Podcast: Critical race theory in medicine
Transcript
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Kirsten Patrick: I'm Dr. Kirsten Patrick, interim editor-in-chief for the Canadian Medical Association Journal. Today I'm talking to Dr. Rahel Zewude and Dr. Malika Sharma, who have written a Medicine and Society Humanities article published in CMAJ on the topic of critical race theory, and how it can be applied in medicine. I've reached them in Vancouver and Toronto, respectively. Rahel and Malika, welcome to the CMAJ podcast. Thanks for joining.
Rahel Zewude: Thank you for having us.
Malika Sharma: Thank you so much.
Kirsten Patrick: So Malika, let's start with you. Why don't you tell our listeners a little bit about yourself?
Malika Sharma: Sure. So my name is Malika Sharma. And while I was born here in Canada, I'm a settler here in Toronto, and I'm currently at the University of Toronto. For 1000s of years this has been the land of the Huron-Wendat, the Seneca and the Mississaugas of the Credit and is still home to many Indigenous people from across Turtle Island. So grateful to be speaking to you from this land. I'm an HIV and infectious disease physician in Toronto and clinician teacher at St. Michael's Hospital. Clinically, I actually particularly focus on caring for people in communities who are often marginalized or oppressed by our healthcare system, including people who use substances and people living with HIV. And as an educator, I spend a lot of time thinking about anti racist and feminist practices within medical education, harm reduction and the structural determinants of health.
Kirsten Patrick: Rahel, would you like to tell us a bit about what you do.
Rahel Zewude: My name is Rahel Zewude. I am currently an internal medicine resident at UBC. I completed my medical school at University of Toronto, and I currently serve as the president of Black Physicians of British Columbia. And I am a black woman physician, first generation immigrant and a settler on the traditional ancestral and unceded territory of the Coast Salish people and Tsleil-Waututh and Musqueam nations.
Kirsten Patrick: So you've written this great article about critical race theory, your understanding of it and how you use it in the work that you do. How do you understand the concept?
Malika Sharma: First off, I think it's actually really just important to clarify that I don't consider myself an expert in critical race theory. And I don't think Rahel does, either. I think both of us have found it helpful in understanding what we see around us. And we've both tried to learn a lot more about it through reading works written by critical race theory scholars like Kimberlé Crenshaw, or Derrick Bell, Gloria Ladson-Billings, and Richard Delgado among others. And so, Rahel and I have written this piece on CRT, but we come to it not as so-called experts but as learners together in this process. My understanding of CRT is really thinking about it both as a theory and as a methodology, a way to actually do something, and in particular, a way to explore the ways in which racism is actually just woven into the very fabric of our institutions and society, with medical institutions being no different, with really the goal of not just identifying it or naming it, but actually challenging it in the pursuit of justice. And while CRT kind of emanated from a legal scholarship, I think there's lots of potential applications to medicine.
Kirsten Patrick: Rahel?
Rahel Zewude: So like Malika mentioned, I also came to CRT as a learner and wrote this article as someone who has learned about CRT and found it quite useful in my professional interpersonal and advocacy work. I came to it through the guidance and encouragement of my mentor, Malika Sharma, who's here with me. And so as, you know, Malika mentioned just reading the earlier works of the legal scholars and understanding where the origin of this theoretical framework is coming from and how it really builds on the struggles of Black and Brown lawyers, and reading the more relatively more recent work of scholars like Camara Jones, Chandra Ford, and their discussion of CRT and the public health arena as well as at the interpersonal level has given me another layer of understanding of CRT as a framework that can be integrated into fields outside of law, and particularly appreciating how this framework could be instrumental in a field like medicine. But overall, in essence, my understanding of CRT is that this is a framework that gives me the tools to understand the structural forces that shaped everyday life. And as a Black woman physician, it gives me a lens to use to examine the workings of structural racism in my interpersonal and professional interactions.
Kirsten Patrick: So, Malika, do you remember when you first encountered critical race theory?
