Feminist
Research
Education
Development
and
Action Centre
The FREDA Centre
for Research on Violence
against Women and Children
for Research on Violence
against Women and Children
Changing Institutional Agendas in
Health Care
Yasmin Jiwani, Ph.D.
Plenary Presentation at
Removing Barriers: Coast Plaza Hotel, Vancouver, Canada
Inclusion, Diversity and Social Justice in Health Care
May 25-27, 2000
Health care is a system which is reflective of the larger society - it therefore mirrors the inequalities in society. Though predicated on the notion of humanitarianism, this notion is rapidly being translated into capitalist terms which impact on service provisions as in the number of beds that are available, the amount of labour available, etc. As with other systems - for example the justice system in which witnesses become fodder for the courts - you can't have a case without witnesses, so you can't have health care without consumers. Ailments become commoditized as do consumers themselves - how many patients one sees in a day, what kinds of ailments one treats, how many examinations are involved, and how many referrals are made. This is a system, and like other systems in society, it is deeply structured around hierarchies - these hierarchies are based on interlocking influences of race, class, and gender (Razack, 1994) which inform the categories of professionals versus workers; doctors versus nurses; patients versus professionals; janitorial staff versus professional staff; preferred and deserving patients versus those who are not perceived to be so.
Within such a system, how do we change institutional agendas? What is the goal toward which such change is oriented? This conference's title highlights the issue of inclusion, diversity and social justice. But inclusion means recognizing and dismantling barriers; acceptance and integration of diversity means recognizing other systems, and removing the negative value connotations attached to them; and social justice means dismantling the hierarchies. How can such hierarchies be dismantled when they are predicated and built using structures of oppression and when they are interlocking so that the privilege of a professional is built on the acquiescence and subordination of another - on accepted and inscribed notions of privilege - social class, education, years of experience, expertise. For instance, the status of a nurse is contingent and defined in relation to the status of a doctor. So even within the dominant, allopathic health care system of western medicine, these hierarchies are based on power and privilege, and with power comes the potential of abuse: the abuse of power. Just last year, the Workers' Compensation Board released a study which indicated that nursing was one of the most dangerous professions.
The health care system as it is now - and I mean the health care system which we see in the hospitals, in doctors' offices, in clinics - is deeply gendered, raced, and classed. Within that system, the patriarchal model prevails in terms of biological research on health issues which have continually focused on the male body (Ahluwalia & MacLean, 1988). Morton Beiser (1998) has noted the case of psychiatrists in one study who were likely to over-diagnose blacks with schizophrenia as compared to whites; similarly, he mentions the case of family physicians who are less likely to refer non-English speaking patients to specialists as compared to English speakers; and surgeons who are less likely to perform cardiac bypass surgeries or kidney replacements for minority people as compared to white people.
The western health care system is a system where the majority of doctors are male, and the majority of nurses are female - again gendered on power lines; where the people of colour tend to be found either in the rolls of the patients, or in the kitchens, laundries, and janitorial services of most hospitals. In his study of a Toronto hospital, Wilson Head (as cited in Henry et al., 1995) found that racial minority nurses were severely underrepresented at the decision making and supervisory levels. Further, they were passed over for promotion with white nurses being promoted at rates significantly higher despite sharing similar levels of qualification with black nurses (Das Gupta, 1996).
Statistics Canada has documented that most racial minorities coming into the country have a higher level of education but are not employed in their area of specialization or expertise. The case of doctors who are "foreign trained" but not allowed accreditation demonstrates one side of the issue of exclusion. On the other side, are the large number of nurses from the Philippines and elsewhere who are not recognized and slotted into domestic work. (see also Das Gupta, 1996). In the meantime, special interest groups decry the "brain drain." Still another side of the exclusion, is the racial minority patient who comes into the hospital to be confronted by stereotypes and racism - both individual and systemic; or the health care system's failure to recognize the health impact of racism, or the impact of the intersection of systemic forms of violence and intimate forms of violence experienced at the individual level. Indeed several studies have demonstrated the particular vulnerabilities and urgent needs of racial minority women who have experienced wife abuse/sexual assault. These studies highlight the impact of dual forms of oppression - sexism and racism in the lives of these women (Henry et al., 1995; Rasche, 1988; Varcoe, 1997).
