit (CAU) from the GP having been off school the previous day. In the surgery his breathing was shallow and lips slightly blue.

10:30 am – Jack is admitted to CAU.

10:45-11am – Dr Bawa-Garba reviews him. He presents with a 12-hour history of diarrhoea and vomiting. He is lethargic and unresponsive and does not flinch when a cannula is inserted. His peripheries are cold and his temperature is raised.

Dr Bawa-Garba takes a blood gas. He is acidotic and has a high lactate.

A “blood gas” is a blood sample taken for analysis of partial pressures of specific gases, ie levels of carbon dioxide and oxygen. Machines for blood gas analysis are available in emergency departments, intensive care and, depending on the hospital, other areas.

The test also shows levels of blood acidity, lactate levels and bicarbonate levels. More modern machines can show levels of electrolytes and haemoglobin but these latter results are not as accurate as a lab sample. Staff can see the results within 2-3 minutes of the sample being run. This does not include time to obtain the sample and get it to the machine.

She diagnoses gastroenteritis with moderate dehydration and prescribes a fluid bolus.

11:30-11:45 am – Jack improves after being given fluids. Dr Bawa-Garba is cautious with fluid administration due to the Jack’s pre-existing heart condition.

12:01 pm – he has an X-ray during which he is “sitting up and laughing” and reacts to having his finger pricked

12:12 pm – on a second blood gas, results are better.

12:30 pm – the X-ray result is available but at this point not seen by Dr Bawa-Garba.

12:00-3:00 pm – Dr Bawa-Garba sees other children including performing a lumbar puncture on a baby. Nurse Amaro stops monitoring Jack’s oxygen saturations, records a high temperature at 2:40 pm and Jack’s nappies require frequent changing (presumably from diarrhoea). Nurse Amaro does not inform Dr Bawa-Garba.

3:00 pm – Dr Bawa-Garba reviews the X-ray and prescribes antibiotics.

4:00 pm – Nurse Amaro administers the prescribed antibiotics.

4:15 pm – Dr Bawa-Garba reviews blood tests ordered at 10:45 am. The results were not back until 4:15 pm due to a failure in the hospital’s electronic computer system. She was unable to obtain them “despite her best endeavours”.

4:30 pm – Dr Bawa-Garba flags a rising CRP (a blood test) with the paediatric consultant, Dr Stephen O’Riordan alongside the patient history, pneumonia diagnosis and treatment. She spoke to him again at 6:30 pm but does not raise concerns. There is no specific mention that she tells him about the high lactate and acidosis.

7:00 pm – Jack is transferred from CAU to Ward 28 “out of Dr Bawa-Garba’s care”. Jack’s mother administers his enalapril though this had deliberately not been prescribed. (It is unclear when she did this.) The plan to omit enalapril is not documented.

7:45 pm – Jack’s heart “fail[s]”. (I have no idea what this means!)

8:00 pm – A crash call is put out. On arrival, Dr Bawa-Garba stops resuscitation as she mistakes Jack’s mother for a different patient’s mother. The other patient has a “Do Not Resuscitate” order. With 30 seconds to 2 minutes, another doctor identifies the mistake and resuscitation is restarted.

Despite resuscitation, Jack dies at 9:20 pm.

The context

Dr Bawa-Garba was a Specialty Trainee Year 6 (ST6) in paediatrics. It takes 8 years of specialty training to become a paediatric consultant. This was her first shift in an acute setting after 14 months of maternity leave. She was asked to cover the CAU, Emergency Department (ED) and the ward.

(54000 doctors claim that there should have been a second registrar – a doctor of Dr Bawa-Garba’s level – to cover CAU, effectively leaving her doing two people’s jobs. They also claim the covering consultant was away teaching. I’ve not been able to verify these facts from the two legal sources to which I refer.)

The computer system was down for some hours. Nurse Amaro was an agency nurse who primarily worked in adult medicine. Dr Bawa-Garba worked a 12-13 hours shift without a break by the time of Jack’s cardiac arrest.

How bad is this?

