Discriminatory Healthcare Is Driving Patients Away and Leaving Behind Open Wounds
Harman Rai
BHSc Honors Specialization in Health Sciences with Biology, Western University
A single encounter, a single experience, a single story is enough to turn people away from seeking health care in Canada. I have heard people say, “trust me, you will be better off driving to a different hospital,” or people begging the paramedics to be taken elsewhere for “better care.” Negative hospital experiences are driving people away, and the lack of trust in Canadian physicians is growing.
Trust is a key factor in sharing relevant health information with physicians and corresponds with using preventative health services like routine checkups, prostate-specific antigen tests, etc. (Musa et al., 2009). Trust in physicians began faltering back in 2010 when a Maclean’s study found that 40% of respondents believe Canadian physicians care less about patients than 10 years prior (Gills et al., 2010). Perception does not equate to reality, but patient belief indicates that trust impacts health outcomes. As a racialized Canadian, and in the face of growing discussions on the intersections between race-based discrimination and health outcomes, I have come to ask myself how this decline in the trust may or may not be affected by Canadians’ social identities, including their skin colour.
Curious, and encouraged by my Social Determinants of Health professor, I asked my family and immediate circle of friends, “do you think your skin colour has impacted your experience of seeking health care in Canada?” Again and again, the answer I heard was “Yes.” No hesitation, and pin-drop silence from those I asked until I invited more detail. In my experience, the rarity had been finding someone of racialized identity to disagree. Even as a South Asian woman aware of inequities, I never imagined the reach and magnitude of biased health care encounters.
One specific instance involved my sister. Around six years ago, she asked our parents to go to the hospital because of severe back pain, a fever, chills, and fatigue. It took her less than five seconds to recall her experience as if it had been an open wound for all these years. At William Osler’s Brampton Civic Hospital, the attending physician incorrectly assessed the severity of her symptoms resulting in a misdiagnosis of urethritis. Less than three days later, when she inevitably returned, the same physician correctly diagnosed her with pyelonephritis. It is relevant to note that an untreated kidney infection can lead to permanent kidney damage.
Immediately afterwards, my sister began analyzing the situation from two lenses: (1) that of a South Asian woman and (2) as a biomedical and psychology undergraduate student. She suspected that the initial misdiagnoses stemmed from biases against women relating to hysteria and racial discrimination. Her suspicions are not without foundation, as women are 10 times more likely to be perceived as hysteric than men (Lines, 2018). This “female hysteria” is a product of emotional or mental disorders and dates back thousands of years. Intersectionally, it is possible to compound this experience with race. Asian ethnic groups still face misguided anger and anti-Asian racism in Canada. The most vulnerable groups are women, children, and youth. Between 2020 and 2022, incidents reported by South Asians have increased by 318% (Passafiume, 2022). The drastic increase can also be attributed to COVID-19, making it difficult for South Asian women to seek health care during the pandemic.
My sister explained how this experience was extremely frustrating because she felt like her voice had been taken away and she was not taken seriously. As a future health care provider herself, she was shocked that what she perceived as treatment influenced by bias, discrimination, and colourism are present in the infamous Canadian healthcare system. Following her treatment, she vowed to check both her conscious and unconscious biases in every future encounter she would have with her own patients. Doing so would ensure none of her future patients felt their concerns were trivialized, misdiagnosed, and dismissed.
Her response to this situation illustrates how statistics are not just numbers we internalize for a test; instead, they represent real individuals with real stories. It is quite easy to lose sight of this reality until it presents itself in your own life. Understanding that fact allowed me to translate my sister’s story using social determinants of health lens into one of reflexivity, patient-provider trust, and individual discrimination.
First, reflexivity is a skill allowing for identifying or correcting biases and assumptions being brought into research, practice, and social interactions. From my sister’s reflection, I know her experience led to the exposure of unconscious bias in her life. She corrected these biases, so they would not present in social interactions or patient-provider interactions. Second, bias can present itself within interpersonal patient-provider interactions. It manifests in the warmth providers have with patients, where warmth builds the foundation for trust. There was a lack of warmth in my sister’s case as she felt ignored and belittled. Lastly, there are two types of discrimination to consider in this case: individual and structural.
Individual discrimination produces negative interactions, experiences, and communication based on an individual’s characteristics that usually result in minorities feeling unsafe. That is what my sister experienced as both a woman and a South Asian minority. On its own, individual discrimination causes physical and emotional reactions that alter psychological responses, biological processes, behavioural responses, and healthcare use responses that produce an overall negative health response. For example, in terms of “healthcare use response,” this situation made me question whether my sister’s experience changed her perception of hospitals. I wondered how similar experiences may impact innumerable racialized Canadians’ willingness to seek help on subsequent occasions. Negative health care experiences have the power to drive individuals away and decrease the number of people who will willingly seek out help.
