UPROOTING MEDICAL VIOLENCE:

Building An Integrated Anti-Oppression Framework for Primary Health Care

By Nanky Rai, MPH, MD

(nankyrai@gmail.com, Tw: @NankyRai)

April 1, 2017

“Ignorance allied with power is the most ferocious enemy justice can have.” - James Baldwin

ABSTRACT

While medical education strives to teach us about the social determinants of health and health advocacy, our formal curriculum is inadequate in examining the power and privilege in medical practice. A reflexive autoethnographic methodology was used to conduct a literature review looking at the role of anti-oppression training for healthcare providers. Historical foundations were presented which showcased the relationship between oppression and health outcomes as well as the Canadian healthcare system’s historical and ongoing role in perpetuating oppression. The principles identified for an integrated anti-oppression framework for primary health care can be grouped into four main categories: i) uprooting medical violence, ii) understanding intersectionality and centering the margins, iii) practicing allyship and solidarity as healthcare providers, and iv) growing health justice by supporting grassroots resistance.

Key words: anti-oppression, structural competency, colonization, oppression, and medical education

BACKGROUND

I’ve completed the writing of this academic project while learning and working in Treaty 3 territory just miles away from some of the Indigenous communities that have declared states of emergency due to youth suicides or limited access to running water or exorbitant food costs or lack of proper housing or insufficient medical care or due to missing and or murdered Indigenous women (Porter, 2017; Gilmore, 2015; Amnesty International, 2004). The fly-in Ojibwa community in Pikangikum First Nation, the reserve closest to the town I was working in at the time of finishing this report, was labelled with having the highest suicide rate in the world in recent years (Patriquin, 2012).

In the same breath, I find news articles that amplify the myth of Canadian benevolence to newcomers (Black, 2016). Our media celebrates Canada’s multiculturalism and racial harmony, distancing itself from the painful unspeakable violence against Black and brown communities in the U.S.  Yet while we uncover the news of missing Black girls in the District of Columbia (Jarrett and Reyes, 2017), I also read headlines of missing Indigenous girls and women from where I currently work and live (Aiken, 2017).

For the last six years, I’ve found myself reading similar headlines documenting unjust violence against dispossessed communities often on my way to work while knowing that the conversations these articles aimed to spark were not being held within my clinical environment. I’ve been trained to believe that professional medical practice is one that remains outside the realm of politics. Many researchers have attempted to move beyond this sanitized culture of medicine by building large databases of evidence showcasing the relationship between social injustice and health inequities (Hyman and Wray, 2013). There are also those who are attempting to bridge the gap between understanding the social production of poor health and teaching learners how to effectively bridge this gap in health inequities for their patients and broader communities (Sharma et al., 2016). This effort receives support from the Royal College of Physicians and Surgeons in Canada as articulated in their CanMEDS framework which declares that health advocacy, defined as the need to promote “health equity, whereby individuals and populations reach their full health potential without being disadvantaged by, for example, race, ethnicity, religion, gender, sexual orientation, age, social class, economic status, or level of education”, is one of the central tenets of physician competency (Royal College of Physicians and Surgeons of Canada, 2015).

Yet, as a family medicine resident in the final year of my medical training, I could not articulate in depth the ways in which the social determinants of health (SDOH) actually cause disease. I have not received training in social theories that can provide us with the frameworks necessary to delve deeper into the mechanisms behind the SDOH. While I’ve been informed about poverty or transphobia or homelessness as SDOH, I have not been made aware of the healthcare systems historical and ongoing contributions to the creation and sustenance of many SDOH like racism or homophobia. While we’ve received didactic lectures in medical school regarding health advocacy and what it could entail, I did not learn about social justice movements that have played significant roles in shaping social welfare systems (Navarro, 1989). Much of the education I’ve received around the role of health advocacy also hasn’t attempted to tackle head on the glaring differences between those called upon to advocate and the communities that physicians feel empowered to speak on behalf of. While we’ve received formal and informal education on the phenomena of the ‘hidden curriculum’, this education is not delivered in conjunction with health advocacy training. This lack of reflective practice on our own power and privilege, and the stronghold of elitism in medical culture are major contributors to poor health outcomes for individuals and communities.