So…I qualify the following comments by repeating that I was not at the trial, I was not in the hospital looking after Jack nor have I reviewed the notes. I’m not a paediatrician though I do look occasionally look after sick kids (probably more so as I’m soon moving to a paediatric anaesthesia rotation).

Initial management

Most of the initial management seems pretty decent. The diagnosis of gastroenteritis (infection of the stomach and bowel, occasionally referred to as “food poisoning”) is not unreasonable and is a condition not treated with antibiotics (indeed they can make it worse). The primary symptoms are diarrhoea and vomiting. This can lead to shortness of breath.

Dr Bawa-Garba gives Jack a fluid bolus and by the time the X-ray happens at 12:01, he’s laughing. That’s a massive improvement from the description of him being limp and unresponsive to pain initially. The second blood gas being better is also reassuring.

This is nonetheless difficult to judge. Should she have informed her consultant that there was a floppy, acidotic child with a background of previous cardiac surgery presenting with a high lactate? Possibly…but then he was getting better after she’d initiated treatment. It’s not unreasonable to initiate your treatment, see what the result is and then call the boss. Especially, if you know your senior is highly likely to institute the same plan as you.

X-ray

There is a 2½ hour delay between the X-ray being available at 12:30 pm and her review at 3:00 pm. It is impossible to say what happened in this time. Doing a lumbar puncture in a baby is no small feat. It’s entirely possible she had spent 2½ hours treating a baby with meningitis.

It also appears nobody informed her the X-ray was being done but in fairness to the nursing staff, it’s not that unreasonable – it’s the doctor’s job to chase up investigations she orders. If the diagnosis is gastroenteritis and the X-ray is not expected to be positive, it’s still understandable that Dr Bawa-Garba prioritises other sick patients over Jack and does not tell the nursing staff to let her know when it’s been done.

Dr Bawa-Garba admits she should have reviewed the X-ray earlier. It is unclear why she believes this.

Consultant discussion

This is where it gets a bit trickier. If Dr Bawa-Garba didn’t mention the blood gas results to the consultant, that’s pretty bad. Then again, at 4:30, Dr Bawa-Garba may have been unaware that Jack’s oxygen saturations were not being monitored and she was not aware of the high frequency of diarrhoea. The continuing high temperature would probably have made little difference to treatment.

(NB: 54000 doctors suggest that she did tell Dr Riordan but he thought the results unremarkable as Dr Bawa-Garba didn’t “stress” their importance. There are some numbers in the 54000 doctors letter. If any of this is true, Dr Riordan’s practice is questionable at best and at worst, gross negligence manslaughter.)

(Presumed) Cardiac Arrest

It is not specifically noted from the judgments where Jack had a cardiac arrest at 8pm. The MPTS record notes a crash call was put out at 8:00 pm so one must assume ward 28.

As an aside, some time ago, Do Not Resuscitate (DNR) orders were switched to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – one can resuscitate somebody with fluid but this is not what a DNR is intended for.

At this point, the trial notes that Jack was beyond the “point of no return” which, from what I’ve read, is a reasonable assumption. In adult medicine, it is certainly rare for somebody to survive a cardiac arrest secondary to septic shock.

How bad was Dr Bawa-Garba’s failure to correctly identify the DNR order? To be honest, given the situation Jack was in, the 30 second to 2 minute delay will have made little difference. Even in a different situation, with otherwise good quality CPR, it would be very difficult to claim that stopping for 30 seconds to 2 minutes would be the key to surviving. I can imagine making the same mistake. I think every doctor can.

It’s worth noting Leicester Royal Infirmary is a tertiary centre for paediatrics. As such, there will likely be a number of children who have DNR orders in place ie it is probably not highly unusual. It is only human that after 12 hours with no break, she picks up the wrong set of notes (or is even handed the wrong set) and sees the DNR without checking the label properly. Yes – even in the case of a DNA-CPR order, I can imagine this happening.

