Beyond Resilience: Addressing Racism as a Syndemic Driver of Adverse Indigenous Health

Outcomes HIV Endgame, November 21st, 2016

Janet Smylie MD FCFP MPHDirector, Well Living House Action Research Centre, St. Michael’s Hospital, Toronto;

Associate Professor, Dalla Lana School of Public Health, University of TorontoCIHR Applied Public Health Research Chair in Indigenous Health Knowledge and Information

The Well Living House is an action research centre that’s focused on Indigenous infant, child and family health and well-being. Our long term vision is that every Indigenous infant will be born into a context that promotes health and wellbeing – at the individual, family and community levels

Today’s Presentation

• Beyond Resilience

• Relevant Calls to Action - Truth and Reconciliation Commission

• Racism as a syndemic driver of Indigenous health inequities

• Knowledge and practice informed approaches to planning and evaluating cultural safety training

Visioning Indigenous Success

Community Vision For Kahnawake

"All Kahnawakero:non are in excellent health. Diabetes no longer exists. All the childrenand adults eat healthily at all meals and are physically active daily. The children areactively supported by their parents and family who provide nutritious foods obtainablefrom family gardens, local food distributors and the natural environment. The schools aswell as community organizations, maintain programs and policy that reflect andreinforce healthy eating habits and daily physical activity. There are a variety of physicalactivities for all people offered at a wide range of recreational facilities in thecommunity. All people accept the responsibility to cooperatively maintain a wellcommunity for the future Seven Generations."

Aboriginal Strategy on HIV/AIDSVision

Aboriginal Peoples will enjoy wholistic lives unified in action to eliminate the risk of HIV infection and the negative effects of HIV for all Aboriginal People living with and affected by HIV/AIDS.

Indigenous/non-Indigenous Health Inequities in Canada –

Why do they persist?

peer reviewed studies have revealed IMR rates that are 190% higher for First Nations compared to non-First Nations3 and 360% higher for Inuit inhabited areas compared to non-Inuit inhabited areas4

Smylie, Lancet: 2013

Indigenous/non-Indigenous Health Inequities in Canada –

Why do they persist?• The prevalence of HIV/AIDs among Aboriginal

people in 2011 was 2.6 times that of the general Canadian population (PHAC)

• The HIV incidence rate in the same year was 3.5 times that of other ethnicities (PHAC)

• Race/ethnicity was only reported on 38% of surveillance reporting forms –misclassification almost always results in an underestimate of Indigenous health disparities

After adjustment for discrimination and deprivation, odds ratios (95%

CI) comparing Māori and European ethnic groups were reduced:

1·67 (1·35–2·08) to 1·18 (0·92–1·50) for poor or fair self-rated health

1·70 (1·42–2·02) to 1·21 (1·00–1·47) for low physical functioning, 1·30

(1·11–1·54) to 1·02 (0·85–1·22) for low mental health, and 1·46 (1·12–

1·91) to 1·11 (0·82–1·51) for cardiovascular disease.

Effects of self-reported racial discrimination and deprivation

on Māori health and inequalities in New Zealand:

cross-sectional study

Ricci Harris, MBChB Dr Martin Tobias, FRACP Mona Jeffreys, PhD Kiri Waldegrave, PGDipPsych Saffron Karlsen, PhD

Prof James Nazroo, PhD

The Lancet, 2006. 367(9527):2005-2009

Colonization as an underlying determinant of health

“Everyone agrees that there is one critical determinant of health, the effect of colonization”

International Symposium on the Social Determinants of Indigenous Health. Social determinants and Indigenous health: The International experience and its policy implications. In: Report on specially prepared document, presentations and discussion at the International Symposium on the Social Determinants of Indigenous Health. Adelaide, Australia: Available at http://www.who.int/social_determinants/resources/indigenous_health_adelaide_report_07.pdf. Accessed June 6, 2008.

TRC report provides a succinct and clear factual history and human narrative of cultural genocide in Canada – make time to read it and encourage others to read it

TRC Calls to Action

• Seven related to health– Make the links between current Indigenous health

disparities and Canadian governmental policies– Establish measureable goals and close the gap in health

outcomes– Recognize and address distinct health needs of Inuit, Métis and

off-reserve Aboriginal people– Fund Aboriginal healing centres to address the physical, mental,

emotional and spiritual harms caused by residential schools– Recognize and use Aboriginal healing practices– Increase and retain Aboriginal health professionals; ensure all

health professionals have cultural competency training– Coursework and training in all medical and nursing schools

Understanding

and Addressing

Root Causes:

Racism

Differential Access to Quality Health Care

• The Institute of Medicine (US) reviewed over 100 studies that assessed the quality of healthcare for various racial and ethnic minority groups,

• Studies controlled for health insurance, income, racial differences in the severity or stage of disease progression, co-morbid illnesses, age, and gender

• Striking consistency of finding that ethnic/racial minorities are less likely than whites to receive needed services, including clinically necessary procedures

• Disparities found across disease areas, including cancer, cardiovascular disease, HIV/AIDS, diabetes, and mental illness, and across a range of procedures, including routine treatments for common health problems

What is at the Root of this Differential Health Care Treatment?

