Fractured futures: Upward mobility for immigrants is a myth as their health declines

2024/05/07 Leave a comment

Odd connection to make between poorer health outcomes and the need for municipal voting rights for permanent residents.

First of all, unclear that this is a priority for most permanent residents compared to more pressing economic and social issues.

Secondly, Canadian citizenship is relatively easy to obtain in terms of residency, language and knowledge requirements.

Third, the author’s general comment on voting rates of immigrants is misleading: the StatsCan study, comparing the 2011 election with recent elections, highlighted small gaps between recent and long-term immigrants and the Canadian-born in the 2019 election before dropping in 2021, but recent immigrant voting rates neverthess increased by 10 points between 2011 and 2021:

Immigrant health research frequently refers to the notion that immigrants are generally healthier than people born in Canadabut that their health worsens with time.

The apparent trend has been attributed to a number of factors, including an unexpected lack of social mobility after immigration. 

The story often goes that immigrant parents willingly make sacrifices for the good of their children, with the widespread assumption that emphasizing good grades and higher education among the next generation will make their sacrifices worth it. 

But recent research finds that this lack of social mobility extends into the second generation.

As someone who’s spent more than a decade conducting immigrant and refugee health research, I am among a growing contingent of researchers who recognize that immigrants in Canada have extremely diverse identities and experiences, all of which affect their experiences with the structural and social determinants of health. 

That, in turn, shapes their health and health-care access, and challenges the notion that immigrants are a monolith with identical health and social trajectories.

This “healthy immigrant effect” and the upward social mobility of subsequent generations are commonly believed theories in academic circles. However, I fear these ideas have caused the nuanced needs of immigrant and diasporic communities to be over-simplified, dismissed and even neglected by policymakers.

The impact of COVID-19

The legacy of this neglect became painfully clear in the early days of the COVID-19 pandemic amid a litany of reports about how long-term care workers, taxi drivers, food processors and other essential workers who came to Canada as immigrants were falling victim to the virus.

Statistics have since backed up these reports. 

Toronto Public Health, the first health unit in Canada to collect race-based data during the pandemic, found racialized Torontonians (including mostly immigrants but also those in racialized diasporic communities) were much more likely to be infected or hospitalized due to COVID-19. 

An upcoming study has found that before high-population COVID-19 vaccine coverage was achieved, immigrants in Ontario — particularly those from Central America, Jamaica, parts of South Asia and East Africa — were much more likely to be hospitalized or die from COVID-19 than other residents in the province.

The major contributing factors are a mismatch between their education and the jobs they end up getting, and employer discrimination, which leads to immigrants being over-represented and trapped in essential, low-wage precarious work. These jobs have a higher risk of exposure to COVID-19, and don’t provide employer-paid sick leave.

Thankfully, an Ontario government focus on equitable vaccine distribution, as well as innovative strategies like Toronto’s Community Health Ambassadors program — implemented by immigrant-serving community organizations — led to a remarkably equitable vaccine rollout and equally remarkable reductions in hospitalizations and deaths, according to the upcoming study.

But considering the subsequent elimination of many of these programs and policies, all of which were put in place to address barriers to vaccination for immigrants and their higher exposure to COVID-19 (due, in part, to the absence of employer-paid sick days), it’s possible that once again immigrants are bearing the brunt of the virus that’s still circulating and mutating.

Policy neglect is also responsible for the current primary-care crisis across Canada, with pre-pandemic inequities becoming further entrenched by the COVID-19 pandemic.

Racialized and low-income Canadians are the least likely to report having a primary-care physician. Meanwhile family doctors nearing retirement have a larger number of patients who face multiple social barriers to health and health care access. Both affected groups are likely made up largely of immigrant and diasporic communities.

The importance of elections

So how can the health and well-being of immigrants — widely praised as being the engine of Canada’s economy — and subsequent generations be prioritized?

First, our elected officials should engage meaningfully and respectfully with immigrants from all walks and stages of life, and avoid stoking xenophobic sentiments among the public.

Second, immigrants with Canadian citizenship — particularly those who’ve been in Canada for fewer than 10 years — are less likely than Canadian-born residents to vote in federal elections. There must be civic engagement initiatives connecting immigrants’ priorities with specific political platforms coupled with “get out the vote” campaigns.

Immigrants who are not yet citizens can’t vote in elections at any level of government, so they have no influence over how their tax dollars are spent. That voter gap should be addressed immediately, particularly given the large numbers of permanent and temporary residents who have made Toronto and other Canadian cities their home in recent years.

Right now, it seems these groups of potential future citizens are good enough to fill labour gaps and contribute their time, money and tax dollars to the economy. But they’re not good enough to have their voices and needs recognized in the political decision-making that governs their everyday lives and futures.

The false notion of the healthy immigrant effect and assumption of upward social mobility among the second generation has been reinforced through a lack of recognition of the diversity of identities and experiences of immigrants in big cities like Toronto and beyond. 