Enalapril

Enalapril is an angiotensin-converting enzyme or ACE inhibitor used to lower blood pressure and treat heart failure. They are potent drugs. It is the only class of anti-hypertensive anaesthetists insist on stopping prior to surgery. From the outside, it seems odd that an ostensibly improving child suddenly went into cardiac arrest.

My best guess, and I emphasise guess, is that the enalapril may have been significant. Again, I was neither at trial nor in the hospital so I cannot say whether that’s a reasonable assumption. Without knowing the child’s blood pressures and heart rates in the intervening period between 12:00-8:00 pm. But enalapril has an onset of action of 1 hour and peak effect between 4-6 hours – it seems Jack’s cardiac arrest was somewhere between 1-2 hours after its administration.

If the nurses were asked about the drug and the mother was told she could give it despite it not being prescribed, that would be shocking. Enalapril has a long duration of action (it’s usually taken once daily); a couple of hours without the drug would have been highly unlikely to have killed Jack. The Court of Appeal notes that the deliberate nature of Dr Bawa-Garba’s omission was not documented; whilst this is good practice, it is not essential. Doctors should expect that drugs which are not prescribed are not given as regular medications are otherwise routinely prescribed.

If they were in doubt, nursing staff should have checked with doctors if the omission was deliberate. If this was simply a mother understandably doing what she thought best for her son – giving him a life-saving medication – that is a tragedy.

Questions

The pressure Dr Bawa-Garba was under was immense. Without timely blood results, a junior doctor down, 14 months out of practice, an adult-trained agency nurse on a kids’ ward with anyway too few nurses and a patient who was when she last saw him getting better and who had presented with atypical symptoms of pneumonia (although all kids can get diarrhoea and vomiting when they have an infection), I find the absence of any investigation into the wider issues difficult to parse.

Indeed, I’m left with a number of questions. (I accept these may have been answered at trial and have simply not been included in the Court of Appeal judgment’s summary of the case.)

Specific to the case:

  • What observations were done between 12:12 pm when the second blood gas was done (meaning Dr Bawa-Garba must have seen the patient) and his cardiac arrest at 8:00 pm?
  • More specifically, what were the blood pressures and heart rates, key in assessing the level of shock? (Note, blood pressures are done less frequently in children than adults but this is still a basic and pertinent observation.) How frequently did Dr Bawa-Garba request observations be done?
  • If blood pressures and heart rates were being measured, how frequently? Was Jack triggering the hospital early warning score system such that Dr Bawa-Garba should have been contacted? If he was triggering, why wasn’t she contacted? If he did not trigger it, how can it be expected that Dr Bawa-Garba know Jack is getting sicker?
  • What was Dr Bawa-Garba doing between 12:00 pm-3:00 pm? What efforts have been made to discover this? Was she seeing patients sicker than Jack had initially appeared?
  • Did Jack’s mother discuss the enalapril administration with nursing staff? If so, did nursing staff advise her either to give or not give enalapril to Jack? What prevented them from discussing this with Jack?
  • What were the blood results? Would they have made much difference anyway? There is no mention of electrolyte abnormalities. Dr Bawa-Garba already knows he has an infection. The raised CRP is marker of infection but a single result is not a particularly useful marker of infection severity.

The wider organisational issues:

  • Why was she covering GP referrals, A&E referrals and another ward? What is the usual cover for this? What efforts were made to find cover given it was a Friday and so regular administrative staff were in?
  • Why didn’t the consultant on CAU step down to do the registrar shift or the regular ward consultant step down to cover so Dr Bawa-Garba could cover CAU?
  • Even if the computer system was down, why weren’t urgent blood results being phoned through to CAU?
  • How often was CAU understaffed with nurses?
  • How often were there too few juniors?
  • Were these concerns escalated to management?
  • If they were, what did managers do?

Doctors’ vs the public’s interpretation

The reason that so many doctors have come out in support of Dr Bawa-Garba is that this just looks like a normal day in the NHS. This post is not meant to conclusively prove Dr Bawa-Garba’s innocence or guilt. It hopefully gives you an insight into some of the thoughts doctors will have reading this case. Though I’ve attempted to be neutral in this post, I can’t help but feel a kinship with those tweeting #iamhadiza.

