Racism and health care
We must acknowledge the impact of white-supremacist logic here, argues LaRon E. Nelson, even though it's a difficult conversation to have
LaRon E. Nelson is a Toronto-based public-health nurse practitioner and researcher working in Canada, the United States and Africa.
I am from Savannah, Ga., one of those places where there were very particular expectations for what black boys did after high school, and the military was one of them. My commanding officer suggested I should go to college. I had to take a special test in order for the navy to pay for my tuition. The test listed particular occupations that I would be good at, and nursing and law were first on the list. Because you had to go to graduate school to get a law degree, the military wouldn't pay for that. So my only option was nursing. I had no interest in it, but here was my opportunity.
When I was an undergraduate, I didn't have a lot of money, so I lived in a very rough, low-income neighbourhood. It was very different from the type of neighbourhood I grew up in and I found it fascinating. I would look out my window at night and see things that I had never seen before. People behaved in ways that were bizarre to me. I don't think I'd ever met somebody who was high on drugs before.
I really wanted to be out in the street working with people, because when people were sick or struggling with their addiction they almost never went to the hospital, they always went to community clinics. I wanted to be there.
The clinic was organized so the nurses could do the intake and assessments, but if there was something more complex – such as a pelvic exam – a nurse practitioner needed to see them. I was seeing a transgender woman and I went out of the room to get something. I was the only nurse practitioner in the clinic and a nurse asked if I could see a complex patient who had been waiting for a while, and she would finish seeing the transgender woman. So, I did that.
All of a sudden, I hear this commotion. The transgender woman was very upset that I had abandoned her. I had done the assessment, she had disclosed these things to me, I left the room and all of sudden someone else comes in.
It was a really bad scene. I was upset because I felt totally misunderstood and misrepresented. But it also made me think about that person's experience. I should have known that there was a better way to transition, given the stigma that folks in this community face. I should have said that something had come up, I needed to see another patient and somebody else would come in and see her. Very simple; a 30-second transition.
I always felt as if you just need to be nice to everybody and things will be okay. But that experience taught me that there are particular nuances of people's life experiences that we can't ignore.
She left and didn't get the care that she came for, and that experience could influence how she engaged with health care in the future. That really made me think about how to work with populations that are stigmatized and marginalized, and the "innocent" ways that providers can cause harm.
The challenge in Canada is a failure to acknowledge the impacts of racism and white-supremacist logic in health-care encounters. Race is so front and centre in the United States that you just can't ignore it. I think in Canada, it's ignored even though the impact is there.
I was in clinic once, and we were reviewing the patients we were supposed to see that day. One of them was a teen mom from an Asian family whose father had kicked her out. We had seen this before – when there's conflict in a family after a young woman becomes pregnant – but this case was extreme. So, I go in the exam room to see her. I pull off the cover from the baby carriage … [wait for it] … It's a black baby! Hello! Nobody thought to say that she had a baby from a black man and that this had something to do with why her family was totally rejecting her. It didn't come up at all! I don't think they were being malicious, but I see that a lot here.
In the United States, somebody would have immediately said, "Listen, she has a baby from a black man. We've got to pay attention here, because it could be a source of conflict with the families." Then it could have been addressed from that standpoint. That's one example, but I think it happens on a broader scale and has implications for how providers play down the role that racism plays in some of the challenges that patients face. For example, studies have shown that patients in the ER who are black are less likely to get pain treatment. That is real. That happens today.
It's a hard conversation to have because when people think about race, they don't think about whiteness as race. In many people's minds, race means other people with different colours. It's hard because sometimes white individuals respond as if they're being personally attacked. "I am not doing anything to discriminate against somebody. So why are you targeting me?" Without understanding that you, the white person, get to benefit from whiteness as a race even if you are not "doing anything."
People must see that they are being complicit in a system that privileges whiteness and criminalizes blackness and Indigenous people.
It's been hard in the United States, but they have been grappling with anti-black racism for a very long time. I don't know how to do it in Canada. I think it could be touchy – it's painful!
We have seen some developments over the last year or so that are encouraging, such as the emergence of Black Lives Matter Toronto and its intervention in the Pride Parade. The LGBT community tends to talk about LGBT in general terms, without any attention to the fact that there are black people within the LGBT community who do not have the same experiences as whites. The privilege that allows mainstream LGBT leaders and communities to say "we're all the same" when it is politically expedient and ignore the realities of life for black, queer, same-gender loving and trans people is something that should be exposed through social protest and ultimately changed. I think people are recognizing that there's a need to really look at who we are as a society.
This interview with Andreas Laupacis first appeared in Healthy Debate, an online publication guided by health-care professionals and patients that covers health policy and evidence-based medicine in Canada. This version has been edited and condensed.