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.”