“Manslaughter by gross negligence occurs when the offender is in breach of a duty of care towards the victim, the breach causes the death of the victim and, having regard to the risk involved, the offender’s conduct was so bad as to amount to a criminal act or omission.”

p. 7, Manslaughter Guideline Consultation, The Sentencing Council, 4 July 2017

The definition on Wikipedia is of negligence such that “it showed such a disregard for the life and safety of others as to amount to a crime and deserve punishment”. (Though this is Wikipedia.)

I suspect many doctors will read this account and think “I’m simply lucky to have not gone to jail”. I will talk more about openess in Part 2 but take this quote:

“I never, ever want another family to go through what we’ve gone through”

Nicky Adcock, mother of Jack Adcock, Leicester Mercury, 25 January 2018

For entirely understandable reasons, Nicky Adcock may have inadvertently achieved the opposite. Indeed, I cannot even begin to blame her given the tragedy she has endured.

However, consider the case of Elaine Bromiley, a woman who died after a poorly managed anaesthetic emergency. Below is the story of her remarkable husband Martin Bromiley who, rather than suing the doctors, went about trying to find out why his wife died and how he could stop it in the future. Dr Bawa-Garba’s practice was, I think, significantly better than that of the doctors caring for Elaine Bromiley yet so many more lessons have been learned from that – and probably lives saved – than will be from the death of Jack Adcock.

In Part 2 (now available), I’ll try and explain some of legal aspects and why much of the interpretation of the case is wrong but its consequences for all healthcare professionals but particularly doctors-in-training (aka junior doctors) are profound.

Edit (30/1/18): the Crown Court does not publish judgments routinely – this post previously implied otherwise. I did not mention that there had been a coroner’s inquest where systemic failures should have been examined. I also mistakenly referred to Chris Day as an EM consultant – he is an EM trainee.

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The tax on doctors’ time

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A couple of days ago I was listening to the excellent New Statesman podcast which had a section on the NHS winter crisis. In amongst some very good points about why major system overhauls are not technically or politically feasible in the UK, they ended:

Stephen Bush: But there are multiple reasons that doctors are leaving to go to other countries many of which are to do with policy choices actively made by the government. But the policy choice not to tackle the housing crisis does mean that if you are in possession of a medical degree, the attraction of staying in London and not being able to buy anything other than a small flat within commutable distance to the hospital where you work quite antisocial hours to being able to buy a fairly large house –

Helen Lewis: yeah, and there’s been a great decline in hospital accommodation as well. I was talking to someone who’s got –

SB: in New Zealand or wherever.

HL: – yeah, exactly – two siblings who both are doctors and for various reasons have ended up practising abroad it is, that it is, very difficult with, and it’s the kind of the other side of globalisation, we talk about importing workers in lower-skilled industries to undercut us. We’ve got the problem at the other end which is we’ve got workers with high-level qualifications. It costs us a lot to train a doctor and then we’ve got a problem retaining them working in the NHS. Yeah again it’s another thing where just small things if you to talk to doctors who get to like only having a single bed in hospital accommodation. You know like they change around the way that on-call works that kind of stuff. You’re just slowly pissing off a group of people who have got a lot of individual power to go “huh, yeah bye. See you later”.

(That was totally not worth the effort to transcribe. But anyway…)

Helen Lewis is right – but lets talk specifics.

Ten years’ ago hospitals stopped providing accommodation to their F1s (Foundation Year 1 doctors – the first year of being a UK doctors). Arguably, this was a hangover from when we did 24 hour on-calls but it was still nice and to be honest, most F1s would rent privately rather than use often quite poor standard hospital digs.

The advent of a 12-hour shift pattern has obvious benefits – doing a 24 hour shift where you’re up the whole time is physically and mentally punishing. It was also accompanied by the European Working Time Directive which mandated an 11 hour gap between a 13 hour shifts and limited the number of hours one could work in the week.

