The past, present and future of race and colonialism in medicine

"The straw that broke the camel's back": An analysis of racialized women clinicians' experiences providing diabetes care

INTRODUCTION

Racialized women clinicians (RWCs) experience the brunt of unfair racial and gendered expectations, which is a direct result of their visible identity. Our study sought to understand how these experiences intersect to impact the personal and professional well-being of RWCs, and their approach to diabetes care.

METHODS

Data were collected from 24 RWCs working within Canadian diabetes care settings, who participated in semi-structured, one-on-one interviews conducted from April 2021 to September 2021. The data were qualitatively analyzed using thematic analysis to develop emergent themes, and interactions were explored using the socioecological model (SEM), adapted to our study context.

RESULTS

We identified three themes: (1) Discordance between self-identity and relational identity impacted how RWCs interacted with others, and how others interacted with them; (2) Tokenistic, "inclusive" organizational policies/practices and inherently racist and sexist social norms permitted acts of discrimination and led to the systematic othering and exclusion of RWCs within the workplace; and (3) Differential treatment of RWCs had both positive and negative impacts on participants' relational, workplace and self-identity. Using the SEM, we also found that differential treatment of RWCs stems from upstream policies, structures, and social norms, percolating through different levels of the SEM, including work environments and communities, which eventually impacts one's relational identity, as well as one's perception of oneself.

CONCLUSION

The differential treatment of RWCs arises predominantly from macro systems of the work environment. The burden to address these disparities must be shifted to the source (i.e., namely systems) by implementing interventions that equitably value diversity efforts, institute policies of accountability and correction of implicit biases, and prioritize an inclusive culture broadly across faculty and leadership.

Mexican American Intergenerational Research: Transformative Model of Occupational Therapy

Thirty-seven interviews of Mexican American women who crossed the border into the United States during the era of the Mexican Revolution of 1910 were analyzed using constructivist grounded theory methods. The intent is to expand the occupational therapy profession's occupational consciousness and cultivate cultural humility. Four themes emerged from the data: suffering, work, yearning for an education, and compassion for others. The findings suggest that environmental barriers such as hierarchy (patriarchy and discrimination) and physical barriers (limited access to built environments, lack of nonexploitative work opportunities, and hostile educational institutions) prevented occupational participation. Small acts of resistance through everyday living (finding joy, playing, self-sufficiency, and community organizing) were identified as facilitators of occupational participation. The research findings challenge proposed assumptions found within the occupational therapy literature: (1) humans and occupations exist as separate from their environments, and (2) work, productivity, and leisure contribute positively to health. The Transformative Model of Occupational Therapy is introduced as a decolonized framework that inextricably links individual health to community and global health. The model centers play, social participation, work, and education as occupations that contribute to the common good. These occupations are kept in equilibrium within the Four Pillars of Culture (self-determination, compassion, sustainability, and language) or the cultural values identified and derived from the stories.

"I Am the Last Priority": Factors Influencing Diabetes Management Among South Asian Caregivers in Peel Region, Ontario

OBJECTIVE

In this study, we aimed to identify sociocultural and systemic factors influencing diabetes management among South Asian (SA) caregivers in Peel Region, Ontario.

METHODS

Twenty-one semistructured interviews were conducted with SA caregivers using a qualitative descriptive design. Data were analyzed using thematic analysis and intersectionality analysis.

RESULTS

Themes identified included 1) prioritizing family caregiving over diabetes self-management; 2) labour market impacts on diabetes self-management; and 3) challenges navigating Canadian health and social service systems. SA caregivers described social, economic, and systemic challenges impacting type 2 diabetes management. Systemic factors influencing diabetes management included discrimination and inequities in labour policies and lack of social and health resources funding. Recommendations by caregivers included whole-family, community-based, culturally tailored approaches to diabetes prevention and management strategies.

CONCLUSIONS

Providing support with system navigation, encouraging family-based approaches, and addressing the social determinants of health could be beneficial for supporting SA families with diabetes management and prevention.

