Lightman and Akbary: New data provide insight into pandemic inequalities

Insightful analysis, contrasting vaccination rates (relatively similar) and health outcomes (disparities):

Existing analyses of COVID-19 in Canada and internationally suggest infection rates were highly variable across populations, with researchers highlighting the disproportionate burdenexperienced by groups that are intersectionally disadvantaged.

Early in the pandemic, widespread evidence emerged of the unequal rates of infection experienced by residents and care workers in long-term care homes in Canada. Soon after, racialized populations and immigrants were also found to be especially hard-hit. The COVID-19 mortality rate was significantly higher for racialized populations.

Our new research finds that while these individuals had higher rates of COVID-19 infection, they were equally or more likely to get vaccinated than comparison groups. This has important policy implications. Rather than focusing on individual decision-making, the data suggest a need to prioritize protections and pay for workers in essential jobs that are unpredictable, dangerous, physically demanding and/or low wage.

Overwhelming evidence shows that vaccines are an effective protective measure, both in terms of reducing infection ratesand severity of illness. Using the 2022 Statistics Canada dataset “Impacts of COVID-19 on Canadians – Testing and Vaccination,” our analyses found that variable vaccination rates were not the reason behind differing rates of infection.

These data were collected as part of Statistics Canada’s crowdsourcing initiative which aimed to gather timely information on Canadians’ experiences of testing for COVID-19 and access to vaccination during the pandemic. Statistics Canada used open advertising to obtain participants who chose to self-select by completing an online questionnaire from February 21 to March 13, 2022.

For racialized minorities, 20 per cent tested positive, compared to 15 per cent for non-racialized minorities (outcomes were similar when comparing PCR to rapid test results). In particular, those who identified as Black and Filipino (populations that also have high rates of employment in care occupations and in service industries fared worst. Black populations experienced a one-third rate of positivity for rapid tests (see Figure 1).

Citizenship was also an important factor. Those without Canadian citizenship status (including temporary foreign workers) fared worse for both types of testing (at an average of 22 per cent positivity), compared to those immigrants with citizenship status and the Canadian-born. The latter fared by far the best, at 14 per cent positivity via PCR tests, and 17 per cent positivity via rapid tests (see Figure 2).

Women and men, interestingly, were found to have had similar rates of infection. However, those who identified as essential workers had higher rates of infection (see Figure 3), with women overrepresented among this population.

Yet the data on rates of vaccination tell a different story. This suggests that variable infection rates were tied to specific jobs or to systemic inequalities, rather than a function of individual choice.

There was only a marginal difference in vaccination rates between essential workers and non-essential workers. Racialized people and immigrants had higher rates of vaccination than non-racialized people and non-immigrants (see Figure 4).

Finally, the data reject explanations tied to access to health facilities. In the five cities in Canada with the highest rates of infection, residents had higher rates of access to at least one health facility and a pharmacy close to them (see Figure 5).

Together, this information suggests that COVID-19 infection rates were not related to personal decision-making or access to health services. Instead, it raises concerns about broader social responsibilities. Populations that are racialized and/or non-citizens and those doing essential jobs were infected at disproportionate rates, even as they took steps to get vaccinated.

Notably, the data do not provide information on time order, so it is plausible that those workers on the front lines reported positive cases prior to having access to the vaccine. This raises further questions about which occupations and which areas of each city were prioritized for personal protective equipment and early access to vaccination, while refuting suggestions of a lack of awareness or interest in vaccination by underserved communities.

As well, the data do not indicate the severity of illness. Thus, the analyses may tell a story of lives saved due to vaccination for populations that were at greater risk of infection due to their workplace conditions.

In terms of policy, this suggests that there is an urgent need to focus on improving working conditions for essential workers. This includes providing paid sick leave and job guarantees for those who take time off work to care for themselves or others. Staffing levels and accommodations to work from home for those who are sick (when possible) should be ensured. Accommodations to reduce workplace injuries and increase mental health supports must be made available. Providing safe transportation to and from work facilities as well as paid time to travel to get vaccinated should be a policy initiative. Finally, emergency housing for self-isolation when needed and access to child and elder care, as well as affordable housing for those with lower socioeconomic status, should also be top priority.

Perhaps most critically, wages must be raised for workers who are systematically at higher risk of infection due to the face-to-face nature of their employment (while also structuring workplaces to avoid dangerous work conditions where possible.) This would at least partially compensate for increased rates of infection within certain jobs and recognize the toll it takes on individuals, families and communities.

All this reinforces a structural rather than individual analysis of disease burdens and public health measures. Clearly, getting vaccinated is not the end of the story. Ongoing social responsibility is needed to protect vulnerable groups – whether this takes the form of masking, work-from-home measures, or other workplace accommodations.

The implications of the pandemic are nowhere near over. There must be a move beyond rhetoric of “gratitude” to essential workers; instead, governments and employers must implement better policies and pay. These policies must be evidence-based so Canadians have an accurate understanding about the pandemic and its effects.

Given the emerging information about the potentially long-term implications of COVID-19, these measures take on added urgency for groups such as children, people with disabilities and intersectionally disadvantaged populations.

A note about methodology

Statistics Canada started the crowdsourcing initiative as part of a data collection series to address the informational needs of Canadians and enhance their understanding related to the impact of COVID-19. According to an evaluation report, Statistics Canada’s crowdsourcing products have proven to be useful for briefing purposes, policy research and analysis, program and service planning and decision-making, as well as knowledge-production and modeling. Statistics Canada uses a number of measures to ensure the quality of data collected through the crowdsourcing initiative. First, the questionnaires are designed based on Statistics Canada’s standard practices and wording used in a computer-assisted interviewing environment. During data collection, a computer application is used to automatically control the flow of questions, depending on participant responses, and to check for logical inconsistencies and errors in participant responses. The computer application used for these purposes is tested extensively. After data have been collected, Statistics Canada maximizes the quality of crowdsourced data through error detection of invalid or missing values for age, gender and postal code at micro levels. Furthermore, Statistics Canada compensates for overrepresentation and underrepresentation by calculating a benchmark factor for every participant based on demographic projections of the number of people by province and territory, sex and age group. As recommended by Statistics Canada, therefore, the authors of this article used the benchmark factor to produce their results in the same way that survey weights are used to produce estimates from non-crowdsourced data.