These assumptions may have led policymakers to neglect the health and health-care needs of immigrants.

Addressing long-standing inequities in immigrant and migrant voter participation in Canada may finally help shine a spotlight on the social and economic hardships that immigrant and diasporic communities have faced for decades, not to mention the adverse impact on their health and health-care access.

Source: Fractured futures: Upward mobility for immigrants is a myth as their health declines

Filed under Multiculturalism Tagged with , ,

How Unconscious Bias in Health Care Puts Pregnant Black Women at Higher Risk

2023/12/14 Leave a comment

Of note (and disturbing):

Shakima Tozay was 37 years old and six months pregnant when a nurse, checking the fetal heart rate of the baby boy she was carrying, referred to him as “a hoodlum.”

Ms. Tozay, a social worker, froze. She had just been hospitalized at Providence Regional Medical Center in Everett, Wash., with pre-eclampsia, a life-threatening complication of pregnancy, and she is Black.

“A ‘hoodlum’?” she said. “Why would you call him that?”

The fetus was 14 inches long and weighed little more than a box of chocolates.

A doctor who came into the room downplayed the comment, saying the nurse was just kidding, but that only hurt Ms. Tozay more. She was already distressed: She and her husband lost an earlier twin pregnancy, and now she worried this baby was at risk, too. The hospital later apologized for the nurse’s behavior, but the damage was done.

Black women , who die of pregnancy-related complications at two to three times the rate of white women, say that remarks like these, often made when they are most vulnerable, reflect pervasive bias in the medical system. They report that medical staff don’t listen to them when they complain of symptoms, and dismiss or downplay their concerns. Studies validate their experiences: Analyses of taped conversations between physicians and patients have found that doctors dominate the conversation more with Black patients and don’t ask as many questions as they do of white patients. In medical notes, doctors are more likely to express skepticism about the symptoms Black patients report.

Hovering over these experiences is the stark reality that Black women have worse pregnancy outcomes, lose more infants in the first year of life and have higher rates of preterm birth and stillbirth, when compared with white women. Glaring racial disparities in health outcomes persist between white women and even the wealthiest Black women, and between Black women and white women who experience the same complications.

These findings have forced the medical establishment to acknowledge and confront its biases. Many health systems have mandated anti-bias training for faculty. Some hospital committees that review cases with poor outcomes in order to identify the causes now consider whether racial bias played a role.

Experts who study bias in medical care say that a vast majority of people in the healing professions have good intentions, but that even providers who reject overt racism have internalized cultural stereotypes, and that this unconscious or implicit bias can influence medical care and bedside manner.

“They will say, ‘Hey, I’m not biased,’ and consciously they are not,” said Dr. Cristina M. Gonzalez, a professor of medicine and an associate director at the Institute for Excellence in Health Equity at NYU Langone Health. “But the unconscious runs a lot of the show during the day.”

The brain is wired to make decisions quickly, said Sarah M. Wilson, an assistant professor at Duke University. It uses cognitive shortcuts that let bias seep in, especially when a person is uncertain, tired or stressed — common circumstances in a busy practice or hospital, where providers often treat patients they do not know.

“If it’s a very complicated situation and you have to make a decision at a moment’s notice,” Dr. Wilson said, “then it is very natural to fall back on these automatic assumptions.”

“They sent us away”

Ms. Tozay was sent home from the hospital that evening in 2017 on bed rest. Pre-eclampsia, a serious condition that causes extremely high blood pressure, can lead to preterm birth, stillbirth, organ damage and ultimately eclampsia — a sudden seizure that can be deadly for mother and baby.

Ms. Tozay and her husband, Glen Guss, kept a close eye on her blood pressure, measuring it often with a cuff. A few days later, it started climbing precipitously. During pregnancy, hypertension starts when the top number, which is systolic blood pressure, reaches 140 or more, or the bottom number, diastolic blood pressure, reaches 90 or more. One of Ms. Tozay’s systolic pressure readings was in the 190s, Mr. Guss said. Deeply worried, he drove her back to the hospital.

The intake nurse looked concerned and told the couple she would measure Ms. Tozay’s blood pressure again once she had calmed down. Some tests were done, and while Ms. Tozay waited to be seen by a doctor, her pressure declined to 149/81, according to her medical records, still too high.

Then, Ms. Tozay and her husband said, the nurse told them that the attending physician had said Ms. Tozay could go home.

Mr. Guss said in retrospect that the hospital did not give enough weight to factors that put his wife at high risk: her relatively advanced age for childbirth, previous miscarriage, uterine fibroids, low amniotic fluid, contractions early in the pregnancy and the pre-eclampsia diagnosis. He and Ms. Tozay said they never got the chance to tell a doctor that she felt something was very wrong, had been lightheaded and had “a surreal kind of feeling.”