Malika Sharma: For me the very first way I came across it was actually when I was doing my Master's of Education at OISE here in Toronto. And, interestingly, even though you've heard that it sort of stems from legal scholarship, my very first introduction to it was from a scholar that Rahel mentioned, Chandra Ford and Collins Airhihenbuwa who applied it to public health. So I think for me, that's kind of an interesting piece is that I already was seeing it applied to the healthcare field, in the very first way I encountered it. But for me, I think when I first started doing some further reading into CRT, it really kind of gave a language to things that I was experiencing, or that I was seeing, and that I didn't know how to talk about. And for me, I think that was kind of revolutionary. I was like, I finally feel like I have words to put to the things that I'm seeing and to help understand them and help explain them.
Kirsten Patrick: That is a useful thing with frameworks much as they're theoretical constructs, they do help you to have touch points for understanding and putting words to things. So what are the key components of critical race theory as a framework for understanding?
Rahel Zewude: Yeah, so we have outlined several of the critical components of critical race theory in our article, and I think the starting place of this framework is that it recognizes that race is a social construct. It's not a biological or genetic entity. So I think that's one of the most important concepts and the starting place of CRT. And then we go on to this idea of race consciousness, which is the idea of examining the process of racialization. So how people become racialized in society, and how that affects interpersonal relationships and professional dynamics and how it just manifests in society. Another important tenet of critical race theory is this idea of centering the margins. So voices and communities who've been pushed out to the sidelines by the mainstream or dominant society, need to be centered when we're using the CRT lens. So the discourse would be beginning at the marginalized group, rather than at the mainstream, or dominant society, as it has been done in society previously. And then another important element of critical race theory is this idea of contemporary orientation. So oftentimes, there is a perception of racism as this overt, very spelled out thing that happens. But racism in the 21st century, is embedded into everyday life. And it's seemingly ordinary and salient. And it does not need to be something that is overt or something that would just stop your day. And you would have to say, like, oh, that racism just happened. Just because 21st racism has been integrated into the fabric of everyday life. And then lastly, and I would say even more importantly, the idea of praxis is a very critical element of CRT. So praxis, meaning pure, important action, where examining structural racism, documenting, you know, the disparities, that result from structural racism is not sufficient, but it has to be coupled by interventions that are targeted and informed from your close examination of structural racism.
Malika Sharma: I think one of the other things to just add to that is that critical race theory really came out of legal scholarship. And it's been around for decades, right? We're sort of talking about it in medicine now, but it's been around for a long time. So it's actually a huge body of work. And there are many other tenants or constructs within critical race theory, including many others that have application to medicine that we don't necessarily talk about in this article, such as the idea of voice and counter story and listening to the narratives of people who are experiencing structural racism, other ideas around property and other ideas around interest convergence and how to align goals in the pursuit of social justice. And I think my hope is that there's going to be, you know, ongoing work in the field of medicine in this area, and I know the CMAJ is doing some work around that as well, which is exciting. But just to kind of, you know, reiterate that we've explored some of the central tenants, but it really is a very rich and large body of work.
Kirsten Patrick: I found it very interesting when reading your article that you emphasize those particular tenets about centering the margins and listening to the voices of people who are and have historically been oppressed and making those voices louder. I'd like to ask you, how do you apply that in the work that you do?
Rahel Zewude: So an example from my personal and professional and advocacy work is my work with the Black Physicians of British Columbia. During my first year of residency here, I noticed that I was the only Black resident in a group of 150 residents. But I also worked with hundreds of medical students, staff, physicians, residents fellows through my first year and I did not work with a single Black trainee or physician until the end of the year. So I had to ask, why is this the case? And is there a structural or system level cost to this rather than being just a mere accident, and this is just the way things are here at UBC. So I went into the work, and formed an association of Black Physicians of British Columbia to bring together the marginalized group of Black physicians and trainees in this context. And then on top of that, the more I learned about CRT and the importance of centering the margins, I went back to interview people who have graduated from UBC, people who had previously trained at UBC medicine, to understand their experience, to seek clarity as to why things are the way they are. Ultimately, I was able to collect qualitative data in regards to their experience as well as quantitative data in a place where we don't have decent repeated data available. So just learning that there has been 36 Black medical students over a course of 70 years of UBC medical school, which is the fifth largest medical school in North America was quite jarring. And learning that there were six Black medical students entering UBC, in 1958, in a class of 60. But having one Black med student entering the class of 288 in 2020. And another single Black medical student entering a class of 288 in 2019, was also very important to understand what has been happening on a structural level to get here. So it was a very important idea of centering the margins, would allow you to understand the structural causes of why things are the way they are. But ultimately, this idea of praxis and the fact that we have to move in pursuit, also of social justice and have to mobilize towards targeted intervention was also very important to me and my understanding of CRT. So I worked along with my board and the association to create targeted intervention. So we communicated a call to action to the Faculty of Medicine here back in October 2020, saying, you know, it is not enough for us to do this work and document that there is marked under representation. But the institution also needs to implement a targeted intervention. So we outline specific concrete actions that can lead to structural change. So I think CRT has been instrumental for me in that way, and has given me the tools to advocate in this space.
