Podcast: Special Episode: Tackling anti-Black racism in medicine
Transcript
Dr. Mojola Omole: Hi, I'm Mojola Omole.
Dr. Blair Bigham: I'm Blair Bigham. This is a special edition of the CMAJ Podcast.
Daniel Woolf: We're gathering prior to Senate today to apologize formally for a past wrong that affected many people and contributed to a culture at Queen's that was neither welcoming nor inclusive of Black people.
Dr. Mojola Omole: That is the formal principal of Queen's University, Daniel Woolf, speaking at a special ceremony in April of 2019.
Dr. Blair Bigham: He was delivering an apology for the existence of a ban on Black students at the medical school. The ban was instated in 1918, but it was not formally repealed until 100 years later in the fall of 2018.
Dr. Mojola Omole: Prior to it being repealed, Queen's repeatedly misrepresented the rationale behind the ban. On today's episode, we're going to look into the real reason the ban was implemented.
Dr. Blair Bigham: And we're going to speak with a former Queen's med student who has helped create a curriculum that seeks to address anti-Black racism in medicine.
Dr. Mojola Omole: Finally, we're going to be ending with two speakers who are going to talk to us about what kind of solutions are possible when talking about anti-Black racism in medicine. This is our second episode of the podcast really delving into anti-Black racism and the health of Black people in Canada.
The rationale behind the special issue was a meeting between the editors of the CMAJ and Dr. OmiSoore Dryden and Dr. Onye Nnorom after the wake of George Floyd to talk about the journal's role also in anti-Black racism. It was a really great time to try and start exploring and think about ideas to dismantle anti-Black racism in medicine. And part of the huge step that's been taken by CMAJ, although there have been blunders along the way, is actually just acknowledging the role that they played in anti-Black racism in terms of researchers trying to submit to the journal.
Dr. Blair Bigham: Let's jump into it.
Dr. Mojola Omole: In 2018, a PhD student at Queen's University gave a public lecture about the 1918 ban on Black students at Queen's Medical School. In the course of his research, Edward Thomas discovered the ban had never formally been repealed. It was just still on the books.
Edward Thomas: And this policy basically stood more or less unmolested until about 1964, and it was two graduate students of Queen's…they were investigating race discrimination in renting arrangements for students, and they came across this quietly circulating policy in the medical school, and they sort of raised the, "You've drawn the color line," and this is around the time that Civil Rights movement in the United States is making it illegal to have these bans. So Queen's is now running concurrently with outfits like University of Alabama in terms of its enrollment. So Queen's doesn't officially drop it, but quietly, Queen's stops enforcing the ban, but it never got taken off the books.
Dr. Blair Bigham: Thomas's research showed that the historical facts of the ban were misrepresented by the university many times in 1978, 1986, 1988, the rationale that was given for the ban was that Black students had been unable to treat patients.
Edward Thomas: The reason Queen's gave. Now they vary a little bit depending on who they were talking to at the time. But then Dean, when he raised this policy first at the medical board meeting, then of course eventually that went up to the Senate for confirmation, was he was arguing that the patients were refusing clinical treatment from Black medical students. In particular, he was blaming soldiers who would've been receiving treatment on campus in Grant Hall, which had been turned into a convalescent hospital in the latter stages of World War I. And that, owing to this rejection of being touched or manipulated or examined by Black medical students, they had no choice but to disbar [Black] medical students from practicing at the School of Medicine.
What I found by looking into the archive is, I was unable to find corroborating evidence of these soldiers complaining. The only soldier I know of who was complaining about Black medical students at the convalescent hospital was the Dean of Medicine who was an officer reservist and essentially the ranking officer in charge of the convalescent hospital.
Dr. Mojola Omole: It turns out the ban had less to do with how Black medical students are perceived by patients, and more to do with how the medical school was perceived by racist institutions like the American Medical Association.
Edward Thomas: So the actual institutional policy barring Black students from being enrolled in the School of Medicine was in early 1918. However, this was a coincident with Queens trying to raise its ranking with the American Medical Association. So there was this sense that the medical school was in danger of closing, and this has to do with the what is largely thought, it was the modernization of medical education starting around 1909, 1910, and it was a report that was basically being funded by the Carnegie Foundation, but was actually backed, instigated by the American Medical Association, which was looking to standardize medical education.
In 1910, they had hired this educational reformer, Abraham Flexner, to basically review, visit all the medical schools, rank them across North America and develop a prescription for what they should look like. In 1910, he releases this report. In it, there's a specific section about the education of Black physicians, in which Flexner basically lays out that a medical school should be segregated, far fewer Black physicians should be educated, and that their practices should be limited to what you call public hygiene work in Black communities. Queen's ranked quite low in that initial assessment, and Queen's was scrambling to bring up its rank with the American Medical Association.
At the time it was understood that the Rockefeller Foundation was going to be putting in, it was some $25 million at the time, to help certain Canadian medical schools, and that there was a much bigger project across North America to raise their standards to elevate themselves into the modern ranks. Queen's was desperate to position itself for it. It became the obsession of the then principal that this should happen, and he put a tremendous pressure on the Dean of Medicine, Jay Z. Connell, to make this happen.
Dr. Blair Bigham: Shortly after, Queen's passed a motion banning Black students from medical school. Shortly after that, Queen's resubmits to the AMA, and this time it received a B ranking, and that ban stood on the books until the fall of 2018. The same year Sabreena Lawal, a Black student, entered Queen's as a first year medical student. She is currently a resident in otolaryngology at the University of Ottawa. She is co-author of a report in CMAJ, looking at the pedagogical approach Queen's developed to address its history. The article is entitled Anti-Black racism in medical education: a curricular framework for acknowledging and learning from past mistakes. Sabreena, thank you so much for joining us.