People can experience discrimination across multiple dimensions, which provides unique and diverse experiences to different members of the same group. Moreover, there exist a range of healthcare scenarios, and potential assumptions, ideas, social or institutional norms a healthcare provider may be drawing upon, if they engage with individuals in their practice in ways that suggest discriminatory thinking. When we speak of individual discrimination, this refers to a specific instance of discrimination where determinants at play, as well as how the discrimination plays out in an interaction, will be particular to that unique day, time, place, and those involved in the interaction. Almost invariably, however, at play in discriminatory healthcare practices are dominant ideas and assumptions that provide a framework where the treatment of individuals in the healthcare system (from patients to family to colleagues) follows certain normative patterns that reinforce inequities in society beyond the healthcare transaction space. This structural discrimination informs and can be reinforced in turn by individual discrimination.
Analyzing the misdiagnosis my sister faced considering known structural discrimination in Canada, it seems likely her misdiagnosis could be a product of dominant gender and race-based biases that encourage viewing certain racialized and gendered patients as more prone to hysteria than others. But, determinants will not be the same for every individual visiting the physician. All health care providers would ideally undertake a mental check as they encounter patients, families, or even colleagues to identify and critically assess any assumptions about racialized identity and differences that may colour their understanding of a situation. This seems crucial to ensuring all patients are treated equitably and thrive upon hospital discharge.
In my opinion, the first step towards such healthcare equity is being cognizant and self-aware of the socioeconomic issues that minority groups are more prone to face. Possible examples include working conditions, food insecurity, income, or education. These determinants make some groups more vulnerable to negative health outcomes. For example, health problems associated with higher allostatic load can be compounded by biological factors that make some groups more prone to chronic disease—like South Asians being more prone to diabetes because of increased insulin resistance caused by more visceral fat (Gujral et al., 2013).
It is imperative to proceed with caution: generalizations based on visible markers of difference must be avoided! The anti-oppressive framework illustrates how there is diversity in experience associated with an unequal distribution of power and stressors in society. This means that we must give attention to the unique experience of each patient coming to the hospital. Two patients may enter the hospital with the same condition, but that does not automatically warrant the same treatment. We should look past theory and focus on individual needs; one patient may have other determinants like job insecurity or food insecurity adding to their plate. To ensure both patients thrive upon leaving the hospital, one individual may require additional community resources. In the process, we may see a need for health care providers to be more aware of available resources in the community.
A real-life example of racial identity awareness comes from a study concerning COVID-19 ventilator distribution. Being aware of racialized identities allowed physicians to learn that Black people generally have higher creatinine levels. This presented in higher Sequential Organ Failure Assessment (SOFA) scores which are interpreted as a lower chance of surviving. To give patients their best chance during shortages, ventilators are distributed to people with lower SOFA scores. As a result, Black people overall were given fewer ventilators in hospitals (Schmidt et al., 2020). Without racial identity awareness, this non-equitable distribution may have gone unnoticed, leading to further marginalization of the minority group.
Being aware of racialized identities means addressing bias and requires skills of reflexivity to ensure no patient is discriminated against. I believe it is important for those in healthcare to be aware of racialized identity, but their work does not stop there. Health care providers must also practice reflexivity and check their biases. In doing so, physicians will have a greater chance of fostering positive experiences with patients that will not drive patients away from Canadian healthcare and propagate negative health outcomes for minority groups; rather, patients will feel encouraged and open to seeking out health care resulting in increased preventative measures and less cases of untreated or mistreated illness.
References
Musa, D., Schulz, R., Harris, R., Silverman, M., & Thomas, S.B. (2009). Trust in the Health Care System and the Use of Preventative Health Services by Older Black and White Adults. American Public Health Association, 99(7), 1293-1299. https://doi.org/10.2105/ajph.2007.123927.
Gills, C., Belluz, J., & Dehaas, J. (2010, August 16). Do you trust your doctor? Maclean’s. https://www.macleans.ca/news/canada/do-you-trust-your-doctor/.
Lines, L.M. (2018, May 9). The Myth of Female Hysteria and Health Disparities among Women. RTI. https://www.rti.org/insights/myth-female-hysteria-and-health-disparities-among-women.
Passafiume, A. (2022, March 29). Anti-Asian racism is soaring in Canada. These numbers tell the story. The Star. https://www.thestar.com/news/gta/2022/03/29/anti-asian-racism-is-soaring-canada-these-numbers-tell-the-story.html.
Institute for Healthcare Improvement. (2017, July 3). How Does Implicit Bias Affect Health Care? [Video]. YouTube. https://www.youtube.com/watch?v=ze7Fff2YKfM&t=1s.
Schmidt, H., Roberts, D.E., & Eneanya, N.D. (2020). Rationing, racism and justice: advancing the debate around ‘colourblind’ COVID-19 ventilator allocation. Journal of Medical Ethics, 48(2), 126-130. doi:10.1136/medethics-2020-106856.
Gujral, U.P., Pradeepa, R., Weber, M.B., Narayan, K.V., & Mohan, V. (2013). Type 2 diabetes in South Asians: similarities and differences with white Caucasian and other populations. Annuals of the New York Academy of Sciences, 1281(1), 51-63. https://dx.doi.org/10.1111%2Fj.1749-6632.2012.06838.x.
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