1. Understanding Racism and Discrimination as Trauma
Ann Phillips, Scientist Lead
Research & Innovation
PPAH
October 29th, 2014

2. Race
“Race”, is not a inherited and fixed biological characteristic, but a socially constructed system of categorization created and sustained for economic, cultural and political reasons. (Gosine, 2002)
Over the past 35 years our biological understanding of race had been expanded. Our knowledge of human genetics has made it is clear that race is not a biological construct but a social one.

3. Racism = Discrimination + Power
Racism is a socially constructed ideology of hierarchy that is based on the idea that the human species can be divided into different groups, characterized as ‘races’ and identified by hereditary physical/biological characteristics.
Racism constitutes phenomena that result in avoidable and unfair inequalities in power, resources and opportunities across racial or ethnic groups.
“Racism occurs at multiple levels, including: internalized (i.e., the incorporation of racist attitudes, beliefs or ideologies into one’s worldview), interpersonal (interactions between individuals) and systemic (e.g., the racist production, control and access to labour, material and symbolic resources within a society)”
Racism has been around in its current form for less than 200 years. Racism stems from the belief that people should be treated differently because of a few phenotypic features. Racism has been used to justify the exploitation of certain groups of people because they are deemed to be inferior based on their specific set of physical/racial/biological characteristics.
“Racism can be expressed as beliefs, stereotypes, prejudices or discrimination and can range from open threats and insults to phenomena deeply embedded in social systems and structures.”

4. Social Determinants of the Health of Aboriginal Peoples
Proximal Determinants of Health
Health Behaviours [C]
Physical Environments [A]
Employment and Income [1, 3,4]
Education [2]
Food Insecurity [C]
Intermediate Determinants of Health
Health Care Systems [E]
Educational Systems
Community Infrastructure, Resources and Capacities
Environmental Stewardship
Cultural Continuity
Distal Determinants of Health
Colonialism
Racism and Social Exclusion [7]
Self-Determination
Some researchers suggest that the social determinants of Aboriginal Health can be categorized as distal (e.g. historic, political, social and economic contexts), intermediate (e.g. community infrastructure, resources, systems and capacities), and proximal (e.g. health behaviours, physical and social environment) (Reading & Wein, 2009) The numbers and letters correlate to the list of determinants of health on slide 13. with the numbers being the determinants that sort individuals into classes and letters being other important determinants. Not all of the most commonly identified determinants of health are included on this list, most notable absent are ethnicity/Aboriginal status; gender; early childhood development, psychosocial and human biology and genetics.
Proximal determinants of health include conditions that have a direct impact on physical, emotional, mental or spiritual health. (Reading & Wein, 2009) for example, ‘Income levels are lower for First Nations than for other Albertans and Canadians. The disparity may be partially explained by lower educational attainment and literacy in the First Nations population. First Nations in Alberta are two to three times more likely to have not completed high school than their Albertan or Canadian counterparts. As well, although issues vary considerably across communities, housing conditions for First Nations are much poorer than for other Albertans and Canadians.” (Health Determinants for First Nations in Alberta Report) “While proximal determinants represent the root of much ill health among Aboriginal peoples, some researchers suggest that intermediate determinants can be thought of as the origin of those proximal determinants. For instance, poverty and deleterious physical environments are thought to be rooted in a lack of community infrastructure, resources and capacities, as well as restricted environmental stewardship.” (Reading & Wein, 2009) “Distal determinants have the most profound influence on the health of populations because they represent political, economic, and social contexts that construct both intermediate and proximal determinants” (Reading & Wein, 2009) Unfavourable distal, intermediate and proximal determinants of health are associated with increased stress though lack of control, diminished immunity and resiliency to disease and social problems, as well as decreased capacity to address ill health. The complex interaction between various determinants appears to create a trajectory of health for individuals that must be addressed through a social determinants approach. (Reading & Wein, 2009)