Dr. Sabreena Lawal: Thank you for having me.
Dr. Blair Bigham: Sabreena, you were a first year medical student when this ban came to light. What was that like for you? Can you tell me about your experience at the time?
Dr. Sabreena Lawal: It was a very odd time for sure, going to Queen's in general. Different institutions have their own reputations in Queen's, and Kingston I think, has a bit of a reputation for being a bit more of a less diverse environment. And when I started, I actually felt quite welcomed because my class was quite diverse. It's mostly students of color. But then hearing about that ban was, it was just a punch to the gut. When I think about how I'm literally at an institution where, technically speaking, on the books, I am banned from learning here, and it's just a really hard thing to wrap your head around that this historical… something you'd think of as historical… is actually quite contemporary. So it was just a very difficult thing to digest. Just hard to wrap your head around. Yeah.
Dr. Blair Bigham: Talk us through the framework for acknowledging and learning from past mistakes that you talk about in the article.
Dr. Sabreena Lawal: So the big goal with that curriculum was, first off, to understand the historical context of the ban, understand how that translates to what the medical field looks like today, and understand how we can take that to make medical education and medical admission more diverse and incorporate frameworks of anti-Blackness- and other anti-racism concepts within it.
It's split up into three parts. The first part is an hour long DIL, a D-I-L, which is direct independent learning, which is something that we use at Queen's to do learning at home. You have a module that goes through the history of the ban as well as history of other discriminatory admissions practices at Queen's, and give some statistics regarding what medicine looks like today in terms of the demographics.
Then, it's a two hour in-person, kind of, small group learning environment. We're split up into small groups and we'll go through some questions about what happened historically, but also discuss different ways that medical admissions can become a bit more holistic, a bit more anti-discriminatory, and trying to think about, "Are these things possible? Are they actually effective? What more can we do?" Then after the session's over, you have I think a week or two to submit a 200 to 300 word reflection, just really trying to think about what that learning experience was like and how you as an individual can take that information forward to, again, create a better learning environment for fellow medical students.
Dr. Blair Bigham: And how have your fellow students or yourself felt going through that process?
Dr. Sabreena Lawal: It was really nice to have the space, particularly curricular space, to grapple with that topic and make sure that everybody's on the same page as to what happened, why it happened, why it was so awful and problematic, and really get to talk about what we can do better together. I know, when the curriculum was designed, there was a bit of fear regarding student comfort, particularly for marginalized students and wanting to not retraumatize them or make them feel like they had to take the lead on this discussion as so often happens when you have sessions on anti-oppression and anti-racism.
But it was led by Dr. Jenna Healy, who is the historian at Queen's, and she's always been a fantastic teacher, and so she really just helped guide the conversation, keep it focused, keep it relevant, and ultimately made it a very productive space to be in. So I think, with that, it felt like a very safe environment to have that discussion and really think about your positionality, how you've gotten to be in medicine, what advantages did you have, what disadvantages did you have, and what does that mean for what we can do in the future? So overall, I think it was a very positive learning experience for sure.
Dr. Blair Bigham: And this is something that every Queen's medical student goes through, is that right?
Dr. Sabreena Lawal: Yes, correct.
Dr. Blair Bigham: At what point in their training does this occur? Is this a day one thing or where in the calendar does it fall?
Dr. Sabreena Lawal: It happens in first year. So there is a course you take in first year called Introduction to physician roles, and that's more of the class where we talk a bit more about professionalism, medical ethics, stuff like that, and they were able to fit it neatly within that curriculum. So you can have that course material early on, and that also helps such that you can build on other anti-racism, anti-oppression frameworks later on in your medical training.
Dr. Blair Bigham: Gotcha. I want to go back to an earlier comment you made about how oftentimes the burden of leading these conversations or curricula can fall on the very students that are oppressed by historical practices or by these outrageous policies. Earlier this year, some Indigenous medical students in Winnipeg had talked about a similar sense from curriculum being introduced by the University of Manitoba and how it felt like they were almost being retraumatized.
They found it difficult and painful to go through those types of conversations. How can schools make these types of activities safe for everybody while still being effective for those who might not be directly traumatized by the types of conversations? I'm just wondering what your thoughts are on that.
Dr. Mojola Omole: Sabreena, first can I just ask, did you have that feeling when you went through this program? Does that resonate with you that it could be quite painful and traumatic?
Dr. Sabreena Lawal: In that session, no. In other sessions, absolutely.
Dr. Mojola Omole: What other sessions would you say?
Dr. Sabreena Lawal: So we have other curricular opportunities to talk about cultural awareness, cultural humility, and sometimes it's hard because I feel like ... I've spoken to quite a few Black medical students across the country, and a common thing is that either people don't take it as seriously as perhaps some of the more directly clinically… like medicine, basic science, educational opportunities… or when you're there, it feels like there's a bit of this expectation. People are waiting to hear what you have to say and it makes you feel as though you have to represent your whole race and-
Dr. Mojola Omole: The model minority.
Dr. Sabreena Lawal: Exactly. And as much people might try to, "Oh,broach those questions really softly," it doesn't take away from the fact that, while you're there, it's this weird, oddly-isolating experience, when you have that expectation to be a learner, but also a teacher simultaneously. So I definitely understand and resonate with what those students are saying.
