‘In Dialogue’ Episode 12: Anti-Black racism’s impact on healthcare
In episode 12 of “In Dialogue,” CPSO EDI Lead and Medical Advisor Dr. Saroo Sharda speaks to Dr. Natasha Johnson, a paediatrician and inaugural Associate Chair of Equity, Diversity and Inclusion in the Department of Paediatrics at McMaster University, about naming racism and engaging with communities to understand their diverse needs, considering the micro, mezzo and macro levels when developing strategies, and history’s influence on interactions with the health system.
Dr. Johnson is an Adolescent Medicine Specialist and Associate Professor of Paediatrics, Adolescent Medicine and General Paediatrics at McMaster. In addition to being an accomplished clinician, she is a leader and steadfast advocate for equity-deserving groups, particularly those historically marginalized in the Canadian health care system. In 2016, Dr. Johnson established a clinical service for trans and gender diverse youth at McMaster Children’s Hospital and was presented The Pat Mandy Inclusion Award for her work with gender-diverse youth just two years later. She was also the medical co-director of the Eating Disorder Program at McMaster Children’s Hospital for eight years.
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CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.
Dr. Saroo Sharda (SS):
My name is Dr. Saroo Sharda. I’m a practicing anesthesiologist, in addition to my roles as a medical advisor and Equity, Diversity and Inclusion lead at the CPSO. Thank you for joining us for another episode of “In Dialogue.”
We are very excited to be joined by Dr. Natasha Johnson today. Dr. Johnson is a paediatrician and also the Associate Chair of Equity, Diversity and Inclusion in the Department of Paediatrics at McMaster University, where she is also an associate professor. We’re going to hear a little bit more about what Dr. Johnson does through the next little while. But Natasha, why don’t you tell us a little bit more about your role at the university and your work in EDI?
Dr. Natasha Johnson (NJ):
Okay, I sure will. Thanks for having me. I’m pleased to be here today. Before I tell you about my university job, or even my clinical job, I’ll tell you a little bit more about my background. My parents are uninvited immigrant settlers to Montreal, actually from Jamaica. And that’s where I was born and raised. I’ve been living in Toronto, in the GTA, for the last 20 years. I have two adolescent boys, and I’m a single mother to them. I’m a sister, I’m a partner, I’m a community member. And I think those are all important aspects of myself that I want to share with the listeners today.
In terms of my clinical work, I am a paediatrician. I am an adolescent medicine specialist. And about two years ago, I took on the inaugural role of the Associate Chair of Equity, Diversity and Inclusion within the Department of Paediatrics at McMaster Children’s Hospital.
SS: Well, thanks so much for that Natasha. And I think it’s really important that we talk about ourselves from the perspective of all the different identities of who we are as people. So, thanks so much for sharing some of that with us.
Coming back to your work, particularly within equity and anti-racism, particularly from the lens of working extensively with learners, with community partners, also with patients, because I know with your adolescent medicine population, you also have a number of patients who are members of the LGBTQ2S population. Can you tell us a little bit about what it means to promote anti-oppression and anti-racism within medicine?
NJ: Yeah, I will. I do want to acknowledge that part of my clinical work is working with trans and gender-diverse youth. And in fact, in 2016, I, with a couple of other colleagues in endocrinology, speech language pathology and social work, established a clinical service for those who were seeking gender-affirming care. And that was the first of its kind directed towards children and adolescents in the region. I spent a lot of my career trying to advocate for equity-deserving populations. And so, part of my EDI work, or the lens that I utilize in my daily work, is influenced by that history. I would say that my approach has always been a multi-level approach, thinking about the micro level, mezzo level and macro level. I first think about how do I improve myself, improve my knowledge, learn and unlearn, and find new ways of doing and approaching things. And then I think about how we should do this as a team. And then finally, how do we do this better as an institution, in terms of policies and procedures.