Disseminated in time…

There are a couple of things to note, however. Firstly, the mandated time off doesn’t mean you’re not just generally tired. I did one, fairly quiet night shift on Friday night. Unexpectedly, I was still feeling quite tired 26 hours later.

When you do weekday (4 nights Mon night to Fri morning) or weekend nights (3 nights Fri night to Mon morning), at the end you spend two days jet lagged, trying to do as little as possible to recover. At 31, many of my colleagues have kids who don’t exactly understand this, let alone the other stresses and strains of home life.

…and space

Further, there’s an uncertainty which I’ve mentioned elsewhere in my blog. An acquaintance living in South Yorkshire told me that her husband, a paediatric surgeon, had been told with a week’s notice that he was moving to Newcastle for 2 years. They had at least one child, I think they may have two.

Yorkshire and the Humber Deanery is split into 3 schools, West Yorkshire (based around Leeds), South Yorkshire (Sheffield), and North and East (around Hull and York). The first two of these have historically filled their posts. Indeed, when I applied for anaesthetics, Sheffield and Leeds were competitive.

The difficulty was and is, fewer people apply for East Yorkshire. There has recently been a drop in the number of applications to Yorkshire and the Humber Deanery.

Because training posts were not being filled in the East, the deanery decided new applicants at an ST3 level (Specialty Trainee Year 3) would be expected to train across the deanery, with some reimbursement of travel and accommodation. There are two different ways to complete your first two years of anaesthetic training (Core Anaesthetic Training or the Acute Care Common Stem) but the point is, anaesthetists ready to move to the next stage were being asked to train, potentially, anywhere between Chesterfield and Scarborough.

Yes, we have been lucky in Sheffield; that all hospitals were commutable was a significant attraction of the school. When compared to the Northern Deanery (which includes hospitals in Carlisle and Middlesborough), the North of Scotland (an entire school of anaesthesia albeit limited to Aberdeen and Inverness from what I can tell) and Wales, Yorkshire and the Humber is not significantly bigger. It’s 186 miles from Rhyl to Cardiff, compared to the mere 100 from Chesterfield to Scarborough.

Your choices are to move every year; live in two places, coming back on weekends off; or commute long distances (possibly staying over on night shifts). None of these are straight-forward particularly for colleagues my age who have kids.

It takes 9 years of postgraduate training to be an anaesthetist, meaning you’ll be 32 before becoming a consultant and having a permanent contract. If you have the temerity to want to do research or an educational qualification, you have to increase that. In specialties such as cardiology or surgery, whilst not technically mandatory, to get a job you’ll need to time outside of training whether as research or a subspecialty fellowship. Completing training before having children is not always possible.

To an extent, none of this is unique to medicine. Soldiers earn less and are away from home longer. Other jobs mandate long commutes. Factory workers do night shifts for little pay. Nurses get paid less for an equally stressful job.

However, when one combines recurrent jet lag from night shifts, prolonged training before being able to settle down, the uncertainty of where one will be in 12 months, the inflexibility of training, the increase in retirement age, recent disputes with government over payincessant workplace assessments and exams, lack of rest facilities, and the possibility of dying on the way home from work, Helen Lewis’s “slowly pissing off [doctors]” encapsulates the factors that are chipping away at doctors’ numbers and doctors’ morale.

PS: for the non-medics, the phrase “disseminated in time and space” is a description used in the diagnosis of multiple sclerosis. This post has nothing to do with MS – the phrase just seemed apt and will ring a bell with medics.

Free speech, persecution and sinful gay sex

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Former Liberal Democrat leader Tim Farron was interviewed on Premier Christian news where he said he regretted stating that gay sex was not a sin.

(You only need to listen to about a minute of this clip.)

Farron’s points are, I think, these. Firstly, that politicians should be allowed to hold personal views on behaviour which they may think abhorrent, immoral or sinful but defend people’s right to practise such behaviour. Secondly, later in the interview, he states Christians shouldn’t have to hide their faith to get elected (though he admits he wouldn’t want an American system where politicians essentially fake it).