There is no such a thing as a 'biological' basis for cancer disparities: A call to end misreporting of the ultimate determinants of health outcomes

Improved strategies of cancer prevention and control have resulted in tangible benefits for patients with cancer. Disparities in outcome have been reported as a result of inequal access to health care. Historically, differences in health outcomes at population level have been reported according to key characteristics, including race, ethnicity and, more recently, ancestry. These population descriptors have been used to display the differences in the outcome and highlight actionable areas of health disparities, through policy and population health interventions. Yet, they have been commonly mis-intended as ultimate determinants of health outcomes, as recapitulating intrinsic biological differences. A plethora of past literature has described "biological" differences in patients belonging to a specific racial, ethnical or ancestral group, with certain cancers - commonly overlooking the social and economic contextures. The attention has ultimately focused on the existence of intrinsic differences and biological reasons, as opposed to social and economic determinants of disparities in the outcome in disadvantaged or excluded communities, thus nurturing double stigma. In our editorial, we evaluate some key roots of racial attitudes in displaying patient outcomes in oncology epidemiological studies, and call to report ultimate determinants of health - that are, primarily social and economic determinants.

Seven Strategies to Integrate Equity within Translational Research in Neurology

The rapidly accelerating translation of biomedical advances is leading to revolutionary therapies that are often inaccessible to historically marginalized populations. We identified and synthesized recent guidelines and statements to propose 7 strategies to integrate equity within translational research in neurology: (1) learn history; (2) learn about upstream forces; (3) diversify and liberate; (4) change narratives and adopt best communication practices; (5) study social drivers of health and lived experiences; (6) leverage health technologies; and (7) build, sustain, and lead culturally humble teams. We propose that equity should be a major goal of translational research, equally important as safety and efficacy. ANN NEUROL 2024;95:432-441.

How the commercial virtual care industry gathers, uses and values patient data: a Canadian qualitative study

OBJECTIVES

To understand and report on the direct-to-consumer virtual care industry in Canada, focusing on how companies collect, use and value patient data.

DESIGN

Qualitative study using situational analysis methodology.

SETTING

Canadian for-profit virtual care industry.

PARTICIPANTS

18 individuals employed by or affiliated with the Canadian virtual care industry.

METHODS

Semistructured interviews were conducted between October 2021 and January 2022 and publicly available documents on websites of commercial virtual care platforms were retrieved. Analysis was informed by situational analysis, a constructivist grounded theory methodology, with a continuous and iterative process of data collection and analysis; theoretical sampling and creation of theoretical concepts to explain findings.

RESULTS

Participants described how companies in the virtual care industry highly valued patient data. Companies used data collected as patients accessed virtual care platforms and registered for services to generate revenue, often by marketing other products and services. In some cases, virtual care companies were funded by pharmaceutical companies to analyse data collected when patients interacted with a healthcare provider and adjust care pathways with the goal of increasing uptake of a drug or vaccine. Participants described these business practices as expected and appropriate, but some were concerned about patient privacy, industry influence over care and risks to marginalised communities. They described how patients may have agreed to these uses of their data because of high levels of trust in the Canadian health system, problematic consent processes and a lack of other options for care.

CONCLUSIONS

Patients, healthcare providers and policy-makers should be aware that the direct-to-consumer virtual care industry in Canada highly values patient data and appears to view data as a revenue stream. The industry's data handling practices of this sensitive information, in the context of providing a health service, have implications for patient privacy, autonomy and quality of care.

Developing an agenda for the decolonization of global health

Colonialism, which involves the systemic domination of lands, markets, peoples, assets, cultures or political institutions to exploit, misappropriate and extract wealth and resources, affects health in many ways. In recent years, interest has grown in the decolonization of global health with a focus on correcting power imbalances between high-income and low-income countries and on challenging ideas and values of some wealthy countries that shape the practice of global health. We argue that decolonization of global health must also address the relationship between global health actors and contemporary forms of colonialism, in particular the current forms of corporate and financialized colonialism that operate through globalized systems of wealth extraction and profiteering. We present a three-part agenda for action that can be taken to decolonize global health. The first part relates to the power asymmetries that exist between global health actors from high-income and historically privileged countries and their counterparts in low-income and marginalized settings. The second part concerns the colonization of the structures and systems of global health governance itself. The third part addresses how colonialism occurs through the global health system. Addressing all forms of colonialism calls for a political and economic anticolonialism as well as social decolonization aimed at ensuring greater national, racial, cultural and knowledge diversity within the structures of global health.

