breaking the cycle of racism and bias in healthcare

healthy debate editor’s note: this is an edited transcript of “facts from the frontlines,” a st. michael’s hospital foundation covid-19 podcast series in which experts provide the knowledge you need to keep you safe and informed. host, scientist and parent sabina vohra-miller talks to seema marwaha, a physician in the general internal medicine department at st. michael’s hospital and editor-in-chief of healthy debate, and ripu minhas, developmental pediatrician at st. michael’s, assistant professor in the department of pediatrics at the university of  toronto and founder of punjabi kids help, a social media literacy resource on instagram and tiktok that has been recognized by the world health organization.sabina vohra-miller: the covid-19 pandemic has brought to light racial disparities and health inequities that have long been an issue because of historic structural racism and have resulted in grossly unequal health outcomes. many within these vulnerable communities are frontline essential workers in health care, food processing, manufacturing and so on. sadly, these very same communities have been vilified and shamed for having high numbers of cases despite the structural barriers they face.add to this their distress with government and health agencies. remember that many bipoc communities – bipoc stands for black, indigenous and people of colour – are distrustful of medicine, health care and vaccinations and with good reason, given the long legacy of systemic racism, discrimination and experimentation. for my guests and myself, this is a professional challenge, but it’s also personal. we’re all of south asian background so we’re bringing our personal and our professional perspectives to the table. seema marwaha is a physician in general internal medicine at st. michael’s hospital and is editor-in-chief of healthy debate. she’s also a regular contributor to cbc and chatelaine. ripu minhas is a developmental pediatrician and assistant professor in the department of pediatrics at the university of toronto. he’s also the founder of punjabi kids help, a social media literacy resource on instagram and tiktok that has been recognized by the world health organization.seema, i’ll start with you. what are some of the health impacts of racism and bias that you’ve seen in the community that st. michael’s serves?seema marwaha: for me, it was starkly visible during the waves of covid. i had seen it previously – a disproportionate number of south asian patients coming in with heart issues, a disproportionate number coming in with renal or kidney issues. but during covid, it was stark because the hospital was devoid of everybody else at the beginning. our ward became the covid ward. and during the second or third wave – everything is all kind of blending together – the majority of patients were south asian or east asian and their families would be infected. we were taking in 10 to 12 transfers a day from outside hospitals into st. michael’s because the communities they came from were so disproportionately impacted. what we noticed was that most of these families were essential workers. many of us were able to stay home because they had to go to work in grocery stores, driving taxis, running businesses, or as essential health-care workers, homecare workers. and they were living in a multi-generational home as many south asians do. it was very difficult for them to isolate and then the whole family would get sick. long covid and the physical disabilities that come with getting covid are going to last in these communities for years to come.we also noticed that the number of rehab beds and resources in these communities was very limited compared to neighbouring communities. when vaccine rollouts came out and you looked at maps of hotspot communities, comparing oakville and brampton was a classic example – vaccine uptake was really high in oakville but then you cross one highway and you’re in brampton, where you have the highest essential worker rates and where the vaccine rates were really low even though they needed them the most. what really bugged me about this is that our natural reaction was to blame these individuals – they’re vaccine-hesitant or they’re not following the rules. but that was absolutely not the case. there were clear structural barriers to access resources to care, to access the vaccines, that were not being acknowledged. i know the government can’t be everywhere at once, but i felt that some communities were more invisible to government and policymakers than others. i think that the entire health-care system is like this in a way. there are certain communities that are less heard, that are less visible, and the systems aren’t designed for them.one of the things that would be a positive pivot with this pandemic is if we start to address those underlying inequities that affect people’s health.sabina: ripu, what are some of the health impacts of racism and bias that you’ve seen in the community that st. michael serves, specifically as it pertains to your role and your job at st. michael’s?ripu minhas: our numbers showed that bipoc communities were seven times more likely to be infected by covid. entire racialized communities have really been “othered” for years, for generations, by our system. there was this quick response to start finger-pointing at these communities, who were not a priority before but suddenly were supposed to trust vaccines. how can you trust health care and education when we have this legacy and this multi-generational cultural narrative that’s been so harmful and hurtful? there’s a lot of healing, a lot of understanding, that really need to happen as we work toward equity across the board. the other piece that really stuck out was from a developmental health standpoint. last fall, when the toronto district school board first released numbers on virtual learning, we saw that families that were of a lower socioeconomic background or had lower parental education backgrounds were more likely to choose virtual education. now, the numbers are showing that