Understanding intersectionality is at the core of building more equitable healthcare in Canada

When I first read this article—U15 Leadership Remains Largely White and Male Despite 33 Years of Equity Initiatives—and saw the included graph I chuckled. Not because it’s funny, but because what ran through my thoughts was the yellow bars (the bars that would represent me) are impossible to see. Tn fact, there are so few Indigenous women in senior academic leadership you could include headshots without taking up too much space. My next thoughts were first, this chart wouldn’t look different if it were about senior leadership in healthcare, and second, we have work to do, and it has to look different than how Equity, Diversity, and Inclusion (EDI) work has looked in the past. Recently, I was asked to expand my portfolio as a vice-dean at the Rady Faculty of Health Sciences, University of Manitoba to include EDI, social accountability and community engagement in addition to my existing work in Indigenous Health and anti-racism. Although cautious about the increase this might bring to the “minority tax” that I pay, I considered this an important opportunity to bring a more explicit social justice and anti-racist approach to our collective EDI efforts. Read: Ontario puts $34 million towards the training Indigenous nurses and personal care workers The concept of social justice originated in the labour movement and, at heart, is about equality of opportunity and the fair sharing of wealth generated through work. Its application extends to the distribution of resources and access to services and opportunities. There are four key principles of social justice: access (e.g. to education and health care), equity (planning, resourcing and decision-making that leads to reduced inequalities), participation (e.g. opportunity to be heard and participate in decision-making), and human rights. Each of these principles provides instruction on how to approach the work of making healthcare or learning environments more just and equitable places. With a human rights foundation, it clarifies that we cannot simply compare outcomes to the progress we’ve already made, but rather to an endpoint of freedom from all forms of discrimination that impact the full expression or achievement of our rights. In her Ted talk The Urgency of Intersectionality, Kimberlé Crenshaw states that a trickle down approach to social justice has not worked and will not work. This counters some past EDI thinking that addressing gender bias alone would benefit all women, for example. Although intersectionality may be a more recent arrival in our societal consciousness, Crenshaw has been learning about and writing about it for many years. In a 1991 paper, Crenshaw writes: “Where systems of race, gender, and class domination converge, as they do in the experiences of battered women of color, intervention strategies based solely on the experiences of women who do not share the same class or race backgrounds will be of limited help to women who because of race and class face different obstacles.” Systems of oppression, including by race, gender, class, and ability, also converge in the experiences of people in: Accessing healthcare; What primary and high schools they attend; Post-secondary opportunities and affordability; Medical school admissions; Day-to-day learning or work life; Employment opportunities; and Career and leadership trajectories. EDI work has led to some institutional progress, if we were only to compare gender representation as done in this paper examining Women’s Health and Women’s Leadership positions in Academic Medicine. A key point in the article is that Women’s Health will be best served through increasing the representation of women in leadership. As Dr. Smith’s work shows, that progress is unequal when we consider both gender and race or ethnicity. Crenshaw’s work on intersectionality gives us insight into why that progress is unequal and how to intervene: by identifying and intervening in the structural obstacles that Black, Indigenous and other racialized people experience because of their race. This is why I believe anti-racism has to be the other core foundation for the approach to our collective work. Read: Practice management: Does your staff need diversity training? In recent years many academic and healthcare institutions and medical associations have adopted anti-racism statements. The need for these is clear in response to the persistent gaps in health and healthcare quality by race and the racialized systemic violence experienced by Black and Indigenous Peoples as illustrated by the deaths of George Floyd and Joyce Echaquan. In 2020 the Canadian Public Health Association statement against racism prompted by these “tragic killings” highlighted that “these unconscionable acts remind us of the individual and systemic racism that exists and that results in negative health outcomes for those affected.” Around the same time, the Canadian Medical Association issued a statement acknowledging that racism is a structural determinant of health that drives health and social inequities. They state, “The recent incidents of anti-Black violence, racism and discrimination in the US and Canada also shed light on the structural inequities and racism that exist within the medical profession and the health system,” and commit to holding themselves accountable for racism. The power of these statements will only be realized through the work of anti-racism within and across systems. Anti-racism is active work to oppose racism by locating and intervening in the roots of racial inequities- power and policies- as described in How to Be an Anti-Racist by Ibram X. Kendi. Former American Public Health Association president Dr. Camara Phyllis Jones describes three key steps to the practice of anti-racism: naming racism, asking ‘how is racism operating here?’ and organizing and strategizing to act. These three steps can and must be included in all EDI work in order to achieve the outcomes we want. Yes, this is complex and will be even more complex as we engage in socially accountable ways with the communities we are responsible for serving, but are currently underserving within our systems. Read: Racism: Call it by its name Twenty years ago, when I was narrowing down the residency programs to which I would apply, internal medicine rose to the top of my list. A major part of what drew me to it was the challenge of its complexity: the required knowledge of our bodies’ systems as discrete parts and also how they interact. (This attraction to complex interacting systems is also now while I will somewhat cringingly admit I play Quordle every day). Maybe this is too simplistic, but many of us will have had the experience of investigating acute or chronic kidney injury. We might chase down a potential primary kidney cause (e.g. IgA nephropathy) while also considering that it is secondary to a primary problem in another system (e.g. hepatorenal syndrome). Of course, it could be that it is some complex mix of both (e.g. acute on chronic kidney injury in someone with diabetic nephropathy experiencing dehydration due to gastroenteritis while on ACE-inhibitors for their congestive heart failure). It is complex, interacting systems that create the gaps we are seeing in health and healthcare as well as the gaps we see in representation in leadership. We can use our same approach to providing care to patients with complex and intersecting illness to these bigger system challenges. If we think it is only about race, or gender, or ability, that narrow perspective will limit the barriers we examine and the solutions we imagine. If our approach recognizes that it is race AND gender AND ability AND other forms of oppression, we widen our view of the existing barriers and the needed structural interventions. Read: Repair and connect: Focusing on constructive solutions to microaggressions in healthcare Knowledge will continue to evolve, and we will need to measure these approaches against the equitable outcomes we have an obligation to seek. My thinking too will evolve as I learn and grow, but this is where my thinking is today, on my sixth day as the vice-dean of Indigenous Health, Social Justice, and Anti-Racism. Dr. Marcia Anderson is a Cree-Anishinaabe general internist and public health physician. She is the vice-dean of Indigenous Health, Social Justice and Anti-Racism at the Rady Faculty of Health Sciences, University of Manitoba.

Understanding intersectionality is at the core of building more equitable healthcare in Canada

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