Source: Lightman and Akbary: New data provide insight into pandemic inequalities

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

Patient satisfaction surveys fail to track how well USA hospitals treat people of color

Of interest:

Each day, thousands of patients get a call or letter after being discharged from U.S. hospitals. How did their stay go? How clean and quiet was the room? How often did nurses and doctors treat them with courtesy and respect?

The questions focus on what might be termed the standard customer satisfaction aspects of a medical stay, as hospitals increasingly view patients as consumers who can take their business elsewhere.

But other crucial questions are absent from these ubiquitous surveys, whose results influence how much hospitals get paid by insurers: They do not poll patients on whether they’ve experienced discrimination during their treatment, a common complaint of diverse patient populations.

Likewise, they fail to ask diverse groups of patients whether they’ve received culturally competent care.

And some researchers say that’s a major oversight.

Kevin Nguyen, a health services researcher at Brown University School of Public Health, who parsed data collected from the government-mandated national surveys in new ways, found that — underneath the surface — they spoke to racial and ethnic inequities in care.

Digging deep, Nguyen studied whether patients in one Medicaid managed-care plan from ethnic minority groups received the same care as their white peers. He examined four areas: access to needed care, access to a personal doctor, timely access to a checkup or routine care, and timely access to specialty care.

“This was pretty universal across races. So Black beneficiaries; Asian American, Native Hawaiian, and Pacific Islander beneficiaries; and Hispanic or Latino or Latinx/Latine beneficiaries reported worse experiences across the four measures,” he said.

Nguyen said that the surveys commonly used by hospitals (called Consumer Assessment of Healthcare Providers and Systems, or CAHPS) could be far more useful if they were able to go one layer deeper — for example, asking why it was more difficult to get timely care, or why they don’t have a personal doctor.

It would also be more helpful if CMS publicly posted not just the aggregate patient experience scores, but also showed how those scores varied by respondents’ race, ethnicity, and preferred language.

Such data can help discover whether a hospital or health insurance plan is meeting the needs of all versus only some patients. Nguyen did not study responses of LGBTQ+ individuals or, for example, whether people received worse care because they were obese.

Hospital surveys — and how to game them — has become big business

The health care provider surveys are required by the federal government for many health care facilities, and the hospital version of it is required for most acute care hospitals. Low scores can induce financial penalties, and hospitals reap financial rewards for improving scores or exceeding those of their peers.

The CAHPS Hospital Survey, known as HCAHPS, has been around for more than 15 years. The results are publicly reported by the Centers for Medicare & Medicaid Services to give patients a way to compare hospitals, and to give hospitals incentive to improve care and services. Patient experience is just one thing the federal government publicly measures; readmissions and deaths from conditions including heart attacks and treatable surgery complications are among the others.

Dr. Meena Seshamani, director of the Center for Medicare, said that patients in the U.S. seem to be growing more satisfied with their care:

“We have seen significant improvements in the HCAHPS scores over time,” she said in a written statement, noting, for example, that the percentage of patients nationally who said their nurses “always” communicated well rose from 74% in 2009 to 81% in 2020.

But for as long as these surveys have been around, doubts about what they really capture have persisted. Patient experience surveys have become big business, with companies marketing methods to boost scores. Researchers have questioned whetherthe emphasis on patient satisfaction — and the financial carrots and sticks tied to them — have led to better care. And they have long suspected institutions can “teach to the test” by training staff to cue patients to respond in a certain way.

National studies have found the link between patient satisfaction and health outcomes is tenuous at best. Some of the more critical research has concluded that “good ratings depend more on manipulable patient perceptions than on good medicine,” citing evidence that health professionals were motivated to respond to patients’ requests rather than prioritize what was best from a care standpoint, when they were in conflict.

Hospitals have also scripted how nurses should speak to patients to boost their satisfaction scores. For example, some were instructed to cue patients to say their room was quiet by making sure to say out loud, “I am closing the door and turning out the lights to keep the hospital quiet at night.”

A new push to survey hospitals about discrimination

About a decade ago, Robert Weech-Maldonado, a health services researcher at the University of Alabama-Birmingham, helped develop a new module to add to the HCAHPS survey “dealing with things like experiences with discrimination, issues of trust.” Specifically, it asked patients how often they’d been treated unfairly due to characteristics like race or ethnicity, the type of health plan they had (or if they lacked insurance), or how well they spoke English.

It also asked patients if they felt they could trust the provider with their medical care. The goal, he said, was for that data to be publicly reported, so patients could use it.

Some of the questions made it into an optional bit of the HCAHPS survey — including questions on how often staffers were condescending or rude, and how often patients felt the staff cared about them as a person — but CMS doesn’t track how many hospitals use them, or how they use the results. And though HCAHPS asks respondents about their race, ethnicity and language spoken at home, CMS does not post that data on its public patient website, nor does it show how patients of various identities responded compared to others.

Without wider use of explicit questions about discrimination, Dr. Jose Figueroa, an assistant professor of health policy and management at the Harvard School of Public Health, doubts HCAHPS data alone would “tell you whether or not you have a racist system” — especially given the surveys’ slumping response rates.

One exciting development, he said, lies with the emerging ability to analyze open-ended (rather than multiple-choice) responses through what’s called natural language processing, which uses artificial intelligence to analyze the sentiments people express in written or spoken statements as an addendum to the multiple-choice surveys.

One study analyzing hospital reviews on Yelp identified characteristics patients think are important but aren’t captured by HCAHPS questions — like how caring and comforting staff members were, and the billing experience. And a study out this yearin the journal Health Affairs used the method to discover that providers at one medical center were much more likely to use negative words when describing Black patients compared with their white counterparts.

“It’s simple, but if used in the right way can really help health systems and hospitals figure out whether they need to work on issues of racism within them,” said Figueroa.