Kirsten Patrick: That's a great example, because you're explaining how you went about collecting the data, to show the deficit, to show the need for interventions to create something that is structurally different. And I think that's another thing to underscore that in the society that we have, or in the medical system that we have that is set up in a certain way to privilege some over others. There's almost a situation where we don't want to know those data. Those data are not routinely sought. We are willful in our ignorance. And so critical race theory, it seems to me in the way that you've used it helps us to see a better and clearer truth.
Malika Sharma: Just to sort of mention, I know earlier in the podcast Rahel mentioned that she, you know that we have a mentor-mentee relationship, but I think as you can probably tell from what she's talked about, like I'm constantly inspired by her incredible advocacy and I feel like I'm learning so much from her in terms of how to do this work. So, you know, I found that really incredible. And I'm very appreciative for that. I guess for me, I'll focus a little bit on how CRT has helped me as an educator and as a teacher. Although recognizing that I'm a learner within that as well. For me, I feel like CRT has really helped me unlearn some of the really, you know, ingrained ways in which I was taught about race during my medical training, really, this idea of race being a biological fact, rather than a social construct, and talking about race as a risk factor, right. So going through your internal medicine, training, and then into practice. And particularly for me, as an infectious disease physician, you know, we talk all the time about race as a risk factor, for example, as a risk factor of getting SARS-CoV-2. But actually, we very seldom talk about racism, which I think has far more explanatory power when thinking about health inequities. And I think, you know, this current pandemic is a really important example of that. And so CRT has given me a way to actually name that and teach around that, you know, I'm certainly not a researcher in that way. And so I think it's, you know, helped me be able to teach others and to, to think through with others, how to think about some of these issues in a way that centers these experiences of the people who are at them, who've been pushed to the margins, essentially. I also think for me, it's helped me identify and name some of the ways in which we've talked about how racism is embedded in medical practice. Well, what does that really mean? Well, you know, there's historical examples that we're still thinking about, right. So for example, Sims' speculum, named after a man who built his, you know, work through experimentation on unanesthetized enslaved Black women, to many of the biometric standards and norms, like the labeling of benign ethnic neutropenia, to Lindy Braun has a historical exploration of the spirometer as a tool in plantation medicine and the management of enslaved Black people. But you know, we're still using some of those tools now, to thinking about the ways in which Indigenous and Black people are treated in emergency rooms around the country still, right. And, you know, in our current time, there's many anti-racism committees or equity, diversity, and inclusion committees happening and, you know, on some of those committees where I might fit, CRT has also helped me kind of so called keep my eyes on the prize, right, like reminder to center in the margin. So if whatever we're talking about does not serve the person who was most marginalized in this setting, then someone is still excluded. And so whatever we're talking about, is not a solution. Whereas you know, we remember that if it serves the person who was the most marginalized in that setting, it's going to serve everybody. And for me, partly, you know, I'm relatively new to practice thinking through what does that look like for me in my clinical work in my teaching practice, in my interpersonal practice at work? And how can it help me engage in advocacy in a bigger picture way, and thinking through how to do that in ways that are thoughtful?
Kirsten Patrick: You talked about how you use it in teaching, going back to the concept of race as a biological risk factor versus racism as a more encompassing thing? How do you teach that now?