The healthcare environment provides a stark representation of the world we live in: a world that continues to be impacted by ongoing processes of colonization and a world that has been forcibly stratified along lines of power and domination, through race, class, gender, sexuality and ability. Simultaneously, as we are trained in one of the oldest colonial institutions in Canada, it is our responsibility to uncover and learn the complete history of medicine. After all, having been trained within a Western biomedical paradigm, how can we responsibly provide healthcare to all people without having any knowledge of the violence – historic and ongoing – that is committed by individual practitioners, institutions and the entire healthcare system. This commitment to uncovering and relearning this history should always remain the first foundational step towards practicing health advocacy. How else can we learn from our mistakes and work towards building a healthcare system that affirms self-determination for all people, the ultimate prerequisite to health and wellness.

However in order to deepen our understanding of this work, we need to first ensure that the terminology used in this report is accessible to trainees and practitioners in primary care. Therefore I would like to direct the readers to Appendix A for a list of definitions that will help with the reading of this report. At the very least, I would like to ensure that readers walk away with a thorough understanding of words such as power and privilege, that they do not replicate the unreflective equating of individual prejudice with racism that is so pervasive in our culture, and that they leave with some familiarity with important theoretical frameworks such as anti-oppression and intersectionality.  

Ultimately, as a soon to be medical graduate, I feel that I have not received the training necessary to critically examine the role physicians have and can play as a health advocate as defined by the Royal College. Rather than speaking on behalf of communities, how can healthcare providers play a role in amplifying the voices of those who are preferentially unheard in society? Rather than assuming positions of leadership, how can healthcare providers work to dismantle their privilege and in doing so help strengthen forms of community resistance and resilience in the face of oppression? It is with this realization that I wanted to embark on this academic research project, with the goal of answering the following question: How do we build anti-oppressive practice among primary care providers?

METHODS

Given my identity of a learner and a healthcare provider, I have had the opportunity to develop an intimate understanding of the ways in which power functions within healthcare. While the way power operates in the world was not a new realization for me, the ways in which it manifests within healthcare have felt uniquely violent because of this system and its constituents’ ability to continue existing without much critical self-reflection and public accountability. However, I have also recognized that guilt and hopelessness uphold privilege yet do little to tear down systems of oppression in society. It is for this reason I undertook a reflexive autoethnographic approach in the writing of this report. I know that my personal knowledge and lived experience of the subject matter I intend to explore is a valuable resource to explicitly draw upon (Lazarus, 2013).

I also want to centralize the legitimacy and value of experiential knowledge particularly as dispossessed communities are hardly provided with access to the production of knowledge that is deemed high in scientific quality. I also aim to problematize the notion that the study of medical practice can and should be devoid of personal feelings or opinions. How can we assume that any study of an institution that is deeply rooted in prejudice and opinion is objective? This decision was made in an active attempt to counter Euro-western frameworks of superiority. It is for this reason that I conducted a review of knowledge produced in academic publications as well as through popular media including but not limited to news articles, government publications, documentaries, poetry, and publications from social justice organizations. The following three electronic academic databases, MEDLINE, PsychINFO and ISI Web of Science, were searched using the following search terms:  “medicine” or “medical*” or “health* AND  “oppression” or “racial bias” or “racism” or “colonial*” or “gender violence” or “anti-oppression” or “structural violence” or “violence” or “structural competenc*”. These databases were selected in order to obtain a comprehensive list of published studies from the fields of social sciences, biomedicine as well as arts and humanities.  All of these databases were conveniently accessed through Scholars Portal from the University of Toronto library website.

The analytical framework used for this report focused on building a historical foundation and analyzing the epistemological (ideas, ideologies and rhetoric) and ontological (actors, motives, and actions) factors that have contributed to the basis of oppression within the healthcare system. The goal was to understand the ways in which oppression operates within medicine in order to offer insights into anti-oppressive practices that can be tailored specifically for those who function within the field. Relevant literature was analyzed and a narrative synthesis approach was used to elicit common themes that emerged from the findings.  I would like to acknowledge that while I focused on the history of these lands as it relates to the creation of the Canadian state and its healthcare system, in doing so I do not aim to erase the rich history of Indigenous societies prior to the arrival of Europeans. This acknowledgement is made in order to recognize the very colonial ways history is documented, by talking about the history of a region as if it begins from the time of contact with European settlers.