As for what to do to prevent that, honestly, I think it's a very difficult thing to do. The first thing is that you need to make sure that you have, in my opinion, I think you need to make sure that you have the right people leading the session. People who actually know what they're talking about. It's always painful, whether it's in school, in medical curriculum, or even outside of it when you have those EDI sessions, and you're sitting there and you're like, "I don't know if you really know what you're talking about here," or they get one hard-hitting question, you can tell that they're really trying to tiptoe about what they have to say, not to upset the institution and stuff like that, but also-
Dr. Mojola Omole: Do you have an example of that, Sabreena?
Dr. Sabreena Lawal: I'm not sure if it's so much as an example, but I think a common thing that can be difficult to work around is the defensiveness. So, it could be something like, we're in this space and we're talking about painful experiences of racism that happens and there's always, there might be someone who says, "I don't really get it. I feel like I'm really kind to everyone and I don't see color. I don't understand why we need to get so specific when we talk about anti-Black racism or other axes of oppression."
And, while a part of me wants to understand that they just want to be nice to everybody, when you do that, it's very invalidating of an experience that I as a Black person will have. No one will experience anti-Black racism except Black people. So when someone says, "Oh look, I don't see color," that's fantastic for you, but I do because I have no choice but to because this is the skin that I inhabit.
So it's the spaces where people get very defensive in that respect and not having someone who can really push why understanding your positionality, your privilege, and the fact that, while you don't have that experience, that doesn't mean that it doesn't exist for other people.
If someone is not able to do that in the educational environment, then it's not going to be a good session. I have had sessions where that's a thing that happens and the person who's leading it can't handle it. And then I don't want to have to be the one to push back against that sentiment because again, I'm trying to be the learner, but now I'm just, like, I've got to say something because this can't go on.
Again, it's like this, we're supposed to be learning. The person in charge should be ready to handle that because you should expect, well, that someone's going to say something. That happens all the time, but that now they're not. So what do I do? What am I left with?
Dr. Blair Bigham: Would you have any other advice? Let's say we have educators or deans or hospital leaders listening in today thinking, "How do I bring this anti-Black racism training into my institution in a more effective way?" Do you have any other sort of tips in addition to the actual engagement and execution of the curriculum with really good facilitators?
Dr. Sabreena Lawal: The key thing honestly is humility and listening. I feel like, for myself, and perhaps for other Black medical students, it doesn't feel like we were really taken seriously until 2020 after-
Dr. Blair Bigham: George Floyd.
Dr. Sabreena Lawal: …George Floyd's murder, when now learning about anti-Black racism almost became trendy. Then they're like, "Okay, let's jump on this wave." And then me and my friends are sitting here, like, "We've been ready to make this happen and now you are too?"
It was great, but I'm not going to pretend there was some part of me that wasn't salty. I was ready to make this happen. But I feel like, again, if we just had more space, had more respect for what we were saying and if there was just more humility and more listening from a higher level, it wouldn't have felt like we were and sometimes still are screaming into a void. So for any of those administrators out there, this is me telling you to just listen because there are already people at your institution who know what the issues are. They are there. It's not like you need to bring somebody else in or look for other expertise. The experts are there. You just need to listen to them.
Dr. Blair Bigham: Sabreena, thank you so much for joining us.
Dr. Mojola Omole: Thank you, Sabreena.
Dr. Sabreena Lawal: Thank you for having me.
Dr. Blair Bigham: Dr. Sabreena Lawal is a resident in otolaryngology at the University of Ottawa. Her article, Anti-Black racism in medical education: a curricular framework for acknowledging and learning from past mistakes, is in this month's special issue of CMAJ.
Dr. Mojola Omole: The anti-racism curriculum at Queen's is one of the examples of an institution confronting its racist history, but it also serves an example of how anti-Black racism is so deeply embedded into the fabric of medicine. So joining us today to discuss the problem, and possibly solutions, are Dr. Onye Nnorom and Dr. Kannin Osei-Tutu. Dr. Nnorom is a family doctor and a public health specialist. She's an Assistant Professor at the University of Toronto and is the co-lead of the Black Health Education Collaborative that was integral into the CMAJ special issue.
Dr. Osei-Tutu is an acute-care hospitalist physician in Calgary. He is the anti-racism and EDI Strategic Advisor to the CEO of the Royal College of Physicians and Surgeons of Canada. That is a very big title and long title. Thank you very much for both of you joining us today.
Dr. Onye Nnorom: Glad to be here.
Dr. Kannin Osei-Tutu: It's great to be here.
Dr. Blair Bigham: So I'm just going to start off, Onye, Queen's program offers an example of an attempt for progress in addressing the history of anti-Black racism. Where else do we see some progress being made?
Dr. Onye Nnorom: Yeah, so we are seeing progress, I would say, in quite a few of our medical schools, and we're seeing progress, I think, with regards to an understanding of Black health and an understanding of anti-Black racism really across the country to differing extents. So I can talk about that after, but when it comes to, for instance, with regards to having Black health in the curriculum, increasing representation, Queen's has really done a really great job at acknowledging their history.