Malika Sharma: It's a great question. And I don't know if I always succeed, I guess, which is the other piece of it. But I think part of it is, you know, often when we talked about race as a risk factor before. So for example, when I was learning it, it was kind of like a laundry list, right? So race, socioeconomic status, housing, like all these things are listed off as the social determinants of health. And you know, I'll never forget, I was on a shuttle bus in Toronto, and I overheard some medical students talking about a quiz that they just had. And one of them said, Well, what was the answer to number three? And the other one said, Oh, you just put social determinants of health, it's always right. And so to me, that was really striking, right? Because it was like, we've been teaching this as a thing to know, rather than something to take action on, which I think is a real failure on our part as educators. And you know, I think in particular with talking about race, it's uncomfortable for people, right. Naming whiteness is uncomfortable, I find it uncomfortable to even say that word right now sometimes, right. So I think it can be uncomfortable. But you know, there's a great James Baldwin quote that says, you know, not everything that is faced can be changed, but nothing can be changed until it is faced. And I thank my friend and colleague Nanky Rai for introducing me to that, that concept. But when I'm teaching trainees or when I'm talking among my colleagues, you know, I may not necessarily name that what we're talking about here is CRT. But when we talk about race, for example, I name racism. So I don't necessarily say, you know, race is a risk factor for COVID-19. And I'd also don't even say, you know, there's hotspots or you know, postal code is a risk factor for COVID and Toronto, because that's actually that's a simplistic flattening of what's really going on, right, because when we look at, you know, where COVID is in Toronto, there's an overlap, right, of certain types of professions, racialization income levels. All of these things intersect in ways that reflect how power flows through our societies and actually being able to name that and talk about that. And you know, everyone comes to it from their own experience and comes to it from varying degrees of how much they've been thinking about these issues. But often, it leads to a much richer discussion than if we just kind of mentioned it in passing and then moved on. So I think that that's part of it. And you know, some of that pedagogically as an educator means that maybe the teaching around that is slower, maybe it's a conversation and less hierarchical, like I'm not the one with all the expertise and the knowledge, right. So many trainees have far more expertise and knowledge in these areas. Many of them are living it right now. And so I think that that, for me, has informed not just the content of teaching, but also pedagogically how you approach that teaching.
Kirsten Patrick: I'm thinking particularly about the ways that I have been taught so for example, somebody who's taught me a lot about racism in medicine is Dr. OmiSoore Dryden, who is a chair in Black Canadian Studies in the Faculty of Medicine at Dal[housie University]. And she pointed out repeatedly that we will, in research papers in CMAJ talk about racism risk factors. So for example, Black race being a risk factor for SARS-CoV-2 positivity among people undergoing dialysis. Like that is actually written in the discussion of a research paper, and Dr. Dryden pointing out that when we do that we perpetuate this idea that it is the race the thing rather than the structural issue that is racism. In your article, you talk about praxis as one of the tenets of CRT and Rahel, you spoke about that as theory-informed action. How do you see that working out in practice in the way that you operate in your lives and in your work?
Rahel Zewude: One is, you know, as you and Malika have been discussing, just starting at the place of recognizing race as a social construct, and particularly right now, at a time where medical institutions, physicians are talking a lot about racial health disparity than ever, maybe because of the COVID-19 pandemic. I think it is a time that racial health inequities have been discussed like never before. But it would be very important to really stop and recognize that we've had decades of data in medicine that have documented racial health disparities and infectious diseases, racial health disparities and cardiovascular diseases, etc. But that hasn't always been coupled with targeted interventions. And we are where we are now, because despite decades of documenting it and studying racial health disparity, as an institution, medicine hasn't mobilized to develop targeted interventions to reduce that racial health disparity. So I think the practice component of CRT would be extremely instrumental right now, to put the responsibility and the onus on clinicians and researchers who are studying this racial health disparity to say it is not sufficient to document this disparity. And we have to look at targeted efforts. So it's, it is racism that subjects people to poverty, overcrowding, limited access to care, not the inherent nature of race, instead of thinking of race as a non-modifiable risk factor. We have to start thinking of racism as a modifiable risk factor and design interventions to reduce it. And so one example that I see in Ontario is there are physicians advocating for paid sick leaves, in light of the significant racial disparity that they have been seeing with COVID-19. And seeing Black and Brown patients who often work as essential workers, and have been subjected to things like poverty, overcrowding, that ended up leading to higher rates of morbidity and mortality in those communities. And coming up ways to create solutions and mobilize change is something that the praxis element of CRT is all about.
