#90 Anti-Black Racism in Healthcare

Dr. Sean Wharton, Medical Director of the Wharton Medical Clinic, Adjunct Professor at McMaster University and York University, Staff Internist at Juravinski Hospital, and founder of the Black Medical Students' Association

February 10, 2021

Like so many institutions, anti-Black racism continues to pervade the healthcare system—rarely in overt, obvious ways, but in ways that undeniably lead to worse health outcomes for Black communities. In this episode, we discuss the uncomfortable truths of anti-Black racism in healthcare, and what we can do about it. We hear from Dr. Sean Wharton, Medical Director of the Wharton Medical Clinic, Internist, and Adjunct Professor at McMaster University and York University, about his experiences in the healthcare system, as a trainee, physician, and researcher. He discusses the roots of racist systems, and the impacts of subconscious biases on both the provision and receipt of patient care. As the founder of the Black Medical Students’ Association, he describes how the unique needs of different trainee and patient populations must be recognized and addressed if we hope to provide equitable care. We also spoke with Jessica Goncalves, a nursing student and the first Black President of the Nursing Undergraduate Society at the University of Toronto. She tells us about the labelling that begins long before members of the Black community enter health professions, and the importance of diverse representation within such professions. We hope that you are inspired—as we are—by our guests, to continue conversations, advocacy, and actions in the pursuit of health equity.

Written by: Rachel Dadouch

Dr. Wharton - Wharton Medical Clinic
Dr. Wharton - Feature UofT Temerty Faculty of Medicine
Dr. Wharton - Inaugural Lecture in Black Health for City-Wide Medical Grand Rounds
Jessica Gonclaves - President of the Nursing Undergraduate Society
Resource - The Implicit Project
Article - The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization
Resource - Anti-Racism Resources
Article - For our White Friends Desiring to be Allies
Book - So You Want to Talk About Race by Ijeoma Oluo
Book - How to be an Antiracist by Ibram X. Kendi
Book - Black and Blue: The Origins and Consequences of Medical Racism by John Hoberman
Event - Black Physicians Association of Ontario Annual Health Symposium (Feb 27, 2021)
Organization - Black Physicians of Canada
Organization - U of T Black Medical Students Association

Colleen Farrell [0:00] Many people see healthcare as a space for healing, a place of humanity, where people seek care and receive it. Healthcare has lived up to these ideals for some, but for some individuals and communities, healthcare has been a place of exclusion, inequity and even distress. From the origins of healthcare, to the society we're in today, the health field is yet another system permeated by racism. Research shows that 50% of White medical students have false beliefs about the human biology of Black people. At the staff level, Black healthcare providers are underrepresented in our systems. At the patient level, health outcomes for Black patients are often poorer than those for non-racialized people. How do we begin to explain these sobering facts? What are the systems that brought us here? And where do we begin to improve them?

Adrine de Souza [0:50] In today's episode, we are discussing anti-Black racism in healthcare. We touch upon the history that has shaped our current health systems, the challenges that Black healthcare trainees and providers face within the Canadian medical system, and how we can begin to dismantle inherent racism.

Colleen Farrell [1:11] I'm Colleen,

Nathan Chan [1:12] I'm Nathan,

Adrine de Souza [1:12] and I'm Adrine. Welcome to Episode 90 of Raw Talk podcast.

Nathan Chan [1:17] Before we begin, we'd like to acknowledge that Toronto was founded on the traditional territories of many Indigenous nations, including the Mississaugas, the Anishinaabe, the Chippewa, the Haudenosaunee, and the Huron-Wendat. This meeting place is still home to many First Nations, Inuit and Métis peoples. And we're grateful for the opportunity to work and live on this land. As we explore the topic of anti-Black racism in medicine, we ask our listeners to reflect upon the intersections and differences between anti-Black and anti-Indigenous racism in healthcare, including historical roots, systems that maintain imbalances of opportunity and privilege, and our own subconscious biases.

Adrine de Souza [2:11] The topic of anti-Black racism in healthcare is urgent and important. Here at Raw Talk, we acknowledge that this episode is a piece of our broader ongoing efforts to understand racism and address it. We are incredibly grateful to all the tireless voices who have been fighting systems of inequality and injustice for decades and even lifetimes. For our team members and listeners, we hope this episode inspires dialogue and actions that don't end here. In our shownotes, we've collected articles and resources that we've found helpful for our learning and unlearning.

Sean Wharton [2:51] People oftentimes say that I'm Canadian, there's no racism in Canada, and I'm not racist myself, so I don't see what the major issue is. What we know is that there can be zero racists in a system and the system is still a racist system. Just by letting the system be, allows the continued systemic racism to actually happen. It continues to let the racism happen if you don't make a change.

Colleen Farrell [3:22] You just heard from our esteemed guest, Dr. Sean Wharton, a medical doctor and researcher who founded the Black Medical Students' Association, two decades ago at the Temerty Faculty of Medicine at the University of Toronto. But before we move forward, a brief introduction from the doctor himself.

Sean Wharton [3:38] I'm Dr. Sean Wharton, I'm an internal medicine doctor. I am a specialist, but a general internal medicine specialist. I work at Juravinski Hospital at McMaster. I'm an adjunct professor and academic staff at Women's College Hospital. I'm also the medical director of the Wharton Medical Clinic. We are an obesity and diabetes clinic in the southern Ontario area.

Colleen Farrell [4:03] Back to systemic racism, a term that many of us have heard, but not all of us may be comfortable defining for ourselves. We asked Dr. Wharton to help shed some light.