5. More SDOH of Aboriginal Peoples
the creation of the reserve system,
forced relocations,
forced placement of children in residential schools,
inadequate services for those living on reserves,
systemic racism, and
a lack of comprehension of the effects of these experiences in the mainstream society.
The Indigenous Physicians Association of Canada & Association of Faculties of Medicine of Canada (2009) identify that the determinants of indigenous health must also include the list on this slide.
The Indigenous Physicians Association of Canada & Association of Faculties of Medicine of Canada point out that because of colonization and by the imposing Western cultural values and laws, non indigenous Canada has significantly influenced many of the determinants of health for First Nations, Inuit and Metis people. Colonization resulted in the loss of lands, resources, and self-direction as well as severe disturbances to Indigenous cultural ways and values."8 Through attempts at cultural assimilation, indigenous groups lost their land, self-government systems, cultures, languages, health care and education systems and traditional economies. This has left Indigenous peoples worse off than other Canadians in social and economic terms, and this has had profound implications for their health. “The legacy of the residential school among Indigenous peoples resulted in a loss of identity, of alienation and cynicism towards the rest of society. The spiral of personal health problems that have arisen from this trauma include addictions, abusive relationships (victims who have been abused and have not healed in turn abuse others) and suicide, and are at risk of being transmitted to younger generations. Indigenous communities have been working hard to heal from this trauma and ensure the resilience of their young people and their cultures” (Indigenous Physicians Association of Canada & Association of Faculties of Medicine of Canada. 2009)

6. What are the Social Determinants of Health?
Income and Income Distribution
Education
Unemployment and Job Security
Employment and Working Conditions
Early Childhood Development
Ethnicity/Aboriginal Status
Social Exclusion
Gender
Social Safety Network
Material (Housing, workplace, food security)
Psychosocial (stress)
Health Behaviours (tobacco use, alcohol use, physical activity, health eating)
Human Biology and Genetics
Health Care System (access to health care services)
What are the health-shaping life conditions or social determinants of health that can make our lives “full of fulfillment or empty with despair” to use a 2004 quote by the honourable Roy Romanow, who chaired the Royal Commission of the Future of Health CareAccording to the AHS Promoting Health Equity Framework they are:
Determinants that sort individuals into social classes:
Income and Income Distribution
Education
Unemployment and Job Security
Employment and Working Conditions
Early Childhood Development
Ethnicity/Aboriginal Status
Social Exclusion
Gender
Social Safety Network
Important Determinants, but ones that do not sort individuals into social classes:
Material (Housing, workplace, food security)
Psychosocial (stress)
Health Behaviours (tobacco use, alcohol use, physical activity, health eating)
Human Biology and Genetics
Health Care System (access to health care services)
In general, the people who are more disadvantaged and who are more socially isolated have poorer health than other (Landis & Umberson 1988).and societies where there is more social cohesion tend to be healthier (Kawachi & Kennedy 1997).

7. Racism & Health
Racism is thought to affect health through a number of pathways:
(1) limited access to social resources such as employment, housing and education and/or increased exposure to risk factors (such as unnecessary contact with the criminal justice system);
(2) negative affective/cognitive and other patho-psychological processes;
(3) allostatic load and other patho-physiological processes;
(4) reduced engagement with healthy behaviours (for example, exercise) and/or increased adoption of unhealthy behaviours (for example, substance misuse) either directly as stress coping or indirectly via reduced self-regulation;
(5) direct physical injury caused by race-based violence.”Paradies et al
A systematic review by Paradies [2] identified 138 international empirical population-based studies of self-reported racism and a wide range of health outcomes, finding that the strongest and most consistent associations existed between racism and negative mental health and health-related behaviors.

8. Racism as Trauma

9. Race-based Traumatic Stress

10. Key social determinants of mental health
Social inclusion,
Freedom from discrimination & violence,
Economic participation,
The WHO, VicHealth and University of Melbourne’s 2004 report on mental health identify three key social determinants of mental health (WHO, 2004):
Social inclusion, including social relationships; involvement in group activities and civic engagement
Freedom from discrimination & violence, including valuing diversity, physical security and self-determination and control of one’s life
Economic participation/access to economic resources, including work, education, housing and money.
The recent 2014 report from the Canadian Mental Health Association, Ontario entitled Advancing Equity in Mental Health in Ontario: Understanding Key Concepts also identifies these 3 social determinants as key in influencing mental health.
Thinking back to the SDOH for Aboriginal peoepl you can see that there are 3 of the SDOH that also have an impact on Aboriginal communities.