RESULTS

BUILDING JUST HISTORICAL FOUNDATIONS

While medical curriculum focuses on the social determinants of health, the root of these health inequities that are embedded within the foundation of all major institutions in Canada are neglected. Take for example the creation of the Canadian state, which was established through an attempted genocide of Indigenous peoples, and forced displacement for the purpose of land theft and plunder (Walia, 2012). The state’s genocidal attempts against Indigenous people in Canada has included smallpox-infected blankets used as biological warfare and the forced relocation of Indigenous peoples onto reserves, segregated tracts of land with contaminated water supplies, which has led to mass outbreaks of typhoid fever and other illnesses (d’Errico, 2010; Annett, 2010). Forty nine per cent of Indigenous peoples in present-day Canada continue to live on fly-in only remote reserves, and so the health inequities in the form of unemployment, incarceration, life expectancy and infant mortality continue to exist “literally over the horizon, out of sight and out of mind” (Gilmore, 2015).  

Cultural genocide has also been integral to nation building in Canada, designed for the destruction of Indigenous peoples’ cultures and traditions. Richard Pratt, the founder and superintendent of the first “Indian Boarding School” in the U.S., best explains the purpose of forced assimilation in the following quote: “A great general has said that the only good Indian is a dead one… In a sense, I agree with the sentiment… all the Indian there is in the race should be dead. Kill the Indian in him, and save the man” (Pratt, 1892). Simultaneously in Canada, cultural genocide was carried out through the passing of the Indian Act in 1876 and forced relocation of Indigenous children into residential schools to carry out this process of “killing the Indian in the child” (Hanson, 2009). Yet I was shocked that up until now, the education I’ve received has not taught us about the state-sanctioned physical, sexual, emotional and psychological abuse carried out in residential schools, or that over 50,000 children died over the course of 100 plus years the schools remained operational, with the last school having closed in 1996 (Annett, 2010). Nor have we learned about the ‘Sixties Scoop’ where thousands of Indigenous children were taken from their parents through institutions like Children’s Aids Society and adopted by settler families (TRC Report, 2015). While much of this information has remained outside the sphere of medical education, University of Victoria’s nursing program has responded by building cultural safety modules that explicitly teach the historical impacts of colonialism in Canada to nurses and nursing students (Colonialism Timeline, 2016).

We cannot challenge the ways control and assimilation continues to be enforced onto Indigenous peoples without learning about Canada’s history. As such the Vancouver Status of Women (2008) timeline provides a detailed history of oppressed peoples’ in Canada. This history includes the creation of the Indian Act and its deleterious health consequences. It includes the Royal Proclamation of 1763 and the years long negotiations that led to the signing of treaties between some First Nations and the Crown, treaties that have since been violated by the Canadian state (Indigenous and Northern Affairs Canada, 2013; McCreary, 2005). These historical injustices centered around forced displacement and assimilation of Indigenous peoples and the ongoing pillaging of Indigenous lands helps us then better understand the current state of poor health and wellbeing of Indigenous peoples. The high poverty rates, food insecurity, homelessness, intergenerational trauma and substance use, disproportionately higher rates of suicide and depression, murder and gender violence against Indigenous women, mass incarceration through prisons, psychiatric facilities and child apprehension directly result from Canada’s legacy of destroying Indigenous traditions, systems and cultures that continue to threaten the vision of a White, European, heteropatriarchal capitalist nation.

The institutional power used to justify exploitation of Indigenous peoples in North America also extends to processes of colonization in the global South. It is similar processes that have led to the forced violent relocation of African peoples, and the ongoing displacement of racialized migrants globally. It should not surprise us then to learn that the current Ministry of Immigration, Refugees and Citizenship was originally named the Ministry of Immigration and Colonialism (Library and Archives Canada, 2010). The building of our settler nation-state of Canada has been accomplished by the destruction of Indigenous self-governance and by the exploitation of slave, migrant and reproductive labour. While we often look to the south of the border to examine institutional anti-Black racism, we neglect to remember that Black slavery was introduced in Canada in 1608 and that Black people first arrived to present-day Canada as slaves in 1629 (Vancouver Status of Women, 2008). Ontario legislature had established and enforced segregated schools for Black people until 1964, just as residential segregation and refusal of services to Black people remains a part of Canadian history (Frances and Tator, 2006).

