Black women’s health matters

As I write this, we are more than 3 weeks into worldwide protests following the killing of Mr George Floyd by a police officer in Minnesota on 25 May 2020. Demonstrators and activists have made it clear that they expect people (particularly White people) in positions of leadership and of privilege, who have a voice to use it. As physicians and community leaders, it is incumbent on us to listen, learn, reflect, and act. It is within our collective and individual powers to improve the health care inequity that our Black patients face. The phrase “silence is compliance” has been emblazoned on signs across the globe at #BlackLivesMatter demonstrations. It is no longer satisfactory to be “not racist”—we must be actively “antiracist.” Actually, being “not racist” is a misnomer because, as Ibram X. Kendi has pointed out, inaction on racist policies has been a form of racism all along.[1]

Women have historically been vastly underrepresented in clinical trials.[2] Black women even more so. In 2019, Nnorom and colleagues published a scoping review on breast and cervical cancer in Black Canadians (people of African/Caribbean/Black ancestry living in Canada).[3] The study found that only 23 out of a possible 1921 papers they examined included health data specific to Black women. The authors wrote that Black women in Canada faced barriers to health care predominantly related to lower screening rates rather than access to treatment.[3] This is concerning because data from the United States and the United Kingdom indicate that Black women are more likely to die of cancer than their White counterparts.[3,4] For example, the American Cancer Society’s 2019 Surveillance Report cited a lower prevalence of breast cancer in non-Hispanic Black women at 126.5 (per 100 000) versus 130 (rate ratio 0.97). Despite this, the mortality rate was markedly higher in Black women at 28.9 (per 100 000) versus 20.6 in White women (rate ratio 1.41).[5] One thing we can derive from these statistics is that Black women might have inadequate access to screening, which results in missed opportunities to detect and treat aggressive cancers at an earlier stage.

The Canadian Cancer Society does not report its annual statistics by race.[6] So, if we don’t collect data to understand the scope of the problem, how can we expect to solve it? It appears that people have been asking this question for years. A Black Experiences in Health Care Symposium held in Toronto in 2017 suggested that to make the system more equitable, “data quality challenges” should be addressed. For example, they identified an urgent need for data sets that include race and ethnicity.[7] During the second Black Experiences in Health Care Symposium, held in January 2020, race-based data collection remained a key theme. The planning committee’s number-one recommendation was for mandated data collection in partnership with Black communities, and including Black leadership, to measure, improve, and publicly report on care and outcomes.[8]

An investigation by the Globe & Mail published last year exposed how far Canada lags behind other nations in collecting racial data.[9] In the article, it was postulated that our “Canadian way” of avoiding the unease of difficult subjects (like race) is part of the reason we are less likely to collect racial data than other countries. In pretending we are “color blind,” we have actually harmed Black Canadians by failing to study and address our health care disparities.

There are Canadian articles that address racism in medicine and how it affects Black women. A complete literature review is beyond the scope of this essay, but a few titles are included here for inspiration. Researchers from Queen’s University and the University of Ottawa recently published a report in the American Journal of Obstetrics and Gynecology called “Behind the times: revisiting endometriosis and race.” In it, they describe the historical bias of treating endometriosis as a “disease of white women in higher income brackets.” This led to years of misdiagnosis for Black women with pelvic pain as pelvic inflammatory disease rather than the complex, chronic disease of endometriosis.[10] The authors explain that these “misdiagnoses stemmed from the still pervasive myth that women of color were somehow immune to endometriosis and the stereotype that African American women were more promiscuous than their white peers.”[10,11]

In Black-White Health Inequalities in Canada, the researchers analyzed multiple health outcomes such as diabetes, hypertension, heart disease, and mental health.[12] One of their conclusions was that “race-based discrimination, a lifelong stressor, contributes to the development of hypertension . . . and to insulin resistance.” The On the Margins project undertaken in rural Nova Scotia concluded that, “ any future research [on Canadian Black women] be undertaken with the recognition that race interacts with numerous other variables and experiences [that] determine health.”[13] This concept was echoed in a December 2019 publication by Chief Public Health Officer of Canada Dr Theresa Tam, in a report titled, “Addressing stigma: Towards a more inclusive health system.”[14] A highlighted excerpt from the report calls on us all to stop the “slow and insidious practice of dehumanizing others.”