To an extent, he has a point. One could think “gay sex” immoral but still support its legality. A woman may think abortion abhorrent but still be pro-choice if regardless of her personal beliefs she does not support imposing them on others. Or in Farron’s case, a vegetarian who doesn’t propose the prohibition of meat consumption.

Freedom of speech can never be absolute. The classic example is it is not legal to shout “fire” in a crowded theatre. Here, it’s clearly reasonable to limit free speech. And often criticism is mistaken for a curtailment of free speech. Take the recent example of Virgin no longer selling the Daily Mail.

Farage is wrong. If Virgin is banning the Daily Mail, then so am I, at every point I am not selling the Daily Mail. Virgin are still allowing customers with a copy on to the train.

6 years ago, when comedian Daniel Tosh was heckled after joking about rape, a number of comedians came to his defence. One argued comedians should be allowed to say “almost whatever they want” and the audience could laugh or not laugh. Heckling aside, the criticism Tosh received is not limiting free speech – it’s free speech in action. You can’t say something and then get angry when others say they think you’re an idiot.

More than anybody, politicians must to be careful about what they say; it can have profound consequences. And politicians accept that – it’s a price of the job. (If you don’t believe me, ask the US State Department about their opinion of President Trump’s tweets.)

This is particularly true for the Liberal Democrats; our party’s manifestos are created democratically. Each policy has to be voted through by the party. The leader is there to advocate policy even when they disagree, a principle which killed Nick Clegg’s political career.

Is there a glass ceiling for Christians?

Yes but no.

He was asked this question originally by Cathy Newman in 2015 after he was elected leader. After two years, when asked repeatedly in 2017 he still had no answer until finally admitting (well, lying) that he didn’t think gay sex was a sin.

It would have been perfectly reasonable for him to say “if you want to know about sin, ask a priest; I’m a politician”. He didn’t – he responded by saying “we are all sinners”, which in the Premier Christian Radio interview he admits is evasive. However, one cannot say “I want to be an openly religious politician” and then complain that one is quizzed on what those religious beliefs are.

Further, Farron admits in the interview that most people don’t understand what “sin” means. As such, he understands that when he says he thinks “gay sex” is a sin, most will interpret that as, “gay sex is a bad thing”.

The glass ceiling is for those whose Christianity justifies abhorrent beliefs. That’s exactly the sort of glass ceiling we should be trying to build.

The false equivalence of immutable characteristics with religion

There is a wider issue here on how criticism of religious belief is conflated with the persecution of minorities. If you are an ethnic minority, LGBT or disabled, it is not a choice. A religious belief is.

Clearly, abuse of religious people simply because they dress or act differently is unacceptable. Shouting at those exiting a mosque because they have “Muslamic ray guns” is indefensible (though it is worth noting that such abuse is usually couched in nationalist terms, religion effectively being used as a proxy for racism). I also don’t think it’s acceptable to criticise a politician’s religious beliefs if they wish to confine them to their personal life.

Liberal Democrats are supposed to support progressive causes unapologetically – calling “gay sex” sinful does the opposite. Claiming to be a Christian is no defence. Moreover, using the term glass ceiling to equate systemic discrimination against women in the workplace with the right to call “gay sex” sinful is indefensible. Or to put it more succinctly:

PS: so…you may have noticed I referred to “gay sex” in quotes. It’s because it’s a form bi-erasure. If two bisexual men have sex or two bisexual women have sex, neither is “gay sex” – no gay people are involved. Unless Tim Farron thinks homosexual sex is a sin but is fine with same-gender bisexual nookie, we shouldn’t really be using the term “gay sex”.

Brown atheists

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The Grand Mosque, Kaaba, Saudi Arabia in 2014 – original image

In the last week, I’ve read two excellent books on race: Why I’m No Longer Talking To White People About Race by Reni Eddo-Lodge and The Good Immigrant by Nikesh Shukla. Both books give an excellent summary of Britain’s issue with race.