Sean Wharton [4:12] Well, I like looking at it as racism first. Racism is prejudice against any one group because of their race and having discrimination against them because of their race. And when we think of that, we think of the overt racism. I don't like the colour of your skin, so I'm going to push you aside as I walk down the street. I'm not going to be nice to you. Overt racism doesn't happen as often as it used to, it was okay back 50 years ago, it doesn't happen as often. Overt racism was easy for us to understand and to see. That's why Martin Luther King had the Selma March and because if you could walk down the street and have the police beat you and have it on film, overt racism was clear that this is not okay. But that's not the biggest racism. The biggest racism is systemic racism. Systemic racism is defined as when you decide that oh, well, we can't do overt racism, we have to ensure that all the power structures that we have are to put others down so that we can be built up. Racism should be more clearly defined as prejudice against a group because of their race, when there are systems of power that reinforce these ideals. Systems of power that reinforce these ideals are everywhere. They come from the people who choose who becomes educated, they come from the systems that help to decide what type of nutrition goes to one area versus another area. It looks at the banking structure, who gets the bank loans versus who doesn't get the bank loans, which farmers get it, at what time do they get it. If the farmer gets his bank loan earlier, so that they can make sure the crops are doing well and that's a White group versus the Black farmers, you're going to get yours eventually. That is a system of power, and that system of power keeps a group down to ensure that there is more for the other group. The only way to have more for another group is to have one group down, and the other group up. Everybody thinks we can all go up together. That's not true. To be able to have that level of wealth and power, you have to subjugate another group.

Colleen Farrell [6:33] Systemic racism and racism directed towards Black individuals and communities, that is anti-Black racism or anti-Blackness, is inextricably tied to a history and legacy of discrimination, marginalization, injustice, and violence.

Nathan Chan [6:47] We have this legacy of racial discrimination in healthcare systems, and it's widespread. We know it's linked to things like low trust, especially towards healthcare providers, and towards medical institutions themselves. Can you give us a little bit of an overview of how that racism has manifested in healthcare?

Sean Wharton [7:02] Right. That's, of course, a big question. So the question where we start is probably one of the more important parts because the underpinnings to systemic racism within medicine starts from slavery. Starts possibly even before slavery, but really starts there. Particularly, if we look in the North American and the West Indian, where the slave nations actually were for the longest. And if, to some degree, we want to say that slavery still exists in America, meaning that intensities of the racial discrimination is so intense in America that you wonder whether slavery ever ended in a proper fashion, that is what underpins the majority of the systemic racism within our world. Wherever there is anti-Black racism, it's throughout the entire world. A lot of it is due to the background of slavery and the continued challenges that people who are descendants of a slave nation end up having. That's a starting point. And that starting point leads us to the challenges that Black people have had with getting proper nutrition status, getting healthy enough to be able to do what they're supposed to do, particularly after they became free by having a healthy free Black individual was not as beneficial as having a healthy Black slave, but made it much more difficult to to try to get the right type of food. When nutrition became a problem for a long, long time, and continues to be a problem, particularly when black people have been brought up on poor food choices. But that's all they've been eating for a couple 100 years. Therefore, that's what their palate is most accustomed to. If we try and introduce in the southern states, very healthy vegetable food options, it doesn't work out very well for a group of people who've been eating the same unhealthy food for a long time. Then we go into the entire system of healthcare, and then how healthcare has manifested in a systemic racism environment. Because, of course, doctors are not immune to racial inequality. There's so much that happens within the anti-Black racism in the world that also affects doctors and healthcare providers and hospital systems that manifest racism within a very similar manner.

Nathan Chan [9:30] Absolutely, it's so important that I think we ground this discussion in that history because without that history, I think we're bound to repeat the past. Right?

Sean Wharton [9:39] Exactly right. We need to know that history, it helps us to understand it.

Nathan Chan [9:43] Totally, I guess, so how does that kind of history translate into the actual health of Black and Indigenous peoples today? What does that inequitable access look like in the current healthcare system?

Sean Wharton [9:54] Starting with the fact that there are unconscious biases. So the unconscious bias is important, because if somebody states that the healthcare in Canada is free, you walk into an emergency department and you get treated accordingly. I don't see where the challenge is, why would one person get treated differently from a another person? Well, we know that this is absolutely true that different people get treated differently for the same medical conditions. It's because of implicit or unconscious bias. For instance, if you have a White male coming into the emergency department with crushing chest pain, sweating, and the feeling of impending doom, which signals a heart attack, the likelihood of getting a cardiac catheterization is very, very high. And that happening quickly is also very high. If we look at a Black female, coming in to the emergency department, exact same symptoms, exact same words, and the study has been done, the chances of cardiac catheterization are 0.4, compared to the White male. Chance of having it much, much later is higher. The question is why? What happened? It's the same emergency department, they both have health insurance, what's going on? It's from the person at the front desk, the triage person, all the way to the cardiologist who's doing the cardiac catheterization all have unconscious biases, because we live in a world that's full of racism. And as a result, if they have to make a choice, if there's a White male and there's a Black female, and they've got to choose which am I going to do the cardiac catheterization for, we know who they are going to choose. They don't even know. We can try and ask them and say, do you think that you have racial tendencies? Absolutely not. Of course, I'm not racial to I see everybody equally. Well, here's a test. Tell me which one you're going to give the cardiac catheterization to? In this scenario of testing, they may not be able to make that decision as easily. You put them in a real scenario, the decision is made unconsciously on a regular basis every single day. That's why we see higher morbidity and mortality in Black people in females and in Black females who are at the bottom of the barrel. In almost every study we've done looking at different medical conditions. You name the condition, I will tell you that the Black females are at the bottom of the barrel in terms of receiving appropriate treatment.