Press Ganey Associates, a company that a large number of U.S. hospitals pay to administer these surveys, is also exploring this idea. Dr. Tejal Gandhi leads a projectthere that, among other things, aims to use artificial intelligence to probe patients’ comments for signs of inequities.

“It’s still pretty early days,” Gandhi said, adding, “With what’s gone on with the pandemic, and with social justice issues, and all those things over the last couple of years, there’s just been a much greater interest in this topic area.”

Direct outreach to improve cultural competence

Some hospitals, though, have taken the tried-and-true route to understanding how to better meet patients’ needs: talking to them.

Dr. Monica Federico, a pediatric pulmonologist at the University of Colorado School of Medicine and Children’s Hospital Colorado in Denver, started an asthma program at the hospital several years ago. About a fifth of its appointments proved no-shows. The team needed something more granular than patient satisfaction data to understand why.

“We identified patients who had been in the hospital for asthma, and we called them, and we asked them, you know, ‘Hey, you have an appointment in the asthma clinic coming up. Are there any barriers to you being able to come?’ And we tried to understand what those were,” said Federico.

At the time, she was one of the only Spanish-speaking providers in an area where pediatric asthma disproportionately affects Latino residents. (Patients also cited problems with transportation and inconvenient clinic hours.)

After making several changes, including extending the clinic’s hours into the evening, the no-show appointment rate nearly halved.

Patient satisfaction surveys are embedded in American health care culture and are likely here to stay. But CMS is now making tentative efforts in surveys to address the issues that were previously overlooked: As of this summer, it is testing a question for a subset of patients 65 and older that would explicitly ask if anyone from a clinic, emergency room, or doctor’s office treated them “in an unfair or insensitive way” because of characteristics including race, ethnicity, culture, or sexual orientation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. It is an editorially independent operating program of KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Source: Patient satisfaction surveys fail to track how well hospitals treat people of color

Pain in Children is Often Ignored. For Children of Color, It’s Even Worse.

Of note, likely similar in Canada:

Judith McClellan, a social worker who lives in Salisbury, N.C., knows what it’s like to see her child in pain. Her daughter Kyarra, 15, has sickle cell disease, an inherited red blood cell disorder that most commonly affects Black people and frequently causes pain so excruciating that emergency opioids are necessary. When she was younger, Ms. McClellan said, Kyarra would describe the pain — caused by blockages in blood vessels — as feeling “like a butcher’s knife stabbing me 1,000 times in the same spot.”

During times of distress, Ms. McClellan said, “the protocol is we go to the nearest hospital” to receive powerful pain medications that will mitigate Kyarra’s discomfort until the crisis has passed. But because the McClellans, who are Black, live an hour and a half away from Kyarra’s primary hematologist, they often find themselves at emergency departments with medical staff who don’t know them and who often doubt Kyarra’s pain.

“If she says she has a pain level of eight — because she’s not screaming and hollering — they question, ‘Are you sure it’s an eight? Or are you making it an eight to get more pain medication?,’” Ms. McClellan said. “Sometimes I think they think she’s seeking drugs.”

Dr. Andrew Campbell, director of the Comprehensive Sickle Cell Disease Program at Children’s National Hospital in Washington, D.C., said that health care providers who don’t understand a condition like sickle cell disease, where pain is the hallmark feature, often mislabel Black children, particularly teenagers, as “drug seekers” or “opioid abusers.” There is also a “potential layer of racism” that can lead to that characterization, he added.

Last year, at a UNC hospital emergency department in Chapel Hill, N.C., a doctor reported Ms. McClellan to Child Protective Services because he was concerned about the fact that Kyarra had received 30 opioid prescriptions from 9 different doctors in North Carolina in the past year. That was too many, in his opinion. Ms. McClellan said that when she explained to the doctor that Kyarra’s prescriptions were necessary and in accordance with prescribing guidelines, he said, “If you’re not hiding anything, this will all work out.”

When asked about the incident, Alan Wolf, a spokesman for UNC Health, said that “hospital providers are obligated under North Carolina law to report suspected child neglect or abuse.”

In the end, the agency decided not to pursue the report, Ms. McClellan said, because “it didn’t meet the qualifications for abuse and neglect.”

Dr. Emily Hartford, an assistant professor in pediatric emergency medicine at the University of Washington who studies how differences in care can affect children, said that Kyarra’s experience is part of “a theme we’re starting to see over and over in the literature.”

In June, for instance, Dr. Hartford and her colleagues published a study in the journal Academic Emergency Medicine that analyzed the medical records of 833 12- to 16-year-olds who visited the Seattle Children’s hospital emergency department for migraine treatment between 2016 and 2020. They found that the children who were Black, Asian, Hispanic or who preferred to speak in a language other than English were less likely than white children to receive strong intravenous pain-relieving medications, despite reporting similar pain levels.

This jibes with past research, Dr. Hartford said, which has found that when children of color visit emergency departments for issues like bone fractures or appendicitis, for example, they are less likely than white children to be given appropriate pain medications, like opioids. Many studies have also found similar variations in pain treatment among adults of color.

“We would like there to be no differences by ethnicity and languages,” Dr. Hartford added. But “we have to uncover them as the first step to addressing them.”

Pain is subjective, hard to measure and often invisible. And in children — even more so than in adults — it is frequently misunderstoodundertreated and dismissed, as research has shown.

But in children of color, treatment can be worse. Dr. Ron Wyatt, a senior fellow at the Institute for Healthcare Improvement who is based in Madison, Ala., noted that false beliefs about biological differences between Black people and white people — dating back to slavery — have had lasting effects on how people of color are treated in medical settings.

As part of an often-cited study published in 2016 in the Proceedings of the National Academy of Sciences, for instance, researchers from the University of Virginia surveyed 222 white medical residents and students and found that more than a third of them believed that Black people had physically thicker skin than white people did. And about 7 percent believed that Black people’s nerve endings were less sensitive than white people’s. The participants with such erroneous beliefs also made less accurate pain treatment recommendations, the study authors found.