Our history also includes the forcible relocation of Japanese people where 23,000 people were sent to internment camps or incarcerated in jails or forced to work on road construction projects in British Columbia, Alberta, Manitoba and Ontario (Sunahara, 2000). It includes the long legacy of racist immigration policies including the Chinese head tax through which the government forced Chinese migrants to pay $500 each, which was equivalent to 2 years of wages of Chinese labour at that time while also denying all Chinese immigrants citizenship through the Chinese Exclusion Act (Mawani, 2003). As I also uncovered Canada’s legacy of prohibiting immigration of Black people, with a 1911 Order in Council stating that “any immigrant belonging to the Negro race…is deemed unsuitable to the climate and requirements of Canada” (CCR, 2000), I couldn’t help but also reflect on Canada’s longstanding history of deportation of racialized immigrants.

Though it is beyond the scope of this paper to present a thorough study of the history of oppression in Canada, it is important nonetheless to understand the reality of dispossessed communities: that individuals in institutions of power and with privilege have and therefore can inflict violence against individuals, communities, and entire nations through the creation of oppressive systems and policies. While it may be intuitive then to understand how racism, xenophobia, colonization and capitalism (as a few root causes discussed above) can cause sickness, oppressed people have spent decades building large databases of evidence to prove it.

OPPRESSION AND HEALTH

“The function, the very serious function of racism is distraction. It keeps you from doing your work. It keeps you explaining, over and over again, your reason for being. Somebody says you have no language and you spend twenty years proving that you do. Somebody says your head isn’t shaped properly so you have scientists working on the fact that it is. Somebody says you have no art, so you dredge that up. Somebody says you have no kingdoms, so you dredge that up. None of this is necessary. There will always be one more thing.”

• Toni Morrison (1975)

A search with the keyword racism in the American Journal of Public Health database revealed 689 online publications ranging from 1961 to March 2017. The publications cover a range of topics showing the negative health effects of racism through infant mortality; preterm delivery; low birth weights; spontaneous abortions; differential HIV/AIDS and STI prevention, screening and treatment; environmental racism including lead poisoning; police violence, mental health issues including depression, paranoia, psychosis and anxiety; ill health effects of stress and perceived discrimination; cardiovascular disease including hypertension and diabetes; breast cancer; and infectious disease from common colds to polio. The publications also focused on factors that intersect with racism to produce health inequity: homophobia, transphobia, social class, wage and land theft, poverty, globalization, neoliberalism, xenophobia, sexism, domestic violence, mass incarceration, and colonialism. While others focused on building effective responses to health inequities by writing about Indigenous knowledge and decolonization, calling out white privilege, myth of meritocracy, challenging carceral responses to substance use, community organizing, fighting for universal healthcare, building anti-racist praxis, trauma-informed policy making, promoting solidarity and social and environmental justice. The publications also focused on the negative health effects from the healthcare system, examples of which included discrimination within hospitals and differential treatment by healthcare providers, medical experimentation and forced sterilization, all of which will be discussed and elaborated upon in detail below.

The Du Bois Review: Social Science Research on Race journal based out of Cambridge University also published a special issue on racial inequality and health in 2011. Drs. Allan and Smylie (2015) have produced a 71-page report documenting in detail the second-class treatment of First peoples in Canada by exploring the role of racism on health. Extensive amount of academic literature has been produced to capture the lived experiences of disenfranchised communities and in doing so it allows us to understand the intimate relationship between oppression and health. Rather than simply reproducing the results of research studies here, I’ve decided to capture the relationship between oppression and health using the analogy of a tree. The roots that form the foundation of oppression give rise to the low hanging fruits of poor health that we often target in the practice of medicine. This analogy speaks to a causative relationship, not mere association, as has been established by lived expertise and academic knowledge.

Figure 1. Digging at the Roots, Not Just Low Hanging Fruit: The Reproduction of the Social Determinants of Health When The Structural Determinants’ Are Left Untouched (Mikkonen and Raphael, 2010; Metzi and Hansen, 2014).

STRUCTURAL VIOLENCE: WHAT DOES THE HEALTHCARE SYSTEM HAVE TO DO WITH IT?

