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Confronting Healthcare Implications of Racism for Indigenous Peoples
Rita Isabel Henderson, PhDLynden (Lindsay) Crowshoe, MD CCFP
Ana Rame, PhD student
March 2, 2019
Rimrock Hotel, Banff AB
Faculty/Presenter Disclosure
• Faculty: Dr. Rita Henderson, University of Calgary
• Relationships with financial sponsors:‐ Grants/Research support: CIHR, Alberta Innovates, CCFP, Policywise‐ Speakers Bureau/Honoraria: N/A‐ Consulting Fees: N/A‐ Patents: N/A‐ Other: The Alberta College of Family Physicians has provided support in the form of speaker fees and/or expenses.
Faculty/Presenter Disclosure
• Faculty: Dr. Lynden (Lindsay) Crowshoe, University of Calgary
• Relationships with financial sponsors:‐ Grants/Research support: CIHR, Alberta Innovates, CCFP, Policywise‐ Speakers Bureau/Honoraria: N/A‐ Consulting Fees: N/A‐ Patents: N/A‐ Other: The Alberta College of Family Physicians has provided support in the form of speaker fees and/or expenses.
Presenter Disclosure
• PhD Student: Ana Rame, University of Calgary
• Relationships with financial sponsors:‐ Grants/Research support: Fulbright‐ Speakers Bureau/Honoraria: N/A‐ Consulting Fees: N/A‐ Patents: N/A‐ Other: N/A
Objectives
• Explore unequal treatment within health systems
• Identify how power & authority play out in systemic ways
• Build capacity to address these in your work
Take a moment…
1. What are common perceptions around Indigenous peoples?
2. How can these play out as biases or stereotypes in healthcare?
RacismWhat is it? How does it influence health and healthcare?
Tendency, inclination, habit for or against someone or something
Often based on stereotypes, which are generalizations or simplified categorizations of people or things
Gender Sexuality Age Ability Religion Race
Stereotyping can be a “… normal, functional, adaptive cognitive process that is oftentimes automatic, and most likely centered on… characteristics that manifest visually.”
‐ Betancourt & Maina (2004) Mt Sinai J Med
Bias
A system that structures opportunities and assigns value based on the social interpretation of how one looks
• Unfairly disadvantages some individuals and communities• Unfairly advantages other individuals and communities• Saps strength of whole society through waste of human resources
‐ Jones CP (2003) Phylon
Keep in mind, how one looks is not purely biological: ‐Inherited physical characteristics (skin color, features, stature)‐Self‐presentation (clothing, gestures, dialect, hair)
Racism
Against Biological Conceptions of Race
Public Health Association of CanadaRace mistakes external characteristics as primary determinant of human traits & capacities
Racism is a social construct embedded in institutions across generations
“…there are not now, nor ever were, biologically significant human races that corresponded to populations that had been phylogenetically separate for some significant period of time”
‐ Pigliucci &Kaplan (2003) Philosophy of Science
Colonial Origins of Racism
“Racism is a global hierarchy of superiority & inferiority…politically, culturally & economically produced and reproduced for centuries…
[where] people classified above the line of the human are recognized socially in their humanity… thus, enjoying access to rights (human rights, civil rights, women’s rights, labor rights), material resources, and social recognition…
[and] people below the line of the human [have] their humanity questioned and, as such, negated.”
‐ Frantz Fanon (1967) Black Skin White Masks
Unequal treatment of people or groups by way of the power & authority to grant or deny certain rights
“[W]e tend to activate stereotypes most when we are stressed, multitasking and under time pressure—the hallmarks of the clinical encounter.”
‐ Betancourt & Maina (2004) Mt Sinai J Med
Discrimination in Healthcare
Pop quiz!
1. How much does the federal government annually pay each First Nations person according to historical negotiated treaty agreements?
A. None, as there were no actual treatiesB. None, as this was not a treaty agreementC. $5D. $500E. $5000F. The government does not pay annually but instead places
all monies in trust until the individual is 18 years, paying out between $20,000 to $50,000, depending on which treaty.
Answer: C ‐ $5
Aside from a limited land reserve and hunting rights, the government agreed to a five dollar annuity. Later treaties included education, hunting supplies, health care and agricultural supplies.
:
On May 28th, 1918, women citizens of Canada became eligible to vote in federal elections. The complementary right to stand for election to the House of Commons was granted in 1919; women were officially deemed “persons” and eligible for senate appointments in 1929.
2. In what year did all Canadian Indigenous peoples receive federal voting rights?
A. 1960B. 1950C. 1918D. 1929E. 1972
Answer: A (1960)
The federal franchise was extended without qualification to all First Nations people in 1960. Previous to that, in 1950, Inuit received federal voting rights.