Dr. Lisa Cooper, a professor of medicine at Johns Hopkins University and director of its Center for Health Equity, has found in her own research that the more implicit (or unconscious) biaswhite physicians have, the more poorly they communicate with Black patients.

One of her studies found that white doctors dominated conversations more with Black patients than they did with white patients, making it far more likely that Black patients’ concerns would go unheard and their conditions and pain would go undertreated. “It’s definitely a safety issue,” Dr. Cooper said.

Dr. Cristina Gonzalez, a professor of medicine at the Albert Einstein College of Medicine in New York City who teaches physicians how to recognize and manage their implicit biases, said she remembered one instance years ago when a young Hispanic patient came into the hospital complaining of severe pain. A staff member said, “I don’t think he is really in pain.” He was eventually diagnosed with a gallbladder infection, ‌Dr. Gonzalez said, but those doubts could have delayed his treatment and caused damage‌ that could have been life-threatening.

“Delaying care has significant health downstream effects,” she said.

Experts emphasized that the onus should not be on patients to improve their own care. In recent years, there has been a push by researchershospitals and lawmakers to help health care providers become more aware of their biases — which everyone has — and to change their behavior accordingly. But “those are things that take time,” Dr. Wyatt said. In the meantime, these strategies may help parents at the hospital:

Keep records. Write down your child’s medications, symptoms and pediatrician’s contact information. Then, give the staff this information, which will help them assess what type of care your child needs faster. This is particularly helpful if your child has a chronic condition and is taking medication regularly.

Get to know the hospital staff. Vanessa Finch, of Fort Lauderdale, Fl., whose son Kahleeb Beckett died at age 24 during a sickle cell crisis at the hospital, said that when Kahleeb was young, she found ways to connect with the hospital workers. “I volunteered. I kicked it with the social workers. I stayed in those doctors’ faces,” she said. “That makes a difference.” She discovered that when the medical staff felt a more personal connection to her son, who was Black, they were more empathetic to his pain.

Try to alleviate your child’s anxiety. Studies show that anxiety and pain are intricately interwoven and some surprisingly simple tactics can help to reduce anxiety and lessen perceptions of pain. These may include having your child imagine a favorite place, listening to a guided imagery exercise or offering distractions, like music or a video. You can use these strategies while waiting for treatment.

Take deep breaths. “We know that parents’ distress about their child’s pain in the E.D. really impacts how their child experiences pain and how they respond to treatment,” said Emily Law, an author of the recent study on migraine treatment in adolescents and an associate professor of anesthesiology and pain medicine at the University of Washington. So do what you can to stay calm, whether that involves taking deep breaths or stepping out of the exam room to call a friend for support.

If necessary, file a complaint. If you feel that your child hasn’t been treated appropriately, ask to speak with a hospital social worker or write a complaint to the hospital to hold them accountable.

Source: Pain in Children is Often Ignored. For Children of Color, It’s Even Worse.

USA: Student loan debt is deepening the racial wealth divide

Of note. Anyone aware of comparable studies, even if Canadian tuition rates are more reasonable than in the US:

By design, economists’ reports are rather staid, which makes it all the more noticeable that in their 2016 report Black-White Disparity in Student Loan Debt more than Triples after Graduation, written for the New York-based Brookings Institution (BI), Professor Judith Scott-Clayton and Jing Li characterised the US$25,000 loan debt gap between whites and blacks in the United States a few years after graduation as “whopping”. 

At graduation, black students owed US$7,400 more than did their white peers (US$23,400 vs US$16,000). 

Since Scott-Clayton and Li’s paper, a series of other papers BI published have shown that the gap, if anything, has grown. 

Last June, a paper prepared for BI by Andre M Perry, Marshall Steinbaum and Carl Romer showed that in 2019, 75% of blacks who took out student loans to finance higher education owed more than they had borrowed as compared with 48% of whites.

“Black students finance their education through debt, and thus college degrees actually further contribute to the fragility of the upwardly mobile black middle class,” wrote Perry et al in Student Loans, the Racial Wealth Divide, and Why We Need Full Student Debt Cancellation.

“And because education does not achieve income parity for black workers, the disproportionate debt black students are taking to finance their education reinforces the racial wealth gap. Today the average white family has roughly 10 times the amount of wealth as the average black family, while white college graduates have over seven times more wealth than black college graduates.”

The debt differential begins as soon as the students write their first cheques. The financial crisis of many black families means that a much lower percentage are able to contribute to their sons’ and daughters’ higher education than is the case for white families. 

Some 72% of black students (as opposed to 34% of white students) qualify for Pell Grants. This federal programme provides the very poor with a maximum of US$6,495, roughly one-third of the cost of tuition, room and board at public universities and colleges, and a seventh of the average cost at private colleges and universities. 

In their study, Perry et al point out that the black student debt crisis is partially fuelled by the shift from “public funding to tuition-based business models in higher education – all financed with federal student loans”. 

According to figures from the American Association of University Professors, between 2009 and 2011 state governments cut their grant for full-time students at state universities and colleges from US$9,124 to US$7,364. 

Only in 2019-20 did the state grant equal what it was in 2009. The cumulative financial loss over this period for each full-time student is more than US$7,800. These figures show the reality behind Perry et al’s claim that “the balance (US$1.7 trillion) on the federal books represents the states’ disinvestment from higher education”.

Further adding to the aggregate black student debt is the fact that about 12% of black students enrol in for-profit colleges and universities, approximately twice the rate of whites. This sector has come under scrutiny for predatory practices that target, among others, economically disadvantaged populations such as blacks. 

“Despite enrolling only 11% of the higher education population, for-profit colleges and universities receive 25% of all federal student aid … Some of the largest for-profit colleges receive as much as 90% of their total funding from federal aid, incentivising schools to target low-income students and veterans who are eligible for large amounts of federal aid,” wrote William Roberts, managing director for democracy and government reform at American Progress, and Marissa Parker-Bair in an article published on the Center for American Progress’s website in July 2019.