In the department of paediatrics, we, several years ago, developed our vision statement and our vision is a brighter path for every child and their family. And I love that, as a department, we acknowledged from the get-go that for some families and some children, there are more barriers that are faced as part of the structure than for others. And so, in order to achieve this vision, we may need to minimize those barriers for certain groups. And we really identified early on that inclusive excellence benefits the whole team. Our department further established guiding strategic priorities that we’re trying to focus on in the next five years and those include five key areas. And those areas are firstly to cultivate inclusive excellence; number two, to build academic impact; number three, to engage with our communities; number four, to drive best care for children and families; and number five, to invest in our people. So, although there is a dedicated pillar for inclusive excellence, we’ve really wanted to think about embedding principles of EDI in every sphere. So, thinking about within a research portfolio, how do you expand diversity and research? How do we dismantle barriers to diverse and equitable employment? How do we create space for Indigenous practices of knowledge and education in health care? So, it ends up almost being a state of mind or a way of being, a way of approaching each situation. And I think in practice, we have a number of equity champions who apply an EDI lens or anti-racist, anti-oppressive lens to everything we do. I would say too that having support by the highest levels of our leadership and having the power to make changes is part of how we’re going to create lasting change in our department.
SS: Thank you, Natasha, for so eloquently laying that out at the micro, mezzo, macro level. And I love that you started with the micro level as being “you,” and what you need to learn and how you need to self-reflect because even as people from equity-seeking groups, or as racialized people or as Black people or as women, it doesn’t mean that we can’t be complicit in these systems, or that we aren’t complicit in the system. So, I really appreciate that you’re acknowledging your own learning amidst all of these bigger structural pieces that need to happen as well.
Actually, you’ve talked more generally and broadly about certain groups of children and certain families who have more barriers within the system. Can you speak a little bit more specifically around how you have seen children, youth and families affected by anti-Black racism? And perhaps what some of the specific pieces around anti-Black racism are, that maybe are not appreciated by everybody? We sort of think about racism sometimes as this one big overarching thing. And certainly, there are overarching pieces that apply to many racialized groups, but if you could give us a little bit of information, more specifically around anti-Black racism.
NJ: Yeah, definitely. I would say that one of the number one barriers that I personally experienced — and, I guess before I go on to this answer, I want to acknowledge my positionality: I am a cisgender, straight, Black paediatrician at an academic centre, and I have a lot of power and privilege relative to many others in my community. And in spite of that position of power and privilege, I would say that some of the things that shock me, in terms of anti-Black racism specifically, would be number one, a lack of awareness that racism exists in Canada. There are many people that do not believe racism exists in Canada. So then, to specifically acknowledge that anti-Black racism exists in Canada — that it exists not only in Canada, but here in Ontario, that it exists in our hospitals and within the specific units that we’re working in.
Also, the fact that it impacts me, in spite of my position of power and privilege. I, like many other patients I think we’ve heard about and heard from in the last couple of years who put on “good clothes” or get dressed up to go to the emergency room, I find myself putting my badge on when I go to the emergency room with a family member because I want to provide myself an additional sort of level of respect, so to speak, by validating who I am, which doesn’t necessarily happen when I enter the room. I think people also need to be aware of the fact that when the first medical schools in Canada were being established, Black people were still enslaved and there are many stereotypes about Black people. For example, that they have a different pain threshold. That’s just one example. But there are many stereotypes of Black people that are abundant in health care and we know this as Black individuals who are experiencing the healthcare system. And so, how that impacts you as a person who is utilizing the health care system is that you know this system was designed to exclude you and so you’re mistrustful — and that’s actually an appropriate response.
Those are some of the things that come to mind when I think about how anti-Black racism impacts me and others today. The other thing that I would say, too, is that I count myself among a few Black paediatricians across the country that I’m aware of, so what is it like to not be able to get a health care provider who understands your background, your history, who’s not going to gaslight your experience of racism that you had when you went to the emergency room — that is very important to have representation at all levels of the hospital system and that doesn’t currently exist.