there are more academic gaps or educational gaps with virtual-learning options. we’re just not able to translate our educational system into a virtual space with the same efficacy, especially for children or students who need it most. and we know that large academic gaps lead to economic gaps down the road and further marginalization and gaps within communities. inequity then perpetuates between generations.sabina: it’s a vicious cycle and we have to break the system down. since we’re all south asian, i want to focus on that for a moment. south asians in canada have been fighting a pandemic here but also fighting the pandemic in india. i don’t think any of us have been spared in terms of our family and friends that are living in india. i want to spend some time talking about what it’s been like to be a south asian here in the gta, in canada, but essentially, globally as well.ripu: it has been tough. there has been perpetual communal grieving and sorrow. when things escalated in india, we were hearing regularly for multiple weeks about family members or friends who were struggling with getting a hospital bed for a family member, or even supplies for funerals or oxygen. you’re seeing this in the news and even if it’s not people you know, you see people who look like you who are struggling. that was something that the south asian community continues to struggle with but is also kind of unseen. we were still at that point in the conversation where there was a lot of finger-pointing and the face of covid at that time was brown.when i think about some of the systemic pieces that could have been done differently, part of it is about the conversation that has been evolving about anti-racism and the care we provide. take linguistic diversity. we need to honour that but there’s more than just putting something into google translate and then posting it. there’s a lot of other adaptations that need to happen, that honour the lived experiences of people in these communities. there’s a lot of work that needs to be done, but at the same time the conversation has really moved forward. we need to carry on with that momentum to make sure no one gets left behind.sabina: seema, your thoughts on this? and i’d also love to hear more about the one-size-fits-all you mentioned in our earlier conversations. explain why one size fits all doesn’t necessarily work.seema: as a south asian frontline worker, there was a lot to deal with. i would treat patients and speak to families that could be my family, then i would go home and turn on the news. and i would see the same thing in india. and, you know, i felt pressure to fill the gaps in the system that existed for people that look like me and talk like me and it was absolutely exhausting.i don’t know if people understand the term structural barrier, what it actually means. but to give you an example, some of the families that i would treat had been transferred from peel because that was one of the regions that was hit hard. they would show up and have no idea why they were transferred to our hospital. they would come alone, while their entire family would be isolating in brampton or mississauga. and they wouldn’t have access to care services in their own language. somebody may have explained why they were being transferred but not in a language they understood. and i could tell that was traumatic for them – they would see me, and they would see the representation in me, and they would hear me speak their language. and that would be instant relief. they weren’t afforded that previously – the rules to get tested, how to get tested, or why they had to isolate. everything was in english. and even if it was translated, like ripu said, by google translate, it wasn’t translated into the cultural context that people understand. when we’re talking about a one-size-fits-all approach, a lot of the early materials that were out there assumed that everybody lived in a canadian nuclear family model or in an urban setting. and for people that lived in multi-generational homes or had multiple family members who had to go in and out, even i could not figure out how to apply the advice that i was printing out from public health units for their own families. i would honestly end up giving my cell phone number and email address because when they would get home, they’d be confused and wouldn’t know what to do. and they were just so happy to have somebody that they trusted, that spoke their language, who could tell them what the right thing was to do because they all just wanted to do the right thing. the same thing happened with vaccines. people wanted to go – they desperately wanted to go – but they didn’t know how to access it. resources were put online but were inaccessible. they assumed that you would know exactly where to go, how to download them and how to translate them. there are just too many steps to expect the average person to be able to do.south asians who immigrate to this country are screened and they are healthier and more educated than the average person. they are integrated into the economy. but they are not integrated into the health-care system. access to primary care, access to school-related health resources is not done with the same seamlessness as integrating them into the economy and making sure they’re working and paying taxes. and then 10 or 15 years later, these people who were healthier when they got here have strokes and heart attacks earlier, and don’t have the same sort of family support that they had back home. you also see that the communities that they settled in have fewer health-care resources and family doctors per capita; fewer long-term care beds per capita; less homecare per capita; and they have to care for themselves. and then add covid and it just was a system that was ready to break along its fault lines. what will improve the health of these communities will improve the health of everyone. so, it’s not a one-size fits-all approach. you have to be inclusive of these communities, lifestyles and cultures.sabina: we can see that even in the current situation with vaccine uptake. and the