Racism as a determinant of health and health care

The SAFE (Social Accountability as the Framework for Engagement) for Health Institutions project team (https://safeforhealthinstitutions.org) has developed an evaluation tool with a framework of 253 comprehensive “top-down” social accountability standards for health care service delivery.¹ Among the many key topics the team identified, the need to address racism was highlighted as being essential in areas such as governance, leadership, front-line health care services, and human resources. Social accountability strategies are grounded in the value of equity, which underscores how important it is that high-quality health care services be available to everyone, free from discrimination of any kind—including racism.^1-8 This is the first in a planned series of brief articles in Canadian Family Physician, based on rapid evidence narratives, that provides context for key social accountability topics and a practical approach that links “bottom-up” actions with top-down standards across micro, meso, and macro levels of care tailored to family medicine (Box 1). A description of the SAFE for Health Institutions project and the team’s approach to rapid evidence narratives also appears in this issue (page 630).⁹

Box 1. Summary of key points.

• Racism is a determinant of health and health care and must be acted on as part of a social accountability strategy

• Racism is a structural system that exists in health care, driven by conscious and unconscious biases that assign human value, privileges, and opportunities to certain groups while oppressing and marginalizing others, creating barriers to health

• Unconscious racial bias is a major contributor to disparities in quality of care and health outcomes

• Interpersonal racism at a micro level (patient-provider) is perpetrated through conscious or unconscious biases toward racialized people during clinical encounters

• Systemic racism occurs at a meso level (health care and community environments) and at a macro level (political and policy contexts), and it is rooted in the policies, processes, and political actions that systematically oppress racialized populations

• Rather than relying on physicians’ self-identified beliefs that they are antiracist, following a pathway to antiracism and developing antiracism standards of care can actively confront racism through reforms across the micro, meso, and macro levels

Providing context

Race does not determine someone’s health, but the experience of racism has a profound effect. Race is a socially constructed categorization of people into groups based on their appearance or other defining features.¹⁰ Racism is a structural system that exists in all aspects of society built on the false belief that different races are superior or inferior to one another. Racist structures and systems assign human value, privileges, and opportunities based on race. It is expressed consciously and unconsciously as bias—either interpersonally or systemically—through hatred, intolerance, prejudice, or hostility that results in oppression, marginalization, and barriers to health.^11,12 Racism is a dangerous social phenomenon that shapes the distribution of money, power, and resources that control or influence health research, health care, social support resources, and the social determinants of health.^10-14

Racism and racialization¹⁰ (the process of assigning privilege to people from certain races while disadvantaging others) are important considerations for family physicians in clinical practice, for the interdisciplinary teams to which they belong, and in other settings where they work, such as in emergency departments. While racism can be described in different ways, such as epistemic, relational, structural, socially exclusive, symbolic, and embodied racism,¹² it is often described as interpersonal and systemic in health care.¹¹

Racism as a determinant of health and health care

Including race, but not racism, as a social determinant of health is an injustice.^14-16 Race as a determinant of health can be inappropriately used to explain health disparities.¹⁷ The concept of race, rather than racism, as a determinant of health puts the emphasis on a person belonging to a particular race—as defined by society—while shifting the onus away from perpetrators of racism. This is especially important considering the minimal biological differences among “socially constructed races.”^17,18

