Sheryl Nestel, Guest Blogger
The launch last week of Colour Coded Health Care: The Impact of Race and Racism in Canadians’ Health, was, by all measures a tremendous success. Clearly, that the issues raised by the report are of immense interest to health researchers, health care workers, social scientists and community activists.
One of the most promising aspects of the report was the use of critical race theory in order to analyse racial inequities in health. In Canada, we tend to labour under the illusion that we are less racist than our neighbors to the south and that our system of universal access to health care prevents those health disparities which occur in the American context from occurring here. Ironically, some recent American research has been instrumental to us in re-evaluating that claim.
A report by the U.S. National Academy of Sciences published in 2002 entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care found that even under conditions of equal access to medical care (such as Veterans hospitals), significant disparities in health outcomes were evident for racialized people. It is this aspect of the US study that renders its result relevant in the Canadian context. Moreover, Unequal Treatment broke new and controversial ground by focusing on the complex causes of inequalities, suggesting that racism in institutional practices, as well as caregiver bias and stereotyping were a significant source of racial inequalities in health and health care thus shifting the focus from patient race as a cause of health disparities to an understanding of racism as a major contributing force in the production of health inequities.
In preparing this review we drew on a body of critical race theory in use in the social sciences and humanities; that cross-disciplinary conversation has proven very fruitful. One of the most important principles drawn from that area of scholarship is the de-linking of concepts of race from mistaken notions of biological hierarchies of human worth. While long discredited, the idea of race as a marker of biological difference is still with us. We saw evidence of this in the responses to both the SARS epidemic of several years ago and the threat of the spread of Ebola virus, both of which linked racialized bodies and contagious disease in ways that were reminiscent of the 19th rather than the 21st century. Instead, we prefer to see race as an imagined hierarchy of human value based on phenotypes, skin color, culture and other fantasized expressions of group inferiority. Slavery and genocide, in the worst cases, as well as exclusion, segregation, inferiorization, discrimination and other forms of systemic and interpersonal injustice have been based on imagined racial differences.
Rather than thinking of racial identity as a biological fact, we prefer to follow critical race theorists in thinking of race as a process through which inferiorization comes to be conferred upon people based on historical, sociological, and geographic factors to name but a few. When we think of people as “racialized” rather than being of a specific race we turn away from biological notions of difference and inequality and are forced to seek other explanations for racial disparities in health. Moreover, critical race theories demand that we understand how racial identities are produced in and through their relationship to gender, sexuality, ability, class and other markers, which must be taken into consideration when thinking about unequal outcomes.
Another approach from the social sciences and humanities that has been helpful in thinking through some of these issues is postcolonial theory. One of the most important voices in this area has been that of the late Frantz Fanon, the French-trained Martiniquan psychiatrist who practiced in colonial Algeria. Fanon remains one of the most trenchant analysts of the encounter between the dominant and the subordinate, arguing that under colonialism, a historical and sociopolitical context of radical social inequality profoundly shaped the encounter between the patient and doctor. We can use Fanon’s anti-colonial insights to understand our own postcolonial context of racial inequality if we heed his observation that:
In the colonial situation, going to see the doctor, the administrator, the constable or the mayor are identical moves. The sense of alienation from colonial society and the mistrust of the representatives of its authority are always accompanied by an almost mechanical sense of detachment and mistrust of even the things that are most positive and most profitable to the population.
In many ways we can see the parallels with the responses to the medical encounter of today’s racialized patients. Interestingly, research with Canadian physicians shows that they are reluctant to acknowledge that power disparities shape relations between socially subordinate groups and their physicians. When health care providers describe marginalized patients’ behaviours as non-compliant and ascribe these to “culture,” they do not take into account that a patient’s behavior might actually be a resistant response to an untenably unequal encounter. Fanon argued that by foregrounding the colonial context we can arrive at other, more power-cognizant explanations for the behaviour of the racialized “other.” It seems that foregrounding race in our context can help to explain much about the behaviour of both the physician and the patient in the contemporary clinical encounter.
Sheryl Nestel received her PhD from the Department of Sociology and Equity Studies of the Ontario Institute for Studies in Education of the University of Toronto where she taught between 2000-2011. She is the author of numerous journal articles on race and the health professions as well as of Obstructed Labour: Race and Gender in the Re-emergence of Midwifery (UBC Press, 2007) which was recognized as the book of the year for 2007 by the Canadian Women’s Studies Association.