Adrine de Souza [12:21] We also reached out to Jessica Gonsalves, a young Black leader in healthcare, and the President of the Nursing Undergraduate Society at the University of Toronto.

Jessica Goncalves [12:33] I know from my own personal experience, I can speak to several episodes where health care providers don't necessarily take your case at face value. Because there are a lot of underlying assumptions in the profession, that goes for many professions as well. But particularly in health, where it is so critical to someone's life. There are assumptions there is race based medicine, there is the tendency to stereotype and to assume. When you're talking about providing health care to Black patients, or marginalized patients, you can't assume anything. There are differences in how certain health conditions manifest. Being aware of that is really important. Often, those who are in that situation, Black health care providers, they will be a little bit more sensitive to those issues than non-Black members of society might be having health care providers who understand your experience, and who value you as an individual patient is really important to make sure that you're getting the health care that you need, and that they are paying close enough attention to your individual circumstances, rather than assuming before you enter what your condition is or how you will respond or what your behaviors indicate. It's really important to be individualized in their care. And I think that Black health care providers will be more likely to do that when they visit with Black patients.

Adrine de Souza [14:05] Given what we know now about the impacts of anti-Black racism on health outcomes, how did we get to this point? Why hasn't medicine been able to address these issues?

Jessica Goncalves [14:18] That comes from a long standing history of how the health care system and healthcare education were set up. It was set up during a time when there were no healthcare providers who were Black. There were no studies that involved Black people. All of the information that healthcare providers are going on was based on White bodies. But of course, they have no idea what is truth or what is fact when it comes to Black members of society. Though they are going based on assumption then you carry that forward that system that was set up in that way and healthcare education has been passed along generation to generation. So there are very, very many assumptions that are still embedded within healthcare teaching. There is race based medicine where stereotypes and assumptions or directly instructed to healthcare providers. We are working to combat those things. As nursing students, we are picking up on these things. And we are seeing how there needs to be correction. And we are, at least our cohort, is attempting to call to action, our nursing program to say, hey, we need to be better. We need to step forward and make those changes in order to better serve our communities.

Colleen Farrell [15:32] Anti-Black racial disparities and discrimination within healthcare systems go beyond just the treatment of patients. As we heard from Jessica, medical education systems have a history of inherently operating on racist elements, still to this day.

Nathan Chan [15:48] Reflecting back to your time in medical school and residency, what did your formal education teach you about racism in health care? And how did your education address the specific needs and disparities of marginalized communities?

Sean Wharton [16:00] How did my education address the fact that there's anti-Black racism within this systemic culture of medicine and of health care? There was absolutely no mention of it ever. There was zero mention of that challenges that the Indigenous people face. Zero mention of the fact that Black and racialized groups have more of a challenge. Almost no mention of the struggles that women faced, as they throughout their lives in health care, and within getting opportunities for physicians within the healthcare field. That is why many of us felt the need to be able to start an association or organization where we could get together and talk about these things that our professors were not addressing. They shouldn't have not even just been addressing it in every single course, there should have been a course for it. So the fact that they were so far behind addressing something that was so blatant was shocking, and is shocking. I can somewhat understand it. Because if you're in a non-racialized group, and if you're in the majority power group, you walk through life every day, and every day is pretty great. Then why would we change it? Why do we need to talk about, what are the issues? What are the concerns, my day is going very well. In terms of the hurdles, and the burdens and the challenges, there's not nearly as many as a Black female would have to face every day. I somewhat see why there has been a lack of addressing this issue. But, when it's brought to the attention of the people in power, that they should be addressing these systemic racism issues, and they still don't, that's when they're telling you that they don't care. That's when they're turning their implicit or unconscious biases into explicit ones, where they actively don't do what is the right thing. And that was very disappointing for me all the way through my undergraduate in pharmacy, through to my doctorate in pharmacy, and my doctorate in medicine, and then my residency program. All four of those higher-end education systems did not address systemic racism. And it was very disappointing for me.

Nathan Chan [18:24] I don't mean to age you, but I'm wondering how long ago was that?

Sean Wharton [18:28] I started pharmacy in 1988 and finished in '92. I did my doctorate and from '95 to '97, in pharmacy, and then doctorate in medicine from '97 until 2001, and finished my residency in 2005. All the way from 1988 to 2005 I was in school pretty much there was a two year timeframe where I practiced as a pharmacist, otherwise, I was in school. During that timeframe, I was the one that addressed anti-Black racism or racial challenges within medicine, within our education system. I was the one that had to start organizations and groups and look for it. It was never brought to me.

Colleen Farrell [19:12] Dr. Wharton makes it clear that even though anti-Black racism has a history spanning centuries, it wasn't a topic that leaders in mainstream medical education felt was important enough to include anywhere in their teaching materials as recently as a decade and a half ago. We'll hear more about his experience as one of a handful of Black medical students in his cohort. But first...

Nathan Chan [19:33] We've been talking about the fact that there's so few Black medical students in medical schools in Canada. Why don't we have more Black physicians and Canadian health care? What's going on?

Sean Wharton [19:42] Excellent question. We believe what's going on is the overall sense of that there is a systemic racism that begins early. It doesn't just begin when we are looking at how many applicants do we have of Black students for medical school. If there's very few applicants, then there's going to be very few medical students. The medical school can say it isn't our problem, we're doing the best that we can to make sure that the diversity happens. Where the challenge is all the way at the beginning of the education system. So we call it the leaky pipeline. It was a leaky pipeline all along the way. Where from kindergarten through to grade school through to high school, talented Black students are being left behind.

Colleen Farrell [20:26] Dr. Wharton mentions that although Black students make up just 11% of the Toronto District School Board student body, they account for 34% of expulsion in grade school through high school. Other students that commit the exact same infractions are expelled at a rate of just two to four percent. Similar studies in the states also echo these findings.