Consequences of racism in health care settings, including primary care, further justify it being regarded as a determinant of health.^10,12 Experiences of racism create barriers to health for diverse racialized people, including Black people, other people of colour, and Indigenous people in Canada.¹⁹ These barriers are relevant to family physicians and manifest through a combination of factors at the micro, meso, and macro levels of care. These include mistrust of health care providers, underuse of health care, and poorer health outcomes.^20-23 It is linked to higher rates of smoking, binge drinking, obesity, cardiovascular disease, poor mental health, and high-risk behaviour.^18,20,24 Racism in health care produces a number of negative outcomes for racialized people, such as experiencing longer wait times,^25,26 being labelled drug seeking and therefore receiving inadequate treatment of pain,^13,21,27 having lower rates of renal transplants,^28,29 experiencing disparities in acute and chronic cardiovascular care,³⁰ having higher rates of adverse effects after surgery,²⁶ being subjected to coerced sterilization,^31-33 receiving lower acuity triage scores,³⁴ having inadequate health resources,³⁵ and having higher mortality rates.^26,35-37 Two of the most publicly reported fatalities linked to anti-Indigenous racism in Canada are the deaths of Brian Sinclair and Joyce Echaquan. “[S]tereotypes … were used to justify ignoring [Mr Sinclair] to death”³⁶ in an emergency department in Winnipeg, Man, on September 21, 2008, where he died in his wheelchair after having waited more than 30 hours without having been seen. Ms Echaquan live-streamed her death on September 28, 2020, at a hospital in Saint-Charles-Borromée, Que, capturing health care providers degrading her with blatantly racist comments and dismissing her concerns.³⁷ Despite widespread conclusions that racism was a factor in their deaths, some individuals with oversight and leadership in health care did not accept this conclusion.^36,37

Interpersonal and systemic racism across the micro, meso, and macro levels

Whether intentional or not, racialized health inequities are the result of racism experienced at different levels of care, including in the clinical settings of family medicine practices.^23,38 Interpersonal racism does occur at the micro level (patient-provider) as open discrimination, but it more frequently occurs without conscious recognition.^24,39-41 Unconscious bias at the micro level reflects a system of beliefs obtained through upbringing and encouraged “via the media, governments, educational institutions, and our social circles”³⁹ that influence decisions, behaviour, and attitudes. Even providers morally opposed to racism are at risk of prevailing unconscious biases.⁴⁰ Interpersonal racism, driven by conscious and unconscious biases, can be described as provider race preference bias and can lead to poor communication, less time spent with patients, and reduced empathy, and it may ultimately⁴² “manifest in differential diagnosis and an inability to see patients beyond the colour of their skin.”³⁹ Unsurprisingly, racialized Black and Indigenous people report experiencing racism from health care providers, underlining the importance of understanding racism and racialization from the perspective of racialized patients.^13,21,43,44

Unchecked, the effects of interpersonal racism become amplified as systemic racism and are perpetuated through historical and colonial structures that uphold privilege for White people while disadvantaging others.^10,40 This occurs at the meso level (health care and community environments), where racialized populations are systematically denied opportunities for health and social gains.^40,45 This includes primary care clinics, interdisciplinary family practices, and community organizations that administer the resources required to address social disparities that affect health. Systemic racism can stem from a collection of individuals who share similar conscious and unconscious biases, which eventually become “organizationally normal” and can be imprinted on the policies and processes of a family medicine practice or an interdisciplinary family practice, and which discriminate against racialized populations, resulting in a failure to provide the expected standard of care.^15,24,40,45 This amplification is further reinforced by historic norms, colonialism, and societal structures that make it very difficult to challenge the systemic disadvantages that racialized people endure in the health care and community environments.^10-12 The same amplification occurs in the broader community with organizations that control the resources linked to the social determinants of health.^40,45

Systemic racism is further amplified at the macro level (political and policy contexts), where policy-makers enshrine racism into the laws and policies that shape health care, social support resources, and the social determinants of health.^40,45,46 At the macro level, racism is seen through socioeconomic disparities in funding, resources, and policies that systemically oppress racialized groups.^{18,24,39,40,46,47} This is particularly true in Canada for Indigenous-specific racism, as highlighted in findings of a report on racism and discrimination in health care in British Columbia commissioned by the province and in the reforms required to address the 94 calls to action in the Truth and Reconciliation Commission’s final report.^43,48 Meso and macro levels of racism are especially vicious and go so far as denying basic human rights, such as safe drinking water and sanitation.^49,50