Progress has been seen at University of Toronto for about 20 years, but we're starting to see the blossoming of the fruits of that labor, I would say' in the last four to five years. And so just to give a concrete example, at the University of Toronto, we saw U of T go from one Black medical student out of a class of 250 to 8, then 16, then 24. And I think now it's pretty much been consistent plus or minus five over the last few years because of the combination of U of T's summer mentorship program, which is for Black and Indigenous and other underrepresented groups in high school who are interested in health sciences. They get to spend the summer and be exposed. There's a community of support that helps Black and Indigenous and other underrepresented groups have access to what I call the dinner table conversation that those with privilege might have where they learn about research opportunities, they have mentorship opportunities, there's ways to cover their MCAT fees if they have that need. So the community of support provides access to that, again, dinner table conversation that other people in medicine naturally had access to if they were privileged.
And then third, there's a Black student application program, which is a more culturally-safe approach to admissions where Black folks, faculty, medical students, residents were involved in the process of the design, help with file review, are there at interview. So they review the files, they're there for interviews, and there's an opportunity for the students to feel like there is representation and connect with the Black Medical Student Association. That combination is being replicated across the country. This gives me hope. This is definitely progress. We're seeing better representation.
Dr. Blair Bigham: Onye, can you tell me a little bit more about that pathway for Black students being admitted, where they get that sort of culturally-safe admissions approach? And tell us a little bit more about how successful it's been. It sounds like it's been transformative.
Dr. Onye Nnorom: Yeah. One thing, I know there are folks listening and thinking about how it can be adopted in other schools. I want to give credit to community. Community was consulted on how to do this in an appropriate and culturally-appropriate manner. For us, there is no quota, and that was a decision by community - not to have a specific quota - when Black community members were consulted, but simply to have a pathway that welcomed or sent this flag that here at U of T we welcoming and look for Black medical students.
What had been done previously was a lot of people would do what's called bleaching your CV. So we're removing your identity as much as possible, removing your Blackness because you would be afraid of anti-Black racism, which is very dominant in medicine. So they didn't want to kind of have those biases, but now it's saying this is a safe space.
The criteria are exactly the same, GPA, the grades, everything is the same except there is a requirement to write a short essay. I think it's a couple of paragraphs simply stating why you're applying to this program. And there is the intentionality of making sure that Black faculty, residents, medical students are part of the file review and there on interview day.
So it's not actually a gigantic leap from standard admissions processes, but it's sent the signal that this is a safer process. I would say, beyond that, if we're going to talk about progress, the next issue that all the medical schools who are doing this need to grapple with, including the University of Toronto, is making sure that when you have this increased number of admissions, this transformation and the demographics of the classroom, that the students are not then experiencing anti-Black racism and emotional violence.
And we are seeing that, getting reports of that across the country, we know that has been the case in medicine and residency, and I'm sure Dr. Kannin Osei-Tutu will speak to that. But at U of T in the spring of this year, 2022, we had an event called Black At Temerty to bring public accountability and awareness around the anti-Black racism that not only created a barrier to admission, but when people get in, they need to be treated with dignity and given equal opportunities and have faculty that they can go to and research opportunities. So that's phase two of the progress that needs to happen, but that's basically the program, that's the success and those are the challenges going forward.
Dr. Mojola Omole: So just both, either Onye or Kannin could answer this. What are some of the pushbacks that you hear about this, the Black application stream, and also from the students? If they're feeling like they're targeted because they came through a Black application stream, and also what are some examples of the anti-Black racism that are being reported to you from the undergraduate medical education and also post-graduate medical education?
Dr. Onye Nnorom: Maybe I'll start for the undergraduate. So a Black student does not have to apply through the Black student application program. Because of that I haven't, at U of T anyways, heard concerns from students about the Black student application program. One of the things because anti-Black racism is so pervasive in medicine, was when community members, including Black physicians and Black residents were consulted about this and the concern about stigma, "Oh, you only got in because you're Black," or something like that. When those topics came up, people said people make all types of assumptions anyways, such that even in schools where there wasn't a Black student application program, which was most, there were assumptions that people came in through some sort of affirmative action like in the United States or didn't deserve to be there, or basically the anti-Black racism was so rampant there was a recognition that at least if there's a cluster, like a larger group that can be or stand up together, that would be more beneficial than worrying about the stigma of the program.
That has proven to be true. So I'll give an example for the Black Medical Student Association where they experienced assumptions or stereotypes with regards to some of the small group settings, they were able to go to the vice dean and address that as a group. So it wasn't the one student who was stigmatized, who was othered, who was made to feel like maybe it's you and not really the class. "Maybe you're too sensitive!"
By having a critical mass of students, they were all able to talk to each other and say, "Hey, there's a problem here." And so went to the vice dean, and came to me as well as the Black health team lead. "How can we change things in curriculum?" And then immediate action was taken so that in some of the small groups and things like that, there was a little bit more standardization. I think, at the time, the complaint was people were being asked to share their experiences of anti-Black racism, and the faculty didn't know how to respond to that and would respond either stereotypically or by dismissing them. So I would say that's an example of challenges students have felt, but it's more likely to be overcome if you've got a group as opposed to the one person by themselves. But I think Dr. Osei-Tutu can speak to PGME
Dr. Kannin Osei-Tutu: Yeah, I can speak a bit to PGME. I can also speak a bit to our experience at UME here as well. We do have a Black applicant pathway as well. And I think, when it was first proposed, there was some concern raised by Black faculty about the pathway, because Black faculty weren't involved with the process and therefore were concerned about potential stigmatization and potential other issues, unintended consequences that might be passed onto the medical students who choose to access that pathway.