Sean Wharton [20:46] We have our own stories as a Black male going through the education system, we are very clear that if we do the same things that our White colleagues do, we are in way more trouble. You have to be that much better. We don't get the luxuries, the privilege, to do the things that kids oftentimes do, that are horsing around that are having a good time, but don't require the child to get expelled. And this expulsion doesn't start in high school. It starts in grade school. And in kindergarten, where Black youth Black kindergarten children are expelled, how do you get expelled from kindergarten, more than the non-racialized childre. When it starts with that early that you're being subjugated on a regular basis, it becomes much more challenging for you to believe that the system is there for you. To believe that your intellectual capacity can actually get you to make it to becoming a lawyer, a doctor, a professional because the world is against you. Many people say just pick yourself up by your own bootstraps just be better. It is very challenging. And we see this beautiful and horrible example of this is the Indigenous group. All bright, intelligent, capable people who have been subjugated to such an extent and their willpower and their self esteem has been driven into the ground, but to such a degree that there's a decimation of the Indigenous community. That is a blazon example of the education system and systemic racism failing people. How do we expect to get to the Indigenous doctor, the Indigenous scholar? If we damage them in kindergarten? How do we expect to get the Black male physician, the Black female physician if we let them know that they couldn't make it in grade school? We have to start early, we have to do better, we must do better.

Colleen Farrell [22:49] Jessica made some more comments about the education system.

Adrine de Souza [22:53] What are barriers for people of color and people of racialized communities entering health care professions?

Jessica Goncalves [23:01] It is a complicated situation to say the least. Some of the challenges for entering a healthcare profession for Black students or any marginalized group start way, way before they are even considering entering a secondary education. When you think about the way the education system is set up, there are lots of smaller hurdles and challenges that come before. For example, a lot of discussion has come up, especially this past year around streaming and pigeonholing students into certain levels of difficulty. Black students have been victims of that where they have been told you're not smart enough. Or maybe you should try this, this will be a little less difficult for you. That's something that I know at least in some school boards, they are working on correcting, streaming children based on their race or their ethnicity or their immigrant status. As you go through the education system, you are hearing these messages. Sometimes those messages are more powerful than the messaging that says you can or you will, you will be successful and achieve. It's a very large balancing act for marginalized students who are considering going into any kind of discipline after high school, elementary school and high school for that matter. Being strong enough and being encouraged that you have the capability to achieve in those areas is a starting point. So that's one challenge. Another would be financial barriers, especially with the setup of the Canadian system and our neighbors to the South, finances haven't always been equitable for marginalized communities. When you think about the costs involved in going to post-secondary school as another challenge that we tend to face. Systemic barriers are in place and those are some of the things that we need to start working on. Recognizing that they exist. And I think this past year has done a lot to some of the people involved in those movements have done lots to bring attention to those systemic barriers, so I think that's a great place to start in those changes.

Adrine de Souza [25:18] Jessica also described the importance of feeling represented and welcomed amongst your professional peers and mentors.

Jessica Goncalves [25:24] I spoke about the challenges of meeting the requirements of those programs, not academically, but maybe financially or emotionally or with self esteem. But once, even if you apply, and you are granted entrance into these programs that doesn't necessarily mean it's a safe space for Black or marginalized students. That is another challenge when considering applying to the program. Will I be represented? And will I be welcomed? Will it be a place where they are educating me in a way that will, I suppose, enhance the way I deliver health care? Or, will it be more difficult to practice in those scenarios? In being in the program, it's important to have representation so that, number one, you see yourself in the discipline and you feel comfortable practicing rather than a constant conflict in trying to find your place and feel like you belong. We hold the people who are running the programs accountable to ensure that these programs are set up in a way that teaches and enriches the education so that it serves all communities equitably. Because if there aren't enough bodies who are different in the program, that may not draw out or require the program to offer a diversified curriculum. We want to make sure there are bodies in the program who will hold the administrators and deliverers of the program accountable, and make sure that the program is well versed to serve all communities.

Colleen Farrell [27:04] Recalling that Dr. Wharton's educational experiences didn't even acknowledge racism and its impacts on health outcomes as recently as 15 years ago, we turned to Jessica to gain perspective on whether things have changed by 2021.

Adrine de Souza [27:16] How is racial bias generally perceived by nursing students?

Jessica Goncalves [27:21] We have talked about this a little bit this year in some of our classes, the number one thing we have recognized is that racism in healthcare still exists. It is still prevalent, and we need to do more to eliminate it. There is nothing that will improve if we don't call it out, recognize it, and admit to it and make the corrections that need to be done. Even if that is small things like making sure we have textbooks or information that represents a diverse community. Making sure that those in the profession are doing research, which involves Black bodies. Understanding that each condition may present differently or health presentations are also heavily linked to one's history. The way they've been treated in the healthcare system before and their circumstances outside of their health conditions. It's all tied together. And the more we understand thatand the more that we appreciate it, then the better we are at providing the care that we all set out to in the first place.

Nathan Chan [28:32] Dr. Wharton alluded earlier to like minded students working together to address issues of racism in medical education and healthcare. In fact, he was the founder of the Black Medical Students Association at the University of Toronto's Faculty of Medicine. We asked what motivated him to start this organization.

