One of the main uses of history is to help us do better in the future. For my black history talk for Toronto Public Health I focused on initiatives that have been put in place elsewhere to decrease the impact of racism on health. If you read a good idea here, steal it.
The scientific literature on disparities in health between white and racialized groups is growing all the time. And we now understand many of the complex mechanisms through which racism impacts health. Some of the harmful effects are caused by racism induced stress on an individual, some are because racism leads to economic and social inequality, others still are linked to inadequate or inappropriate medical and social care offered to racialized groups; and last, there are reports that industry specifically targets vulnerable populations in advertisements for cigarettes and fast food.
Just as the impacts of racism are complex, so are the different ways countries have tried to combat it. I have surveyed the work in the US, UK, Australia and here in Canada. There were a lot of different interventions. Here, I focus on 15 that I think could be put in place, or at the very least start an interesting conversation in Toronto. Do not read anything into the fact that positive discrimination is not included – it is known to work and level the playing field but I chose not to include it here this time.
These initiatives are grouped initiatives into three buckets: those that decrease racism, those that increase resilience, and attempts to increase equity in services.
1. Decrease Geographical Segregation
If we could move towards John Tory’s call for One Toronto we would decrease the impact of racism on health. At the moment Toronto is three cities with three different trajectories. Using David Hulchanski`s Three Cities Map, City 3 on the outskirts is predominantly racialized and is becoming poorer while City 1 down town is 84 percent white and getting richer. As the disparities increase so will the racialization of health in Toronto. When different communities are linked the differences between them diminish. If different parts of the city work together, the knowledge, power, social links and expertise in the city are more equally shared. Therefore wealth is more equally shared and disparities due to race decrease. If the city and other institutions want to move towards One Toronto they will need to take action to make different parts of the city work together. A way of doing this is to require applicants for new funding to demonstrate how their project would promote One Toronto. This could stem the tide of segregated money, power and access. For instance, funding schemes could require City 1 applicants to include City 2 and City 3 applicants as full partners and vice versa. We would link the creativity in City 3 and 2 with the access to power in City 1 to decrease the disparities in Toronto that will cause racial inequalities in health. Proximity and shared goals decrease racism.
These sorts of schemes are not new. When the European Union welcomed the former Eastern Bloc countries they looked to integrate them by making a proviso of some new funding schemes that you had to include a former Soviet Union country alongside existing long standing EU members. This is just one example.
2. Ensure Youth from Different Groups Interact with Each Other
The more time individuals from different groups spend together, the less racism there is. If we want to decrease racism we have to actively ensure that different groups mingle. One way of doing this is by making multiculturalism part of the curriculum. But not just in theory, it needs to be multiculturalism in action. An initiative that would decrease racism across Ontario would be to use one week a year to get youth from different backgrounds to meet. Those from rural Ontario could mix with those from cities. Those from the outskirt of Toronto could mix with those from downtown; those from bigger cities could mix with those from smaller cities. Racialized youth would mix with non-racialized youth. Youth would attend culture camps for one week in each academic year. They would be residential and away from where they live. Small groups of youth from different schools would come together so none was isolated but also so educators could ensure mingling. The youth would have to do group activities and a joint project. Culture camps would increase the ability of youth to understand others. They could change the tone of discussion in the next generation from “them and us” to “us.”
3. Get Involved in Politics
What politicians say matters. A way to decrease racism is to join a political party and change what they say and do about racism. Studies have shown that the views of racism in the population mimic those of political parties. If we want to decrease racism then political parties, of all alignments, need to lead. In order to do that they need people in them who think this is important. In the 1980s and 1990s in Canada it was the strategy of White Supremacists to infiltrate political parties by running for seats. Their aim was to change the political tone and roll back the rhetoric on multiculturalism. If we want our Governments to lead on racism then anti-racists need to help them.
4. Use Race Impact Assessments for New Policies
When I left the UK all Government policies were supposed to undergo a race relations impact assessment. The assessment question was simple: will this policy have positive or negative impacts on race relations or on a particular racial group? The impact assessment was published alongside the white paper. If there was likely to be a negative impact on race relations the Government needed to demonstrate what they would do to mitigate this. Race relations impact assessment makes Governments reflect makes Government transparent and opens up important discussions. It helps Governments and policy makers who want to decrease the impact of racism ensure that their actions do not by mistake increase racism and its impacts. Ontario already has a model of Health Equity Impact Assessment. The Ministry of Health and Long Term care have a great tool, super training and communities of interest online. If those creating policies used the same methods, scoping, impact assessment, mitigation, but focused on racial disparities they would have a viable model for race impact assessment. In fact this would be very similar to the methods used in the UK. Race Relations Impact Assessment is a cheap and efficient way of any government stamping out unwitting discrimination. If a government is committed to decreasing disparities then analyzing new policies using this lens seems like a good idea.