Fortunately, I think it's been well-supported now that the pathway's been implemented and moving forward. We are seeing increases in numbers as well. And I think, by and large, the students aren't reporting any evidence of feeling more stigmatized by having accessed that pathway. To Dr. Nnorom's point, people are going to think what they're going to think regardless, and it's more important that we get the numbers and the representation at this time than worrying about other barriers that could be real or imagined.
So I think, overall, it's been positive. I think the barrier is, however, that we are still welcoming our Black students into environments that are harmful and hostile. And unless we are actively working to shift culture and change those structures and change those policies, these pathways and these pipelines end up being just leaky pathways and leaky pipelines where students enter, they experience harm, and they don't finish. We see this more commonly happening at the residency level within PGME, where, particularly in surgical programs, Black trainees tend to have harder times completing their training and their programs due to racism, explicit or implicit, and other factors that are difficult to ascertain.
Dr. Blair Bigham: Kannin, what does anti-Black racism look like? I think everyone understands explicits, everyone understands when someone is called a derogatory term, but most people don't understand what implicit looks like and if they're guilty of it. So can you explain, at the resident level, what does that look like to other people who are not necessarily experiencing it?
Dr. Kannin Osei-Tutu: Yeah, that's a great question. And I can tell you from my work with residents over the past couple of years, particularly around accreditation, where we've had conversations, there are experiences of, for example, not being believed by your staff when you're reporting a case. There's been stories of not having the same access to surgical cases in the OR, getting relegated to the wards while your white colleague is in the operating room getting access to cases, being evaluated differently, not being allowed to make the same mistakes. As a Black resident, if you make a mistake, automatically you're labeled as unsafe. As a white resident, it's considered a learning opportunity.
So those are things that may seem insignificant or subtle, but they completely can alter the trajectory of a resident in a training program over the course of their five years. So by the time they enter their senior years, they've already had a reputation, or an image created about them, that makes it very difficult to progress in their training. That's some of the feedback that the residents have shared with me.
Dr. Blair Bigham: And so is this tied into your work at the Royal College where you are looking at targeting anti-Black racism in a systemic way?
Dr. Kannin Osei-Tutu:
Absolutely. Yeah. That's been my focus over the past 18 months, exactly, to find the highest impact way to influence the system and really start transformational change, I hope, within the whole healthcare system. So we've been working within the context of accreditation to use the levers of accreditation to set new standards that will apply across the country. And our working group, in combination with the Indigenous working group, have produced 40 new standards that will be going into effect hopefully in 2024. And this will represent, in my opinion, the largest transformation and the biggest impact we can see in terms of anti-Black racism and anti Indigenous racism in the training environment.
These recommendations have to work their way through committee, but by all accounts, things are going very well. Just to give you an idea of some of the things that we're looking for, we're looking for an anti-racism policy as an institutional standard, which seems like a small request, but when you consider that of the 17 institutions in Canada, only two actually have a policy that specifically and explicitly identifies race. You can understand how systemic racism lives on.
Systemic racism lives in the policies that we have, and also lives in the policies that we don't have. And so having structures, creating new structures that don't exist or dismantling the ones that do exist, really is very important. So, setting zero tolerance for anti-racism is a first step, as a requirement. The next step is that institutions will have to have reporting mechanisms explicitly for race-based harm. They currently don't exist. You can access your discrimination pathway and find harm in that pathway because you meet people on the other end that don't have lived-experience with racism. So these pathways end up becoming ineffective because they're designed, whether intentionally or unintentionally, not to deal with racism. There's other pathways for other complaints. For example, a resident could get a needlestick injury and know exactly where to go and what to do when they're harmed in that way. A resident that has a racial injury has nowhere to go.
Dr. Mojola Omole: Most institutions have anti-discrimination policies. So how does the anti-discrimination policy, how is it different from anti-racism? How would that look like different for the students who are going through this?
Dr. Kannin Osei-Tutu: That's a great question. So I think one of the differences is that if you review the discrimination policies at the institutions across Canada, which I've done, they will name discrimination, they will name harassment, they will name intimidation more commonly now, they will name mistreatment, but they don't explicitly name racism. And even many of these policies that use the word mistreatment don't include racism as a form of mistreatment. So you have these policies which appear that they would be effective or that they appear that they would be capable of addressing a complaint about racism. Yet they're designed, either intentionally or unintentionally, not to be able to handle that complaint, and therefore they become essentially ineffective.
So one of the first principles that Dr. Nnorom and I will talk about when you're talking about anti-racism 101 is to name it. So we have to name anti-Black racism for what it is.
We have to name anti-Indigenous racism for what it is. Those names, those titles, labels, that verbiage needs to be in the policies. Otherwise, it gets ignored, it gets watered down, it gets brushed-over, it gets talked about as something else, mistreatment, EDI, some other term. That is a way to make other people feel comfortable and they can be aspirational goals, but they're not actionable.
So we've been very strategic in our ask for this policy. The requirement will be that institutions have to have an explicit standalone policy that addresses anti-Black racism and anti-Indigenous racism. They won't be able to use their existing pathways, which are ineffective. They need to show a standalone pathway specifically to address racism. And then, within that, there are requirements for a racial judicial panel that needs to be staffed by physicians with lived-experience. There needs to be other supports built into that process for residents as they're accessing that pathway. Those are things that we've implemented or included in our recommendations based on the feedback from the residents as to what would make them feel safe in going forward.
Dr. Onye Nnorom: Yeah, I think this work that Dr. Osei-Tutu is doing is phenomenal and so much needed, particularly here in Canada where we've been functioning, largely, if we're going to say as a field of medicine, under the illusion that racism is not an issue here in Canada, that we are not causing harm to our colleagues and patients due to racism.