A spokeswoman for the hospital, Melissa Tizon, said only a doctor could have ordered the tests Ms. Tozay was given, but she could not confirm from hospital records whether a physician actually examined her. She said that a physician had been “engaged” in Ms. Tozay’s care, but added, “We can’t tell if the physician was face to face with the patient.” Ms. Tizon said a hospital review of the interaction concluded that it “met the appropriate standards of care.” (Ms. Tozay gave written consent for hospital officials to discuss her care.)

Not having a physician examine a woman who came into the triage room at Ms. Tozay’s stage of pregnancy would be very unusual, said Dr. Tanya K. Sorensen, an obstetrician specializing in high-risk pregnancies who oversees women’s health care for a region of the Providence health system that includes the hospital where Ms. Tozay was treated.

“I wish that I had said, ‘No, I’m not going home,’” Ms. Tozay said recently. “But I didn’t know what was going on. My husband didn’t know. We were trusting that they knew.”

“There were so many red flags saying they should just take him out right away,” Mr. Guss said. “But they sent us away.”

The next morning, the fetus was not moving.

Stereotypes and skepticism

To better understand how bias plays out, I interviewed dozens of Black women who described disturbing experiences with health care providers during their pregnancies. Their accounts were corroborated whenever possible by medical records, emails with providers and other documentation, as well as interviews with family members and hospital officials.

In Ms. Tozay’s case, the hospital spokeswoman, Ms. Tizon, confirmed that Ms. Tozay filed a complaint with the hospital on Nov. 6 about the nurse’s hoodlum remark on Nov. 3. The manager of the hospital’s childbirth center, Lisa Von Herbulis, met with the nurse to discuss her lack of sensitivity and wrote a letter of apology to Ms. Tozay, dated Nov. 16, a copy of which Ms. Tozay shared with The New York Times.

In interviews, many Black women complained of being stereotyped by administrative staff, nurses and doctors and of being repeatedly asked about their marital status and insurance — even when they wore a wedding band, had a hyphenated last name or had private insurance.

“I was always being asked, ‘Where’s your baby daddy?’” said Ruhamah Dunmeyer Grooms, 35, a business analyst and mother who lives outside Charleston, S.C. “I don’t have a baby daddy. I have a husband.”

Black women are more likely to be tested for illicit drugs during labor and delivery than white women, regardless of their history of substance use, and even though they were less likely than white women to test positive, a recent study found.

Other studies indicate that physicians may express less empathyfor Black patients, compared with white patients, and their notes reflect a belief that Black patients are less likely to follow medical advice.

They are more likely to describe Black patients as uncooperative or “noncompliant,” and they may prescribe less aggressive treatment because they don’t think Black patients will adhere to it, experts say.

In one study of patient records, researchers found that doctors signal disbelief in the records of Black patients, appearing to question the credibility of their complaints by placing quotation marks around certain words — for example, writing that the patient “had a ‘reaction’ to the medication” — or by describing a complaint with words like “claims” or “insists.”

Failure to take patients seriously and believe their accounts can have deadly consequences.

Shalon Irving, a 36-year-old public health expert at the Centers for Disease Control and Prevention, sought help from doctors at Emory Saint Joseph’s Hospital in Atlanta at least six times in the weeks after her cesarean section, according to her mother, Wanda Irving, who was helping her with the new baby and who accompanied her on three of the visits.

Shalon Irving felt ill, had severe headaches and gained almost 10 pounds, her mother said, but was sent home every time.

“Her blood pressure was so high the last time she went in that the nurse checked it twice,” Wanda Irving said. “She demanded to see the doctor and sat there waiting, but was told he was too busy.”

Within hours of returning home from that last visit, Dr. Irving collapsed and died, her mother said. An independent autopsy determined the cause of death was complications from hypertension. “We need to make doctors accountable for these deaths,” she said. “If it was a crime, they would pay more attention to what the patient is saying.”

A conservator for Dr. Irving’s baby girl, Soleil, reached a financial settlement with Emory Healthcare. The hospital, citing federal medical privacy laws, declined to comment.

Doctors who don’t listen

Black patients say that health providers often disregard and overrule their wishes.

Pregnant Black women are more likely than white women to say they were pressured to undergo cesarean section deliveries and other childbirth interventions, such as epidurals and labor induction, when they sought to avoid them. Although a C-section may be unavoidable when a woman develops complications or the fetus is at risk, it is major surgery and can be more dangerous than a vaginal delivery.

When Tennille Leak-Johnson’s fetus stopped growing at a normal rate, her doctor in Chicago counseled her and her husband about the option of terminating the pregnancy, even before genetic testing was carried out, Dr. Leak-Johnson said. Her doctor also offered the option of placing the infant with a family that wanted to adopt a sick or disabled child.

The doctor, who is no longer practicing in Chicago, did not respond to repeated requests for comment, but Dr. Leak-Johnson’s medical records contain a note her doctor wrote expressing concern about the baby’s health early on in the pregnancy and a lengthy summary of the doctor’s counseling on abortion or adoption.