• Differences in effectiveness of interventions across populations and/or differences in patient preferences?– disparities shown in interventions that are

equally effective across racial and ethnic groups and patient preferences don’t differ so much – especially with ER treatment

• Differences in Health Systems/Environments– Ie availability of interpreters, systemic issues

• Discrimination: Biases, Stereotyping, and Uncertainty

Differential Access to Quality Health Care

• For Indigenous populations there is domestic and international evidence that Indigenous patients are less likely to get life-saving acute interventions for cardiovascular disease – ie. angiography and coronary artery bypass surgery

• For example a recent study in Canada showed that First Nations patients in Alberta were 27% less likely to receive coronary angiography within the first 24 hours of acute MI compared to non-Frist Nations patients. First Nations patients were also found to have higher mortality rates.

Racism Impacts Health and Health Care Access

• Annette Brown’s study of people accessing the ER in a large urban centre found that Aboriginal patients anticipated that they would experience stereotyping and discrimination based on being Aboriginal in advance of going to the ER and worked on anticipatory strategies to manage this.

“they have an attitude, especially the admitting clerks….i don’t know…maybe because I’m a drug addict, maybe because I’m native – today they’re nice – but I avoid coming here in a big way”

Defining Racism

“avoidable and unfair actions that further disadvantage the disadvantaged or further advantage the advantaged”

Paradies, Y., Harris, R. & Anderson, I. (2008). The impact of racism on Indigenous health in Australia and Aotearoa: Towards a research agenda (Discussion Paper No. 4). Darwin, Australia: Cooperative Research Centre for Aboriginal Health.

Defining Racism• Systemic Racism is enacted through societal

systems, structures and institutions in the form of “requirements, conditions, practices, policies or processes that maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups

• For Indigenous people, racism is linked to colonization - as it required at its core, racist beliefs about and practices towards Indigenous peoples.

Defining Racism• Attitudinal or Interpersonal Racism includes

discriminatory treatment in employment or educational settings or in relational contact that occurs in day-to-day interactions

• It may range from being ignored, to poor treatment, to more overt and severe forms such as name-calling and physical or sexual violence (Reading)

• It includes intentional/unintentional and explicit/implicit assumptions and behaviours

Epistemic Racism:“The Problem with Universities”

• The positioning of the knowledge of one racialized group as superior to another

• Includes a judgment of not only which knowledge is considered valuable but is considered to be knowledge.

• For Indigenous peoples the imposition of western knowledge systems and particularly the use of western “science” to demonstrate the supposed inferiority of Indigenous peoples and Indigenous ways of knowing constitute acts of epistemic racism (Reading, 2013).

Negative Images and Stereotyping of Aboriginal People

Implicit Association Testing

The majority of people hold implicit associations regarding race

• Majority of Americans participating in the Harvard IAT associate White with Good and Black with Bad compared to vice versa

• American physicians from diverse racial and ethnic backgrounds overall have a strong implicit preference for White American patients compared to Black American patients and these implicit preferences are much higher than explicit preferences as measured by self-reported attitudes.

Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Green et al.

J Gen Intern Med. 2007 Sep; 22(9): 1231–1238.

• Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness.

• In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001).

• As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009).

Hypothesis

• Unintentional, implicit racist assumptions and behaviours are the most common and most harmful/life threatening in the health service setting

TRC Calls to Action• Seven related to health

– Make the links between current Indigenous health disparities and Canadian governmental policies

– Establish measureable goals and close the gap in health outcomes

– Recognize and address distinct health needs of Inuit, Métis and off-reserve Aboriginal people

– Fund Aboriginal healing centres to address the physical, mental, emotional and spiritual harms caused by residential schools

– Recognize and use Aboriginal healing practices– Increase and retain Aboriginal health professionals; ensure

all health professionals have cultural competency training

– Coursework and training in all medical and nursing schools

Cultural Safety• Advancing relationships across difference through the

skill of self-reflection.

• Self-reflection in this case is underpinned by an understanding of power differentials.

Cultural Safety

Cultural safety takes us beyond:– Cultural awareness, the acknowledgement of

difference;– Cultural sensitivity, the recognition of the

importance of respecting difference, and– Cultural competence, which focuses on the

skills, knowledge, and attitudes of practitioners.

Taking Action – Critical Thinking and Reflexivity

P.G. Devine et al. / Journal of Experimental Social Psychology 48 (2012) 1267–1278

Training Development and Testing at St. Michael’s Hospital• Supported as part of the strategic plan for

health care professional education in the hospital

• Indigenous race preference IAT under-development and to be piloted later this year

• 3 arm randomized trial in the planning phase with 2017 scheduled start date

• Study will include assessment of system level factors

So What? (Evaluation)

• At the health and social provider level what we want is for Indigenous clients to be offered high quality care

• To feel comfortable, respected and able to be themselves in the interaction and setting

• To receive benchmark treatments/services

Today’s Presentation

• Beyond Resilience

• Relevant Calls to Action - Truth and Reconciliation Commission

• Racism as a syndemic driver of Indigenous health inequities

• Knowledge and practice informed approaches to planning and evaluating cultural safety training

Take aways• 4 actions

– Read the report if you haven’t already– Take an Indigenous cultural safety training

course that applies a critical, self-reflexive approach

– Begin to integrate “habit-breaking” and/or self-reflexive activities into your day to life and work

– Build Indigenous-led partnerships with Indigenous peoples and organizations to implement systemic level change

Taking Action

• www.welllivinghouse.com• http://www.trc.ca/websites/trcinstitution/ind

ex.php?p=3• www.sanyas.ca• http://walkingwithoursisters.ca/

Questions and Comments?