Instead of dealing with issues of exclusion through integration, the health care system - like its counterpart the criminal justice system - tends to employ a piecemeal approach that, once again, conforms to the dominant ideology. It multiculturalizes the approach so that rather than viewing the situation in terms of power, the tendency is to use the lens of culture - in a partial way and from a dominant perspective. Thus, the emphasis tends to be one of providing culturally sensitive health care, and to favour cultural prescriptions that identify cultural preferences. So for instance, language becomes the focal point and change is translated in terms of having multilingual information.
Language is just one small part of the issue as Carol Christiansen (who made a presentation at this conference) and Joan Anderson (1985; 1987) have pointed out in their research. Such an approach fails to do justice to the very notion of culture - as a whole way of organizing information and relating to the world. It also discounts the crucial role of history - how that culture came to be what it is through its historic encounters with other cultural systems, notably through colonization. And let's not forget that most immigrants and people of colour - along with Aboriginal peoples - were colonized at one time. In fact, by 1914, 85% of the world's surface was colonized by the European powers (Said, 1979). Cultures have not remained static - they have evolved - and in many cases, they have suffered tremendously as a result of the colonial encounter. Further, cultures are not homogenous - they are extremely diverse and marked by waves of migration resulting in diasporic and hybrid communities. But using a cultural lens in a narrow way, discounts the import of traditional forms of medicine and healing as these are seen as threats to the very privileged position held by western medicine.
Drawing from her perspective as a Maori nurse, Irihapeti Ramsden (1993; Polaschek, 1998) describes an alternative method - that of assessing cultural risk and increasing cultural safety - but as she argues, that approach is only possible when cultural groups have the power to determine policies and practices which ensure the safety of their own people within systems which are clearly not of their own design. So instead of assessing cultural safety or risk in terms of how the nurse interacts with the patient, she posits a model whereby patients determine how much of a risk or safety factor they are likely to experience in their encounter with a white nurse in a white institution. Such a perspective not only validates the patient's standpoint, but more obviously underscores the reality that medical institutions as other institutions in society are not safe places for those who have no power or very little power.
The cultural safety model is an ecological model that actually argues for the health care professional to take into consideration the sociopolitical reality of the patient - not the cultural stuff alone in isolation - especially not as it is interpreted within the ideological framework of multiculturalism, but rather, in terms of the political status and historical experiences of the patient/group with which one is dealing.
Now for changing institutional agendas. This shift in focus - from addressing issues strictly through a cultural lens to one which actually focuses on the sociopolitical aspects and influences that inform the reality of a particular group - requires a paradigm shift.
Paradigm shifts are not safe nor are they always welcomed because the health care system, like other systems, relies on a bedrock of routinized practices and assumptions (Varcoe, 1997). Those practices revolve around understanding issues using a medical model - a disease model. Second, within such a system, the patient is not seen as a whole person but rather as a set of physiological symptoms that need to be processed (Ahluwalia & MacLean, 1988; Kurz & Stark, 1988; Warshaw, 1993). And third, within such a system, economic constraints create a reluctance to move beyond addressing immediate needs. Finally, as a system within society, the health care system is permeated by assumptions, stereotypes, values and beliefs which echo those in the larger society. So racism, sexism, homophobia - all of these are manifested in the health care system and are perpetuated within it. And the system protects itself against incursions that it perceives as threats. One only has to look at how privilege is protected in terms of the lack of accreditation given to foreign-trained doctors, or how nursing credentials from white Commonwealth countries are recognized, but not those from parts of the Commonwealth that consist of developing countries.
But if we are to draw from this Maori model, what would safety and risk look like for racialized groups of people - people of colour? Instead of a culturally prescriptive model, the agenda would be one of looking at the structural issues that impact on people of colour. Foremost is the issue of institutionalized racism. And there is no medicine for racism aside from structural change, just as there is no antidote for sexism aside from structural change.