Fetal growth restriction can signal a serious medical condition in the fetus, but Dr. Leak-Johnson and her husband were unequivocal about wanting to keep the pregnancy.

“I told the doctor that even if I could only love him for one day or one hour, I was not getting rid of him,” said Dr. Leak-Johnson, who has a doctorate in molecular genetics and genomics and was familiar with the medical risks.

Dr. Leak-Johnson said she was a high-risk patient because of her weight, so she saw her doctor frequently. At each appointment, she said, the doctor raised the question of termination — continuing to do so even after genetic testing and a 20-week anatomy scan found neither genetic nor structural abnormalities.

A brief note the doctor put in Dr. Leak-Johnson’s chart after the normal test results reiterated the doctor’s concern that something was wrong with the baby. The only reference the note made to the normal genetic test results, which revealed the sex, was that the fetus was male.

Mid-pregnancy, Dr. Leak-Johnson switched doctors.

Her son, Stanley Johnson III, was born 11 weeks before his due date, and Dr. Leak-Johnson became acutely ill during the delivery. But the baby — who spent two months in neonatal intensive care — survived and has thrived.

He turned 12 this year, and “aside from his wearing glasses because of his prematurity, you wouldn’t even know that he was born a pound and 14 ounces,” Dr. Leak-Johnson said. “He’s the love of my life.”

Prioritizing the mother’s care

A lack of empathy in medical settings can put pregnant women at risk.

In New York State, Assemblywoman Rodneyse Bichotte Hermelyn pushed for a measure, which became law in 2020, that requires hospitals to care for women in preterm labor, after she herself was turned away from Columbia University Irving Medical Center.

Ms. Hermelyn, who was 43 at the time, said her Columbia-affiliated doctor sent her to the hospital in 2016 when her labor started at 22 weeks. She was distraught over the possible loss of the pregnancy, she said, but hospital doctors told her that they were not required to intervene to save the pregnancy at such an early stage in gestation. They told her she was almost three centimeters dilated and that they could not do anything to stop the labor or save the fetus at that stage, she said.

“They said, ‘We can terminate your baby,’ but that was not an option, and made me cry even more,” Ms. Hermelyn said. The doctors told her they had other patients to tend to and “sent me home,” she added.

Columbia University officials refused to comment on the case.

In interviews, experts not involved in the case noted that when preterm labor starts before 24 weeks of gestation, the baby is extremely unlikely to survive, so hospitals do not generally take extraordinary measures to save the fetus. Labor in these cases can be protracted, so a woman who is admitted might be hospitalized for several days.

Ms. Hermelyn turned to Wyckoff Heights Medical Center in Brooklyn, a hospital that predominantly serves patients who are low-income, on Medicaid or uninsured, and where the staff knew her. They admitted her, sought to relieve her emotional distress and tried, but failed, to save the baby.

The mother herself needed care, said Dr. Daniel Faustin, director of Wyckoff’s division of maternal and fetal medicine. Ms. Hermelyn had a high-risk pregnancy, and preterm labor put her at risk of serious infection. If she delivered at home, she would risk deadly hemorrhaging.

“Even if you give up on the baby, you cannot give up on the mother,” he said. “The best place for her to be if she’s going to deliver is in the hospital, to make sure that after this unfortunate experience, her life is not at risk.”

When Ms. Hermelyn gave birth to a son last year, she named him Daniel, after Dr. Faustin.

From tragedy, reforms

After Ms. Tozay and Mr. Guss’s baby stopped moving, they returned to the hospital. Doctors could not find the heartbeat, confirming the couple’s fears. The placenta had separated from the wall of the uterus, cutting off the flow of oxygen to the baby, a complication that occurs more frequently when the mother has high blood pressure. The baby they planned to name Jaxson was dead.

A hospital doctor who had not cared for her before performed a cesarean section. As she handed the dead newborn to Mr. Guss, the doctor said, “Congratulations — I mean, I’m so sorry for your loss.”

Ms. Tozay and Mr. Guss said they were still reeling from the stillbirth when the doctor told them that she should never have become pregnant, and that they should not try to conceive again.

“I felt blamed, like she was saying: ‘Why would you ever think about having a kid? You just killed your son,’” Ms. Tozay said.

Mr. Guss said, “Even if it was true, it didn’t need to be said right then and there.”

Dr. Sorensen, the executive medical director of Providence, and Dr. Nwando Anyaoku, chief health equity officer, said they did not doubt Ms. Tozay’s recollections. “For her, that moment is probably etched in her mind,” Dr. Anyaoku said.

The doctor who did the C-section might have been exhausted, distracted or distressed, but that did not excuse the lack of sensitivity, Dr. Sorensen said. “The whole case is incredibly heartbreaking,” she said. “That’s not the experience we want to deliver.”

In 2020, Providence invested $50 million to reduce health inequities and racial disparities in maternal outcomes. It has educated its staff about implicit bias and started new programs for pregnant women: JUST Birth Network, which matches pregnant women of color with doulas who help them navigate the health care system, and TeamBirth, a framework for open communication between patients and providers.