I read Eddo-Lodge’s book first. Though the book is indeed very good, I found the first couple of chapters initially irritating due to the seeming lack of discussion of British South Asians and virtually no mention of British East and South-East Asians. In the Histories chapter, amongst the descriptions of riots, there is no mention of the 2001 Bradford and Oldham riots involving British South Asians. Perhaps this was an editor’s choice but it still left me feeling slightly empty even if I enjoyed the book as a whole.

As such, I then found The Good Immigrant which is a collection of essays – one from Eddo-Lodge herself – from a variety of first- to third-generation immigrants of colour. (Amusingly, my partner already had a copy which I realised halfway through reading the version I’d bought on Kindle.) This book too is excellent but only one essay is written by a non-religious person.

What brand of immigrant am I?

I am Asian/British Asian according to the 2011 UK Census categories. This makes me part of a 7.5% minority or 4213531 of the population. I am also of Bangladeshi heritage – 447201/4213531 or 10.6% of the Asian/British Asian population and 0.8% of the total population. Even amongst Bangladeshis, my parents are from the city of Rajshahi putting me in the 5% not originating from the northeastern district of Syhlet (p 247); a minority within a minority within a minority, if you will. (For comparison, there are 1864890 black Britons – 3.3% of the population.)

I’m also of “No religion”. Now, the 2011 Census would suggest that makes me a part of a 14097229-strong group, about 25.1% of the total population (though the British Social Attitudes survey suggests this number is closer to 53% and is probably the more accurate number; a debate for another time).

Put those together and what do you get? The 2011 UK Census states there are 6093 Britons of Bangladeshi ethnic origin with no religion (0.011% of the population, 1.3% of Bangladeshi Brits). At this point, the percentage becomes meaningless other than to say, it’s very small and probably an underestimate.

I am nonetheless privileged. I’m privately educated, straight, able-bodied and am in full-time professional employment. Further, I’m arguably a very “white” Asian. My favourite sport is rugby union and when I go I often joke about being the only Asian in Twickenham (though not always true – last time I went with my brother).

I don’t eat many “Indian” sweets – I’d much rather have Dairy Milk. I drink alcohol – haram according to the beliefs of of the 402428 (89.9%) Muslims amongst the Bangladeshis in Britain. And I spurned Bhangra and Bollywood for 2000s indie and Netflix.

At least, I’m a doctor, I guess.

Coconuts

I have been to Bangladesh a number of times though not for 16 years, shortly after I finished my GCSEs. There are a number of reasons for this which I’m not going to go into here but it’s why I am irritated by Britons with South Asian parents who are deeply patriotic to Pakistan, India or Bangladesh only to tell me they’ve never been.

Bizarrely, it was a white friend who revealed the term “coconut” to me. She had gone to school in Leicester with a large number of Asian pupils. A coconut is a brown person who is white on the inside. Initially, I was unaware Asians use it as a pejorative term, a less harsh version of “race traitor” or “Uncle Tom”.

For most of my life, most of my friends have been white and so – as you may have gleaned – I largely associated Asian culture with my parents and with Islam. Indeed, I’ve probably had more South-East Asian, East Asian and black friends than South Asian ones. To some minor extent – and fitting with a stereotypical teenager – I felt the need to rebel against my parents. But not really as I was pretty much a goody-two-shoes at school.

In fact, my parents are remarkably liberal for Muslim, Asian parents. They never tried to arrange a marriage, never asked much about the fact I drank at Uni and after the age of 12, allowed me to make my own decisions about religion, even if it meant I’ve ended up faithless.

The bottom line is, I often feel far more at home in typically white environments than Asian ones. Much of the constant explaining of culture people of colour have to do, I don’t. I don’t have to explain why I don’t drink alcohol, my religion, my “weird” hair, my different clothes, my accent.

Don’t get me wrong, I have on a number of occasions been asked “but where are you originally from?”, “Telford” apparently being an insufficient answer. I’ve had a patient assume I was interested in the cricket score. I’ve been mistaken for another Asian doctor with whom I have never worked (despite the fact he is thinner and half a foot taller than me). And I’m still taken aback that so few people know that Bangladesh used to be East Pakistan and fought a war for its independence.