5. Get into People’s Fantasies to Change Their Reality
Racism grows in people’s fantasies. Studies show that stereotypes that are set in the media are important. They change the way that people think about racialized groups and change their support for policies that decrease racialization. They also change the self-esteem of some within racialized groups. Both self stigma and external stigma have important impacts on health. Your chances in life can be limited by your view of what is possible but are definitely limited by what other people say is possible. The media may be important here. For instance, some have focused on how Obama came to office. It had always been unthinkable that an African American could get the Democrat nomination. What changed? Years before Obama came to office another African American president was seen on the screen; President Palmer, from the long running, award winning series 24 starring Kiefer Sutherland, appeared for 72 episodes. Some have argued that the fact that Palmers race ended up not being a big issue and that the series did so well was influential in the choice of Obama to be the Democratic nominee. Palmer demonstrated that having a black president on TV may be possible and acceptable. Fantasy is important for helping us to change reality. It changes what is imagined to be possible. There is current discussion about whether Idris Elba will be the next James Bond. That single act could do a lot for changing racial views worldwide. But closer to home the CBC may want to consider what it is doing to develop series with diverse Canadians in lead roles that are not about race or slavery. Where is Canada’s President Palmer?
6. Decrease Racism in the Workforce
Decreasing racism in the workforce is important. This needs functioning race relations policies in the workforce, and is helped by hiring of a diverse staff but relies on leadership. Having a diverse board and executive group ensures that no one in an organization is left behind because of their race. Widening and deepening the work of the Maytree Foundation with their Diverse City fellows, the next generation of city leaders and board members will improve race in relations in the workforce. This will decrease racism at work and the impact of race on health in Toronto.
7. Strengthen Hate Crime Law in Canada
There are nearly two thousand Hate crimes in Canada each year. But there are many more that never get documented or brought to prosecution. Firm enforced laws on hate crime decrease racist acts. They give a firm message to the population that racism is not tolerated by the state. Prosecuting hate crimes in Canada is difficult. This is in part because you not only have to prove the crime but also that it was intentionally motivated by hate. However, human rights law only requires proof of harm, not of intent. If hate crimes law was better aligned with human rights law this may make it easier to prosecute racially motivated crime.
8. Avoid Unnecessary Mention of Race in the Media
The print media can inadvertently promote racialization. Flick through any paper and see how many times race is mentioned. Then flick through it again and see how many times when it is mentioned it is actually relevant to the story. In some countries there are regulations stating that race can only be mentioned in a story if it is directly relevant. Use of the race of a person as a way of describing a person is considered part of the method of racialization of a group. If we want to decrease the racialization process, where race is made to be important where it may not be, then we should push for race only to be used when it is really relevant. This could be done by law or by the press regulating itself.
9. Create Public Awareness Strategies
Public awareness campaigns can decrease the amount of racism in an area if they are done properly. An awareness campaign which increases people’s awareness of the impacts on racism on health may help decrease racism. These can be tricky to get right but the important factors are promoting the similarities between groups before the differences, trying to change racist behaviors and actions rather than trying to change people’s beliefs and giving people positive skills to combat racism. A decade ago, Murdoch University undertook a study of the important facets of an anti-racism public awareness strategy for Australian provincial government. Their report on the dos and don’ts has stood the test of time.
10. Start Or Join A Local Anti-Racism Group
Set up a local anti-racist group. There has been some question as to whether setting up an anti-racist group to comment on racism locally, in politics or in the media actually increases the visibility of racist groups. But, studies show that being silent about racism is seen as tacit support. It emboldens racist groups and increases their recruitment. Anti-racist groups make a clear statement that racism is wrong, they support Canadian values and decrease recruitment to racists groups. They decrease the amount of racism in an area. There are a number of websites that will tell you how to set up your own group.
11. Teach Resilience in Schools
Much of the work on increasing resilience has focused on schools. In Toronto anti-racism could be taught to all children as part of the curriculum. This would be in line with our Canadian values. Such a curriculum could be based on the idea that multiculturalism is part of our heritage and is a positive force for building Canada. Rather than focusing on the negative, the curriculum could be strengths-based and focus on the fact that multiculturalism is a national treasure. It would include the fact that protecting multiculturalism and so fighting racism is everybody’s business not just that of those who face discrimination, then it would teach skills for dealing with racism, negotiation and resilience. These transferable skills will not only build a better and more resilient next generation, they are also important life skills for all Canadians. For specific communities who are at risk of racism studies have shown that actively coping with racism, positive group identification and social support decrease the impact of racism on health. These can be promoted at school or in the community. Resilience training in schools would help support all of these.