The health system is seeking to reduce C-section rates for Black women and to improve care after birth, when many complications occur. Clinical review committees that examine hospital cases have been instructed to consider whether implicit bias played a role in poor outcomes.

A Washington State initiative aimed at improving outcomes for women with pre-eclampsia encourages health providers to give pregnant women with high blood pressure blue wristbands to draw attention to the condition — and to ensure no doctor or nurse overlooks it.

Ms. Tozay and Mr. Guss have decided not to try another pregnancy, though her regular obstetrician said it would be safe to do so.

“The words of the delivering doctor will always stick with me,” Ms. Tozay said. “Doctors need to realize that what they say carries power and weight.”

Source: How Unconscious Bias in Health Care Puts Pregnant Black Women at Higher Risk

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Tackling the health burden of anti-black racism and violence

2022/09/19 Leave a comment

As described, the new program seems more focussed on histories and ideologies than on practical measures to improve health outcomes for Blacks and other minorities, generally reflecting lower income levels, as the differential impact of COVID made clear:

As professors across Canada have been handing out syllabi and giving their first lectures of this school year, Professor Roberta Timothy has her eyes firmly set on next September, when the Dalla Lana School of Public Health at the University of Toronto will welcome the first cohort into the two-year Master of Public Health in Black Health programme.

In addition to the regular public health curriculum, the 10 to 15 students will follow a programme that includes six courses devoted to black public health, including ones on the socio-historical context of black health, chronic diseases and reproductive health and decolonising theory and method.

“A masters in public health in the field of black health is needed,” says Timothy, who proposed the programme in 2021, “because of how the experience of anti-black racism impacts black health. There’s a correlation between what I call ‘anti-black violence’ and black health outcomes. 

“If we’re looking at factors such as higher diabetes rates, higher cancer rates, higher HIV rates and who has been impacted by COVID more, we see there’s a direct correlation with health outcomes and anti-black racism and violence.”

The fight for race-based data

In designing the programme, Timothy has, in large measure, drawn on her 30 years of being a public health practitioner because unlike, for example, the United States, Canada does not routinely collect race-based medical data.

“There are only two million of us, and most of us are located in Toronto, Montreal with smaller populations in Alberta. There’s this kind of notion that we don’t exist.

“We are a smaller population, we are absorbed,” Timothy told University World News, nodding to the fact that blacks account for only 3.5% of the Canadian population, while in the US blacks account for 13.4% and in states like Mississippi, Louisiana and Georgia blacks account for more than 30% of the population. “We’ve been fighting to get raced-based data,” Timothy says.

After we spoke, she e-mailed me an April 2020 letter sent to the Ontario government that called for the collection of socio-economic and race-based health data. 

A total of 192 community-based health and advocacy groups and 1,612 individuals signed the letter, which underscored that “Ontario, like other provinces and territories in Canada, continues to deal with the ongoing legacies of colonisation, structural inequality and systemic racism. Responding to COVID-19 with the expectation that all people will experience the pandemic in the same way hurts the already marginalised people and communities.”

When I asked how health outcomes for blacks, who, as in the US and the United Kingdom, are disproportionately poor, differ from poor whites, Timothy noted that there is evidence that shows that in terms of HIV the black community is more impacted.

Further, she pointed to a 2015 study and one she has been working on dealing with COVID rates for two years. The 2015 study showed that in Montreal the maternal morbidity of blacks was three to four times higher than it was for whites. (Because of Canada’s universal medical system, this difference cannot be attributed to lack of access to medical care.)

“I’ve been collecting data on COVID among blacks for two years. If you look at these COVID numbers from the UK, the United States and Canada, we see the similarities in terms of how COVID has disproportionately impacted folks of African ancestry,” says Timothy.

As the students will begin learning next year in the socio-historical course, Timothy told me, this fact, as well as the higher rates of diabetes, HIV and other diseases among blacks in the US, UK and Africa, must be handled extremely carefully. This is because of the long history, going back to the early 1800s, of racialist biological determinism.  

“The connection between African folks [ie, those in Africa or the diaspora] and these disorders is not biological, not as explained by the ‘biological determinist perspective’, but rather from the impact of racism and colonisation globally for black folks. 

“It’s not about being black. It’s about anti-black racism and experiencing anti-black violence. It’s about the implications of that extreme grief, trauma, violence that you experience as a black person anywhere you travel. It’s about a lifetime of being treated that way that impacts our mental and physical health no matter where you are, even if you come from the African continent.”

Critiquing Eurocentric methodologies

By training Timothy is a ‘methodologist’. Accordingly, I asked her how the methodology course she is presently designing differs from a traditional methodology course. The answer does not lie in ignoring traditional methodology. 