Attempted Medical Genocide

Jim Flaherty, Ontario’s finance minister in the early 2000s, stated that the federal government could increase health-care funding for “real people in real towns” by cutting funding for health services available only for Native peoples (Pedwell, 2002). This process of dehumanization and devaluing of Indigenous peoples as not real to justify the exploitation of their bodies and homelands, is the very definition of colonization. This colonial logic is what formed the basis of the “Indian [only] hospitals” in order to protect Whites against the spread of infectious diseases such as tuberculosis and smallpox that had been deliberately introduced and made endemic within Indigenous communities while simultaneously having made Indigenous healing practices illegal (Annett, 2010). Just as there have been survivor accounts of residential “schools”, there are numerous accounts from survivors of ‘Indian hospitals’ who experienced medical abuses such as forced sterilizations and medical experimentation. Joan Morris of the Songhees Nation in southern Vancouver, described that “The Indian agent came and got me when I was five years old. I wasn’t sick at all but he said I had tuberculosis and needed treatment. So they shipped me off to the Nanaimo Indian hospital where they used me like a guinea pig. They broke the bones in my feet. They took out parts of my lung and made me drink this bad stuff that I later learned was radioactive iodine. I came down with TB when I was in there so I believe they infected me. … I saw lots of other Indian kids in there too, all of them the same: healthy when they showed up, then they got TB and a lot of them died off. … I remember the doctors there, Dr. Weinrib, Lang, Connolly and Schmidt, they were all taking notes but never helping anybody” (ibid pg. 91). Joan Morris spent over 6 years incarcerated in Nanaimo Indian Hospital in the early 1960s and is one among many that has provided a narrative account of the genocidal practices occurring within medicine.

As scholar Andrea Smith explains, “women of colour are particularly threatening, as they have the ability to reproduce the next generations of communities of colour. … In particular, Native women, whose ability to reproduce continues to stand in the way of the continuing conquest of Native lands, endanger the continued success of colonization” (Smith, 2005, pg. 79).  Forced sterilization of residential “school” inmates was legislated in Alberta in 1928 and in British Columbia with the “Sexual Sterilization Act” of 1933 (Annett, 2010, p. 67). The 1933 “Sexual Sterilization Act” described how a judge, a psychiatrist, and a social worker would make up the “board of eugenics” that would oversee the mass sterilization programs in residential “schools”. Indian hospitals, such as the R.W. Large Hospital in Bella Bella, were also well known sterilization sites where doctors carried out the procedure without prior consent or knowledge of Indigenous men, women and children (ibid, pg. 105).

North American medical and psychiatric institutions, having been inspired by European colonial doctors elsewhere, used the eugenics ideology that believed in the domination of the “superior” European race to justify destruction of “inferior” peoples, particularly Indigenous and Black peoples. Our medical institutions, including Tommy Douglas, the father of Medicare, advocated for sterilization of “unfit” peoples in Canada. Eugenics laws therefore were much more widespread in Canada, focusing on Indigenous peoples, those with disabilities, “morally unfit” queer and trans peoples, and immigrants (Wong, 2016). Hitler and other German eugenicists learned directly from eugenics research conducted in North American hospitals (Hansen and King, 2013). Eugenics based targeting of Indigenous peoples and racialized people continues into the 21st century (Nittle, 2016). Stole (2015) reported that 580 sterilizations of Indigenous women have taken place in federal hospitals between 1971 and 1974 including the hospitals in Moose Factory and Sioux Lookout, Ontario. The most recent reported cases of forced sterilizations against poor racialized imprisoned women occurred merely 7 years ago in 2010 (Johnson, 2013).

Medical Experimentation

Where attempted genocide continues to occur, Western medicine has used Indigenous, Black and other people of colour communities both within North America and in the Global South for experimentation and medical advancement. Western medical history includes the experimentation on captive queer bodies to find a cure for homosexuality and numerous psychological studies aimed at determining the most efficient torture techniques that have been used globally (Tatchell, 2015). I was surprised to learn about Dr. Ewen Cameron, a psychiatrist at the McGill University Health Centre and also the director of the renowned Allen Memorial Institute, also happened to conduct torture experiments (D’Alimonte, 2015). What was most shocking is that this CIA-funded medical researcher had also been the president of the American Psychiatric Association, chairman of the Department of Psychiatrist at McGill University and is still revered in academic circles for his role in furthering psychiatric education through undergraduate and hospital based curricula (ibid). Yet we are never taught of this Canadian physician’s role behind advanced torture techniques that were used throughout Latin America in the 1960s or his predecessor Dr. Hebb who has a lecture series named after him now in the Department of Psychology at McGill University (Klein, 2007; The Justice Campaign, 2017). Both of these men’s experimentations have also been used in places like Guantanamo Bay (Ch 1, Klein, 2007).