And yet – I’d still rather sample a real ale in a hipster pub in one of the whitest parts of Sheffield than watch Bollywood or listen to South Asian music.

As-salamu alaykum and other bones of contention

Every now and again, somebody would phone the house, immediately saying “as-salamu alaykum” and speaking in English nor Bengali. My brothers and I would invariably respond with “hello” until the other person spoke a language we understood.

I know this is a pretty standard greeting in Muslim countries but ultimately, I am not a Muslim. I have had a couple of people assume I was religious for no other reason than skin colour. They all have the same look of confusion as they try to pigeon hole a brown atheist. And to be honest, this is white and brown people equally.

Muslim countries the world over persecute atheists. Most have blasphemy laws. Raif Badawi languishes in jail having been lashed by Saudi Arabia for apostasy, possibly awaiting more. Ahmed Rajib Haider, Avijit Roy, Washiqur Rahman, Anata Bijoy Das, Niloy Chaterjee, Faisal Arefin Dipan and Ahmedur Rashid Chowdhury Tutul were all Bangladeshis killed, most hacked to death, for expressing secularist views. Shahidan Kassim, a Malaysian government minister, has said atheists should be “hunted down”.

Faith to Faithless is a UK-based charity founded by ex-Muslims Imtiaz Shams and Aliyah Saleem. Run by volunteers, it helps those seeking to leave religion. This video on their website created by VICE News shows the lengths some have to go to stay safe.

In it, we see a British man who has his kneecap fractured and wrist broken defending himself from attackers after fellow Muslims discovered he had become an atheist. There is a British woman who age 17 escaped the imprisonment of her family when they discovered she had a boyfriend. And worst, the story of an atheist woman (by whom the the above photo was taken) who tried to flee Saudi Arabia and the possibility of being murdered by her brother.

“…clowns to the left of me, jokers to the right…”

Brown atheists are in something of a bind, even in the west. The conservative right will not defend them because they are atheists, refugees and/or immigrants. Progressive liberals will not defend them because they criticise Islam and the cultures of conservative minorities. And when Britain thinks of atheists, it thinks of a male, pale and stale middle-class former Oxford professor. What could be more privileged than that, right?

Personally, it puts me in something of bind too. I get the desire for safe spaces at Universities. There isn’t really a de facto neutral position on free speech – if you have no safe space policy and discussions are dominated by straight, middle-class, able-bodied white men, that’s hardly conducive to the sort of open discussion free speech proponents advocate. Indeed, it’s still a safe space, just a safe space for straight, middle-class, able-bodied white men.

But if an organisation set up by two brown atheists escaping persecution is not allowed to criticise the religion responsible for their persecution, the notion this is about defending victims is a pretence. At the point you’re banning an ex-Muslim human rights activist Iranian woman, you’re not doing safe spaces properly.

Millions of Muslims go about their day without persecuting anybody whilst themselves being marginalised because they dare to wear non-Western clothing, no doubt, but this is something of a #notallmuslims #notallreligiouspeople argument. Yes, there are women wearing a hijab who do so freely and may have very good reasons for doing so. The difficulty is, the ones who are forced to (like Rana in the VICE News video) tend to shed them when they get the chance. And at the point they’re still wearing them, they’re not in a position to speak lest they get slightly killed.

Yes, there are Muslims tolerant of LGBT people. But that’s different from being an ally of LGBT people, particularly LGBT Muslims and ex-Muslims. And where Muslims (or Hindus or Buddhists or whoever) don’t support LGBT rights, they should be roundly and routinely criticised for it.

I once had a white person point out to me that Muslim-majority countries’ illiberalism was very complicated and one could not place all the blame on religion. I didn’t realise quite how patronising a bit of whitesplaining that was at the time but I’m not doing that.

I’m saying that if you think Islam has nothing to do with the persecution of atheists in Muslim-majority countries, it’s no worse than saying men having nothing to do with sexual assault because #notallmen.

Most of those victims are brown and you should care about that, even if it makes you feel uncomfortable with Islam.