11. SDOH & Mental Health in First Nations Communities
Canadian Nurses Association
quote a 2006 study
“disparities in circumstances and lifestyles explained most (but not all) of differences in depression rates between Aboriginal and non-Aboriginal people in off reserve areas,”
A 2014 Report entitles Current Issues in Mental Health in Canada: The Mental Health of First Nations and Inuit Communities notes that First Nations and Inuit communities experience mental health problems and their consequences – such as depression, anxiety and suicide – at significantly higher rates than the general population, and young people are the most dramatically affected. The report suggests that the disproportionately high prevalence of mental health problems in Aboriginal communities can be linked, in part, to a history of cultural disruption, oppression and marginalization.
The Canadian Nurses Association’s National Expert Commission found that The rates of mental health problems and suicide are significantly higher among Aboriginal peoples than in the general population (CMHA, 2012). Tjepkema (cited in Government of Canada, 2006, p. 170) found that “disparities in circumstances and lifestyles explained most (but not all) of the differences in depression rates between Aboriginal and non-Aboriginal people in off reserve areas, and that education and economic security were ‘critical determinants’ of peoples’ ability to make positive changes....”
The rate of suicide among Aboriginals is 2.1 times the overall rate in Canada (Canadian Mental Health Association [CMHA], 2012). Suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to 44 years of age (Health Canada [HC], 2012). For Inuit youth, suicide rates “are among the highest in the world, at 11 times the national average” (HC, 2012).

12. Possible Mechanisms for the Action of SDOH
Stress, stress, stress. stress
Stress is one of the proposed physiological pathways that connects the conditions in which we live to our experience of health.
Stress: The Canadian Facts starts with a discussion of stress, bodies and illness.
Stressful living conditions and chronic stress cause physiological changes that can strain the human body
These lead to patho-physiological changes that affect well-being, increase morbidity and mortality

13. Pathways between Racism and Health
Paradies et al, Racism as a determinant of health: A Protocol for conducting a systematic review and meta-analysis

14. Possible Mechanisms for the Action of SDOH
Epigenetics: the idea that gene expression can be shaped by external factors and these can be shaped by social experiences.
The emerging Science of Epigenetics provides a mechanism that is particularly relevant to the understanding of social determinants of mental health but also relevant to the overall social determinants of health.
Source: National Institutes of Health website, 2014

15. What can be done in health care settings?
Trauma-informed Care
Being trauma aware
Ensuring safety (physical, emotional and cultural safety)
Building trust
Ensuring choice and collaboration
Building strength and skills
Cultural Safety
being power aware
ensuring safety
establishing trust
empowering patients
opening channels of communication
Working in a trauma informed way requires a shift in thinking and in practice and the understanding that anyone may have experienced many different types of trauma in their lives and that health care settings cannot be effective if they re-traumatize clients. Trauma informed practices require shifts on a personal level, such as including self awareness and self compassion as a part of health car practice. It also requires shifts on the practice level which requires re-thinking how health care practitioners connect with or interact with clients and it requires a shift on the institutional or organizational level through a commitment to trauma-informed practice.
The term “cultural safety” was developed in the 1980s in New Zealand in response to the indigenous Maori people’s discontent with nursing care. Cultural safety moves beyond the concept of cultural sensitivity to analyzing power imbalances, institutional discrimination, colonization and relationships with those in positions of power and authority, as they apply to health
Care. Cultural safety requires that health care practitioners become respectful of nationality, culture, age, sex, political and religious beliefs. A key element of culturally safe practice is establishing trust with the patient. Culturally safe care empowers people because it reinforces the idea that each person’s knowledge and reality is valid and valuable. It facilitates open communication and allows the patient to voice concerns about health care that he or she may deem unsafe (NAHO factsheet). The Alberta Health Services Aboriginal Health program’s Cultural Competency Framework focuses on 5 key eements which are : advocacy; relationship building; team work; patient centred care and communication.