Systemic racism relates to systems, which we can control and change. This can be differentiated from individual racism, which refers to “assumptions, beliefs, and behaviours,” conscious or unconscious that are, arguably, more difficult to change.[15] Recognizing the way our health systems discriminate, and actively working to fix them, will promote change and fairness. The data, scant as they are, indicate that addressing systemic racism will lead to better health outcomes for Black women in Canada. We all have a role to play in this problem and in its solution.

I am pleased to “turn the pages over” to an invited contribution by Dr Marjorie Dixon.

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This article has been peer reviewed.

References

1.    Kendi IX. Ibram X. Kendi says we are either being racist or antiracist, there is no middle ground. CBC Radio. 15 November 2019. Accessed 9 June 2020. www.cbc.ca/radio/outintheopen/ibram-x-kendi-says-we-are-either-being-racist-or-antiracist-there-is-no-middle-ground-1.5350278.

2.    Yakerson A. Women in clinical trials: A review of policy development and health equity in the Canadian context. Int J Equity Health. BioMed Central 2019 Apr 15;18:56-58.

3.    Nnorom O, Findlay N, Lee-Foon NK, et al. Dying to learn: A scoping review of breast and cervical cancer studies focusing on Black Canadian women. Journal of Health Care for the Poor and Underserved. Johns Hopkins University Press 2019;30:1331-1359.

4.    Jemal A, Center MM, DeSantis C, Ward EM. Global patterns of cancer incidence and mortality rates and trends. Cancer Epidemiol Biomarkers Prev 2010;19:1893-1907.

5.    American Cancer Society. Cancer Facts & Figures for African Americans 2019-2020. Surveillence Report. Accessed 7 June 2020. www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-facts-and-figures-for-african-americans/cancer-facts-and-figures-for-african-americans-2019-2021.pdf.

6.    Cancer statistics at a glance—Canadian Cancer Society. Accessed 7 June 2020. www.cancer.ca/en/cancer-information/cancer-101/cancer-statistics-at-a-glance/?region=on.

7.    Sinai Health System. Black experiences in health care. Sinai Health system. 2017 Accessed 9 June 2020. www.mountsinai.on.ca/about_us/health-equity/pdfs/SHS-BEHC-report-FINAL-aoda-final.pdf  .

8.    Orridge C, Bernard C, Quaison G, et al. Black Experiences in Health Care Symposium 2020. Accessed 13 June 2020. www.healthcommons.ca/blackhealth.

9.    Grant T, Balkissoon D. How Canada’s racial data gaps can be hazardous to your health. Globe and Mail. 6 February 2019. Accessed 10 June 2020. www.theglobeandmail.com/canada/article-how-canadas-racial-data-gaps-can-be-hazardous-to-your-health-and/.

10.    Bougie O, Healey J, Singh SS. Behind the times: Revisiting endometriosis and race. Am J Obstet Gynecol 2019;221:35.e1–35.e5.

11.    Chatman DL. Endometriosis in the black woman. Am J Obstet Gynecol 1976;125:987-989.

12.    Veenstra G, Patterson AC. Black-White health inequalities in Canada. J Immigr Minor Health 2016;18:51-57.

13.    Etowa J, Wiens J, Bernard WT, Clow B. Determinants of Black women’s health in rural and remote communities. Can J Nurs Res. Can J Nurs Res 2007;Sep;39:56-76.

14.    Tam T. Addressing stigma: Towards a more inclusive health system. Accessed 13 June 2020. http://nccdh.ca/resources/entry/addressing-stigma-towards-a-more-inclusive-health-system.

15.    Alberta Civil Liberties Research Centre. Forms of Racism. Accessed 13 June 2020. www.aclrc.com/forms-of-racism.

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Dr Dunne is a clinical assistant professor at the University of British Columbia and a co-director at the Pacific Centre for Reproductive Medicine in Vancouver. She serves on the BCMJ Editorial Board.