Sean Wharton [28:48] I did start the Black Medical Students Association. That was in the year 2000. Prior to the year 2000. I'd gone through pharmacy from 1988 to 1992. And I was one Black pharmacy student in a class of 170. That was disappointing for me because I was coming...I did my high school in Sudbury, where there were very few Black people. I thought I was coming to Toronto. I would now I encounter a lot more Black people and get immersed into the culture. And I found myself one out of 170. I thought as I go on in school, maybe there'll be more Black people representative of what my world looks like and the world is in part of Toronto. As I move on, when I got to medical school, I thought now I'm going to see some more Black people. There were three Black people in my class out of 270 students. Again, it was very low and the year below me there was one Black student again out of 270. That really told us this is not changing. There's a systemic problem here and if we don't start some type of organization to address it, it's not going to get any better. The idea of the organization was can we reach out to undergraduate Black students who want to get into medicine but don't have the resources? And I'm not talking just about the monetary resources about the assistance with the MCAT. How do you get through the application process? How do you take your brights, because they have the intellectual capacity, and put it onto paper so that we can see it so that you can get into medical school. Many people have the advantages of having family members and other people who are already in medicine or know how to navigate the system. We want to help young Black undergraduate students navigate the system to have the appropriate students get into medical school.

Nathan Chan [30:39] So it's been nearly two decades since the BMSA was inaugurated. And now there's a scholarship named after you at the BMSA. Can you tell us about the scholarship? What aims is it trying to achieve?

Sean Wharton [30:48] The scholarship was this idea of giving back and reaching back. When I started the association BMSA in 2000, I was a third year medical student. I didn't have the resources to start a scholarship knowing that there were Black medical students that came in that had difficulty with their finances. We know it's become even more challenging from when I was there, because at that time, we had something called tuition regulation. The tuition was regulated throughout all of the professional schools. So tuition was between $2000 a year to $5000 a year and it didn't go above that for any professional schools. At that stage in the year 1997, they decided to deregulate the professional schools. That included law school engineering, medicine, because they felt that these people were all going to make tons of money afterwards and they're going to have really good jobs so they could pay their tuitions off without much of a problem. That is correct. These people in these professional programs do pay off their tuition in a very expedient, appropriate fashion. The challenge isn't paying off your tuition. The challenge is getting to pay your tuition in the first place if you're coming from a position of disadvantage. So we knew that deregulation of tuition was going to cause a disadvantage to racialized groups and marginalized groups and those who had financial challenges. Even though I was a pharmacist, and I was doing fairly well so things worked out, okay and I could do some part time jobs. Even I had to get a loan from the Alumni Association in my third and fourth year. What I wanted to do with the scholarship now was ensure that there were not going to be any Black medical students left behind because of financial challenges. Last year, we saw that this almost happened. A second year medical student had significant financial challenges. Our whole community had to rally around this student and raise the necessary funds because the funds for her and she was already giving back. She's doing all this stuff and she had the threat of being kicked out of medical school because she was actually a Black foreign student, and her tuition was in the range of $125-250,000 per year. We rallied behind her to ensure that her tuition was paid properly. I am rallying behind all the students who have financial challenges to ensure that they do not have to drop out of school because of finances. That should be the last thing.

Colleen Farrell [33:21] Increasing representation in healthcare has many positive downstream effects. Shared racial identity between a healthcare provider and patient, also known as racial concordance, can help facilitate the patient provider relationship and improve communication, as well as the quality of the care the patient receives.

Nathan Chan [33:39] Can you tell us about the impact of racial concordance on patient health outcomes?

Sean Wharton [33:43] We've done studies that looked at if you have a healthcare provider that is from the same ethnic background versus one that is from a different ethnic background, will the patient take on the advice from that physician in a more readily fashion? The evidence is yes, that is true. We probably didn't need to do the study to actually know that. If somebody from your own background who you either like or trust or don't have a challenge with, you're not trying to figure out where they're coming from because they're from your own groups. You understand everything. You understand their nuances. Of course, you'll pick up their information better, you'll understand them better, you'll understand their accent, their idioms. This study was in the states, it looked at Black male patients, these Black male patients had got prevention advice, you should take your flu shots, you should eat healthier, from a Black physician, a White physician or a Asian physician. The advice was taken out a much more readily when the Black physician was speaking to the Black male patient to the tune of decreasing the risk of coronary artery disease by 20%. If we look at the notes that were written by the doctors, the notes that were written by the non-Black doctors were one word note. Things like needs to lose weight, anxiety, stress. Whereas the notes from the Black doctor had a lot more content in them. Things like patient initially disagreed with me but I made him laugh and he now wants to take the flu shot. Patient needs a job, needs money, needs shelter, we need to help this patient. Those types of notes were there was more of an explanation as to what was going on. They were engaged in the situation. That engagement shows compassion and empathy. Compassion can be shown by multiple doctors from multiple levels. Empathy is much harder. Empathy is I actually have been in your position or so close to being in your position that I get it. We talk about compassion a lot more than we talk about empathy, actually, because different physicians come from everywhere, so we need them to be as compassionate as they possibly can. When you're coming from the same ethnic backgrounds, same struggles, you need to be empathic also and let them know that you actually can understand what they're saying, You're with them. Either family member of yours or Black female ran into trouble, and you get it. Or you ran into difficulties and you get it. That's where we know that we need to have faces that are similar to ours as racialized groups to be able to move forward with getting a healthier population.

Nathan Chan [36:25] You're the medical director of the Wharton Medical Clinic for weight and diabetes management, which is named after you, of course, and located in Burlington, Ontario. And you also recently delivered the inaugural lecture in Black Health at the University of Toronto's Department of Medicine. Your lecture examines weight bias and racial bias in medicine and I'm wondering if you can tell us a bit more about how these biases are learned? What makes them similar or different and how do they intersect with one another?

