I Introduction – Canada: A Post-Racial Society?
II Deconstructing Race, Racialization and Racism
III Avenues for Change – Public Health’s Role in Closing the Racial Health Divide
–Submitted by Anjum Sultana
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” – Dr. Martin Luther King Jr.
I Introduction – Canada: A Post-Racial Society?
Over the last few years, there has been a growing discussion on the increasing nature of the violent and discriminatory nature of policing practices on both sides of the 49th parallel. With the non-indictments of police officers involved in the deaths of Michael Brown and Eric Garner, as well as the police brutality faced by Sandra Bland, Tamir Rice, Freddie Gray and many other African Americans in the hours before their death, as well as the protests in response across the US from Ferguson to Baltimore to New York, the conversation around race relations and racism is at an all-time high. This has sparked the Black Lives Matter movement to fight against the racial injustices faced by African Americans. Many might say that although this conversation is warranted in the US, given the legacy of colonization and the transatlantic slave trade that manifests itself in social and economic inequities, this does not apply to Canada, the world leader in multiculturalism and immigration policy.
However, as much as Canada likes to pride itself on this identity of being a diverse and tolerant nation, we are far from being a post-racial society. You only have to look towards the recent police shootings of Jermaine Carby (http://www.thestar.com/news/crime/2015/07/31/jermaine-carby-taken-in-und…, Andrew Loku (http://www.thestar.com/news/gta/2015/07/18/mourners-gather-to-remember-a…), and the debates around the arbitrary policing practice of carding in Toronto (one that unfairly targets Black and Brown bodies), to see that the nature of police action in Canada is also under question and is problematic. In addition, we too share a collective history with our neighbours to the south of settler colonialism that has resulted in stealing land from the indigenous peoples of this nation. This has led to far reaching effects including the creation of poor social, economic and health outcomes for Aboriginal communities across Canada. In the recent harrowing findings by the Truth and Reconciliation Commission of Canada (http://www.trc.ca/websites/trcinstitution/File/2015/Honouring_the_Truth_…), we have seen the immense intergenerational trauma and cultural genocide the residential school system and other colonial policies have caused to the Aboriginal people in this country.
The injustice faced by racialized and indigenous people in Canada, in multiple sectors and areas of life, has been well-documented but what has been missing from these discussions of racism has been the public health perspective. Racism has an immense impact on the health and well-being of people in this country and as public health professionals, with social justice and equity as critical guiding principles in our work, it is our duty and obligation to address these inequities. This piece will begin to outline what the terms race and racism mean, the pathways by which racism impacts health, and present ways forward. Ultimately, it will demonstrate that racism is indeed a public health issue and why when it is necessary when it comes to the issue of racial justice, the public health community must join together and act.
II Deconstructing Race, Racialization and Racism
Discussing racism is a difficult and sensitive issue but it is very important to have a shared understanding of these terms before delving deeper into the material. In Mikkonen and Raphael’s 2010 publication, Social Determinants of Health – The Canadian Facts (http://www.thecanadianfacts.org/the_canadian_facts.pdf), they list race as a determinant of health, alongside income and income distribution; education; unemployment and job security; employment and working conditions; early childhood development; food security; housing; social exclusion; social safety net; health services; Aboriginal status; gender; and disability. I would argue that race, and more importantly racism, are two of the most fundamental determinants of health because they structure the way in which one experiences and has access to many, if not all, of the other social determinants of health.
Race and racism are not the same thing. Race is a social category that groups individuals into certain ‘races’ based on a combination of factors that includes the colour of one’s skin, other arbitrary phenotypic characteristics, and shared ancestry. Although there may be limited biological differences of a superficial nature, there is no real genetic difference between different ‘races’. It is well established now that race is a social construct, not a biological one so we have advanced from the troubling notions of the category that was once the foundation of the eugenics movement. Racialization, according to the Ontario Human Rights Commission (2015), is “the process by which societies construct races as real, different and unequal in ways that matter to economic, political and social life.” People are referred to as being racialized to make the point that this is a social process that is being done to them, they are not inherently a particular race.