Quite the opposite, the course examines the Eurocentric history of research methodologies – in order to critique them. One notorious so-called methodology was that used by George Gliddon (b 1809) and Josiah C Nott (b 1804) in their Indigenous Races of the Earth (1857) in which, via measurements of skulls and other pseudo-scientific methods akin to phrenology, they adduced a hierarchy of brain development that placed blacks between Caucasians and chimpanzees in terms of intelligence.

As well, students will learn about the horrid Tuskegee experiment in the US. In 1932, 400 black men, impoverished sharecroppers in Macon County, Alabama, were infected with syphilis to “observe the natural history of untreated syphilis”. 

None was given penicillin after its invention in 1947. By 1972 when the study ended, 128 of the men had died either from syphilis or complications arising from it. Forty of the men’s wives had been infected and 19 children had been born with congenital syphilis. The violation of ethical norms and the human cost of the study is one of the reasons why many African Americans are vaccine hesitant.

The students in the programme will learn of the importance of looking at factors such as race, racism, class, gender, gender identity and sexual orientation when they collect data.

By way of example, Timothy turned our discussion to how she would approach a study of post-partum depression among black women. 

Noting the influence of Black Feminist Theory, she said, she would begin with such questions as, “How does the impact of anti-black racism impact the subject you want to inquire about? Does the question make sense to the population being studied?” An equally important question is, “How will the data from this study be used to advance the health care of black women?”

While white women also experience post-partum depression, Timothy notes, they are not burdened by the socio-historical narrative that burdens black women – a narrative that is informed by the experience of American slavery in which female slaves who had just given birth were expected to go back to the cotton fields, often within hours of giving birth. 

Further, because of the sundering of the black family during slavery and continued disruption of it because of the high incarceration levels of black males (which is part of the ongoing anti-black violence Timothy refers to), black women have historically been seen as the rock upon which the family relies.

“This false notion of the strong black woman is of one who is not human. We are not given human qualities. We are not allowed to be vulnerable or human.” 

The violence of the state

Yet, there is a second piece of the violence that is part of this stereotype. “It is the imagining of the violence of the state. It comes from the reality that you don’t have the right to be depressed or emotional because if you are a black person who is, there is a chance that your children will be taken away from you.”

(Timothy, who comes from a working-class background, holds a PhD and has worked in public health for decades and is now at the University of Toronto, exemplified this last point by telling me that when she has to bring her children to the doctor, they are dressed up. “You’d think we were going to church. But I do this because we are racially profiled on a daily basis, even in terms of our children.”)

Timothy’s students will also learn how the experience of being a black male in Canada contributes to diabetes and cardiovascular problems such as high blood pressure.

“The question students will have to ask is how criminalisation (or the threat of it) and anti-black violence by the state contribute to these diseases in black men. The inquiry will show that no matter what their socio-economic status is, where they work or live, black men know that they are profiled on a daily basis and this creates anxiety, higher blood sugar levels and high blood pressure.”

Public health practitioners who provide health care to black men must be aware not only of the effects of being hypervigilant but also of the depression these men carry, of the intergenerational transfer of post-traumatic stress disorder and how systems of enslavement and colonisation violated black men’s masculinity, says Timothy. The heightened tension of being black in Canada does not vanish even when home.

“Your home is never really safe because you are never sure when the police are going to come in the door,” she says, referring to, among others, D’Andre Campbell, a 26-year-old immigrant with mental health issues, who was shot in his home by a constable belonging to the Peel Regional Police (near Toronto) after he had been tasered and was already on the ground.

Professor Akwatu Khenti, who teaches courses on the public health implications of anti-black racism and the criminal justice system, told University Affairs in late August that there is “a lot of epistemic violence that takes place as a sort of intellectual microaggression [that] devalues or invalidates other ways of knowing. For me, it means building appreciation for the epistemic approaches of different groups and [giving] more space to traditional wisdom that worked for thousands of years.”

Inoculation for smallpox, for example, was practised in Ethiopia and West Africa a century or more before Edward Jenner noticed that milk maids with cow pox scars appeared to be immune to smallpox. The first inoculation in America was in 1721 by Puritan minister Cotton Mather, who learned of the practice from his slave Onesimus, who had been kidnapped from Africa and whose Latin name meant useful, helpful or, tellingly, profitable.

Dismantling a system

Since the beginning of the COVID-19 pandemic two-and-a-half years ago, doctors and public health practitioners have been uncharacteristically vocal for the most part, advocating for masking, the safety of vaccines and for improving ventilation in schools before they re-opened. Timothy views the role of graduates of the Master of Public Health in Black Health programme to be similarly engaged.

“I know that I’m teaching at the University of Toronto. I’m very aware that this education system has a history of colonial violence. Yet, we are going to train people in terms of how to resist anti-black racism and other forms of violence. We’re creating a place where we create practitioners who know how the system works and, therefore, understand how to begin dismantling it.

“Obviously, we are not going to do that tomorrow. But we can begin the conversation about how being a public health practitioner is to be part of a decolonising process. It’s part of a movement towards justice, to dismantle systems that create violence.”