At the provincial level, non‐status Aboriginals received voting rights starting in BC in 1949 and ending with Québec in 1969.
Enfranchisement DefinitionTo give full status to a person as the citizen of a country or member of a group.
Indian Act definitionSurrender their special status as an Indian to become legal, full-fledged Canadian citizens and obtain voting rights. Repealed 1985
The first Residential School in Canada opened in 1831 in Brantford Ontario (Mohawk Institute Residential School).
3. When did the last government run school close?
A. 2001B. 1996C. 1985D. 1979E. 1962
“Kill the Indian, Save the Man”Carlisle Indian School 1882
Tom Toslino
Answer: B The last Canadian government residential school closed its doors in 1996.
• In 1920, Duncan Scott, Deputy Superintendent General of Indian Affairs, makes attendance compulsory. The number of schools reached a peak of 80 in 1930. About 150,000 children were forced to attend.
• During the 1850s, assimilation of Aboriginal people through education becomes official Imperial government policy. The determination to ‘assimilate Indian Peoples’ remained government policy until the failure of the Trudeau/Chretien White Paper proposal in the 1970s.
• In 1996, the Royal Commission on Aboriginal Peoples, or RCAP final report dedicates entire chapter to residential schools. The 4,000‐page document makes 440 recommendations calling for changes in relationship between Aboriginal &, non‐Aboriginal people, and governments in Canada.
• In 1996, the Gordon Residential School, the last federally run facility, closes in Saskatchewan.
The Scream, Kent Monkman
Health & Healthcare Implications
Case Study: Lucille48 yo female presented to ER 3x w/ headacheDx: migraineRx: im morphine
“When they’d see on my chart what my nationality was and that I was Métis, they immediately started to question me about how much I had been drinking because I was having trouble speaking and then they would send me home. Three times they just gave me a shot of morphine and sent me home.”
Eventually readmitted w/ unilateral weakness and aphasiaultimate Dx: left‐sided CVA
“So then finally I suffered a major stroke, my brother and sister‐in‐law came in and my mother and took me to emergency at Foothills and they kept saying how much did she have to drink because I couldn’t speak ...”
Excerpt from transcribed interview with a Métis woman in AB:
•What stereotypes were the emergency docs employing?
• Have you seen this experience in your patients within healthcare system?
• Is it something you might have participated in at some in time?
‐Jones (2000), Amer J of Pub Health
The Gardener’s Tale
Institutionalized
Personally Mediated
Internalized
Manifests itself in material conditions and access to power (e.g., poverty, safe housing, differential access to healthcare)
- Satcher & Pamies (2006) Multicultural Medicine and Health Disparities
Differential assumptions about others; Manifests as lack of respect, suspicion, and devaluation (e.g., patient ‘non-compliance’, police brutality); Unintentional or intentional
Levels of Racism
Manifests as resignation, helplessness, hopelessness, self-devaluation; ”accepting limitations of box in which one is put”
Case Study: JJ
• 3 year 9 month female presented to reserve clinic with grandmother
• HPI: • whole body bruises since 2 yo, • periodic nose bleeds, • no bloody stools, • no joint swelling or pain, • first presentation to clinic for this issue
• No FHx of bleeding d/o• Parents are young and healthy and live in the city. Grandmother is primary care giver for last few months
• PE:• Pale• Impressive ecchymosis on legs, arms, abdomen and back
• Normal joints
When asked why health service was not accessed earlier:“Parents were afraid of possible charge of child abuse”
• What stereotype are the grandparents reacting to?
• Have you seen this before?
• What can we do about this?
Stereotype Threat• A situational predicament in which individuals suspect their behaviourscould be judged on the basis of negative stereotypes about their group instead of their personal merit
‐Steele and Aronson (1995) J Pers Soc Psychol
• Occurs when cues in the environment make negative stereotypes associated within an individual’s group status salient, triggering physiological and psychological processes that have detrimental consequences for behaviour
‐ Burgess et al. (2010) J Gen Intern Med
Clinical Consequences of Stereotype Threat• Non‐adherence to treatment
–Reduced memory capacity–Negative effect on self control–Lower effort and motivation
• Impaired communication–Due to anxiety and phys. arousal
• Discounting feedback
• Reinforcing of stereotypes
•Disengagement–To avoid situations where threats may occur (e.g., missed appointments)
•DisidentificationCease to identify with domain in which threat often experienced
• Associating health promotion activities (e.g., exercising) as ‘white’ behavior
‐ Burgess et al. (2010) J Gen Intern Med
How do we not perpetuate this?