Sean Wharton [36:50] That's what I learned quite a bit by running this clinic is that we all have these biases. And there's no way for you not to have them. We have associations every single day, as soon as you're born, you start to associate where my food is coming from, what a safe environment looks like versus a non-safe environment. If that association doesn't work in your brain, you don't survive. Let's go to the next association that we end up having. If somebody tells you every time you see somebody with elevated weight that they're funny, they are not quite as bright, they're not going to be the president, or not going to be the CEO of a major company because every cartoon that I've watched as a child doesn't have the person with a bigger weight being the bright, intelligent person. They have them being the goofy sidekick, the one who's kind of dumb. I can't get rid of the unconscious biases that I have because I grew up in this same world to. I have that bias too. I can work on it, I can try to recognize it, and I can do better. And then I can show compassion. Hard to show a lot of empathy, but I can show compassion. And I can put things in place that allow me not to act on my biases. Things that we put in place or clinic to ensure that the doctors and the clinicians don't act on their bias is we ask them to ask the same question to every patient who comes in on a systematic basis. If you're not asking the same question to every single patient, then you're not working at my clinic. I can't get you to stop your biases or to get rid of them. But I can't get you to not act on them.

Nathan Chan [38:29] And it's the same thing with racism?

Sean Wharton [38:31] That's the same thing with racism. We learn racism early. And don't forget that the people living with obesity have the biases against themselves too. They live here in society. Also, what we see is that Black people have unconscious biases. People who are non-racialized have unconscious biases against Black people. And Black people have unconscious biases against themselves. Studies in the '60s, where you would show a Black child in kindergarten, a doll, a Black doll, versus a White doll. And you would have a bunch of words. Words like intelligence, smart, nice. And put those words to the doll. Of course, the White students will put the nice and intelligent to the White doll. The Black students will also put nice and intelligent to the White doll. And the bad words to the Black doll. That's the way we thought of ourselves because of the implicit and unconscious biases that we have internalized. That's where the concept of being woke ends up coming from. There's a lot of this idea of can you wake up to the fact that you've got your own biases, your own things to work through, your own chips on your shoulder, your own challenges. Then you've got the society's challenges as well. You've got two things to battle to try to get to a level of anti-Black racism within yourself and within society where they treat you equally. We love to see equal treatment. We're starting from such a low standpoint that we don't if you get just equal treatment and always be equally, the non racialized groups will always be higher, higher, higher, higher. We don't need equality, we need equity. To round it off as to where I see the challenges in obesity biases, the injustices, they start early. Anti-Black racism starts early because of these unconscious biases that we all have. And we all need to work on it. We all need to recognize and then we need to put systems in place so that we don't act on it. We cannot trust ourselves to not be part of systemic racism, to not be racist, and to not be biased against people living with obesity. You cannot trust yourself. You have to put things in place to ensure that you can do a better job consistently.

Adrine de Souza [40:52] As we work to address systemic biases in our healthcare system, racialized patients continue to face barriers to access and poorer health care that results in worse outcomes. Next, we talk to our guests about how these issues affect patients interactions with the health care system.

Nathan Chan [41:14] What does this actually mean for a patient's health in their experience in health care?

Sean Wharton [41:18] Great question, how do patients experience health care when they themselves are the subject of this bias. The way that they experienced it is learned helplessness. They frequently know that when they engage with a health care provider, the chances that they're going to get effective health care that's similar to what they should get and they frequently know that I'm not getting the right care, they know that it's going to happen, they expect that they're going to get subpar care and they either accept it and end up dealing with it and don't push the envelope and just take that subpar care which is most people. That's as people living with obesity, that's people from racialized groups, that is the indigenous group, or they try to speak up about it. And speaking up can sometimes be a challenge. When you speak up you lose your doctor, you lose your friends, you butt up against a number of stakeholders, the government and others. Then you become an advocate because you're angry, and you may get labeled as that angry person and that person that healthcare provider may not want. So this is one of those angry patients, I may not want to see this patient. Well, they're angry because I am part of a systemic racist system and I can do better. If I do better, they won't be angry, it'll be appropriate. Oh, I get this. So maybe that's what we need to actually end up looking at. We see that people living with obesity oftentimes have to doctor shop and they're not looking for the smartest doctor. They're looking for the most compassionate doctor and Black women have to do this often. Also, doctor shop or looking for a doctor that will be compassionate to them will listen to them about all of their challenges and be able to refer them in an appropriate fashion. Why do I say Black females? Black females over and over again are the bottom of the barrel when it comes to comparing Blacks and Whites. Black people and White people will see that the Black females get the worst medical care. The indigenous population as a whole get even worse care than the Black female does. And that is a problem that North America has and needs to figure out. I do think that the options of just giving up and saying I'll deal with this sub par care is most common. Advocating is less common, but absolutely necessary. But certainly the experiences of almost every racialized group is to, at some point, experience subpar care and expect it. Expect subpar care. And that's unfortunate.

Adrine de Souza [44:06] We know that racism affects everyone that interacts with the health care system, from patient to provider. We asked Jessica, how she navigates experience of racism in the healthcare setting.

Jessica Goncalves [44:21] I definitely have, but I try not to look backwards and I try to look forward. Everyone's have had bad experiences. In some respect. When that happens, you can take one of two options. You can do nothing about it or you can do something about it. What we are doing in the nursing society, as well as with our classmates and fellow students, is trying to do something about it. We can start with the place we have the closest reach and that is in our program. Hopefully carry that forward as we move out into the profession and start to do something about it there as well. Speaking to our colleagues and setting a good example for our nurse managers and calling to accountability those in decision making positions, writing letters to our government demanding better. Those are some of the things that we are hoping to do as we move forward so that the system and other factors, hopefully that will spill over. The nursing collective is a huge, huge number of members. The more that we exert our influence, the better for everyone. And for all sectors.