Source: Tackling the health burden of anti-black racism and violence

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Lost in translation: Patients more likely to die, have serious outcomes when their physicians don’t speak their preferred language

2022/07/12 Leave a comment

Serious study and implications. During my experience as a cancer patient, I often reflected on how hard it must be for patients with weaker language skills, education and income:

Patients treated by physicians who speak their own language are healthier and less likely to die while in hospital, according to a new study led by Ottawa researchers.

The study, published in the Canadian Medical Association Journal, showed significant differences in outcomes among frail, older patients who were treated by a physician in their own language, compared to those who were not.

Francophones treated by a French-speaking physician had a 24 per cent lower chance of death than those who received care from a non-French-speaking doctor, according to the study. They also had shorter hospital stays and had a 36 per cent lower chance of adverse events, such as falls, while in hospital.

For patients whose first language was neither English nor French, known as allophones, the impact was stark. This group had a 54 per cent lower chance of death when treated by a physician in their own language and a 74 per cent lower chance of hospital-related harms, according to the research.

But fewer than two per cent of allophones and fewer than half of the Francophones in the study received physician care in their own language.

Co-author Dr. Peter Tanuseputro, a physician-scientist at The Ottawa Hospital, Institute du Savior Montfort, Bruyere Research Institute and The Ottawa Hospital, called the findings staggering.

“It’s clearly easier to convey important information about your health in your primary language. Regardless, the more than doubling in odds of serious harms, including death, for patients receiving care in a different language is eye-opening.”

Tanuseputro said the research underscores why it is important for hospitals to pay attention to the language patients speak as well as the languages physicians and other health workers speak.

The findings are likely to resonate in Ottawa and Eastern Ontario, where the Franco-Ontarian community rallied to save Montfort hospital after the Ontario government announced plans to close it in 1997. The battle, won after five years of political activism and legal fights, galvanized the community. Today, Montfort is a Francophone university health institution that provides care in both languages and has a research institute.

Still, Tanuseputro noted that the majority of Franco-Ontarians studied did not get health services in French.

The study’s lead author, Emily Seale, a medical student at the University of Ottawa and Institut du Savoir Montfort, said more must be done to make sure patients are heard and understood by referring them to physicians who speak the same language or by using interpreter services.

“This is not only good patient-centred care, but our research shows that there are grave health consequences when it doesn’t happen.”

Dr. Sharon Johnston, scientific director and associate VP research at the Institut du Savoir Montfort said the study is important because: “(it) helps us quantify the risk of greater harm faced by patients who cannot receive medical care in their preferred language. Understanding and addressing this issue, particularly for our francophone community in Eastern Ottawa and Ontario, is a key part of the mission of Hôpital Montfort and l’Institut du Savoir Montfort.”

The researchers relied partly on data from home care services, which keeps track of patients’ first languages.

They studied more than 189,000 adult home care recipients who had been admitted to hospital between April 2010 and March 2018. They compared patients who received care from a physician in their primary language and those who received care in a different language.

Most of the home care recipients in the study spoke English. Thirteen per cent spoke French and 2.7 per cent spoke another language.

Just over half of the physicians in the study spoke only English and the remainder were multilingual. While 44 per cent of Francophones received care primarily from French-speaking physicians, only 1.6 per cent of allophones received most of their care from physicians who spoke their primary language or one they could understand.

Tanuseputro said, in his own experience, making attempts to find a physician who can provide care in a patient’s language, or translation services, is not always a priority in a busy hospital.

“I am guilty of this too. What our study shows is that there are risks and consequences if you don’t do that.”

Among other suggestions, Tanuseputro said teams of physicians should consider a patient’s language and find someone better able to communicate with the patient. And translation services should be used, even if it takes time.

He also said hospitals should assess patients to understand how well they understand English. If they can’t, hospitals should have interpretive services or multi-lingual family available.

While the study looked at home care patients who were in hospital between 2010 and 2018, Tanuseputro said the situation may well have worsened during periods of the pandemic when family members were generally kept out of the hospital and unable to help interpret.

The study can be found at: https://www.cmaj.ca/lookup/doi/10.1503/cmaj.212155

Source: Lost in translation: Patients more likely to die, have serious outcomes when their physicians don’t speak their preferred language

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Race and Medicine: The Harm That Comes From Mistrust: Racial bias still affects many aspects of health care.

2020/01/14 Leave a comment

Good overview of the data and issues:

Racial discrimination has shaped so many American institutions that perhaps it should be no surprise that health care is among them. Put simply, people of color receive less care — and often worse care — than white Americans.

Reasons includes lower rates of health coverage; communication barriers; and racial stereotyping based on false beliefs.

Predictably, their health outcomes are worse than those of whites.

African-American patients tend to receive lower-quality health services, including for cancer, H.I.V., prenatal care and preventive care, vast research shows. They are also less likely to receive treatment for cardiovascular disease, and they are more likely to have unnecessary limb amputations.