Past Is Prologue: Dismantling Colonial Legacies to Advance Black Health Equity in the United States

Colonialism underlies the commodification of health care in the United States and continues to harm well-being among Black Americans. We present four recommendations for addressing its health consequences: (1) Investments in epigenetic research to improve our understanding of how systemic oppression becomes biology. (2) Centering Black experiences and knowledge traditions in education, practice, and policy. (3) Support for Black scholars, trainees, and practitioners when they critic disciplinary tenets and practices. (4) Expansion of preventive care. Our health care system is a for-profit industry that exploits workers and harms the most marginalized, much like colonialism. Advancing health equity requires dismantling colonial legacies.

Workplace Environment Microaggressions in Otolaryngology-Head and Neck Surgery: An International Survey

OBJECTIVE

To survey members of the otolaryngology community about their personal and observed experiences of being treated differently because of one's physical attributes, cultural norms, or preferences in the workplace.

STUDY DESIGN

Cross-sectional survey.

SETTING

International Electronic Survey.

METHODS

We invited members of the international otolaryngology community including 3 European or American otorhinolaryngological Societies to complete a survey about personal/observed experience of differential treatment in the workplace related to age, biological sex; disability, gender identity, language proficiency, military experience, citizenship, ethnicity/race, political belief, and sexual orientation. Results were analyzed according to participant ethnicity/race (white vs non-white) and gender (male vs female) RESULTS: Four hundred seven participants completed the evaluations: 301 white (74%) and 106 non-white (26%) participants. Non-white participants reported significantly more experiences of differential treatment (microaggressions) than white participants (p < .05). Non-white participants more frequently felt that they needed to work harder for the same opportunities as their peers and were more likely to consider leaving a position because of an unsupportive environment. In general, females reported more frequent experiences with differential treatment related to sexual orientation, biological sex, and gender identity than males.

CONCLUSION

We recognized reports of differential treatment as a proxy for microaggressions. Non-white members of the otolaryngology community self-report experiencing or observing more microaggressions than white members in the workplace. Acknowledging the existence and impact of microaggressions in the field of Otolaryngology is the first step towards cultivating an inclusive, diverse workforce where all members feel supported, validated, and welcomed.

Journey across the world to study medicine: The Anandi Joshi story

Women faced significant barriers to pursue education in the 19th century, yet modern history has witnessed bold women overcoming insurmountable odds in this quest. To this end, Anandi Joshi braved monumental odds to successfully become the first female physician in India. Born in 1865, Anandi was one of 10 children. Her zeal for knowledge was noted early by her father, who ensured that his daughter was well-educated. She married Gopalrao Joshi as a child when she was nine; a practice that was common at the time. Anandi's quest to become a physician stemmed from a traumatic event which saw the death of her child due to the lack of medical care. Despite the numerous prevalent barriers which prevented women from indulging in education, Anandi was determined. She travelled to the United States, where through sheer persistence, she was admitted to the Women's Medical College of Pennsylvania, where she graduated with a Doctor of Medicine (MD) degree in 1886. She subsequently returned to her home country, making her the first female physician in India. Despite her untimely death, Anandi became immortalised as a legend, a beacon of hope, and continues to serve as an inspiration for generations of Indian women.

The Intersectoral Global Action Plan (IGAP): A unique opportunity for neurology across the globe

The World Health Assembly (WHA) approved the Intersectoral Global Action Plan (IGAP) in 2022. This ambitious project, formally called the Intersectoral Global Action Plan for Epilepsy and Other Neurological Disorders, is a 10-year plan to enhance neurology implementation worldwide and to raise the status of brain health and neurology services for patients with neurological diseases. The IGAP has 5 important components: relation with policy makers, therapy, prophylaxis, research, and public health. The implementation of IGAP is a challenge, not only for the specialty of neurology but for the whole neurological community, encompassing patients, carers, healthcare providers, and the public. The lack of a unified definition of neurology and the great variety of health systems, as well as the dependency on socioeconomic status, will necessitate custom-made solutions in all regions.