According to Jon Boeckenstedt, vice provost for enrolment management at Oregon State University, “in addition to predatory practices, for-profit colleges and universities have very successfully lobbied the federal government to reduce oversight of their programmes”. 

“Further, for-profit colleges and universities tend to have lower graduation rates (26% v 60%) which means that students who took out loans to attend these institutions are unable to benefit from the increased salaries that are expected for college graduates. Historically, default rates for students who don’t finish the degree or programme they started are considerably higher than for graduates,” Boeckenstedt said.

Struggling to repay

The wage gap between blacks and whites is a significant factor in why black students – both those who drop out as well as those who graduate – struggle to repay their student loans. 

In 2019 the US Department of Education reported that one year out from graduation, blacks who hold bachelor degrees earn 10% less than their white counterparts (US$36,000 to US$40,000). In 2020 the New York City Department of Consumer and Worker Protection reported that, for whites and blacks who are further into their careers, the annual salary gap grows to US$21,900: US$64,700 to US$42,800. 

Nor does higher education close the gap. A slightly higher percentage of blacks go on to graduate school than do whites (14% to 13%). Yet, wrote Scott-Clayton and Li, “blacks with graduate degrees still earn less on average than whites with only a bachelor degree.” 

Equally important for why blacks are less able to repay their college loans is the structure of the federal student loan programme. As soon as a student drops out of college or university, or graduates, the interest clock starts ticking. 

Graduate students are given a forbearance from repaying their undergraduate loans for the period of time they are enrolled in graduate school; however, the interest keeps accruing. 

The accrual of interest onto the principal debt, what economists call ‘negative amortisation’, is why nearly half of all blacks who took out student loans owe more on their loans than they did upon graduation.

A further factor mitigating against blacks repaying student loans is the direction of intergenerational transfer of wealth in black families. 

According to a 2017 study covering 23 years beginning in 1989 and conducted by the Economic Research unit of the Federal Reserve Bank of St Louis (FRBSL), after graduation white students benefit from their families transferring money to them to, for example, put a down payment on a house. By contrast, the FRBSL found that black graduates are much more likely to transfer money to their families to, for example, support their parents, thus leaving less money each month for loan repayment.

Neither the ability of well-off families, which are disproportionately white, to refinance student debt at favourable rates, nor what the income tax act allows former students to deduct from their income taxes, directly contribute to the debt crisis faced by blacks. 

They do, however, contribute to the wealth gap between the two groups and, thus, skew perceptions of the issue, leading some to argue that those who cannot repay their debts are the authors of their own misfortune.

Graduates from well-off families benefit from their history of positive credit scores. The interest rate on federal student loans is presently 6.8%. The most creditworthy customers, however, are able to refinance student debt for as low as 1.8%, says Carl Romer, Perry’s co-author. 

All former students can deduct US$2,500 of interest charges from their federal taxes. However, as Romer explained to me, the greater benefit goes to those who have borrowed less money. “If your loan is US$100,00 and you are paying 6% interest, then you are paying US$6,000 in interest. But you are still allowed to deduct only US$2,500 in interest. This penalises households with high amounts of student loans, which are disproportionately black households,” he told University World News.

The inequity is even more striking if we look at it over 20 years. Students who can refinance their debt at 1.8% repay the debt at the rate of US$496 a month and pay US$19,150 in total interest. Students whose debts are repaid at 6.8% interest pay US$763 per month and over 20 years pay US$83,000 in interest, or more than four times the amount their peers from well-off families pay.

Alleviating worst consequences

In their 2016 paper, among their proposals, Scott-Clayton and Li theorised that a ‘Revised Pay As You Earn’ (REPAYE) could alleviate the worst consequences of the racial debt disparities. 

Their caveats, including daunting paperwork and the fact that “too often students do not learn about the income-contingent options until after they are already in trouble – having missed payments, accumulated fees and damaged their credit” have proven all too prescient.

“Policy-makers as far back as the Clinton administration were very much influenced by the income-driven repayment plans in place in Australia and the UK,” Scott-Clayton says. 

“The difference in both of these cases, though, is that in those countries the plans work much more seamlessly with the treasury and payments are integrated into the tax system. So, this [the American system] is kind of trying to take that model and fit it into the very not automatic US system.”

REPAYE may look fair on paper, having, for example, former students pay 15% of their income towards their debt. Yet, Romer notes, because these households are in such straightened conditions, the presence of, in many cases, decades-old student debt on their credit report means “they are unable to access the type of credit that middle-class households need in order to thrive”.

“They are not able to get a credit card. They are not able to purchase a home. They are not able to do the types of things that would make their lives that much easier.”

Nor, Romer says, does the government’s logic make sense. For those who have been paying 15% for 20 or 25 years, the government cancels the debt.

“This is another reason why we say to cancel the debt instead of holding these households really hostage to their student debt for minimal levels of repayment, if any, it is better to just make their lives better by cancelling the debt.”

After underscoring that 51% of the student debt is held by households with zero or negative net worth, and that black households at every income level and at every age are more likely to hold student debt than are non-black households, as had Scott-Clayton, Romer framed the question as a social justice issue.

Romer concluded, however, by speaking the language of political economy, saying that cancellation of student debt can help in the economic recovery from the COVID crisis. The FRBSL, he says, found that student debt slowed the recovery from the 2009 Recession. According to Romer, the Lee Institute based in Charlotte, North Carolina, reported that cancelling student debt would grow the economy by US$100 billion every year for the next 10 years. 

“They did this study five years ago. So, the amount of student debt has only grown since and it is pretty simple to infer their projection would have grown as well. As we recover from the pandemic-induced recession, it’s important to think about how previous economic studies on the macro-economic effects of student debt have shown that the answer is to cancel it in order to grow the economy,” says Romer.

Targeted or piecemeal approach?

A few days before I interviewed Scott-Clayton, the Biden administration cancelled the student debt of 323,000 people who together owed US$5.8 billion, which brought the number of former students whose debt the government had wiped out to 455,000 and the amount to US$8.7 billion. 