SS: Yeah and I think that’s so important, Natasha, because not only is that a really important lived experience that you know about and you have obviously talked to other people about. We now actually have pretty good data showing that things like cultural concordance patients and their physicians actually results in better outcomes in terms of healthcare outcomes for those patients. And so, I think that’s something that isn’t always appreciated — that there is that safety that you talked about that people have when they are with a provider who inherently understands their experiences. And it was interesting to me when a lot of the narratives during COVID, really there was a big piece missing around thinking about why some communities and some groups of people were vaccine-hesitant. And it was really because of that distrust that has happened because of the exclusion and the harm that you talk about, Natasha, for certain groups of people. Yeah,
NJ: Yeah, I think that’s such a good point, Saroo. I didn’t learn about the Tuskegee Study until I was in medical school. And then I learned that that study had occurred over years and I think ended just a few years after I was born in the mid-70s. And this was a study where the natural history of syphilis was studied in poor, Black sharecroppers in the southern United States. And there were physicians that were leading the study. And this was at a time when the treatment was known to be available and healthcare providers just studied the natural history without making available the treatment that was effective, and also not being honest about the testing that they were doing. And so, it’s not “just” being suspicious — and I put “just” in air quotes — it’s actually having experienced harm from a system. And I think that is different when you become suspicious in that context versus when you are suspicious outside of that context. I think there’s a difference.
SS: Yeah, absolutely. Which is why I think it’s important for those people listening to talks on anti-racism or doing our own work in anti-racism, that we understand that anti-racist work has to be embedded within the appropriate historical context in order for us to actually understand these kinds of nuances.
So, Natasha, I wanted to come back to two things that you said actually. I’ll do them one by one. The first thing you said was that there are very few Black paediatricians across the country. And I think, if I’m not mistaken, the same goes for many other medical specialties in terms of the number of Black physicians we have in the country and in the province in those specialties. And we talked about why that’s a problem in terms of cultural concordance and that kind of thing. But could you maybe take that a bit further for us and talk about the importance of having that kind of diversity, not just from a patient-care perspective, but also from a medical leadership perspective? And you talked a little bit earlier about why it’s really important that all equity, and anti-racism and anti-discrimination efforts are supported in a very tangible way by leadership. But we also know that racialized people, Black women and Indigenous women in particular, are very poorly represented at senior leadership levels in health care, and in many other sectors. Can you speak a little bit to that and why you think that that needs to change?
NJ: Yeah, I’m thinking of a few things as you were asking me the question. And I think one of the important things that we haven’t covered yet, but that is important is the importance of collecting race-based data. I am not actually sure that it is known in Canada how many Black paediatricians there are. So, what I’m talking about is based on my experience, as an example, with the Canadian Paediatric Society, of which I’m an active member, kind of knowing who’s been there for the past few years, I’m extrapolating. But we do actually need to have concrete data. And part of the reason for concrete data is so that we can address some of the gaps, so that we can lay out what our workforce looks like relative to what it could look like based on the general population, and then working to address those gaps. And when I talk about collecting the data, I want to make it clear too that even collecting the data needs to be approached from the standpoint of acknowledging, “Look, our system has done harm and has not committed to doing anything with data that it’s collected in the past, but this is what we’re going to be doing moving forward,” and then actually demonstrating that in order to help communities feel more comfortable with sharing their data.
And then to speak to the question you asked about the importance of having Black representation, as an example, amongst leadership levels, I think that is so important for so many different reasons. We talked about in our department, some results about an employment equity survey. And we were talking about the fact that there were certain groups, including Indigenous people and those with disabilities, who continue to be underrepresented; that racialized people are improving in terms of the numbers and also women. But then, if you think about their experience of inclusion, I think you might get a different response. We do know that equity leaders in the corporate world don’t end up having a long stay. I think the average length of stay is about three years, something like that. And part of that, I think, speaks to this issue of not feeling valued, supported, included. And I think having representation at the higher levels will help facilitate a number of steps that can be taken to improve the sense of inclusion and belonging that is needed to retain our Black faculty, our Black staff and other equity-deserving groups as well. Yeah, I
SS: Yeah, I love that distinction that you make, Natasha, which I think is so important, between diversity versus actual inclusion and belonging, because the two do not necessarily automatically go hand-in-hand. And I think that’s a really important point that you bring up there. And I think the other thing about belonging is that we know from the data that when people feel that they belong in the workplace, including physicians, we’re actually much more effective at doing our work. And therefore, if we want to provide really high-quality patient care, then we have to make sure that people feel that they belong and that they’re not harmed at work.
