Rethinking race in healthcare
From an Indigenous patient in Quebec recording nurses’ insults as she lay dying to allegations of prejudice in B.C. emergency rooms, racism in Canadian healthcare resurfaced this year amid the pandemic.
As the healthcare system grapples with systemic racism, educators and researchers say doctors need to rethink how race is connected to health.
Medical education about race has traditionally been limited and largely disease-based. For example, sickle cell anemia is more prevalent among people with Mediterranean or African ancestries; Fijians and South Asians are at higher risk for coronary artery disease and heart attacks; and Black Canadians have higher rates of diabetes than white Canadians as well as more frequent preterm births.
However, there is growing recognition that it is largely racism, not biology, that links race with health outcomes. And, experts say, physicians must recognize that race-based health differences are actually rooted in structural inequalities like disparities in income, housing, access to nutrition and education.
“We have been erroneously taught in medicine that racial categories are biological but they are social,” says Onye Nnorom, a public health physician and Black Health Theme Lead at the University of Toronto’s faculty of medicine. “Population health inequities need to be understood with a lens toward structural injustice … not by pathologizing an affected group.”
Among other harms, systemic racism causes patients to be reluctant to even see a doctor.
“Because of past experiences, there are Indigenous patients who have a significant barrier to coming to the emergency department even when they are very, very sick,” says Kendall Ho, an emergency physician in Vancouver who works with the interCultural Online Health Network.
These fewer interactions with the healthcare system lead to worse health outcomes.
“African Canadians are under-represented in attendance of prevention programs for diabetes and over-represented on dialysis units,” says Sharon Davis-Murdoch, co-president of the Health Association of African Canadians.
And, according to Kwame McKenzie of the Wellesley Institute in Toronto, “when (Cancer Care Ontario) looked at cancer screening for cervical, breast and colon cancers, Black women were much less likely to come forward for it.”
Ho adds that “it doesn’t matter how much knowledge I have about treating a heart attack if a patient doesn’t want to come (to the hospital). I’ll never be able to help that person.”
He suggests physicians actively think about racism during a medical assessment the way they regularly consider other social factors behind health, such as housing, substance use and occupation.
“We need to think about … how we can best serve (our patients) not just in their physical needs but also their emotional needs. We need to be humble and try to anticipate … what we can do to make the journey smoother.”
Says Davis-Murdoch: “Get to know the patient in front of you and your local community of patients … You need to really understand the different lived realities of the people you are serving … When a physician is ignorant about cultural differences and wants to apply one-size-fits-all, something will go wrong.”
Terri Aldred, a family doctor in northern B.C. from the Tl’azt’en Nation, says it’s important for doctors to engage in cultural sensitivity training that is available but has not been widely adopted or mandated by health authorities.
“It’s not enough to do it once, just one time, and call yourself competent,” she says.
As the Indigenous site lead for Family Medicine at the University of British Columbia, Aldred also recommends doctors take time to learn the historical context of racism against Indigenous people, naming books such as The Inconvenient Indian, 21 Things You May Not Know About The Indian Act, and Medicine Unbundled.
Aldred says the biggest barrier to interest in cultural sensitivity training is shame, “especially in healthcare where people have a lot of pride. It’s tied to the idea that if you’re racist, you’re a bad person or a bad doctor.”
“We share stories and people cry but the moment you move into action, the tears dry up,” she says. “People say, ‘Maybe this was just one story,’ or, ‘We don’t fund data on racism because it’s not sexy.’”
She says doctors should not just think about calling out racism in others but also reflect on how they will react when they are called out.
“Moving forward, we need to be able to move past the walls of ‘I don’t think this exists.’”
Lack of data on the effectiveness of cultural training is another problem, says Aldred. As a result, “we don’t know what will work well … and nobody’s looking at whether there’s meaningful change. They’re only surveying opinions of courses.”
Race-based data on health outcomes at large is also considered to be widely lacking in Canada.
“Medicine in Canada is one-size-fits-all and then we’re surprised that some people don’t turn up and some say it doesn’t fit them,” says McKenzie.
But “if it is not done in a culturally appropriate way, (race-based data) will be misinterpreted and likely reinforce stereotypes. It needs to be collected in a culturally safe manner with the affected communities at the table,” says Nnorom.
Ho warns that “we can’t look at data without relationship and trust or else a certain categorization can happen and we end up treating a categorization instead of a person.”
Nnorom says she hopes race-based data will be used to promote institution-level change and that as patterns are identified, physicians can focus on learning greater cultural safety for specific racialized groups.
Looking ahead, physicians can also help fight systemic racism by changing how the system trains Canada’s next generation of doctors.
“Currently, teaching about systemic racism is variable,” says Maria Hubinette, assistant dean of equity, diversity and inclusion at the UBC Faculty of Medicine. “Students do get teaching about social determinants of health and about health inequities. But, in general, little curricular space is given to exploring root causes … or how to actively adopt anti-racist practice.
“We need to critically evaluate our admissions policies and who we are (and are not) admitting to medical school,” she adds. “We also need to consider who our teachers, mentors and leaders are… Whose voices and stories are amplified? Whose work are we highlighting?”
Medical schools are making changes to address the issue. Dermot Kelleher, UBC’s dean of medicine, noted in an email: “We’re actively increasing the number of Indigenous physicians and health professionals in B.C. … We are also committed to increasing the number of Indigenous leaders in senior positions across the university.”
And he identified UBC’s Indigenous Cultural Safety Training as a growing program that “was developed, with significant consultation, involving Indigenous students, leaders and organizations.”
“We aim to obtain funding to broaden (its) scope and reach … as a critical and mandatory element in our collective efforts to raise awareness and promote cultural safety,” he wrote.
In Toronto, Nnorom is working with others to create a series of online modules about anti-Black racism in healthcare that she says she hopes will be a teaching resource for medical and health professional schools across the country.
At the University of Manitoba, the Rady Faculty of Health Sciences has released a policy on dismantling racism, specifying what behaviours are not to be tolerated. The University of Toronto has an Academic Strategic Plan that includes a focus on equity, inclusion, and mobilizing resources to address racial under-representation. McGill University recently released its own five-year strategic plan for addressing racism.
Hubinette says she is optimistic for the future generation of Canada’s physicians.
“My own institution has started to grapple with change. I am hopeful that this is changing.”