Adrine de Souza [45:32] Once these concerns are raised, do you feel there is adequate institutional support to address the issues or make the appropriate changes? Or when advocating outside your institution, do people really listen?

Jessica Goncalves [45:45] It depends on the issue, how much backing they have. There have been lots of instances where nurses have spoken out and have made those changes. For example, smoking in public places or seatbelt lawsor a number of changes that have come as a result of nursing action. Speaking to government, raising those issues, organizations like the RNAO, they have many initiatives that they are working on.You have to go based on the assumption that somebody is going to listen and we are going to get our message across because otherwise, you don't have any hope. And you have to work with evidence, you have to work with influencers, hopefully, and again, action to backup that hope. You can't go blindly. But, you have to at least have faith that you're reaching the right people, do the research, and know that change will happen. Even if it's not that day, or even if it's in incremental changes. Change is going to happen. You just have to keep pushing for it.

Nathan Chan [46:49] How can we improve access to health care and downstream health outcomes for Black, Indigenous and non-White racialized people? What needs to change?

Sean Wharton [46:57] What I think needs to change is not just equality, but I think we need equity. What I mean by equity, is that we need to put appropriate resources into those areas that have been marginalized. We need to ensure that the First Nations and the reserves are getting appropriate health care, what does that look like? It means that there's more funding that goes there, there's probably some virtual medicine that happens a little bit better. There are Indigenous people that are on the line that can help to appropriately connect that person from the reserve who has a specific way of talking, of acting, of moving, to be able to ensure that they're getting the best care from this neurologist, who is in Toronto and is not accustomed to and and doesn't understand the Indigenous accent or the reserved way of approaching health care because of the distrust that they have in the health care system, because the health care system has treated them so poorly for so long, that the distress makes sense. We should put the right resources in place to not just window-dress it,but to do a really good job of every time you speak to an Indigenous person, you should have somebody from the Indigenous population ensuring to interpret it, to turn to help ensure that to get that person to where they need to actually be. That's the same things that we should start to see in the immigrant populations. When you're in Brampton, when you're in the Mississauga area, when we are in North Toronto and not just the downtown core, we need to put the right systems in place for those groups. The Ethiopian group may need a different type of equity and different type of system than we normally have. We may need to reach these people when they're at work. So how do we do a phone call when they're at work? We may need different hours, we need to have stuff at seven o'clock in the evening, to be able to address this. That is a better lens and a better focus. And we have to have health care providers go to education classes on systemic bias in their system. Learning how not to be just compassionate, but how to work with in the system. And we're doing it this way. Why are we providing seven o'clock in the evening sessions? Because of equity and because the Eritrean groups primarily work throughout the entire day, and they need us to be able to provide care at seven o'clock in the evening. Why are we doing that? Because we care about them and we love them. That's why we're doing it, because we are a compassionate group of people that are here to do health care for everybody, not just the privileged. That's how I think that we can get there. We'll get there by collecting more data and people go out collecting data is hard collecting data not hard. Collecting data is easy. We came up with a vaccine in eight months. We can collect race based ethnicity data when everybody from their race based groups will wants to give us their data. They actively want to give us data so that we can help their communities more so, and we say it's too difficult to collect that data? That makes no sense. That is completely the exact component of systemic racism that keeps us in this groove is that everything is just fine and dandy right now, why should I change anything? Why should I expend energy to collect data? Because that's the right thing to do. It's going to help our communities in an appropriate way. Doing nothing is systemic racism. Doing something that's appropriate gets us out of this.

Nathan Chan [50:39] Rather than pushing for equality per se, which is typically understood as providing equal opportunities to everyone, Dr. Wharton speaks of achieving equity. That is directing resources to reach equality and outcomes as the key to dismantling systemic racism in healthcare and beyond. By prioritizing equity, we can better understand how historic injustices have resulted in and continue to perpetuate intergenerational trauma and the ongoing marginalization of Black, Indigenous, and racialized peoples.

Adrine de Souza [51:09] For example, last episode, we heard about COVID-19 vaccine hesitancy among Afro-Barbadians, rooted in the distrust of the government and their historically racist health policies.Tackling this distrust meant tailoring specific vaccinations policies and compaigns to regain the trust of the people negatively affected by racist institutions in healthcare. We asked Jessica, what measures should be put in place here to address systemic racism in healthcare in Canada.

Jessica Goncalves [51:46] We spoke earlier about how it starts right from the beginning in the education system, the way that we raise Black children in education and encourage them which disciplines they have the right to access. It starts from there. Changing the education system to welcome Black bodies in these health education programs. There needs to be policies in place and or changes to the curriculum that include a diversified curriculum, having experts in the field who are Black, who can speak to their knowledge and their experience and not just when it comes to racism on all topics, that they are well versed in. Having health care providers who can also set an example and mentor up and coming Black health care providers. I also think it's really important to continue to have Black members of policy and decision making bodies. Having people in all areas, but diversified people, will help to make sure that health care is equitable, health care education programs are equitable, Black members of society have a positive experience when it comes to accessing and receiving health care in Canada.

Adrine de Souza [53:04] Do you think we still have a long way to go?

Jessica Goncalves [53:07] You know, we've made some changes. But I do believe there is still much to be done. Some of those steps are being taken. I think we need to continue to push. I think we need to keep our foot on the gas. And I think with more call to action and more power behind it, more influence. Just more, more and more and more. We will start to see those changes. And I believe we can come to a place where we won't have to fight so hard anymore.

Colleen Farrell [53:35] To address systemic racism requires adopting a critical perspective towards whether a proposed solution will actually result in meaningful and lasting change for the people it's intended to help. And in many cases, a successful solution requires transforming systems that have supported racism and reimagining the way services can be provided.