As part of “The 1619 Project,” Evelynn Hammonds, a historian of science at Harvard, told Jeneen Interlandi of The New York Times: “There has never been any period in American history where the health of blacks was equal to that of whites. Disparity is built into the system.”

African-American men, in particular, have the worst health outcomes of any major demographic group. In part, research shows, this is a result of mistrust from a legacy of discrimination.

At age 45, the life expectancy of black men is more than three years less than that of non-Hispanic Caucasian men. According to a study in the Quarterly Journal of Economics, part of the historical black-white mortality difference can be attributed to a 40-year experiment by the U.S. Public Health Service that shook African-Americans’ confidence in the nation’s health system.

From 1932 to 1972, the Public Health Service tracked about 600 hundred low-income African-American men in Tuskegee, Ala., about 400 of whom had syphilis. The stated purpose was to better understand the natural course of the disease. To do so, the men were lied to about the study and provided sham treatments. Many needlessly passed the disease on to family members, suffered and died.

As one scholar put it, the Tuskegee study “revealed more about the pathology of racism than it did about the pathology of syphilis.” In fact, the natural course of syphilis was already largely understood.

The study was publicized in 1972 and immediately halted. To this day, it is frequently cited as a driver of documented distrust in the health system by African-Americans. That distrust has helped compromise many public health efforts — including those to slow the spread of H.I.V., contain tuberculosis outbreaks and broadenprovision of preventive care.

According to work by the economists Marcella Alsan and Marianne Wanamaker, black men are less likely than white men to seek health care and more likely to die at younger ages. Their analysis suggests that one-third of the black-white gap in male life expectancy in the immediate aftermath of the study could be attributed to the legacy of distrust connected to the Tuskegee study.

Their study relies on interpreting observational data, not a randomized trial, so there is room for skepticism about the specific findings and interpretation. Nevertheless, the findings are consistent with lots of other work that reveals African-Americans’ distrust of the health system, their receipt of less care, and their worse health outcomes.

The Tuskegee study is far from the only unjust treatment of nonwhite groups in health care. Thousands of nonwhite women have been sterilized without consent. For instance, between the 1930s and 1970s, one-third of Puerto Rican women of childbearing age were sterilized, many under coercion.

Likewise, in the 1960s and 1970s, thousands of Native American women were sterilized without consent, and a California eugenics law forced or coerced thousands of sterilizations of women (and men) of Mexican descent in the 20th century. (Thirty-two other states have had such laws, which were applied disproportionatelyto people of color.)

For decades, sickle cell disease, which mostly affects African-Americans, received less attention than other diseases, raisingquestions about the role of race in how medical research priorities are established.

A ‘Rare Case Where Racial Biases’ Protected African-Americans

Outside of research, routine medical practice continues to treat black and white patients differently. This has been documented in countless ways, including how practitioners view pain. Racial bias in health care and over-prescription of opioid painkillers accidentally spared some African-Americans from the level of mortality from opioid medications observed in white populations.

“While African-Americans may not have died at similar rates from opioid misuse, we can be sure needless suffering and, perhaps even death, occurred because provider racism prevented them from receiving appropriate care and pain medication,” said Linda Goler Blount, president and chief executive of the Black Women’s Health Imperative.

Of course, health outcomes are a result of much more than health care. The health of people of color is also unequal to that of whites because of differences in health behaviors, education and income, to name a few factors. But there is no doubt that the health system plays a role, too. Nor is there question that a history of discrimination and structural racism underlies racial differences in all these drivers of health.

Reinforcing the fact of racial bias in health care, a recent studyfound that care for black patients is better when they see black doctors. The study randomly assigned 1,300 African-Americans to black or nonblack primary care physicians. Those who saw black doctors received 34 percent more preventive services. One reason for this, supported by the study, is increased trust and communication.

The study findings are large. If all black men received the same increase in preventive services as those in the study (and received appropriate follow-up care), it would reduce the black-white cardiovascular mortality rate by 19 percent and shrink the total black-white male life expectancy gap by 8 percent, the researchers said.

But it is unlikely all black men could see black doctors even if they wished to. Although African-Americans make up 13 percent of the U.S. population, only 4 percent of current physicians — and less than 7 percent of recent medical school graduates — are black.

This study does not stand alone. A systematic review found that racially matched pairs of patients and doctors achieved better communication. Other studies found that many nonwhite patientsprefer practitioners who share their racial identity and that they receive better care from them. They view them as better than white physicians in communicating, providing respectful treatment and being available.

Racial bias in health care, as in other American institutions, is as old or older than the republic itself.

Title VI of the 1964 Civil Rights Act stipulates that neither race, color nor national origin may be used as a means of denying the “benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” As nearly every facet of the American health system receives federal financing and support, well-documented and present-day discrimination in health care suggests the law has not yet had its intended effect.

Source: Race and Medicine: The Harm That Comes From Mistrust

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