NJ: One-hundred percent. I totally agree.
SS: So, I wanted to come back to this idea of inclusive excellence, which you mentioned, Natasha, as one of the five key areas that you’re looking at in your department and that I know is something that McMaster is looking at in terms of their EDI work as an institution as a whole. And you said something, which I think is really important and which I think is often misunderstood in equity and anti-discrimination work, which is inclusive excellence benefits the whole team. It benefits everybody. And I don’t know about you, but I often hear from people when I’m talking about these things, “Well, you know, what about X people? And what about Y people? And what about Z people? You’re only focusing on certain groups of people,” without really realizing — this sort of idea for want of a better analogy that a rising tide lifts all boats — is this idea of inclusive excellence and it really being a benefit to everybody.
NJ: Yeah, I hear what you’re saying that a lot of people have difficulty kind of grasping — maybe grasping is not the right word — but understanding that making room for others doesn’t necessarily take away from what you have. And I think that’s one of the biggest conceptual ideas to think of. I think in our colonial capitalist society, we are taught that there’s a pie and if someone else comes to the table, then necessarily there’s less pie for us. Whereas other approaches really consider the fact that when there are more of us, it’s a richer makeup and the things that we can create are perhaps richer. Maybe we’ll get to our destination faster because we have more different and varied ways of thinking. And we will come up with ideas that we haven’t contemplated before. And the evidence actually shows that to be true — that a diverse team has better creativity and innovation, better problem solving and decision making, better profit margins, higher employee engagement, and, then for institutions or organizations, better reputations as well. The evidence is actually that having a diverse team actually does benefit everyone. So, I feel like if we can do a better job of letting people know that, they might be more open to sharing the table with others.
SS: Yeah, I love how you frame that, Natasha, around just really moving away from this idea of scarcity to an idea of abundance, right? And, you know, we can be abundant in this work together. And really, it is about us coming together to do this work because none of us can do it alone. Can you talk a little bit about some specific things that you have seen work well, that organizations have done or could do? And I’m thinking about CPSO as an example of that — you gave some amazing teaching to our Council, which was really well received. But strategies, ideas, concrete things that you would like to see organizations do, specifically when it comes to anti-Black racism and helping Black patients get access to the safe, dignified care they need.
NJ: Yeah. I’m glad that you raised the issue of the CPSO and your leadership there, because I think that having an equity scholar who is connected to various communities and will bring people with lived experience to share is really key. And people who are compensated for their time — that’s one of the important things we are definitely focusing on in our capitalistic society. That’s one of the ways that we acknowledge a person’s contribution. And this work is not necessarily easy. There has been a thread or a conversation on Twitter about the fact that for some of us who are racialized or belong to other equity-seeking groups, we can’t separate ourselves from the work because this is who we are. And so, in addition to having the internal drive to want to talk about this, I also experience trauma when I’m talking about racism, as an example. So, really acknowledging that and compensating people for their time is important.
I would encourage people — well, really, what I want to do is join the community of people who are already advocating to have racism, anti-Black racism, specifically named. To think about do we add it to diagnostic codes? Do we explicitly name it in our learning materials? I am arguing for yes. And surprisingly, it is not heard in many of our learning curricula at this point. I think it’s really important for organizations to engage with communities, to understand their diverse needs. So, I happen to be a Black woman and a paediatrician, but I am not representing every Black person’s opinion because that would be ridiculous to assume, just like a White person cannot represent the needs of an entire community. It’s important to understand diverse needs. Remember that racism is complex and it requires complex solutions. And I also want to just highlight the fact that anti-bias training alone to a White workforce is not going to cut it — we need to move beyond that. And that’s probably one of the most important things that I wanted to highlight today.