Our knowledge of nutrition and dietary supplementation also comes from medical experimentation on hundreds of malnourished Indigenous people across Canada, including children in residential schools as per Dr. Ian Mosby’s doctoral research findings in 2013. Our 1947 “medical discovery” of the use of penicillin to treat syphilis comes in large part from the 1932 Tuskegee Syphilis Experiment, where U.S. Public Health Services lied to over 600 Black male participants that they were being monitored and “treated” for syphilis over a period of 40 years (Brandt, 1978). Washington’s book titled ‘Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present’ documents this history and more as she presents an in-depth study of medical experimentation and its deep-rooted ties to structural racism in the U.S (2008).

Medicalization of Social Injustice and Denial of Structural Violence

“If a white man wants to lynch me, that’s his problem. If he’s got the power to lynch me, that’s my problem. Racism is not a question of attitude; it’s a question of power.”

                                                                                                    - Stokely Carmichael (1968)

Western medicine also continues to exercise control over Indigenous and racialized communities through medicalization of social injustices, effectively turning social problems into individualized pathology requiring medical research, intervention and further control. “Drapetomania” was one of the first medical diagnoses in the U.S. and was described by Dr. Samuel A. Cartwright as the “disease causing slaves to run away” (Cartwright, 1851). Dr. Cartwright stated that this medical disorder could be treated, and that with “proper medical advice, strictly followed, the troublesome practice that many Negroes have of running away could almost entirely be prevented” (ibid). Cartwright’s prescription for this disease included "whipping the devil out of them" as a "preventative measure" and he believed that the ultimate remedy for this “disease” would be for doctors to prescribe the removal of the slaves’ big toes bilaterally so that running would become a physical impossibility (ibid). A century later psychiatrists introduced a new form of ‘reactive psychosis’ they labeled as “The Protest Psychosis”, which ‘affected’ young Black men often under the age of 35 (Bromberg and Simon, 1968). A Black male who was diagnosed with psychosis was someone who was “influenced by social pressures (the Civil Rights Movement), dips into religious doctrine (the Black Muslim Group), is guided in content by African subcultural ideologies and is colored by a denial of Caucasian values and hostility thereto [emphasis added]” (ibid). This “new” psychotic illness was later replaced with a rise in the diagnosis of schizophrenia among African-American men, as well documented by Dr. Jonathan Metzi in his book titled ‘The Protest Psychosis: How Schizophrenia Became a Black Disease’ (2011). Menzies and Palys’ (2006) study of Indigenous people incarcerated in B.C’s psychiatric system had similar findings, that Indigenous people were labeled as being “mentally ill” as result of “social and racial conventions”, as “Aboriginal persons [were] seen as troublesome, obdurate, wild, abusive, resistive, or otherwise indecipherable” (pg. 161). Similarly, Crystal et al (2009) showed that antipsychotic medications were prescribed four times more often for children on social assistance (Medicaid) when compared to children covered by private insurance for child behavioral concerns which were seen as fixable issues with counseling and therapy for the latter group of children. Poor racialized children are pathologized and deemed to be in need of medications in contrast to children from households wealthy enough to obtain private insurance (Tsai, 2014).

Indigenous people and racialized peoples belonging to communities that are working hard to retain their own health and healing practices and cultures often have to rely on Western medical institutions that continue to legitimize colonialism, capitalism, racism, and sexism. What results is a vicious cyclical process where societal oppression produces poor health outcomes, which are then seen as individual pathologies requiring medical intervention, thereby reinforces rather than counteracting forms of social oppression leading to deteriorating health outcomes and even death (see Figure 2). Perhaps Brian Sinclair’s death could have been prevented had colonization and systemic racism been addressed within the practice of medicine, so that Indigenous people who present to an ER aren’t considered to be intoxicated upon first glance (Puxley, 2014).

Dehumanization in Healthcare: Micro to Macro Aggressions

Another major theme that arose from my literature review pointed to the impact of longstanding dehumanization of large numbers of communities and identities. For example, our healthcare system reinforces xenophobia as we deny migrants access to health services in the same way that policies and politicians push for the deportation of migrants due to a belief system that equates lack of immigration status with illegality. These mechanisms continue to lead to disability and for some, like Veronica Castro or Grise, even death (Keung, 2009; Sheppard, 2012; Amatulli, 2017). Currently we have an estimated 500,000 individuals with precarious immigration status in Canada who work, live, and build community and contribute to our social welfare system through taxes without having access to health care despite our supposed universal healthcare system (Simich et al., 2007). A Harvard Latino Law Review study found that non-status immigrants pay disproportionately more taxes (including sales taxes, property taxes, other taxes such as gas tax) than U.S. citizens because they are barred from accessing public services like housing, Medicaid, Medicare-funded hospitalization assistance or even food stamps. Another study based out of Harvard Medical School found that counter to the xenophobic arguments of immigrants draining the system, they generated a surplus of $115 billion from 2002 to 2009 that directly paid for the part of Medicare that pays for hospital care  (Zallman et al, 2013).