When I asked her about the government’s approach, given that the amount on the government’s books was US$1.7 trillion, Scott-Clayton said: “It is obvious that rather than pushing hard for some kind of blanket forgiveness, they’re trying to do a more targeted approach. And, to the extent that they are committed to that, they’ll keep identifying additional groups that are at high risk of delinquency and default.”

The problem with this piecemeal approach, she says, is that it “won’t reach all the borrowers who urgently need help”.


Immigration and natives’ exposure to COVID-related risks in the EU | VOX, CEPR Policy Portal

Interesting assessment that immigrant workers in EU countries helped non-migrants avoid COVID-related risks given that immigrant workers filled the more difficult and dangerous jobs and that native workers were more able to shift to jobs that could be filled from home:

In recent years, immigration policy has been at the forefront of political debates in high-income destination countries. The UK completed its withdrawal from the EU on 31 January 2020, due in part to the desire to have more control over its immigration policies and to limit migrant flows. Intense political debates and polarisation on immigration helped fuel the rise of right-wing parties in Europe and political controversies over the border wall and the Dream Act in the US.

Despite these high-profile examples of the popular and political backlash against immigration, the academic literature provides evidence that immigrant workers often fill difficult and dangerous jobs that locals are not willing to undertake (Orrenius and Zavodny 2009 and 2013, Sparber and Zavodny 2020).

The recent COVID-19 shock exerted unforeseen and sudden pressures on labour markets across the world. While the negative effects of the pandemic were widespread, some categories of workers were hit much harder than others due to their occupations (Adams-Prassl et al. 2020a and 2020b, Dingel and Neiman 2020, Garrote-Sanchez et al. 2020, Gottlieb et al. 2021). Migrant workers, in particular, have been more exposed to the negative impacts of COVID-19 (Basso et al. 2020, Borjas and Casidi 2020, Fasani and Mazza 2020 and 2021). Another strand of the migration literature shows that in response to immigration, native workers reallocate to different occupations in which they have a comparative advantage (Peri and Sparber 2009).

Against this backdrop, a question of interest is whether immigration contributed to reducing locals’ exposure to the COVID-19 pandemic. In a recent paper (Bossavie et al. 2020), we explore how the prevalence of immigration in a labour market affects different types of workers’ exposure to COVID-19 related risks. We provide evidence that not only were immigrant workers more exposed to the economic and health-related shocks of the pandemic; they also served as a protective shield for native workers. By selecting into higher-risk occupations prior to the pandemic, immigrants enabled native workers to move into jobs that could be undertaken from the safety of their homes or with lower face-to-face interaction with customers and co-workers during the pandemic.

To assess the exposure of immigrant and native workers to the economic and health risks posed by the pandemic, we construct various measures of vulnerability. We look at three main dimensions of occupational vulnerability in the context of COVID-19: whether an occupation can be carried out from home, whether it has been categorised as essential by governments in the context of COVID-19, and whether it is exposed to COVID-19 health risks. In general, lower-skilled occupations such as machine operators, waiters, and day laborers tend to be less amenable to work from home than professional and managerial occupations. Essential jobs are concentrated in key sectors such as healthcare or agriculture. The higher health risks are found in essential occupations that require intensive face-to-face interactions such as doctors, personal care workers, or bus drivers.

We focus on destination countries in Western Europe, including the 15 countries that were the initial members of the EU (prior to the 2004 enlargement), Norway, and Switzerland. This region is the destination for an estimated 60 million of some 272 million immigrants worldwide. The analysis is based on a harmonised labour force dataset (EU Labor Force Survey) that contains detailed information on personal characteristics (such as age, education, occupation, and sector) of native workers and labour migrants in hundreds of local labour markets in subregions within European countries.1 The distribution of occupations by type of exposure to COVID-19 and by migrant status in the EU is reported in Figure 1.

Figure 1 Relative size of telework, essential, and non-face-to-face jobs in the EU

Source: Own calculation based on EU-LFS 2018 data, following EC directive (2020) and Fasani and Mazza (2020).

We first find that immigrants are generally employed in occupations that are more vulnerable to COVID-19-related risks (Fasani and Mazza 2021 report similar findings). Our estimates show that only 27% of employed migrants in the EU15 have a job amenable to telework, compared to 41% of native workers (Figure 2). On the other hand, migrants are slightly more likely to be in essential occupations. Combining those two categorisations of job vulnerabilities, migrants are more than 10% less likely than natives to hold jobs that are shielded from negative income shocks associated with the COVID-19 pandemic. Furthermore, migrants are also more likely to have jobs that are exposed to health risks, though we report significant heterogeneity in exposure among immigrant groups. The higher vulnerability of migrants is common across skill levels but varies depending on country of origin, with Eastern European migrants being the most exposed to income risks while migrants from Western Europe or North America have a similar risk profile to natives. Recent Eurostat statistics show that the higher vulnerability of migrants to the COVID-19 shock in Western Europe resulted in higher employment losses in 2020 (4% drop vis-à-vis 2019, compared to 0.8% fall for natives during the same period).

Figure 2 Share of workers by region of origin and risk type

Source: Own calculation based on EU-LFS 2018 data, following EC directive (2020) and Fasani and Mazza (2020).

We then examine whether the presence of immigrants in local labour markets has a causal impact on the vulnerability of native workers in the same geographic areas. Our empirical analysis is motivated by a general equilibrium model of comparative advantages in task performance between immigrant and native workers (Peri and Sparber 2009). In the model, native workers reallocate to other occupations in response to an influx of immigrant workers. In the empirical analysis, we use an instrumental variable approach to account for the non-random location choices of migrant responses to local job opportunities, which is based on past migration presence in the same region. Because of information, networks, and preferences, there is a strong positive association between current and past immigrant presence across European regions, as immigrants tend to move to the same locations where previous immigrants from the same country already live.

We find that native-born workers in those European subregions with a higher share of immigrants are significantly less likely to be exposed to various dimensions of occupational vulnerability associated with COVID-19. This association is especially strong when looking at the likelihood of being employed in teleworkable occupations (Figure 3), and the results get stronger once the endogeneity of immigrants’ location choices is taken into account. Immigration thus had a causal impact in reducing the exposure of native workers to some labour markets risks associated with the COVID-19 pandemic.

