Tackling the health burden of anti-black racism and violence

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

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

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

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

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