But in particular, when we think about ... because this doesn't exist only in a vacuum. There's a reason why he's mentioning Indigenous and Black. When we have to kind of peel the strings or pull the strings of colonization one at a time. And so we have to understand that this country was really built fundamentally on two key pillars that allowed North America to be North America or Canada to be Canada. One is the taking of land and the dehumanization of Indigenous people as part of that rationale to take land. And the second is the taking of Africans for free labor, and the dehumanization of African peoples. And so the stereotypes that exist in what my colleague, Dr. OmiSoore Dryden, talks about as the afterlife of slavery, the legacy of it, the legacy of colonization is that you tend to see these two groups experiencing highly disproportionate disparities. Whether we're talking about health disparities, or we're talking about social disparities, or we're talking about the dynamics within medicine, how we have been kept out and the barriers that we face within.
So one of the key stereotypes of slavery, whether or not somebody has slavery in their lineage, the stereotypes that come with the phenotype of the darker skin and the curlier, kinky, coily hair is that, through slavery, it's that we were less human. We had a different pain threshold, less intelligent, not to be trusted. So when the surgical resident who is Black, perhaps somebody has those biases, again, comes from slavery and that's played out in our media and in our literature.
There's so many places where it still lives continuously. And that resident says this patient had such and such, but perhaps the white resident says, "No, I didn't notice that." The Black resident is not to be trusted, the Black resident in the OR makes a mistake. Now it's, "You know what? My gut is telling me that you should be out on the wards." But if Johnny who's white does it, he's seen as a full human being. And so he made a mistake. And so there's that empathy there and the offering of second chances. But it is not a coincidence that we need to address it first for Indigenous and then Black folks. And then we have to continue pulling that string of colonization and all other groups that have been impacted, but we can't leapfrog over our past. And two key pillars of our past is the treatment of Indigenous folks and the treatment of Black folks on this land.
Dr. Mojola Omole: You talked a bit about what the Royal College is doing in terms of accreditation for the medical students post graduate and medical education, but oftentimes when we maybe face the most anti-Black racism is once we're out of training and there's no longer any protection and we are in our institution. And whether it's even talking about having more inclusive hiring practices, because every organization likes to put out that and they welcome everybody into their interview process, but we all know who ends up getting interviews and who also ends up getting all the positions. So what's being done to reach other healthcare settings in hospitals when it comes to talking about anti-racism and anti-Black racism policies?
Dr. Kannin Osei-Tutu: Yeah, that's a great question and it remains a huge challenge. I mean, we know that there's a lack of Black physicians in leadership, for example, at the institutions. We don't have a single Black Dean, for example, in the country. And when we're not at the decision-making table, decisions are getting made for us by other people or about us by other people. And sometimes, even when we are at the table, decisions still get made in our presence that we expect to go a different way.
So part of the work that Dr. Nnorom and I are doing, we're looking at education curriculum, we're looking at access pipelines, we're looking at structures within the context of education to provide safety and support. Then, on the other side, we hope that the trainees and residents now won't just have to survive their training, but will actually thrive and can become the leaders in the future that are sitting at those tables, making those decisions, interviewing the candidates, setting the policy.
So that is the vision, that is the goal, and we are operating at multiple levels to try to achieve that, but we have to increase our capacity, our human capacity to do that so that we can get through the system, get on the other side, and try to influence when we're in those positions of leadership.
So, I'm optimistic that it's going to happen. I see the incredible talent of residents that we have currently, the incredible medical students that are pushing us as Black physicians to do more. I'm very optimistic that the future's going to be much different. If we meet again in 10 years… It's going to take time, but, if we meet again in five years or 10 years and have this interview again, I think we'll be having a different conversation. Some things will be the same, but I think other things will have changed significantly.
Dr. Mojola Omole: Onye, we've had several guests speak about the need to develop an Afrocentric lens for healthcare for the Black population. Can you try to just explain to us and our listeners, what does Afrocentric healthcare look like?
Dr. Onye Nnorom: Afrocentric healthcare, or I guess anything that we do that is Afrocentric, is anchored and focuses on the values of African peoples. So our values, and sometimes our beliefs, as well. The work that we did at TAIBU Community Health Centre, which is a health center located in Scarborough here in Toronto that has a mandate to serve the Black community in the greater Toronto area but also serves the very diverse community in that geographic community as well… it now has a mandate to serve Indigenous communities and French communities as well.
We have low cancer screening rates. We decided to use an Afrocentric approach, which means speaking about community. Even within our providers, we framed it as not about statistics and not about just numbers of who is screened, but really caring about the dignity of others.
There's a South African principle called Ubuntu: "I am because we are." And so we incorporated that. Not only thinking about our patients, we told them that we were getting screened. We asked them about what the barriers were, and we listened. We engaged in deep listening. We did this for cancer screening, we did this for flu vaccine and just listened to what people said were the barriers without arguing with them, without belittling them, without interrupting them, which we often do in medicine. And then we started to address those issues. So whether it was their fear that they would go and have a mammogram with a male, perhaps, we let them know that there was a female technician. And in fact, right across the street was a Sri Lankan woman who is the technician there. So we took her picture, we had information about Black representation.