Sean Wharton [53:55] Policing in Canada and in America is a racist organization. That needs to be really clear to everybody. It's not the police themselves that are racist. There are some that are racist because there's racist people everywhere. But it's the whole organization that has the problem. When people talk about defund the police, which is an aggressive move, it's an aggressive statement. They're talking about dismantling the police system, not getting rid of a few bad apples. Dismantling a racist system and making it a non-racist system. It's important to use as assertive and aggressive words as we have because Black and Indigenous people are shot and killed by police regularly.

Nathan Chan [54:42] Defunding the police does not mean the abolishing of community safety. It urges the implementation of alternatives for supporting community safety and security, decriminalization and the repeal of outdated laws, and the disarmament and demilitarization of law enforcement. It emphasizes the prioritization of public health social services and non-violent action to support communities. You can learn more about the movement at defundthepolice.org and continue the discussions on the comments on our social media. Of course, this idea of rebuilding systems in a way that better serves individuals and their communities also applies to health care.

Sean Wharton [55:17] Let's work on the healthcare example. Who runs the hospitals? What is the placement if you're a nurse, if you're an orderly if you're a physician, like I'm not a racist physician. But if your system that has been put in place does not allow for appropriate understanding when an Indigenous person walks into your setting, how to treat them. Somebody from a West Indian background or an accent walks walks in, somebody from South Asian, someone who is Sri Lankan versus somebody who is Sikh walks in and brings their challenges from their own groups that have caused significant discriminations in the Sri Lankan group versus the northern Indian group. If there aren't things in place to be able to help those specific people to navigate the system, then we're working in a biased system. That doesn't matter what your ethnic background is, as the healthcare provider, your system is not set up for them. If your only system set up is that you've got to get your patient to the appointment at one o'clock in the afternoon. They're an immigrant and they work in a place where they can't get one o'clock off, they're not a lawyer or having one of the jobs that has a privileged job, then your system is set up for the privileged. Not for the immigrant worker, not for the person on the reserve. I can't make it in. Change your system to deal with those biases that you've brought into your system. That's what the dismantling ends up being. And that's what this concept of defund the police, it's dismantle the entire police structure, build it back up in an appropriate level, dismantle the way that we think about how we do health care provision to all of our people so that when we build it up properly, it's built in a way that provides for the people that we actually have here in Canada, in Toronto, in southern Ontario. They're from everywhere and our system is not set up for them. That's what we need to do. And that's what I'm trying to do and hoping that others will join me.

Colleen Farrell [57:26] Our guests provide us with a few final comments before heading back to their days.

Jessica Goncalves [57:30] When I think about the future of health care in Canada, I'm again hopeful because I am starting to see more Black bodies in health care programs. And I know that admissions is a large area, they are considering reforming. And I'm I'm thrilled that I've had some impact in this area as President of the Nursing Society and just as a person in the program. I really appreciate the opportunity to have a say, and I'm glad that we got a chance to talk about these issues today.

Sean Wharton [58:08] It's time to make a change. It's time to really get this going. Not with violence, not with any means necessary, but with the appropriate means and we're not going to stop. Colin Kaepernik losing his career for anti-Black racism, that young guy...just incredible. We can go on and on with examples of people who have sacrificed themselves and their careers for this important cause. If the number one quarterback will sacrifice his entire career for something like this, sounds like this is pretty important. I would like to see us putting those people up on a pedestal and ensuring that we do the work that they asked us to do. We do the work that James Baldwin asked us to do, that Malcolm X, Martin Luther King asked us to do, that all the new guard are asking us to actually do.

Colleen Farrell [59:03] Dismantling racism in all aspects of our lives begins with listening. Listening to understand, listening to feel compassion, and listening to take action. So thank you for listening to our episode on anti-Black racism in healthcare today. Of course, we've only just scratched the surface. We invite you to take the time to explore the resources in our show notes. For example, Dr. Wharton recently delivered the inaugural lecture on Black Health at the University of Toronto's Faculty of Medicine, where he explores weight and racial bias in greater depth. He also recommends a book "So You Want to Talk About Race" by Ijeoma Oluo for further reading,

Nathan Chan [59:40] As our guests know all too well., it takes courage to speak up when you see racism firsthand. But it's important to speak up when you can. We hope you can be inspired by Dr. Wharton's parting words.

Sean Wharton [59:50] I know that you're tired of hearing about this racism and anti-Black racism all the time. If you're tired of hearing about it, imagine how tired we are of experiencing it.

Adrine de Souza [1:00:02] A very special thanks to our guests today Dr. Sean Wharton and Jessica Goncalves for sharing with us their passionate voices and insightful ideas. There were other voices we hope to including today's episode as well, many of whom were already stretched in supporting racialized and marginalized communities who continue to be hardest hit by the COVID-19 pandemic.

Colleen Farrell [1:00:30] This episode was hosted by Adrine de Souza, Colleen Farrell, and Nathan Chan. Nathan and Adrini conducted the interviews and Rachel Dadouche and Colleen helped develop content. Jessie was our Executive Producer and Anukrati was our audio engineer. Be sure to check out our next episode in two weeks, where we explore the social determinants of health.

Adrine de Souza [1:00:48] RawTalk Podcast is a student presentation of the Institute of Medical Science in the Faculty of Medicine at the University of Toronto. The opinions expressed on this show are not necessarily those of the IMS, the Faculty of Medicine, or the university. To learn more about the show, visit our website RawTalkPodcast.com and stay up to date by following us on Twitter, Instagram and Facebook at rawtalkpodcast. Support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes and Spotify or wherever else you listen to podcasts and rate us five stars. Until next time.