Kirsten Patrick: I love the way that you put it that we need to stop seeing it as a non-modifiable risk factor. It's something that we can make a difference on.
Malika Sharma: You know, it's almost a question that we can be asking ourselves at every point. And I think that that's true for those of us who have primarily educational roles, for those of us who have primarily research roles like Rahel was talking about, also for those of us who have administrative and leadership roles, right. So, you know, if we're planning an educational module around anti-oppression like I was doing earlier this week, or you know, if we're sitting at a board table talking about EDI [equity, diversity and inclusion] initiatives for a hospital as members of the leadership team or something like that. I think with any action or anything that's being discussed, there has to be this question of is this working towards justice? And I think part of the challenge is people want, you know, understandably, people want a tool or a solution. And I think that the other thing that's really important to remember is, this is a big problem. And it's not going to have an easily recovered or, or comfortable solution, I think, was just the other piece of it. And so, you know, practice might be uncomfortable, and it might be messy, and it might also not look as narrow or focused, as we're used to thinking in medicine, it really does require us to have, what Delese Wear talks about, is this like dialectic gaze, right, Where you have like one eye on your patient and one eye on the concentric circles of their social contexts that have brought them to you. And so I think similarly, you know, if we really are only focused within our small healthcare space, in terms of thinking about how we address healthcare inequities, but I don't think we're actually going to achieve praxis, I actually think we do need to look broader into society around the broader ways in which that inequity is manifest, whether that's housing, whether that's transit justice, right, I think so much about who is on transit coming from Scarborough and Brampton to do what we call essential labor, but then when we don't actually protect the people who are doing that labor.
Kirsten Patrick: Now, the other concept you talk about is centering the margins. What does that look like?
Rahel Zewude: Medical institutions and universities across the globe now are increasingly talking about equity, diversity and inclusion. And so at a surface level, this may still seem to be working in line with this idea of centering the margin inside CRT. But I think it is also important to recognize when we talk about centering the margins, it's quite different from maybe previous approaches where the institutions wanted to quote unquote have a diversity checklist. So we have to ask the questions of it's not necessarily about who is in the room, it's not necessarily about who is sitting at the table, but also whose voices are being heard in the room, and who is sitting at the head of the table and who is left in the corners. Because I would like to raise that as a caution flag as we move towards doing more EDI work across medical institutions, that we don't stop at inviting marginalized into our discussions. And we don't think that we have fulfilled our diversity, responsibility by the virtue of having one person from each marginalized group sit at the table, we have to actively work to create spaces that those voices are being heard. And those voices are being centered.
Malika Sharma: I think when we think about centering the margins, we do really need to think about it in an intersectional way. There's this tendency, I think, within medical practice to somehow think that people fit into one particular, you know, so called minorities box and not others. But you know, I'm not a woman at nine o'clock, and Brown at 10 o'clock. And this is something that I heard a colleague say once and I can't remember who it is, I apologize, I can't cite them properly. But, you know, I'm all of those things all of the time. And so, you know, I think that that's the other piece of it, is it sometimes this work when done in in ways that actually don't dismantle some of the hierarchical and supremacist ways of thinking, actually create these boxes that no one really fits into, right. So I think it's actually really important that we recognize that we need to think about how power and privilege actually intersect to create that marginalization. And it's not just about the identity, it's not about identity, actually, right. It's about power. And to actually engage in EDI work in a meaningful way involves dismantling power somehow. And, you know, I can't pretend like I have all the solutions in terms of how to do that. But I think it's important that we recognize that that is actually what the call is for.
Kirsten Patrick: Thank you so much for this fantastically interesting discussion. I've learned a lot from you. And I hope our readers will too.
Rahel Zewude: Thank you very much for having us.
Malika Sharma: Thank you so much. We really appreciate being here.
Kirsten Patrick: I've been talking to Dr. Rahel Zewude and Dr. Malika Sharma. To read the article they co-authored, visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on Soundcloud or a podcast app. I'm Dr. Kirsten Patrick, interim editor-in-chief of CMAJ. Thank you for listening.