Increase Equity In Services
12. Legislate Positive Race Relations in Public Services
The Race Relations Amendment Act in the UK made it incumbent on public bodies to do three things: promote positive race relations, ensure service equity, and prove that there was no inequity in the services they offered (so they had to collect data). If a public body, including a health provider, did not manage to do these three things they could be prosecuted. Any person could raise a complaint and this could lead to prosecution. The UK Audit Commission reported that the single most important intervention for improving health service equity in the UK was the Race Relations Amendment Act. Fear of prosecution was the main lever for service change. The Act was not proscriptive, it allowed public bodies to be creative in how they improved services, but it was quite clear about what the duty of a public body was. Canada and Ontario should develop a specific act for public services to underline their importance in improving race relations and delivering equitable services. That Act should have teeth if it is to make a change.
13. Fund Programs Based on Equity Compliance
The Lord Mayor of London, shortly after the millennium, discharged its race relations duties by simply saying to any company that wanted a contract from them that they needed to demonstrate they had a race relations strategy in place. The National Health Service in the UK is thinking of going further. They have noticed that some companies have a highly diverse workforce but that it becomes less diverse the higher up the hierarchy you get. They are considering a process whereby, to get their full funding, hospitals would have to demonstrate that they not only have internal race relations policies but that people of color can rise through the ranks. The dual importance of these sorts of policies is that they make sure that the use of public money is in line with the values of society and they help industry to develop processes that improve them. Public services can decrease the impact of racism and health by direct provision of services as well as by ensuring that one of the most important social determinants of health – work – is equitable. Equity of services is considered quality of services. The City, LHINs and Provincial Government should consider including similar stipulations in their contracts.
14. Collect Data
If you do not count people they do not count. This is a simple democratic principle. With regards to race and health, if there is no data it is difficult to document what is happening and whether any initiatives improve matters. When the UK developed a strategy to improve mental health services for its diverse population – Delivering Race Equality – it set up a yearly census of all people in psychiatric hospitals to ensure that the strategy led to improvement. Thirty-thousand people were surveyed each year and the results such as length of stay, what types of care they got etc. were reported by ethnic group. Everyone could see where the disparities were. They could see possible targets for improvement and year-on-year whether their health service had decreased differences between groups. Each hospital was sent their own data so they could see how well they were doing at meeting the need of diverse populations. In Ontario, there is welcome progress here in Toronto Central LHIN to collect socio-demographic data. It is being done at all hospitals. But it would be better if data was collected across Ontario. If everyone filled in a form with their ethnicity when they renewed their OHIP card, we would have data on services use for ethnic groups. Ethnic group would not be on the OHIP card itself, data on ethnicity would not be held with an individual’s name anywhere, but in data vaults with the right privacy controls, OHIP number and ethnicity could be linked for assessment of the equity of our services. We already collect data on all OHIP service use for each card; we know the gender of the person using their card, age and the general area they live in. This would add a new layer to the data. We would be able to monitor service use and morbidity and mortality by ethnicity easily and report that each year. We could identify disparities and promote equity in treatment. Each person would only have to fill this is once and we would have all the data we needed for as long as we needed it.
15. Get The Right Research
There is not a lot of good research on the health of diverse populations. This is in part because racialized groups often do not get into research studies. In the US the National Institutes of Health developed a policy which said that researchers had to demonstrate how they would get people from diverse communities into their research studies. This increased both access to research and the ability of research to investigate ethnic differences. However, there are other issues in research. One is that we have a lot of research on access to care and much less on interventions to improve care. Moving the lens of research now away from inequalities in access towards looking at inequalities in outcome of treatment – and how to decrease them – may be more likely to have an impact on disparities in life expectancy.
If we believe in excellent health care for all, health equity should be part of our health leaders’ performance reviews. These 15 historical ideas all have been either developed elsewhere or actually tried with some success elsewhere. We can decrease racism and its impact on health. But we have to change how we are currently working if we are going to have an impact. Take any of these ideas, steal them, and use them. And let us know how you got on.
Dr. Kwame McKenzie is the CEO of Wellesley Institute. This post was from his talk on February 12, 2015 for Toronto Public Health, Black History Month. To download the slideshow: Race and Health TPH Feb 12 2015 McKenzie