However, with the concept of race as a social construct, it produces and rationalizes inequitable distribution of power and resources in societies that has a real impact on people’s lives. According to Camara Jones (2003), racism is the “system of structuring opportunity and assigning value based on the social interpretation of how one looks (which is what we call ‘race’).” What this results in is the simultaneous unfair advantage certain individuals and communities have at the cost of unfairly disadvantaging other individuals and communities based on arbitrary notions of what ‘race’ they belong to. This is very important to note because the flip side of racism and racial discrimination is not only that one group gets unfairly treated but another group unfairly benefits from this. Ultimately, this leads to a society whereby racism, as Jones eloquently states, ‘saps the strength of the whole society through the waste of human resources’. This is one of the fundamental reasons why combating racism, in all of its forms, is essential to the health of society as a whole. Because when one group is unjustly targeted, not only is that an infringement on their human rights, we all also lose our collective potential to be a vibrant and inclusive society.
There are three key levels of racism – the interpersonal, the internalized, and the institutional – and they each have a unique impact on health.
The interpersonal form of racism, also known as personally-mediated racism, is what traditionally comes to mind when discussing this issue and is characterized by prejudice and discrimination experienced by people on the basis of their race. The source of this prejudice comes from differential assumptions and judgements in the abilities, motives, capacities and intents on the basis of race that construct stereotypes and inaccurate generalizations. The results of which are differential treatment and action along those racial divides. For example, this includes actions such as racial slurs, police brutality, shopkeeper vigilance, teacher devaluation, waiter indifference and physician disrespect (Jones, 2003). This personally-mediated racism contributes to increased stress for racialized people and subsequently higher rates of cortisol in the body.
The consistent negative stereotypes found in society has the potential to lead to internalized racism whereby racialized people begin to believe the negative stereotypes and supposed inferiority of their racial group and may start to partake in behaviours and beliefs that are detrimental to their health such as substance abuse to cope with the stress (Jones, 2003).
Finally, institutionalized racism is the ways in which racist policies, practices, programs have become codified within the very structures of society from sectors as diverse as housing, education and yes, even health care, that systematically disadvantage people of colour in this nation. We see this in lower rates of graduation from high school, post-secondary institutions, and professional schools for people of color. We see this in the lack of diverse representation in our political leaders at all levels of government. We see this in access to social determinants of health whereby racialized people have higher rates of unemployment and lower rates of income.
All these forms of racism contribute to lower rates of health outcomes as we have seen in the US, but this is the case in Canada as well.
What is Racism’s Impact on Health in Canada?
Racism & Health: Domains, Levels & Lifecourse
Dr. Nancy Krieger (2011), one of the pre-eminent social epidemiologists of our time has conceptualized an ecosocial model and has suggested six distinct pathways through which racism impacts health:
Economic and social deprivation
Toxic substances and hazardous conditions
Discrimination and other forms of socially inflicted trauma (mental, physical, and sexual, directly experienced or witnessed, from verbal threats to violent acts
Targeted marketing of harmful commodities (examples include ‘junk’ food, tobacco, alcohol, as well as legal and illicit drugs)
Inadequate or degrading medical care
Degradation of ecosystems, including as linked to systemic alienation of Indigenous populations from their lands and corresponding traditional economies.
In the interest of brevity, evidence will be shown to demonstrate that racialized people have lower quality of and poorer access to health care services as well as that there is an inequitable distribution of power, resources and privilege that results in less than optimal access to other social determinants of health.
When it comes to describing the state of health care services of indigenous people in Canada, the case of Brian Sinclair (http://globalnews.ca/news/1723206/inquest-report-on-brian-sinclairs-winn…) provides a tragic example of the type of indifference and stereotypical assumptions experienced by Aboriginal Canadians, and in this case, led to his death. For many measures of social and health inequities, Aboriginal Canadians experience far worse outcomes than African Americans, so it is clear to see that racism is not just an American issue.