Again, in a lot of African humanities, experiential knowledge matters. So it was part of our pamphlets to say, "We got screened. Have you?" Those same principles helped to increase breast cancer screening at the center. So we were able to triple it, more than triple colorectal cancer screening and increase cervical cancer screening. When COVID-19 hit, we knew that Black communities were disproportionately impacted. We knew that there was distrust for the vaccine, given the history and legacy of experimenting on Black folks, but also our everyday experiences of racism in healthcare. And so the Black Physicians Association of Ontario, we came together, realized that we were positioned to address this, and use the same principles of Ubuntu in our mass clinics, of welcoming people, introducing ourselves as opposed to just "line up here and get a vaccine." We worked with our Indigenous colleagues to incorporate some aspects of cultural safety, but we certainly incorporated Ubuntu, of just being there and caring about the person and their dignity as opposed to just the vaccine.
Some people came and they didn't want the vaccine, but we were there to answer their questions with dignity. We were there to do that deep listening. We were there to provide PlayDo for their children, or food or music or what have you, such that not only Black people came to our clinics, but we saw Indigenous folks come to our clinics, other racialized folks, differently-abled folks from different walks of life, people who had been previously incarcerated or even international agricultural workers. It became a place and spaces for people who were experiencing marginalization to feel heard and to feel safe. And I think that is an example of how you use Afrocentric approaches to better serve Black communities. But actually going away from the Eurocentric approach and adding an Afrocentric approach, and also we also consulted our Indigenous colleagues, made it such that we were able to offer clinics and serve very diverse communities who often feel othered, excluded, or experienced violence in our healthcare systems.
So that's basically what it's about. It's Afrocentric and beyond, I guess. And if I may, it also brings the point of why equity matters, why equity is part of excellence. Because for those of us who have been left out of medicine, particularly Black and Indigenous, we have approaches that all of healthcare can benefit from. So these programs are not just about having the number of Black people increase, it's really about transforming medicine and providing better care if we do it well.
Dr. Blair Bigham: For sure.
Dr. Mojola Omole: How optimistic are you that medicine is making progress and real concrete progress in combating anti-Black racism in the near term?
Dr. Kannin Osei-Tutu: So neither Dr. Nnorom or myself are naïve, but I think we're both idealists, which is why we're doing this work. I think that there's never been a better time and a better opportunity for change to happen. At the same time, when that opportunity and the momentum starts to shift, the resistance also increases. So we have, I feel a window, and probably a closing window, where we can make a dent and make some progress and some steps forward.
I think we're going to do that. I think we're going to get through that window. What it looks like on the other side remains to be seen. We have a sphere of influence within education and within residency education, which is an impactful sphere. But then there's a larger system that also needs to change and move with us. So, to the extent that we can be a catalyst, our work will continue. What it looks like on the other side is going to depend on allies, partners, other people that want to be part of the solution.
Dr. Onye Nnorom: I'm more radical than Dr. Kannin Osei-Tutu, which he knows, I tend to be more radical. Yes, we have a window, but I'm really determined and hopeful that we keep it lodged open. And that's effort that's required from Black physicians, Indigenous physicians and allies to keep that window open. Because not only does it matter for the field of medicine and for our colleagues, but the price is too great for our patients.
We do know of cases here in Canada where we know through social media that a patient died or did not have the treatment they needed because of biases due to their skin color, due to racism. And then there's all the cases that we don't hear of that are happening right now in healthcare, where people are dying because of anti-Black racism and other forms of racism and oppression. And so the cost is too great to a field where we made a vow to do no harm. Harm is being done, and we have to be committed to leaving that window wide open so we can address it. I'm radically hopeful.
Dr. Mojola Omole: Who's trying to close the window? Who do you think is trying to close this window though? What is this obstacle that's trying to close the window?
Dr. Onye Nnorom: I'll be blunt, white supremacy sometimes is trying to close that window. And I'm not talking about people dressed in white with the Ku Klux Klan kind of thing, but people understanding that the way we have functioned and the way that it has disproportionately advantaged certain groups, particularly like white males, of course there's going to be resistance. And I think there's a natural resistance to change. I studied at McGill when we were trying to deal with C. difficile, and they were telling everybody to wash their hands. And I remember the resistance, "It's going to slow us down." Even something that's basic microbiology that we all studied, that change, that cultural shift was very difficult at that time. And that was just like the early 2000s. So I think it's a combination of both. We are resistant to change in medicine, and there is, I think, a desire among some to keep status quo, because it's been to the advantage of certain folks with power. So I think that's trying to close the window, but I think so many of us can see the benefit of leaving it open.
Dr. Kannin Osei-Tutu: I agree with that. I was going to add that one of the biggest things we need to be alerted to is neutrality. So, those who want to maintain the status quo, those that don't think things can change while racism is killing people. If we maintain the status quo, racism continues to kill people. I think it's the most untreated and poorly treated disease in medicine.
Dr. Blair Bigham: So there's obviously urgency to dismantling racism and the impact that it's having on people, whether they're working in the healthcare system or trying to be served by the healthcare system, is through the roof. So I'm a white guy. What can white men do? What can white people do who say, "Oh, I'm an ally," to better understand their own implicit biases and how they can really contribute to the change that needs to happen far more quickly than it's going to?
Dr. Onye Nnorom:
I would say three things. Earlier, I mentioned the need around decolonization and starting from the beginning. So I would say first you need to do Indigenous cultural safety. Kannin and I are both involved with the Black Health Education Collaborative that's going to be teaching around Black health and anti-Black racism. To listen and learn from experts, but also community members and support changes.