Institutionalized racism has a devastating impact on people of colour. The history of colonialism is evidence of this impact. It is an impact that has sociological, psychological, physiological and structural dimensions. Institutionally, racism is evident in the exclusion of people of colour from positions of power; it is evident in the kind of values (that same word that Dr. Kenny mentioned yesterday), beliefs, attitudes and practices of those working in the institution which effectively work to contain, minimize, trivialize or erase the contributions and realities of people of colour. It is evident in the daily lived realities of people of colour and Aboriginal people in this country. And it is apparent in the stereotypes that inform the interactions of people of colour with health care professionals - stereotypes which not only contain people in tight little boxes, but also victimize them further by blaming their cultures for perceived and negatively valued practices.
Racism as a system of domination and oppression works in the same way as sexism and homophobia. In fact, these systems of oppression are interlocking - they do not operate in a vacuum or separately - they are interwoven and their intersections serve to worsen the situation of those who cannot be neatly categorized into any one group (Razack, 1994). Think for instance about the ways in which women of colour are conceptualized - they are either lumped in with racialized minorities, or they are lumped in the category of women. And within that category, the hierarchies between women are obscured - hierarchies based on race, class, sexuality, citizenship. Similarly, yesterday we heard a presentation about sexual minorities - even there, race, gender, and class intersect to complicate and compound the situation of say a woman of colour who is also a lesbian, or the man of colour who is gay. These are structural issues that clearly influence policy, and when these intersections are not accounted for, the reality is that a whole group of people fall through the cracks - their needs are not being met - but worse still, their realities are completely erased and or categorized into stereotypical frames (Cave et al., 1995).
But racism, like the other systems of domination, is about violence. And violence has a profound impact on health and well-being. Systems have to learn to recognize racism in order to be able to "treat" it - if the political will exists. So if one were to use the cultural safety or ecological model, how would one begin to deal with racism - within the context of the encounter of a racialized person/patient with a white, patriarchal western medical system? The first would be to understand the process of colonization, the impact of migration (historically and contemporarily), and then to understand how the intersections of race, class and gender work in creating the particular lived conditions of racialized people. It means grasping where these people are located in the economic system - are they migrant workers, farm workers, garment workers?; are they professionals? - because each one of these levels is going to result in experiences of racism that are different and health outcomes that are different. For example, Bolaria and Bolaria (1994) point out that there is a higher rate of suicide for homemakers than for women employed outside the home. For garment workers, the stress and strain combined with dust, lint, fabric scraps and the like contribute to illnesses and respiratory problems. In the United States, Meleis (1991) has identified that immigrant women are a high risk population because of the structural conditions associated with being women in a patriarchal society and immigrants in a hostile society simultaneously. Gender and poverty have now been recognized as social determinants of health. It is time that we begin to recognize race in a similar way, albeit with the proviso that it is not the racialized person here who is the "problem" but the social systems that interact with her/him.
Dealing with racism means recognizing the double- or triple-jeopardies that arise when multiple forms of oppression are intersecting and influencing a person's life. And it means understanding the factors that cause people to feel powerless, isolated, dependent, stripped of their dignity, violated - and the impact of having their identities erased and their contributions appropriated by others. These dynamics of racism are not unknown, in fact, they have been amply documented in the literature from the psychological works of Albert Memmi, Franz Fannon, to the sociopolitical analyses of Edward Said, and others. They continue to be documented by many of the researchers present here in this very room. And they mirror the physiological and psychological impacts of intimate, gender-based forms of violence.
In dealing with a structural analysis, it is crucial to examine how these different forms of violence intersect in the lives of racialized minority women who are also immigrants. How do the women deal with racism from the outside - from dominant institutions such as the health care system, and intimate forms of violence resulting from sexism from within their communities coupled with sexism from the outside. How do these various forms of violence intersect and combine with the effects of migration, social class, language barriers, etc. (See for instance work by Moussa, 1994; Razack, 1994).
The literature on violence indicates that physicians and nurses are often in key positions to provide services to women in abusive relationships (Archer, 1994; Henderson & Ericksen, 1994). The visit to the physician is sanctioned in a way that few other visits outside the home are for women in abusive relationships; further, in cases of extreme injury, going to emergency services becomes a necessity (MacLeod & Shin, 1990; Sidhu, 1996).