Social and Health Inequities for Aboriginal Canadians and African Americans
Another recent article found that Ontario Metis face higher risk for cancer (http://www.thestar.com/news/canada/2015/07/29/ontario-mtis-face-higher-c…) compared to non-aboriginal residents. In one of the most thorough reports on evidence regarding the health of Aboriginal people in Canada, First Peoples’, Second Class Treatment (http://ywcacanada.ca/data/research_docs/00000325.pdf) by the Wellesley Institute, it details not only the state of health inequities but also the specific policies that have codified institutionalized racism to produce such outcomes.
In Toronto, Canada’s largest and most multicultural city, a 2013 report by Toronto Public Health found that on several health outcomes, racialized people fared worse than White people. Black residents of Toronto had higher rates of obesity, high blood pressure and chronic pain compared to non-racialized people. In 2009, Veenstra, found that racialized groups had higher rates of diabetes, hypertension, and fair self rated health and that this was linked to factors such as the everyday wear and tear of racial micro aggressions and institutional racism (Veenstra, 2009). Sarah Nestel’s Wellesley Institute report, Color-Coded Health Care: The Impact of Race and Racism on Canadians Health (http://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Code…) cites several studies that demonstrate racism’s impact on specific health conditions such as very high rates of cardiovascular diseases in South Asian residents (http://www.ncbi.nlm.nih.gov/pubmed/11944758) of Canada, poorer access to liver transplantation among East Asian, South Asian and African Canadian (http://europepmc.org/abstract/MED/20116643) communities, and cervical cancer rates ranging from 45 to 64 times higher in refugee born women as compared to Canadian born women.
In Canada, the impacts of racism on health appears to be somewhat attenuated (http://www.ncbi.nlm.nih.gov/pubmed/19542077) due to our single-payer health care system, but the impacts are still there in the scant evidence that is available (though much more research is urgently needed) (Siddiqi & Nguyen, 2010). Unlike the US, there is a paucity of research delineating the racial disparities in health in large part due to the lack of race-based data. Often, immigrant status is used as a proxy measure to detail the racial health inequities. One must be careful when doing so as it may erase the specific influence of racism that racialized residents feel whether they are new immigrants or third generation Canadians.
Some might question that while there may be evidence of racial health inequities in Canada, is this really the domain of public health? I would argue yes, because the public health sector has unique expertise and resources it can leverage to make a real difference on this issue in Canada.
III Avenues for Change – Public Health’s Role in Closing the Racial Health Divide
When it comes to the issue of racism and population health, the public health sector has a critical role to play in not only health services and the social determinants of health, but as Camara Jones and others put it, on the social determinants of equity. In a recent commentary (http://www.nejm.org/doi/full/10.1056/NEJMp1500529?viewType=Print&viewCla…) in the New England Journal of Medicine, Dr. Mary Bassett, the New York Commissioner of Health and Mental Hygiene, delineates three specific ways in which public health can act – through critical research, through internal inform and through public advocacy. These three distinct actions map out very nicely with recommendations and avenues of change public health can act on in the domains of research, practice and advocacy to mitigate and eradicate racial health inequities in Canada.
Research: The Need for Race-Based Data and Targeted Research Questions
One of the greatest challenges in addressing racial health inequities is the lack of targeted research to find out exactly how racial health inequities play out in Canada and usually other measures – such as immigrant status – are used as a proxy. One technique that could be used within research is to start to collect race-based data as it pertains to health. Our neighbours to the south have decades of data to show the pervasiveness of racial health inequities and we need to follow suit, especially as we are starting to become a more diverse nation. It is not enough to stop at just using the ‘race’ variable but this must be expanded in research methodology to start to measure the impacts of ‘racism’ as well. The tendency to focus on the ‘race’ variable without understanding the context of how particular races are treated differently, has resulted in negative health outcomes, should there be any, becoming attributed to belonging to a racial group. This happens as opposed to attribution to the lived realities and experiences of being a member in that society that may have several manifestations of internalized interpersonal and institutional racism.