Figure 3 The relationship between share of immigrants in the working-age population and share of natives employed in jobs amenable to work from home in European regions

Source: Authors’ calculations using the EU Labor Force Survey 2018.
Note: The sample includes NUTS-2 regions from the EU-15 as well as Switzerland and Norway.

We also find heterogeneous effects depending on the characteristics of native workers. The effects of immigration on job safety are stronger for highly (i.e. tertiary) educated native workers, who benefit from the presence of both high-skilled and low-skilled migrants. By contrast, the effects are smaller and statistically insignificant for less (i.e. non-tertiary) educated native workers. We also assess whether these compositional effects on employment of certain types of native workers are accompanied by overall changes in total employment and wages. We find no evidence of wage or employment impacts among native workers, suggesting that the increase in job safety among native workers is driven purely by their reallocation from vulnerable jobs to safer jobs.

In short, we find that immigration to Western Europe reduced the economic exposure of natives to COVID-19 related labour market shocks by pushing them towards occupations that are more amenable to work from home. Our paper thus provides another example of immigrant workers in effect ‘protecting’ native workers by taking on the riskiest jobs during the pandemic.

Source: Immigration and natives’ exposure to COVID-related risks in the EU | VOX, CEPR Policy Portal

The Black Mortality Gap, and a Document Written in 1910

Important history:

Black Americans die at higher rates than white Americans at nearly every age.

In 2019, the most recent year with available mortality data, there were about 62,000 such earlier deaths — or one out of every five African American deaths.

The age group most affected by the inequality was infants. Black babies were more than twice as likely as white babies to die before their first birthday.

The overall mortality disparity has existed for centuries. Racism drives some of the key social determinants of health, like lower levels of income and generational wealth; less access to healthy food, water and public spaces; environmental damage; overpolicing and disproportionate incarceration; and the stresses of prolonged discrimination.

But the health care system also plays a part in this disparity.

Research shows Black Americans receive less and lower-quality care for conditions like cancer, heart problems, pneumonia, pain management, prenatal and maternal health, and overall preventive health. During the pandemic, this racial longevity gap seemed to grow again after narrowing in recent years.

Some clues to why health care is failing African Americans can be found in a document written over 100 years ago: the Flexner Report.

In the early 1900s, the U.S. medical field was in disarray. Churning students through short academic terms with inadequate clinical facilities, medical schools were flooding the field with unqualified doctors — and pocketing the tuition fees. Dangerous quacks and con artists flourished.

Physicians led by the American Medical Association (A.M.A.) were pushing for reform. Abraham Flexner, an educator, was chosen to perform a nationwide survey of the state of medical schools.

He did not like what he saw.

Published in 1910, the Flexner Report blasted the unregulated state of medical education, urging professional standards to produce a force of “fewer and better doctors.”

Flexner recommended raising students’ pre-medical entry requirements and academic terms. Medical schools should partner with hospitals, invest more in faculty and facilities, and adopt Northern city training models. States should bolster regulation. Specialties should expand. Medicine should be based on science.

Source: The Black Mortality Gap, and a Document Written in 1910

Why Racial Inequities Still Persist in Health Care

Likely fewer disparities in Canada given medicare but some commonaliyies:

Two decades ago, only 9 percent of white Americans rated their health as fair or poor. But 14 percent of Hispanic Americans characterized their health in those terms, as did nearly 18 percent of Black Americans.

In recent years, access to care has improved in the wake of the Affordable Care Act, which reduced the number of uninsured Americans across all racial and ethnic groups. But the racial health gap has remained, according to a series of studies published on Tuesday in the journal JAMA.

A dismal picture of persistent health disparities in America was described in an issue devoted entirely to inequities in medicine. The wide-ranging issue included research on spending and patterns of care, comparative rates of gestational diabetes and the proportion of Black physicians at medical schools.

The journal’s editors committed to a sharper focus on racism in medicine after a controversy in June, in which a staff member seemed to suggest that racism was not a problem in health care. The ensuing criticism led to the resignation of the top editor and culminated with a pledge to increase staff diversity and publish a more inclusive array of papers.

“The topics of racial and ethnic disparities and inequities in medicine and health care are of critical importance,” Dr. Phil B. Fontanarosa, interim editor in chief of JAMA, said in a statement. He noted that JAMA has published more than 850 articles on racial and ethnic disparities and inequities in the past.

The new issue offers studies on disparities in the utilization of health care services and in overall health spending. Together, the findings paint a portrait of a nation still plagued by medical haves and have-nots whose ability to benefit from scientific advances varies by race and ethnicity, despite the fact that the A.C.A. greatly expanded insurance.

The racial health gap did not significantly narrow from 1999 to 2018, according to one study whose author said it was tantamount to “a comprehensive national report card.”

“We’re failing,” added Dr. Harlan Krumholz, the study’s senior author.

“If our national goals are to improve the population’s health and promote more health equity, then we have to admit that whatever we’re doing now is not doing the trick,” he said. “This should wake us up, and spark us to think of new and better approaches.”

Other studies in the journal teased apart factors that may be contributing to the gap, including different patterns of care-seeking. White Americans, for example, are more likely than members of minority groups to visit primary care physicians and specialists in the community, rather than a hospital or emergency room.

Source: Why Racial Inequities Still Persist in Health Care

Why doctors want Canada to collect better data on Black maternal health

Need this for many groups:

A growing body of data about the heightened risks faced by Black women in the U.K. and U.S. during pregnancy has highlighted the failings of Canada’s colour-blind approach to health care, according to Black health professionals and patients.

Black women in the U.K. and U.S. are four times more likely to die in pregnancy or childbirth than white women, according to official data. A recent U.K. study published in The Lancet found that Black women’s risk of miscarriage is 40 per cent higher than white women’s. In Canada, that level of demographic tracking isn’t available.