Educating for Equity Care Framework
‐ Crowshoe, L., (2019) Canadian Family Physician
Re‐Center Relationships
Unequal treatment
Reciprocity
Process & place
Connectedness
Power & authority
Cultu
reColonization
Culture Informs Relationships Colonization, Inequity and Healthcare
‐ Crowshoe et al. (2019) Canadian Family Physician
Colonization, Inequity, and Healthcare: Colonization is a traumatic historical episode and ongoing process resulting in uneven power relationships.
Unequal Treatment: The health system, as a social & cultural construct of Canadian society, is perceived (and experienced) by patients as an institution that supports & facilitates ongoing colonization & control over Indigenous people through oppressive & exclusionary practices, often experienced as racist.
Power and Authority: Indigenous patients’ heightened awareness & reaction to the power & authority mismatch within the doctor‐patient relationship arises from historical injustices that undermined individual autonomy and negative experiences of authority from residential schooling.
Culture Informs Relationships:
• Cultural perspectives inform how patients experience and engage with healthcare, as well as how physicians approach care.
• Patient resistance may reflect incongruence and need for physician reflection.
Reciprocity: Creating an authentic relationship involves sharing key social contexts in order to build rapport & trust.
Process and Pace: Providing appropriate care requires attention to issues of process and pace to allow for exploration and reflection of the patient’s lived experiences
Connectedness: Patient experience of diabetes and diabetes care is embedded in relationships, family dynamics, and community supports and structures.
Towards Structural Competency
“[T]he trained ability to discern how a host of issues defined clinically as symptoms, attitudes, or diseases (e.g., depression, hypertension, obesity, smoking, medication “non‐compliance,” trauma, psychosis) also represent the downstream implications of a number of upstream decisions about such matters as health care and food delivery systems, zoning laws, urban and rural infrastructures, medicalization, or even about the very definitions of illness and health.”
‐ Metzl JM, Hansen H. (2014) Soc Sci Med
Structural Competency1. Recognize the structures that shape clinical interactions
2. Develop an extra‐clinical language of structure
3. Rearticulate “cultural” presentations in structural terms
4. Observe and imagine structural intervention
5. Develop structural humility‐ Metzl JM, Hansen H. (2014) Soc Sci Med
Structures Embedded in Language
Can you list common expressions or idioms that reveal dominant bias about Indigenous peoples?
chief Indian giver Indian time Indian summer on the war path circle the wagon the natives are restless
low man on the totem polequit acting like a wild Indian!Eskimo kissesbury the hatchetholding down the fortred devilsput that in your peace pipe and smoke it!
Top 4 Questions—that colleagues have asked me!
• Can you recharge my crystal?
• “HOW …” Is that how your people greet each other?
• How did you learn to speak English so good?
• Can you tell me what my spirit animal is?
Verbal & Non‐Verbal Cues
What happened to Brian Sinclair did not happen in isolation; many people were
complicit in the forces created by inequity
Remembering Freddie Gray: Medical Education for Social Justice
“[O]ne would be hard pressed to find a medical curriculumthat does not address health disparities in somemanner…But the curriculum rarely focuses on the forces—from individual biases and stereotypes to the myriadsocietal, cultural, legal, political, and medical structures—that impact health outcomes..”
‐ Wear, D. et al. (2016) Academic Medicine
Street mural of Freddie Gray, Baltimore
Mural by Justin Nethercut.
How best would you access this kind of ongoing learning?
Concluding Resources
References1. Betancourt JR & Maina AW. The Institute of Medicine Report “Unequal Treatment”: Implications
for Academic Health Centers. Mt Sinai J Med. 2004;71(5):314‐21.2. Jones CP. Confronting Institutionalized Racism. Phylon 2002;50(1‐2):7‐22.3. Pigliucci M & Kaplan J. On the concept of biological race and its applicability to humans. Philosophy
of Science. 2002; 7 (5):1161‐1172.4. Fanon F. Black Skin, White Masks. 1967; Gover Press, NY.5. Satcher D & Pamies RJ. Multicultural Medicine and Health Disparities. 2006; McGraw‐Hill, NY.6. Burgess DJ, Warren J, Phelan S, Dovidio J, van Ryn M. Stereotype threat and health disparities: what
medical educators and future physicians need to know. J Gen Intern Med. 2010: 25 Suppl 2:S169‐77.
7. Crowshoe L , Henderson R, Jacklin K, Calam B, Walker L, Green M. Educating for Equity Care Framework: addressing social barriers of Indigenous patients with type 2 diabetes. Canadian Family Physician. 2019; 65(January): 25‐33.
8. Metzl JM & Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Social science & medicine 2014; 103:126‐133.
9. Wear, D., Zarconi, J., Aultman, J., Chyatte, M., Kumagai, A. Remembering Freddie Gray: Medical Education for Social Justice. Academic Medicine. 2017 Mar;92(3):312‐317.