Practice: Incorporating Anti-Racism in Education, Training, and Service Delivery
Alongside research, it is important that we start to recognize diversity of our population and the implications that will have in how we structure the education, training, and service delivery of public health and health care in this country.
The recent establishment of the Waakebiness-Bryce Institute for Indigenous Health (http://www.news.utoronto.ca/waakebiness-bryce-institute-indigenous-health) as well as the forthcoming graduate-level course Ethnic and Racial Disparities in Public Health at the Dalla Lana School of Public Health, both at the University of Toronto, are promising steps forward in ensuring that future public health practitioners have a more thorough knowledge of how to deal with racial health inequities and we need to start to see greater uptake of this in other fields. We also need to broaden the current model of cultural competency to look towards an anti-racist approach to delivering health care services. Anti-racism approaches to health care service delivery demands that we interrogate the power and privilege we take for granted and instead challenges us to unpack and deconstruct those implicit and explicit biases that we (or society) may carry, to dismantle racist structures and policies.
We also need to improve diversity in terms of leadership in public health and the healthcare sector to ensure that it is being representative of the population it is serving as well as is responsive to the needs of diverse communities. A 2013 report (http://diversecitytoronto.ca/wp-content/uploads/Counts_8_Full_Report_web…) by the DiverseCity – The Greater Toronto Leadership Project and Mount Sinai Hospital found that racialized people, termed visible minorities in the report, were under-represented, holding only 16% of senior management positions and 14% of board members in the healthcare sector in the Greater Toronto Area. This is despite the fact that in Toronto, 47% of the population self-reported as belonging to a racialized group (Statistics Canada, 2013).
Advocacy: Taking Action and Addressing Racism Across Sectors in Society
Racism is a public health issue and we have a role and responsibility in utilizing our platform as members of this field to raise awareness and produce evidence that sheds more light on this issue. We need to advocate for public policy that challenges social inequalities, such as those stemming from racist policies, because they have an impact on health. It is important while recognizing the impact race has on health, that we deepen our social analysis to include how other aspects of our identities such as gender, age, sexual orientation and disability also contribute to this issue.
Dr. Kwame McKenzie, CEO of the Wellesley Institute, spoke earlier this year at Toronto Public Health about Racial Health Inequities. There, he introduced 15 actions (http://www.wellesleyinstitute.com/health/racism-health-what-you-can-do-a…) that have been shown to reduce the impact of racism on health and many of them require public health professionals to be involved in sectors across society from urban planning, politics, mainstream media, education, the criminal justice system and others.
An infographic by the Wellesley Institute featuring 15 ideas for decreasing the impact of racism on health
An infographic by the Wellesley Institute featuring 15 ideas for decreasing the impact of racism on health.
Finally, a way to combat institutionalized racism is to counter with a systemic tool that becomes embedded within the very infrastructure of power and privilege in our country. One such example that is starting to get more attention is the campaign to establish an Ontario Anti-Racism Directorate. Such an office was in place within the Ontario government in the past but in the 1990s, it was cut and nothing has been created since to replace it. This is despite the fact that in 2006, Bill 107, the Human Rights Code Amendment Act, was passed to call for the establishment of an Anti-Racism Secretariat. The aim of the campaign is to persuade the government to create an institution that would be tasked with ensuring that principles of anti-racism and anti-oppression would be embedded in the creation of government policies and legislation so as to not unknowingly perpetuate and codify racist notions.
It is widely accepted in public health circles that health and access to health care services is a human right as codified by numerous pieces of legislation and universal declarations, and that addressing the social determinants of health is key to improving health equity for all. Yet, even though race, and by extension racism, are perhaps the most fundamental determinants of health, they have had limited attention within the field of public health in Canada. Given Canada’s growing diversity, it is important that we begin to integrate understanding of race and racism in our conceptualizations of health.