Pathway to antiracism

Family physicians, like other health care providers, make health care decisions that, without acknowledgment and conscious effort to address personal racial bias, can adversely affect racialized patients. Mahabir et al identified that nonracialized health care providers tend not to consider racial discrimination to be a contributing factor to the quality of care received by racialized patients, despite evidence of health disparities between White patients and other patients.²³ It is not enough to rely on primary care physicians’ stated attitudes about racial bias to ensure that the negative effects of racism in health care do not occur.⁵¹

A pathway to antiracism (Figure 1) is proposed as a means of developing antiracism standards of care for family physicians and other health care providers within the health care and community environments where they work, and as a way to help shape political and policy contexts. A pathway to antiracism acknowledges that racism exists and that it is driven by conscious and, importantly, unconscious biases, and that there is a need for continual reflection, self-improvement, and reform across micro, meso, and macro levels.^41,52 Antiracism standards of care would actively confront racism, support front-line bottom-up interventions rooted in education, and simultaneously focus on top-down strategic reforms that address systems of oppression.^11,40,41 Although a few examples of antiracism standards of care are presented here, more can be found in reports from the Wellesley Institute,^17,53 in the scoping review of antiracism interventions by Hassen et al,⁴¹ and in a paper from the National Collaborating Centre for Indigenous Health.⁵⁴ The SAFE for Health Institutions social accountability standards that address racism are provided in Appendix A, available from CFPlus.^*

Figure 1.

A pathway to antiracism

Antiracism standards of care should begin with bottom-up actions at the micro level and focus on helping health care providers acknowledge and accept the consequences of their personal conscious and unconscious biases while also encouraging reflection and supporting self-improvement.^14,41,53,55 Addressing interpersonal racism specifically in smaller primary care clinical practices is crucial to bridging gaps in health disparities for racialized patients.⁵⁶ Assessing patients’ perceptions of racism can be helpful for primary care practices.³⁸ Setting the expectation of an antiracist approach to patient care, coupled with education, training, and accountability measures for those unaccepting of self-improvement, can help make this expectation clear.

At the meso and macro levels, antiracism standards of care cannot be achieved without an antiracist foundation at the micro level.^40,45 A top-down reform of policies and processes that shape the health care environment should focus on those that perpetuate racism and create others that promote racial equity. Prioritization of antiracism from leadership⁴¹; having a diverse, equitable, and inclusive health workforce^21,55; and shifting power to racialized voices through community engagement^{11,24,40,41,53} can catalyze these reforms. As resources to the communities, family physicians can use their voices to advocate and act for racial equity beyond the micro, interpersonal interactions over which they have more control. At the meso level, family physicians can advocate more effectively for racial equity through antiracist policies that govern their family practices and the hospitals where they work, and with the community organizations that help address their patients’ needs.

With the knowledge that systemic racism also extends to political and policy contexts, antiracist primary care providers and organizations should also be active at the macro level, working to dismantle structures of racial oppression. This includes actions that lead to changes in laws and in health and social policies—particularly those that affect the social determinants of health—to support equitable opportunities for health and social gains for racialized populations. Collectively, family physicians can also work to dismantle racist policies and legislation within their medical organizations. By using their collaborative influence, family physicians can create sustainable change that helps close health equity gaps for racialized populations in their practices and beyond.

Conclusion

The experience of racism determines health and health care across micro, meso, and macro levels of care. It is a barrier to health equity and a key topic that requires action as part of a comprehensive social accountability strategy. Knowing this, family physicians and the organizations to which they belong have an obligation to take action that assures high-quality health care services are available to everyone, free from racism. This can be achieved through a pathway to antiracism and the development of antiracist standards of care that address interpersonal and systemic racism across patient interactions, health care, and community environments and that advocate for racial equity in the laws and policies that control health care, social support resources, and the social determinants of health. With these efforts, family physicians can not only counter racism in health care, but also help define a better world—one free from hatred, intolerance, prejudice, hostility, and oppression based on the false belief in race.