Arjumand Siddiqi, Sc.D., Associate Professor , Canada Research Chair in Population Health Equity , Dalla Lana School of Public Health, University of Toronto
When Symbolic Solutions are Offered to Structural Problems : The Case of Racism in Canada
My talk is going to be really an overview of what I see as issues of race and racism and health in Canada. I’m not an HIV researcher so this will sort of be a more global perspective and I hope that by the end we sort of bring it home to this context. Anyways so what I sort of noted is that there seems to be three narratives that seem ever-present in Canada in the health communities. The first is that race and racism are an American problem and that this is not something that we really need to grapple with here at least to any major extent. The second narrative I hear is that race is biological and that Canada has effectively been ignoring this important fact about race. And the third is that racism is an injustice and this is something that we should address by eliminating unconscious biases that we have. And I wanted to start by just doing a sort of quick overview of what we know about the relationship between race and health in general.
So this is one of many many sources of data I could show you that kind of give a picture of what race is and what race isn’t. So what we know from ample literature ample genetics literature and so on is that race is not biological. This is a graph that depicts the birth weight distributions of three groups in the state of Illinois. These are babies born to moms who were white Americans, longtime residents of America, black Americans, longtime residents of America, likely descendants of slaves, and the third group was black Americans whose moms were actually born somewhere in Africa and emigrated in their lifetime and gave birth in the United States. And the two distributions that most closely overlap are the distributions of white American moms and black immigrant moms. The distribution that is shifted to the left is the distribution of longtime American resident black moms.
So the two black distributions are not the most similar. So data like this starts to show us that what we think of as a biological construct is anything but. Rather race is a social category. It is a category that we use in order to stratify people, in terms of resources, in terms of power, and ultimately this leads to differences in social experiences across a range, and unfortunately too many to mention, fears of life. We see it in policing, we see it in education, we see it in the labor market, the marriage market, on and on and on. There is almost no where we can look where we don’t see differences by racial groups in social experiences. And there is a sort of schematic done by Bruce McEwen and his colleagues, that is a nice way to understand how it is that this social construct, these social experiences manifest biologically. So the general idea is that the brain experiences stresses from its environment. The sort of top row are the experiences that you could register as stressors. And then that stress is biologically manifested in different ways.
It can be manifested directly in our physiology which is why we see things like higher rates of hypertension amongst blacks compared to whites in both countries. I’ll add the US and Canada. It might manifest as differences in health behaviors, things like smoking, drinking, sedentary behaviors, differences in diet can also be triggered by the stress we experience in the world. There are many other manifestations of stressful experiences that become biologically embedded. And it is the difference in stressful experiences that leads to racial differences in health. So it is not a difference in fundamental biology, rather it is a difference in how the environment treats people that leads to differences in the biological burden of existing effectively. So against this backdrop there are these three narratives. As I mentioned and the first is that race is an American problem. I’ve had grant reviews that have told me this many times. And indeed you see a large black/white disparity in the U.S., this is a graph that highlights differences in that physiological burden I mentioned.
This is allostatic load and measure physiological burden, and you can see that throughout the life course, blacks have a higher level of a low static load than whites and this gap actually increases over the life course for various reasons. Indeed you see large differences in overall population health metrics like life expectancy this is a graph that depicts large disparities both amongst women and amongst men between blacks and whites in the US. We’ve been doing some work to try to look at how different social experiences of the world are that can become biologically embedded in Canada. And we use the Canadian Community Health Survey which had done a module on discrimination, to look at racial differences in experiences of what David Williams has termed everyday discrimination. And with him and others we did a paper on this, which demonstrated across a range of different types of experiences like whether you routinely experience less courtesy or respect, whether you experience poor service, whether you are treated as not smart, and whether you are feared by others.
Blacks out pace whites and out pace every other racial group, followed by indigenous people in Canada. So we see this systematic difference in experiences of discrimination, which leads us to believe that that model of stress accumulating in the body from social experiences is indeed not just an American phenomenon. We have looked at black-white differences in health status across a range of health outcomes in Canada, and it is absolutely true that the disparities are not quite as large in Canada as the U.S., at least that’s what we’re finding so far. But it is not the case that they’re non-existent. And you can see from this graph which has Canada in red and the US and blue, that for hypertension self-rated health and obesity you see a black disadvantage, though more mitigated one than the disadvantage you see in the US. On the other hand things like heavy drinking and smoking are less evident amongst blacks than whites in Canada and the U.S., leading us to believe that it’s other things besides health behaviors that are causing the racial difference in both countries.
We’ve done some work in the past on immigrant related health inequalities. Probably a little hard to see, but the punch line is that we stratified our analyses of immigrant non immigrant disparities by crude racial categories, white and non-white, because we didn’t have sample to do anything more. And amongst whites you see far fewer disparities, so it’s not entirely clear to me at least yet that what we think of as immigrant based disparities are not intimately tied to racial disparities. So the second narrative that I see is very prevalent is that race is biological and we’ve just kind of been ignoring that in Canada. We’ve done this really bad job of not acknowledging genetic differences between racial groups. You see a lot of papers coming out that are suggesting that we should have different thresholds, cut-offs, clinical benchmarks for different race ethnic groups. This is a paper on what the thresholds should be for for-gestational-age amongst newborns of East Asian and South Asian ancestry. They did a study and they said look you know if you look at the curves for East Asians and South Asians those who are above the third and tenth centile in their own racial group actually we’re below those thresholds on the Canada-wide measures.