“For our country, we don’t have that data. So it’s difficult to know exactly what we’re dealing with,” said Dr. Modupe Tunde-Byass, a Toronto obstetrician-gynecologist, and president of Black Physicians of Canada. “We can only extrapolate from other countries.”

Source: Why doctors want Canada to collect better data on Black maternal health

New data provides a rare glimpse at ‘substantial’ Black overrepresentation in Ontario’s jails

Of interest:

Nearly one out of every 15 young Black men in Ontario experienced jail time, compared to one out of about every 70 young white men, and incarcerated Black people were more likely to live in low-income neighbourhoods, a new study of hard to come by race-based inmate data shows.

Using a snapshot of every Ontario inmate released in 2010, self-reported race data, home address data and 2006 census demographics, researchers from the University of Toronto, Ryerson University, McMaster University, St. Michael’s Hospital and ICES, a non-profit clinical research institute, have provided a rare glimpse at “substantial” Black overrepresentation in jails.

“The key thing here is really just the extent to which young Black men experience incarceration in Ontario,” said lead author Akwasi Owusu-Bempah. “It’s hugely troubling, especially in light of what we know about the consequences of criminalization, of incarceration for their futures and the futures of their families and their communities. We know what it does. Incarceration derails lives.”

The jail data, provided by the Ontario Ministry of the Solicitor General, held details of 45,956 men and 6,357 women who were released from provincial correctional facilities, which house accused awaiting bail or trial, and offenders sentenced to less than two years.

Overall, 12.8 per cent of men identified as Black and had an incarceration rate of 4,109 per 100,000; 58.3 per cent identified as white, for an incarceration rate of 771 per 100,000, and 28.9 per cent as “other,” for a rate of 1,507 per 100,000.

“Other” includes Indigenous, another group vastly overrepresented in jails and federal prisons but not the focus of this study.

For women, the rates were much smaller for all groups but, overall, Black women were incarcerated at a rate of 259 per 100,000, white women had a rate of 96 per 100,000 and the rate for “other” was 248 per 100,000.

Young men between the ages of 18 and 34 had the highest rates of incarceration in all groups, but young Black men had rates ranging around 7,000 per 100,000, compared to about 1,400 per 100,000 for younger white men.

Neighbourhood demographic data gleaned from the forward sortation area of postal codes showed Black men and women were more likely to come from low-income areas of the province. Black men spent more days incarcerated than white men and had higher rates of being transferred to a federal prison.

“This study demonstrates that incarceration is heavily concentrated among young Black men who come from economically marginalized neighbourhoods,” concluded Owusu-Bempah, an assistant sociology professor at U of T, and co-authors Maria Jung, an assistant criminology professor at Ryerson, Firdaous Sbai, a doctoral sociology student at U of T, Andrew S. Wilton, an ICES researcher, and Fiona Kouyoumdjian, an assistant professor in McMaster’s department of family medicine.

At the root of the higher rates are “historical and contemporary social circumstances of Black people in Canada,” note the researchers. These include 200-plus years of slavery and anti-Black racism, and disparities in many systems, including education, employment, child protection and justice.

Black people experience higher rates of child apprehensions and school suspensions and expulsions, and are more heavily policed, the authors said in highlighting disparities found in numerous studies, and also groundbreaking reporting done by the Star around Toronto police arrest and charging patterns and carding, when police stop, question and document citizens in non-criminal encounters.

Lower incomes for Black people have resulted in Black families living in areas that are “underserved by transit, libraries, schools and hospitals,” and those neighbourhoods tend to have higher levels of crime and crime victims, and concentrated law enforcement, the paper notes, citing academic work done by David Hulchanski on Toronto.

In the United States, the “American experience” with race and incarceration “shows us that concentrated incarceration has negative consequences at the individual, family and community levels, including social problems relating to poverty, mental health, education, employment and civic involvement,” the researchers wrote.

That ends up distorting “social norms, leads to the breakdown of informal social control, and undermines the building blocks of social order which are essential for community safety,” the paper concludes.

The often claimed but false trope that Canada is better on race and racism than the United States is also examined at the outset of the paper, which is published in the journal Race and Justice.

While not directly comparable, the authors later note that 2016 data from the U.S. Bureau of Justice Statistics showed Black men were jailed in state and federal institutions each day at a rate of 2,417 per 100,000. In the Ontario study, the annual incarceration rate in 2010 for Black men was 4,109 per 100,000.

That, the authors wrote, helps to “contextualize the extent of Black over-incarceration in Ontario.”

Owusu-Bempah, in an interview, said that “when we think about mass incarceration and we think about this kind of concentrated incarceration as an American phenomenon, I think we can see very clearly here that the levels of overrepresentation that we see in the United States is here in Canada.”

The age of the Ontario data — now over a decade old — speaks to how rare it is to come across race-based Canadian data, the researchers noted in an emailed response to Star questions.

“While these data are from 10 years ago, our ongoing involvement in the criminal justice system indicates that the overrepresentation of Black people persists today,” said the research team. “We think that monitoring and publicly reporting on the overrepresentation of Black people on an ongoing basis is important.”

In order to examine Ontario jail demographics, the researchers used gender and birthdates to link the provincial jail data to health administrative data held by ICES that was used in a 2018 study that looked at use of health care during incarceration and following release from jail. That study found the access rates of all types of health care were significantly higher for incarcerated people.

There is also a huge financial cost involved in jailing people. The Star has twice used inmate postal code data, length of incarceration data and daily cost of housing an inmate to show that in some Toronto city blocks, tens of millions of dollars are being spent to jail their citizens.

Preventing and reducing incarceration could free up money that could be reinvested in those neighbourhoods.

The authors of this report are part of a growing chorus of researchers, academics and advocates calling for more racially disaggregated justice data in Canada, which lags behind the U.S. and U.K.

More data around Canadian incarceration populations in provincial and territorial jails that identifies areas and groups experiencing high levels of incarceration, the paper concludes, “will help inform targeted initiatives to prevent criminal justice involvement” and “mitigate” the impacts on people and communities.

Source: New data provides a rare glimpse at ‘substantial’ Black overrepresentation in Ontario’s jails