In a recent study that we conducted with immigrant women from racial minority communities who had experienced violence, many reported that they had sought health care for injuries and illnesses suffered as a result of their abusive relationships (Jiwani forthcoming). As with the findings in the violence-related literature, few physicians responded nor did many nurses. In fact, in some instances nurses simply suggested that the women came from abusive cultures. These are the kinds of stereotypes prevalent in the system. Dealing with gendered violence is difficult for health practitioners (Warshaw, 1993), add other forms of violence, and the result is disastrous. In fact, many of the studies show that women who are clearly injured as a result of abuse and who have attempted suicide, are sent home to their abusive partners by hospitals and medical practitioners (Kurz & Stark, 1988).
While cultural prescriptions might have helped in these cases, they don't address the kinds of structural issues facing these women. Many immigrant women come into the country as dependents of their spouses, are unaware of their legal rights, and in numerous cases are suspicious of authority figures or even the documentation of their problems. They are afraid of deportation, of having their children taken from them. In these cases, where isolation works to cut off any form of support or information, the health care system becomes a critical avenue (Sidhu, 1996). It becomes virtually the only site of intervention for immigrant women in rural settings. But again, even here, physicians tend not to respond, and as one community worker told me, women in abusive relationships are simply prescribed tranquilizers. Talking culture doesn't make sense here, but understanding the impact of migration, of gendered relations, does. Knowing where to refer these women becomes critical and treating women as whole beings is an absolute necessity. The issue isn't one of cultural sensitivity - its one of respect.
Changing institutional agendas means having a voice - it means having that voice heard, and it means sitting at those tables where decisions are made and resources allocated. It means having power. Are those who hold power and privilege willing to share it when that power actually emerges from the subordination of others? The tendency of most systems that are confronted with this issue is to opt for an illusion of shared power. In these instances, minorities are tokenized. You have the one or two success cases and these are held up as models. When issues of racism are raised, the tendency is to deny them outright; dismiss or trivialize them as resulting from the over-sensitivities of specific people; silence them by firing those who have raised the issue; or contain them through institutional mechanisms of co-optation and appropriation.
Until we sit at that table with a semblance of power, structural issues are not going to get on the table. It requires commitment from the highest levels, and a firm political will to be able to engage in any institutional change. Furthermore, for those who do have political commitment, it will take a concerted effort not to succumb to a piecemeal approach, but to truly embrace an integrated and socio-political perspective.
At the present time, changing institutional agendas is a Herculean task particularly as it affects the inclusion and access for racialized people to health care. With the growing economic disparity, the emphasis on fiscal constraints, and a politically conservative climate, it is a matter of urgency to retain the momentum of a social justice agenda. A critical first step in the process is to legitimize the voices of racialized people - whether it be in research or in practice. This means that rather than framing research which problematizes racialized groups as constituting a drain on health care expenses, research must centre on the experiences of racialized peoples and examine their issues from their perspectives. In practice, credentials earned elsewhere must be recognized, and further, efforts need to be made to ensure representation within boards' management structures, and at the front-lines. Moreover, integration means recognizing other systems of health care and respecting them, particularly if they are the chosen avenues for treatment by particular groups.
These are just some of the rudimentary steps in changing institutional agendas. However, change is slow as can be evidenced from the repetition of many of these same themes at the last conference. Nonetheless, change is a necessity in a growing diverse society and economy. And it is up to us, collectively, to ensure that we can direct the changing currents toward the common goals we envision.
References
Ahluwalia, Seema and Brian D. MacLean. "The Medicalization of Domestic Violence." In Sociology of Health Care in Canada, ed. B. Singh Bolaria and Harley D. Dickinson, 183-197. Toronto, ON: Harcourt Brace Janovich, 1988.
Anderson, Joan M. 1985. "Perspectives on the Health of Immigrant Women: A Feminist Analysis." Advances in Nursing Science, 8, 1 (1985): 61-76.
________. "Migration and Health: Perspectives on Immigrant Women." Sociology of Health and Illness, 9, 4 (1987): 410-438.