SS: Thank you for that, Natasha. And I think, also, this idea that even if you did do anti-bias training, it’s not a one and done, right? It’s about really thinking about how does this show up in everything we do, from, as you said, diagnostic testing, to curricula, to policy, to procedure, to every single little thing in our institution, we have to be looking at it through that lens.
I learned recently, actually, thanks to some scholars who’ve been doing this work and putting it out in some of the more mainstream medical journals, that pulse oximetry, when it was developed at the time — and as an anesthesiologist we rely on heavily — but was mainly tested on people who have white skin and really underestimate in people with darker coloured skin, particularly people who are Black. And so, there’s actually a number of papers now showing that we might be severely under estimating hypoxemia in Black people, leading to delays and treatment and all kinds of things. So, it really does show up everywhere. And it’s not until we start asking the right questions, and looking for it and naming it, as we say, that we’re actually going to see it and then figure out what to do about it.
NJ: Agreed. Yeah.
SS: I want to just highlight one last thing that you said, Natasha, and maybe ask you one last question before we wrap up. But you talked about something very pertinent and I think you talk about this in a really moving and eloquent way when you present on this topic as well, which is that talking about your own experiences of racism, and even the experiences of racism of your community, of your family, it can be very traumatizing and emotional and difficult. And I think the one thing about that is we shouldn’t assume that all racialized people want to talk about it. But the second thing I want to highlight around that is really, for people to recognize that you can be very composed and giving a beautiful presentation, but there’s actually a lot of emotion that goes around all of that.
What keeps you going and optimistic, and what brings you joy, because you mentioned earlier in this interview that this work is hard. And even when you have support and you have groups of people that you’re doing it with, it can be very emotional. So, can you talk a little bit about what brings you joy in the world?
NJ: What brings me joy? Thanks for asking that question because I do make a point of trying to find joy on a regular basis. So, I would say… oh, there’s so many. Being part of a community of practice. So, I will talk about a couple of different communities of practice. One is the anti-racism coalition within the department of paediatrics, which is a group of five racialized women who came together with a common goal of reducing racism and reducing oppression within our department. And so, to have this type of close-knit group where we can debrief, and also identify mutual goals and build each other up when we’re having a bad day, that’s been super therapeutic. Joining the rising tide of equity scholars, including yourself, there’s other people that I’ve had the pleasure of meeting over the last couple of years and that’s been amazing in terms of being connected. My family, my loved ones, I would say is always a group that brings me joy. I have two boys, I have a three-year-old nephew, my siblings, my parents, my partner. These are all things that bring me great joy. And then, of course, my cats. Anybody who’s seen me on Zoom in the last couple of years knows that I have two cats that are wild and wacky, but they bring me a lot of joy.
SS: Very cute. Natasha, is there anything else you’d like to share with us before we kind of — you know, we could talk for so long about so many things that are really important. But is there anything that we haven’t touched on that you think is really important for people to know? As you know, we have an audience here of physicians, maybe some public folks, some people who are patients, and what else would you like to say if anything?
NJ: The only other thing that I’ll say — one of the things that has been most helpful to me on my learning journey is impact is more important than intent. And so, it’s not about the fact that I am a good person trying to do the right thing that means that I cannot harm somebody from an equity-deserving group. I make mistakes and it is brought to my attention on a regular basis. And so, I would plea, I think, for those that want to do anti-racism work to have that same approach that being advised that something was harmful isn’t to call someone racist, it’s really to bring their attention to the fact that their behaviour has been harmful. And if they’re committed to anti-racism work, then reflecting on a way that perhaps they can do things differently in the future, that’s more important than their intent. So that’s what I want to end on.
SS: I think that’s a beautiful note to end on, Natasha, and a really important concept to end on as well. Thank you so much for your time, always a pleasure chatting with you. Thank you for all the work that you’re doing in your anti-racism work and, of course, your work as a paediatrician, especially during the really difficult time of the pandemic. So, thanks so much, Natasha. It’s great speaking with you.
NJ: Thank you too, Saroo. Always nice speaking to you.
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