These are difficult conversations to have but it is essential that we as public health professionals take an active role in addressing racism, especially as it contributes to population health. It is only by naming the issue can we begin to address it. We must put racism on the agenda, because not doing so risks our collective ability to realize healthy lives for everyone, irrespective of racial identity. This piece is just starting to scratch the surface in terms of highlighting steps we can take to address racial health inequities in Canada, but I hope that by recognizing that racism is indeed a public health issue, we can all start to see why racial justice must matter to all.
To continue the conversation, be sure to purchase tickets for the upcoming 8th Annual Dalla Lana Student-Led Conference happening in Toronto on October 23rd and October 24th. The conference, titled Racial Justice Matters: Advocating for Racial Health Equity, seeks to explore public health’s role in combating racism and its impacts on health. To find out more, check out our website at http://www.racialjusticematters.com.
Bassett, M. (2015). #BlackLivesMatter – A Challenge to the Medical and Public Health Communities. New England Journal of Medicine, 37(12), 1085-1087. Retrieved from: http://www.nejm.org/doi/full/10.1056/NEJMp1500529?viewType=Print&viewCla…
Garcia, J.J.L. & Sharif, M.Z. (2015). Black Lives Matter: A Commentary on Racism and Public Health. American Journal of Public Health, 105(8), 27-30. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504294/
Gupta, M., Doobay, A. V., Narendra, S., Anand, S. S., Raja, F., Mawji, F., et al. (2002, March 19). Risk factors, hospital management and outcomes after acute myocardial infarction in South Asian Canadians and matched control subjects. Canadian Medical Association Journal, 166(6), 717–22.
Jones, C.P. (2003). Confronting Institutionalized Racism. Phylon, 50(1), 7-22.
Jones, C.P. (2000). Levels of Racism: A Theoretic Framework and a Gardener’s Tale. American Journal of Public Health, 20(8), 1212-1215.
Krieger, N. (2003). Does Racism Harm Health? Did Child Abuse Exist Before 1962? On Explicit Questions, Critical Science, and Current Controversies: An Ecosocial Perspective. American Journal of Public Health, 93(2), 194-199.
Krieger, N. (2011). Epidemiology and the people’s health. Oxford, England, and New York, NY: Oxford University Press.
McDermott, S., DesMeules, M., Lewis, R., Gold, J., Payne, J., Lafrance, B., Vissandje´e, B. Kliewer, E., & Mao, Y. (2011). Cancer incidence among Canadian immigrants, 1980–1998. Journal of Immigrant and Minority Health, 13, 15–26.
Ontario Human Rights Commission (2015). Racial discrimination, race and racism (fact sheet). Retrieved from: http://www.ohrc.on.ca/en/racial-discrimination-race-and-racism-fact-sheet
Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology, 35(4), 888-901.
Retrieved from: http://ije.oxfordjournals.org/content/35/4/888.full
Rosenberg, L. (2015). Is the problem cultural incompetence or racism? Journal of Behavioural Health Services & Research, 2015, 7-10. Retrieved from: http://link.springer.com/article/10.1007%2Fs11414-015-9481-8
Siddiqi, A., & Nguyen, Q. (2010). A cross-national comparative perspective on racial inequities in health: the USA versus Canada. J Epidemiol Community Health, 64(1), 29-35. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/19542077
Statistics Canada. (2013). Toronto, CMA, Ontario (Code 535) (table). National Household Survey (NHS) Profile. 2011 National Household Survey. Statistics Canada Catalogue no. 99-004-XWE. Ottawa. Released September 11, 2013. http://www12.statcan.gc.ca/nhsenm/2011/dp-pd/prof/index.cfm?Lang=E
Veenstra, G. (2009). Racialized Identity and Health in Canada: Results from a Nationally Representative Survey. Social Science and Medicine, 69, 538-542.
