During a pandemic, we forget that health is more than simply avoiding a virus. The more sinister attacks on our health have historically been, and continue to be, related to the “social determinants of health,” everything from income and employment to housing and education.
One of those powerful determinants that can make Canadians squirmy is racism. Discussing racism causes eye contact to be avoided and chairs to be shifted. But even more uncomfortable is acknowledging the profoundly harmful burden of decades of unrelenting racism toward BIPOC (Black, Indigenous and people of colour). White supremacy is baked right into our country, and inevitably, into our health-care system.
Since 2013, the St. Michael’s Hospital Academic Family Health Team has created programs related to literacy, employment and access to legal services, to name a few. A racism and health committee was assigned to conduct a review of anti-racism interventions in health-care settings. Our findings recently appeared in a special issue of the International Journal of Environmental Research and Public Health. These findings are summarized below and in the conceptual model that outlines key strategies and principles. Our goal was to find effective strategies and lessons, not to prove that racism exists in health care. We should be past that by now. There is extensive documentation of racism in health care, particularly anti-Black racism and anti-Indigenous racism.
Reviewing the literature on anti-racism actions in health-care settings revealed no surprises and our findings are likely to be unsurprising for those who have been engaging critically with anti-racism work in other settings.
But we must actually embark on the work. Here are a few suggestions:
Lay a foundation for anti-racism interventions
Organizations ought to define the problem(s) and set clear goals and objectives. For instance, a lack of knowledge around Indigenous health practices is a specific problem with different objectives than aiming to reduce Black infant mortality. Be bold and clear – avoid using the vague terms of “diversity,” “inclusivity” and “cultural competency” and choose instead to explicitly name racism. Build sustainable organizational change with consistent leadership actions that address racism. Drawing on lessons from the Aboriginal Torres Strait Islander Strategic Leadership Committee in New South Wales, establishing leadership buy-in and commitment is crucial.
Leaders must commit to the long-term investment of resources including time, staffing and funding for programs, services, training and community participation. It is not an overstatement to say that this work is hard and nuanced, thus the right support and expertise are necessary. Involve members of racialized groups in creating interventions and educational materials and hire skilled facilitators from specific marginalized groups. Failure to do so can lead to unintended negative consequences that can cause more harm. Focus on those you are failing to serve. Developing ongoing, meaningful partnerships with communities of colour is necessary to address community-prioritized issues. Be patient and persistent. Establishing relationships with communities that have been harmed for many years is a complex, long-term process. Take some deep breaths – this isn’t a race, it’s a life-long walk.
Begin with addressing institutional racism
Many organizations have focused on individual-level training; however, sustainability is a key issue that cannot be achieved through one-time interventions. We urge the use of a multi-level, multi-pronged approach for long-term change. Start with broad policy and organizational interventions with community input. Practically speaking, this could look like implementing policies, guidelines and recommendations across a health-care network (policy level); embedding an explicit anti-racist lens to hiring and promotion (organizational level); and establishing meaningful community and patient partnerships with Black, Indigenous and racialized populations (community input). Non-tokenistic action is essential if your organization is to go beyond merely “ticking boxes.” In other words, assiduous, arduous work is required by leadership versus perfunctory, symbolic gestures such as recruiting from underrepresented groups to give appearances of anti-racism action. Individual behaviour is influenced by organizational culture and practice, not the other way around. Ongoing, mandatory, tailored staff education and training come in after organization-level interventions.
Monitor processes and assess anti-racism actions
This work requires a keen, unflinching eye. It is often the more subtle manifestations of racism throughout an organization that go unaddressed. An important caveat is that not all interventions are good or effective at mitigating racism. Thus, monitoring progress is another key component in creating systems-level change to dismantle racism. Accountability stems from continued efforts to monitor and evaluate anti-racism initiatives in a transparent manner.
The St. Michael’s Family Health Team Racism and Health committee has since been reconfigured and renamed the anti-racism advisory panel to highlight that this work is ultimately the responsibility of health-care leadership. While expressed intent to tackle racism is important, the measures of successful anti-racism actions in health-care settings are uptake, impact and outcomes. Health-care institutions need to reflect critically on whether they are ready to make the commitment necessary to do this work and invest time and money to bring about sustainable system-level change. Anything less is performative. Without a solid commitment to incorporating the principles of anti-racism work developed by racialized people, primarily Black and Indigenous scholars and activists, health-care institutions will continue to create and perpetuate harm.