reason is because many of them, in fact, don’t even have a primary care provider. we’ve seen that taking that hyper focus on targeted approaches has worked. full disclosure, if it sounds like the three of us have talked about this before, it’s because we have and, in fact, launched an initiative called the south asian health network, of which i am a co-founder, as is seema. let’s talk a little about the work that we’ve done for the network; how we’ve provided some of that culturally sensitive, trauma-informed and targeted outreach programs, and how we’ve tried to meet our communities where they are.seema: i’ll try to be brief, but i think it’s super important. the south asian health network is an example of the advocacy and health-education groups that have popped up during the pandemic out of sheer need. we’ve that one-size-fits-all doesn’t work. you need to have grassroots movements. and because every community looks a little bit different, having movements that come from the ground up is important. that’s exactly what the south asian health network is. we’re essentially a group of canadian professionals, advocate health professionals, most of us south asian, but some not, who looked at the on-the-ground experience of what was happening and realized that this was not a covid problem. and this was not a south asian problem. this was a structural health-system problem that affected many different racialized communities. even though we’re branded south asian health network, the work that we do benefits other communities as well. essentially, what we’re doing is trying to identify the different needs communities have on the ground, produce educational resources and create networks that information can pass through so that it can get to where it is needed. where do some south asians access information? it might be whatsapp, it might be their local mosque or temple, or their community centre. we’ve put on dozens of town halls, we’ve created our own social media channels and we’ve made ourselves available as resources for people to randomly message. we will always recognize their concerns, elevate them if possible, and try to address them. and we’re partnering with other community organizations so that we can have an effect across multiple communities in the gta.sabina: the south asian health network is something that’s very near and dear to my heart. but i’m also really excited about this other fantastic initiative that is being put together by st. michael’s hospital – the centre for anti-racism is going to personify what it means to make sure everyone is getting equitable and accessible health care. it’s going to be part of st. michael’s commitment to equity, diversity and inclusion. and that’s because anti-racism, equity and social accountability are all central parts of patient care. these concepts must be built from the foundation up; they’re not something that are add-ons. importantly, at the core of the centre is building partnerships with communities that historically have been underrepresented. creating the centre will build on existing expertise at the hospital and improve diversity in hiring at st. michael’s. i’m excited to see how this centre comes into play, what it means to be anti-racist and how to put that into health care and make sure that it’s accessible and equitable for every single person walking into the hospital. we should have more information in the coming months on what this is going to look like. ripu, i would love to get your perspective on why representation matters.ripu: it matters in all the ways we’ve been talking about. as the diversity of our communities evolves, the manner in which we provide health care needs to evolve in accordance. we have a lot of data that shows health outcomes improving when the diversity of the patient population is reflected in the provider population. in my clinical space, we see improvements in maternal mortality, in neonatal outcomes, in the appropriateness of diagnosis of things like children’s mental health issues when there is more diversity within that provider population. that’s something that’s important in clinical encounters and certainly in giving voice to those communities at an institutional level as well. we’re just starting to understand the importance of that and the lifesaving impact of that representation.sabina: seema, your thoughts.seema: representation is so important. i’m also a journalist and a storyteller and some of the narratives that we’ve heard about south asian families during covid have been positive, but many have been negative. ripu, you mentioned that the face of covid during the third wave was brown, right? so, it’s important to have other positive, strong narratives of people in this society, retaining their cultural values and language and succeeding. we need to have representation on the frontlines so that when patients access services, they feel that they’re being cared for by a culturally sensitive organization that employs and understands what it is to be from where they are. it’s important that we have research as well. a lot of knowledge, a lot of what we know about how we treat people is eurocentric and not specific to different ethnicities. even much of the body of mental health research is based on caucasian research subjects. so how do we even treat mental health in people from other ethnicities? the last point i’ll make about why i’m so excited about our anti-racism centre is that the starting point is not that racism exists, but that we know it exists and immediately begin to mitigate it. and it shouldn’t be up to these communities to prove that they’re being treated in a way that’s disproportionate or different. we can see that it’s happening. we don’t need more proof other than what we’ve just seen during covid.sabina: what a great point to end on. i absolutely agree with you entirely on what you’ve said. thank you both for this important, critical conversation and thank you for your ongoing relentless advocacy in trying to serve our communitiesthis story was originally published on healthy debate. find the original story here.