So the work that Dr. Osei-Tutu is doing, when it comes really into our real life, not resist those structural changes. And be part of that change, it's going to be structural, it's going to have to be major. And so deciding if you're going to help co-lead or you're going to support or you're going to speak up at the table becomes key. But, ideally, before you do that, you've done some reading and some listening to know what you're talking about as an ally. So it's all of those things, I think.
Dr. Kannin Osei-Tutu: That's wonderful. And I think that you can operate on at least two levels, the individual level, what you're going to do as an individual in this fight and what you can do on a systemic level. As an individual, I think that to become anti-racist, it is a process. You have to make a decision, am I going to become anti-racist? Is that important to me? And what does that look like?
Because it will require a fundamental reorientation of thinking about the world in a different way than you've looked at it before, acknowledging your own privilege, acknowledging perhaps harms that you've caused, acknowledging times when you've done well in that space, and what does that mean?
So you have to want to get better because it has to be important to you if you recognize other people, not as others, but recognize the shared humanity in other people. It is a process that you have to engage in. And just like going to the gym and working out, it requires flexing those muscles.
On a systemic level, as a white male physician, you are in the room, you have access to power, you have access to decisions, you have access to the structures and the policies. You know how they work for you. You know how they don't work for other people. And as an ally, you can make a decision to try to change those structures and policies. Those are two areas I would say to start.
Dr. Blair Bigham: Thank you.
Dr. Mojola Omole: Wonderful. Thank you very much for joining us today.
Dr. Onye Nnorom: Thank you for having us.
Dr. Kannin Osei-Tutu: Thank you. It was great being here.
Dr. Mojola Omole: Dr. Onye Nnorom is a family doctor and a public health specialist. She's Assistant Professor at the University of Toronto and is the co-lead of the Black Health Education Collaborative. Dr. Kannin Osei-Tutu is an acute care hospitalist physician in Calgary. He's the anti-racism and EDI Strategic Advisor to the CEO of the Royal College of Physicians and Surgeons of Canada.
Dr. Blair Bigham: Jola, how does it make you feel to know that we have this special issue on anti-Black racism in Canada, as a Black physician?
Dr. Mojola Omole: That's a bit of a tough question for me because I worked with the CMAJ, I was on the working task force for the special issue, and it definitely has been a labor of love. And there were some stops on the road, but we were able to get back on track. I'm super proud of the work that's been put out, but I would be lying if I didn't say that I'm exhausted.
Talking about anti-Black racism, something that occurs to me pretty regularly in medicine, is exhausting. And I find that I'm probably going to sleep about 10 hours tonight because, to be honest, the shit hurts. Because part of it is, as we're talking, I start reflecting on some of my own experiences. And I can imagine other people in the audience, especially when Dr. Osei-Tutu was talking about surgery tends to be the discipline that we notice the anti-Black racism more, that there's probably some female surgeons who trained 20, 30 years ago that will say, "That happened to me too. How is this different than when they were mean to us for being the only women in the training program?"
And I would say, as someone who intersects being female and being Black, is that it is very different, because when someone discriminates against you based on your perceived gender, there's usually numbers in that. And so it's kind of like, well, the otherness doesn't feel so otherness, but when someone discriminates against you based on your skin color and it's anti-Black racism, it really cuts really deep. And I can say that even up to four years ago, I had an incident in an operating room that I left, I went upstairs, I called my cousin, I described it to her, and she was like, "Sounds racist to me," and I just bursted out crying because that vulnerability comes back out. And you feel, because you know that when it comes to race and Blackness is that there is a lack of social power. This has social ramifications beyond that moment. And I tend to be the only Black person in certain operating rooms, and so, therefore, it really just magnifies that.
I would say that it probably is akin to, if you're speaking to someone of Indian descent, of what colorism is, because part of colorism is a caste system. It determines who you're going to marry, what social capital you have, and that's what it's like to be Black in Canada, is that, and especially in medicine, is if you have one bad evaluation as a resident, or if you have mistakes, it's viewed very differently. A complication, all of us, Black physicians, Black surgeons, were terrified of having complications because it just feels as if people will view that as, "They're not that strong, they're not that great." And you know that you have other white counterparts, usually male, who can do no wrong.
Dr. Blair Bigham: Jola, you've put in all this effort, this special issue is a total knock out of the park. Every single article in it is so amazing. What, in your wildest dreams, will come of this and this sort of focus of CMAJ on this special issue? A quantum leap forward, what does success look like when it comes to getting rid of anti-Black racism in Canadian medicine?
Dr. Mojola Omole: I would say that when it comes to the journal itself, some of the work that we did discussing how articles are reviewed, that work continues. and that we use that same critical lens when we look at other marginalized groups when they want to publish within these journals. Also just being supportive of researchers from underrepresented groups in medicine.
So that's what the promise has been from CMAJ to continue, that it doesn't end with a special issue, but that work continues within the community to encourage under-represented groups in medicine to continue to submit for publishing.
Dr. Blair Bigham: Well, we've heard from some amazing speakers, who have dedicated substantial amounts of their professional lives to righting the personal wrongs that anti-Black racism in Canada has aggrieved on them. Jola, you're one of those people. It's an honor to have been involved in this podcast and these two special issues. And I hope that this podcast has those positive outcomes that we all hope for, and that we can all contribute to incremental change or massive change, quantum leap change, that is needed to level the playing field and bring fairness to our shameful history.
If you have a chance, it'd be great if you could like or share our podcast wherever it is you download your audio. Until next week, I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole. Until next time, be well.