Yeates, K. (2010, January). Health inequities in renal disease in Canada. Seminars in Nephrology, 30(1), 12–18.
8th Annual Dalla Lana School of Public Health Student-Led Conference – Racial Justice Matters: Advocating for Racial Health Equity. In Toronto, ON on October 23-24th, 2015. Website: http://www.racialjusticematters.com
Adelson, N. (2005). The Embodiment of Inequity: Health Disparities in Aboriginal Canada. Canadian Public Health, 96(S2), S45-S61.
Harrell, C.J., Buford, T.I., Cage, B.N., Nelson, T.M., Shearon, S., Thompson, A., & Green, S. (2011). Multiple Pathways Linking Racism to Health Outcomes. Du Bois Review, 8(1), 143-157. doi:10.1017/S1742058X11000178.
Paradies, Y. (2006). Defining, conceptualizing and characterizing racism in health research. Critical Public Health, 16(2), 143-157. Retrieved from: http://dx.doi.org/10.1080/09581590600828881
Tang, S.Y. & Browne, A.T. (2008) ‘Race’ matters: racialization
and egalitarian discourses involving Aboriginal people in the Canadian health care context. Ethnicity & Health, 13(2), 109-127, DOI: 10.1080/13557850701830307
Vissandjee, B., Desmeules, M., Cao, Z., Abdool, S., & Kazanjian, A. (2004). Integrating Ethnicity and Migration As Determinants of Canadian Women’s Health. BMC Women’s Health, 4(Suppl 1), S32.
Williams, D., & Wyatt, R. (2015). Racial Bias in Health Care and Health
Challenges and Opportunities. Journal of American Medical Association, 314(6), 555-556.
Reports and Presentations
Access Alliance Health Services. Racialized Groups and Health Status: A Literature Review Exploring Poverty, Housing, Race-Based Discrimination and Access to Health Care as Determinants of Health for Racialized Groups. Retrieved from: http://accessalliance.ca/wp-content/uploads/2015/03/Racialised_Groups_He…
Addressing Health Inequities for Racialized Communities – A Resource Guide by Health Nexus and Health Equity Council. Retrieved from: http://en.healthnexus.ca/sites/en.healthnexus.ca/files/resources/address…
Blog Post by Dr. Kwame McKenzie on Wellesley Institute Blog – Racism, Health and What You Can Do About It. Retrieved from: http://www.wellesleyinstitute.com/health/racism-health-what-you-can-do-a…
Colour-Coded Health Care: The Impact of Race and Racism on Canadian’s Health. Report published by the Wellesley Institute. Written by Sarah Nestel. Retrieved from: http://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Code…
First People’s, Second Class Treatment. Report by The Wellesley Institute. Written by Dr. Billie Allan and Dr. Janet Smylie. Retrieved from: http://ywcacanada.ca/data/research_docs/00000325.pdf
Hyman, I. & Wray, R. (2013). Health Inequalities and Racialized Groups – A Review of the Evidence. Prepared in collaboration with Toronto Public Health. Retrieved from: http://www1.toronto.ca/City%20Of%20Toronto/Toronto%20Public%20Health/Hea…
Racialization and Health Inequities in Toronto – October 2013. Produced by Toronto Public Health. Retrieved from: http://www.toronto.ca/legdocs/mmis/2013/hl/bgrd/backgroundfile-62904.pdf
The Global City: Newcomer Health in Toronto – November 2011. Produced by the Toronto Public Health. Retrieved from: http://www.toronto.ca/legdocs/mmis/2011/hl/bgrd/backgroundfile-42361.pdf
Powerpoint Presentation by Dr. Kwame McKenzie for Toronto Public Health Black History Talk entitled ‘Racism, Health and What You Can Do About It’. Retrieved from: http://www.wellesleyinstitute.com/wp-content/uploads/2015/02/Race-and-He…