Archer, Lynda A. "Empowering Women in a Violent Society, Role of the Family Physician." Canadian Family Physician, 40 (May 1994): 974-985
Beiser, Morton. "Towards a Research Framework for Immigrant Health." presented at the Metropolis Health Domain Seminar, December 12-13, 1996. In the Metropolis Health Domain Seminar, Final Report. Pp. 23-32. Ottawa: Minister of Public Works and Government Services Canada, 1998.
Bolaria, B. Singh and Rosemary Bolaria. "Immigrant Status and Health Status: Women and Racial Minority Immigrant Workers." In Racial Minorities, Medicine and Health, ed. B. Singh Bolaria and Rosemary Bolaria, 149-168. Halifax, NS: Fernwood, 1994.
Cave, Andrew, Usha Maharaj, Nancy Gibson and Eileen Jackson. "Physicians and Immigrant Patients." Canadian Family Physician, 41 (October 1995): 1685-1690.
Das Gupta, Tania. Racism and Paid Work. Toronto: Garamond Press, 1996.
Henderson, Angela D. and Janet R. Ericksen. "Enhancing Nurses' Effectiveness with Abused Women: Awareness, Reframing, Support, Education." Journal of Psychosocial Nursing, 32, 6, (1994).
Henry, Frances, Carol Tator, Winston Mattis, & Tim Rees. The Colour of Democracy: Racism in Canadian Society. Toronto, ON: Harcourt Brace Canada, 1995.
Kurz, Demie and Evan Stark. "Not-So-Benign Neglect, the Medical Response to Battering." In Feminist Perspectives on Wife Abuse, ed. K. Yllö and M. Bograd, 249-266. New York, NY: Sage, 1988.
MacLeod, Linda and Maria Shin. Isolated, Afraid and Forgotten: The Service Delivery Needs and Realities of Immigrant and Refugee women who are Battered. Prepared for the National Clearinghouse on Family Violence. Ottawa, ON: Health and Welfare Canada, December, 1990.
Meleis, Afaf I. "Between Two Cultures: Identity, Roles, and Health." Health Care for Women International, 12 (1991): 365-377.
Moussa, Helene. Challenging Myths and Claiming Power Together: A Handbook to Set Up and Assess Support Groups for and with Immigrant and Refugee Women. Toronto, ON: Education Wife Assault, 1994.
Polaschek, N. R. "Cultural Safety: A New Concept in Nursing People of Different Ethnicities." Journal of Advanced Nursing, 27 (1998): 452-457.
Ramsden, Irihapeti. "Cultural Safety." The New Zealand Nursing Journal, Kai Tiaki, 83, 110 (1990): 18-19.
________. "Kawa Whakaruruhau: Cultural Safety in Nursing Education in Aotearoa (New Zealand)." Nursing Praxis in New Zealand, 8, 3 (1993): 4-10.
Rasche, Christine E. "Minority Women and Domestic Violence: The Unique Dilemmas of Battered Women of Colour." Journal of Contemporary Criminal Justice, 4/3 (1988): 150-171.
Razack, Sherene. "What is to be Gained by Looking White People in the Eye? Culture, Race and Gender in Cases of Sexual Violence." Signs, 19, 4 (1994): 894-923.
Said, Edward. Orientalism. New York, NY: Vintage Books, 1979.
Savary, Rosalind. What Does Gender Have to Do with It? An Environmental Scan on Women's Health Issues. Prepared for the Adult Health team, Health Promotions and Programs Branch, Health Canada, BC/Yukon Regional Office, 1998.
Sidhu, Surjeet. Perspectives of Women Who have Experienced Violence in Relationships and Their Children. Research initiated and conducted by the Richmond coordinating Response Committee to End Violence Against Women. November 13, 1996.
Varcoe, Colleen M. "Untying Our Hands: The Social Context of Nursing in Relation to Violence Against Women." Doctoral dissertation, School of Nursing, University of British Columbia, 1997.
Warshaw, Carole. "Limitations of the Medical Model in the Care of Battered Women." In Violence Against Women: The Bloody Footprints, ed. Pauline B. Bart and Eileen Gail Moran, 134-146. Newbury Park, CA: Sage, 1993.
Yasmin Jiwani is a senior researcher at the FREDA Centre
for Research on Violence against Women & Children, Simon Fraser
University, Harbour Centre, Vancouver.