TORONTO — In Canada, many medical students aren’t taught specifically how best to treat Black patients and how to keep anti-Black racism out of health care — with patients suffering the consequences.
Now, a collaboration of prominent Canadian Black health researchers are coming together to change that, aiming to create the first health primer of its kind to educate health care providers and ultimately improve care for Black Canadians.
“I think this is a really unique time in history, where there is much greater mainstream awareness and desire to change when it comes to addressing anti-Black racism,” Dr. Onye Nnorom told CTVNews.ca in a phone interview.
“And in my work with medical students, even right now they are so keen and enthusiastic to learn about anti-Black racism and how they can help to address it and treat their own patients with dignity and think about health care in a different light.”
Nnorom, an assistant professor and associate program director of the Public Health and Preventive Medicine Residency Program at the Dalla Lana School of Public Health at University of Toronto, is one of the founders of the Black Health Education Collaborative (BHEC).
The Black Health Education Collaborative (BHEC) has been in the works for a while, but with the announcement of an executive director this August, the collaborative is officially taking off after the pandemic both stalled its progress and exposed why its work is essential.
“The three areas we want to talk about [are]: anti-Black racism and how it impacts health; how it also impacts the quality of care that Black people receive when they’re in health care; and then thirdly, really amplify community voices, solutions, and approaches to improve the quality of health care that Black people and a number of different members of our society receive,” Nnorom said.
The primer itself, as well as modules to educate medical students, are expected to arrive next year.
HOW THE COLLABORATIVE BEGAN
The need for more attention on Black health has existed long before the pandemic revealed the inequities in our health-care system.
Nnorom took on the role of the Black Health Team Lead for the faculty of medicine at the University of Toronto in 2016, a role where she was tasked with providing educational material regarding anti-Black racism and its affect on patients.
She said it became clear that in Canada, when it comes to health curricula for care providers such as nurses and medical students, either data on the Black population wasn’t included in lessons, or curricula used American data.
“So even though we’re the third largest, quote unquote, visible minority group in Canada, either there was nothing about us in the materials or it was often the wrong information,” she said.
Although the problem was obvious, the solution wasn’t so easy to come to.
“There isn’t a textbook or an online resource that really speaks to Black population health in a Canadian context and the social factors that impact Black community health and all of the other intersecting factors like culture, and also the lack of race-based data,” she said.
Nnorom spoke about the issue with Dr. OmiSoore Dryden, the James R. Johnson Chair in Black Canadian Studies at Dalhousie University, and the two decided to bring together a group of Black scholars, health experts and researchers in order to address the issue by producing education materials.
In 2019, they were just beginning to shape modules and increase awareness, doing projects such as providing webinars for leaders in health care. And then the pandemic hit.
COVID-19 not only paused their work. It shifted the focus.
During 2020, the ways that COVID-19 was disproportionately affecting Black and racialized Canadians came to the forefront. And that summer, a racial reckoning surged across North America following the murder of George Floyd, a Black man, by a white police officer in the U.S.
Nnorom said that while the issue of anti-Black racism in Canada has been starkly clear for a long time — the United Nations even put out a report in 2017 calling on Canada to address anti-Black racism stemming from the country’s history of slavery — 2020 made those who weren’t paying attention before finally open up their eyes.
“I think the fact that Toronto Public Health and other public health organizations, when they declared anti-Black racism a public health crisis last summer, also helped to create awareness in health care,” she said.
“So now we were faced with a situation where we no longer had to explain what anti-Black racism was to our colleagues in health care, [and] there was a greater awareness that this was a problem.”
So the BHEC decided to think bigger.
“We actually expanded our vision to not only provide modules and online resources for medical students and other health professional students, but also to the faculties, so people who are educators who would be teaching that content, and people actually working in the field right now,” Nnorom said.
The pandemic also showed the benefit of collecting race-based data, something Nnorom said Canada doesn’t do enough when it comes to health care.
“With the COVID-19 pandemic, the advocacy that was done to collect race-based data, when it came to COVID-19 infections, by the time we got to August of 2020, we realized in Toronto that 89 per cent of the COVID-19 cases in Toronto were Black and racialized people,” Nnorom pointed out.
“And so that allowed for recognizing the numerous social factors and vulnerabilities that Black and racialized people were facing and it became possible to advocate for resources and for change because realizing these were system issues.”