And they go on to say that the data suggests infants born to parents of East Asian and South Asian ancestry may be of lower birth weight than white European descendants and they say sort of the curves that we use in Canada are based on a small sample of three hundred infants of white European ancestry and we shouldn’t do that anymore. The idea is my god we’ve been so racist we’ve ignored the genetic differences between racial groups the problem is these are not genetic groups, so what you’re calling East Asian and South Asian is not a genetically identifiable group. So the reasons they have lower birth weight are less likely to be about their genes and more likely to be about a whole host of other social differences. So this sort of paradigm that here we are being benevolent by including people in our genetic categorizations I think is really quite disturbing. This is a study where they said you know diabetes in suburban Toronto is high due to ethnic background, lack of walk-ability, in other words juxtaposing ethnicity with a social exposure and it’s there’s just simply no good evidence that these are genetic groups. So you don’t need a social epidemiologist like me to tell you this, the population geneticists will tell you this.
It’s just there’s no real basis to it and we keep doing this over and over again. We’re doing it for BMI as well. In fact I think this paper won a CIHR paper of the year type award as well. It’s very prevalent and it’s very difficult to fight because it seems so intuitive to people to think of these categories as biologically essential. So the third narrative I hear most frequently is that racism is an injustice and that we should be working to eliminate it by addressing unconscious biases. That we have in fact, you know the presentation that I’m giving is sort of under the guise of dealing with this issue of bias. Just a quick sort of overview, the implicit bias literature, the unconscious bias literature, sort of says that these are attitudes or stereotypes that affect our understandings and our actions and our decisions, largely in an unconscious manner. That this is sort of activated involuntarily without our being aware or being able to control it. Biases are different from things that individuals know and act upon. They are sort of unconscious somehow sort of something that are subconscious, that can we cannot really control. They reside in our subconscious, they cause us to have feelings and attitudes about other people based on characteristics such as race and ethnicity, and they sort of develop over a lifetime. So we have these attitudes that develop over a lifetime.
This is a very popular way in which we are framing racism particularly in the health care system these days, but also in businesses and other arenas. We think of this as a very powerful way to address racism. That we should sort of find ways to to target implicit biases. And the idea is as far as I can tell, it’s not enough to say we’re not racist, it’s happening, so let’s target our sort of unconscious attitudes. And what the literature is also starting to show is that it doesn’t work very well. So many studies are suggesting in fact, bias training is not a good way to approach racism. My contention today is that this is because racism is not born of implicit bias. And I turn your attention to a very well-known recent example, which is the 2016 presidential election in the United States. This is data from exit polls, which showed that 57 percent of whites voted for Trump whereas the vast majority of minority groups voted against Trump. And this is not only a Republican, and I don’t need to remind you, but one who had extremely vitriolic racist rhetoric was not implicit by any stretch of anyone’s imagination this was incredibly explicit, and you know this is someone who also had very misogynistic rhetoric. And a very misogynistic history.
And yet the majority of white women voted for Donald Trump. And I think what the social science literature is teaching us is that this is because there is an actual benefit to identifying with your whiteness. That this is not about an implicit process that we don’t sort of know that we have these attitudes and if we just kind of tap what we don’t know we’ll be okay. This is deliberate and beneficial, to make sure that the group in power that you belong to actually stays in power and maintains its resources. And so this kind of data makes it difficult to ignore that sort of sensibility. William Garrity jr. and Derek Hamilton have recently been developing a theoretical basis to help us understand this. They call their work stratification economics and the general idea is that inequality happens on a group level. It’s not about individual biases, it’s about group interests and that people do what they can in order to promote the well-being of the group or groups with which they identify.
And so you get racism because it’s actually a very functional way for the group in power to keep its power. Lots of social psychological and political science literature is echoing the sentiments both by survey work and experimental work showing that in fact the major predictors of voting for Donald Trump were senses of racism, of white threat from higher immigration, and so on they were not the major predictors, were not economic insecurity. They really were about white insecurity. And so you’re starting to see this picture emerge that really calls into question whether this this implicit bias orientation is the best way to think about racism we often talk about the fact that racism is structural. I think that’s not something that’s very controversial in a group like this. We see lots of evidence of this right here at home. This is recent data about residential segregation by race and income.
You can see that in low-income neighborhoods blacks are over-represented, whites are underrepresented, and the reverse is true as the neighborhood income level increases. We know that from experimental work, that Asians are less likely to be called back for interviews, even when they have a Canadian education. So this is not just a story of not having Canadian education or experience. It’s even true when you have a resume that looks like you were born and bred in Canada. And so my sense is that implicit bias is not a good framework to talk about racism and that racism really can only be eliminated if you address the fact that there’s an actual interest in maintaining power and resource differentials and that people will pursue that at the group level. And that racism really can only be eliminated once those power and resource structures are dismantled. And I think importantly, that is about income and wealth which seem to drive much of well being. And I will leave it at that. [Applause]