If we don’t collect this type of data in other areas of health care, it becomes hard to find disparities and advocate for more support.
HOW LACK OF EDUCATION ON ANTI-BLACK RACISM HURTS HEALTH CARE
Nnorom explained that there are a number of consequences for patients when health-care providers are not properly educated about anti-Black racism and Black health.
Care providers might have implicit biases, which is when they apply stereotypes to their work without even realizing it consciously.
“A lot of the stereotypes about us stem from the legacy of slavery here in Canada and across North America. So these myths about our pain threshold, for instance, like that we have a different pain threshold or thicker skin means that you see a lot of Black patients being undertreated for pain,” Nnorom said.
Other negative stereotypes she’s seen applied are that Black patients are “not to be trusted” or are less intelligent, all which could lead to health-care providers not believing patients who are describing their lived experiences.
“All of these can affect the kind of care somebody receives,” she said. “The other way that it can also play out is health-care providers might not realize all of the different ways in which racism impacts Black people’s lived experience.”
This could mean health-care providers not understanding the daily stress of racism, or minimizing mental-health struggles that may arise from it, leading to them being unable to relate fully to the patient and understand how these factors impact physical and mental health.
The third way that anti-Black racism permeates the health-care system is through explicit bias, Nnorom explained.
“Sometimes people will make outright assumptions about where a patient might come from or their culture, or assumptions about their beliefs just based on the colour of their skin. And those types of explicit biases can then impact the therapeutic relationship because it impacts trust, right?”
She gave the example of a young Black man in a hoodie going to a doctor’s appointment and telling the physician he is a law student, only for the doctor to react with visible surprise.
“For that young Black person who constantly experiences being carded or not believed and has done all this hard work to go to law school, now that has severed the trust between that patient and that provider,” she said.
She hopes that by providing more education to health care providers and practitioners, they will be more aware of their biases and more aware of the lived experiences of the different patients they may encounter.
Another goal is to inspire institutions to implement policies and regulations regarding anti-Black racism in their workplaces to keep track of it and stamp it out, such as monitoring whether Black patients are left waiting in the waiting room longer than other patients, and having consequences for care providers who use anti-Black rhetoric.
The project isn’t just about teaching about the damage anti-Black racism causes, and where improvements can be made.
A big part of the wider project, Nnorom said, is to also amplify solutions that the community has put forward.
“There are a number of people who have lived experience who can speak to alternative approaches to being able to actually treat all patients with dignity,” she said.
“Black community members who have been advocating for so long, but not been heard in health care with regards to the mistreatment.”
As an example, she explained that at a community health centre that she used to work at, she learned of a South African philosophy called ubuntu, which means recognizing the humanity in everyone.
“This was suggested by the community and became a way that we approached how we provided health care,” she said.
This is a philosophy that has been helpful in her work trying to do community outreach about the COVID-19 vaccines. She explained that there is a greater distrust of the vaccine in Black communities, stemming from how the community has been historically mistreated in the health-care system.
“We apply that philosophy of ubuntu, of really seeing people’s humanity and recognizing them and dignity so that people will come to us and ask about the COVID-19 vaccine,” Nnorom said. “And they may not decide to get it right away, or they may decide to get it, but we really try to connect with them on a very human and respectful level.”
Learning about the history of anti-Black racism in Canada and how it still persists today will help care providers know how better to address issues like vaccine hesitancy, she explained.
“The distrust that you see with Black, Indigenous, and other racialized communities with regards to acceptance of the vaccine has made it very clear that in health care, there is much work to be done to earn the trust of Black communities. And so for the Black Health Education Collaborative, we are really keen to be part of that work.”
When the primer is completed, it will be available online along with a suite of online resources, but its main target is medical classrooms from coast to coast.
“We are in conversations with a number of medical educational organizations that are involved in testing students or qualification exams and that type of thing,” Nnorom said. “So we’re hoping that the work that we do will be incorporated into the learning objectives across the country for the students.”
As this primer will be the first of its kind in Canada, the collaborative are hoping that it will have a real impact in improving patient care for Black Canadians.
The road has been long, but the health care world seems ready to learn.
“I think that is what gives me the greatest hope. It’s not just that we’re going to be providing educational resources, but it’s the fact that there is such a great welcoming for this type of information,” Nnorom said. “There’s a genuine desire for it across health care.”