The same way that systemic racism allows for police officers to kill unarmed Black children and adults due to a longstanding belief system that delineates blackness with criminality, so does the dehumanization of blackness within healthcare. Multiple research studies exist looking at the systematic under treatment of pain for Black patients in contrast to White people in many different age groups ranging from veterans to children with appendicitis (Dobscha et al., 2009, Goyal et al., 2015). It was long hypothesized that this racial difference in the treatment of pain may have had to do with coexisting comorbidities such as poverty or substance use amongst Black patients that prevented providers from using opioids for management of pain. However Hoffman et al. (2016) published a study that shed light on another potential cause to this differential treatment: racism. Their study found that medical students and residents believed in false biological differences between White and Black patients, differences that have strong roots behind the justification of slavery and White supremacy. The results were shocking: 50% of white medical students and residents (a sample size of over 200 people) believed in at least one of the seven false statements they had been offered about Black people such as that Black people’s skin was thicker or that their brains were smaller than Whites or that their nerve endings were less sensitive in comparison to White people. Those who believed in at least one false statement about Black people were also much more likely to report lower pain ratings for Black patients versus White patients (Hoffman et al., 2016). Believing that Black people have different pain perception than White people is of course not new to the practice of medicine. Dr. Sims, labeled as one of the fathers of obstetrics and gynecology, experimented on Black women who were his slaves or his neighbor’s slaves to find a surgical technique to treat vesicovaginal fistulas and he did this without the use of anesthesia because he believed Black women to be primitive and therefore less sensitive to pain (NRP Staff, 2016). We know Dr. Sims’ name well and while we don’t know the names of all the women he experimented on, we do know three of their names: Anarcha, Lucy and Betsey (ibid). Imagine if we learned their names through medical education as the ‘mothers of modern gynecology’ rather than Dr. Sims.

While this research was done in the U.S, we have similar studies in Canada that have examined Indigenous peoples’ experiences with our healthcare system. Jacklin et al. (2017) conducted focus group interviews in five different Indigenous communities across Canada with the goal of better understanding people’s experiences with healthcare while living with type 2 diabetes. The findings were clustered into four major themes that study participants felt impacted their healthcare experiences: 1) colonial legacy of healthcare and the ways it still structures the healthcare system and healthcare providers mindset, 2) the perpetuation of inequalities through health care providers bias and discrimination, and 3) structural barriers to care as a result of the bureaucracy and deficiencies in healthcare funding between federal and. provincial governmental bodies. Their last and fourth theme focused on the role of the relationship with health care providers in mitigating harm, which focused mainly on building comfortable relationships with providers who approached them with humility and a sense of working together (Jacklin et al., 2017). The second theme from this study describes the concept of microaggressions: the casual degradation of people based on race, class, gender, sexuality, and ability that can result from our sense of superiority (the healthcare worker) and hatred or fear of the other (the patient). It can also result from unconscious bias, negligence or ignorance. The consequences however still remain the same: poor health outcomes for some people more than others. While societal level oppression already impacts the physical and mental health of patients seen in primary care settings, judgment or blame by healthcare professionals only further marginalizes those living on the margins of power in society.

Figure 2. Oppression and Healthcare: Understanding the Reinforcing Nature of Medical Violence

DISCUSSION

“Optimism is a strategy for making a better future. Because unless you believe that the future can be better, you are unlikely to step up and take responsibility for making it so.”

- Noam Chomsky

This academic endeavor to uncover historical colonial practices and injustices within medicine have led me to further explore the ways in which I have witnessed, remained complicit in, challenged or actively reinforced power and violence through the practice of medicine. I have witnessed the misdiagnosing of Black Caribbean youth with schizophrenia in Toronto. I remained silent in face of countless child apprehensions, disproportionately from Indigenous women, young Indigenous parents, and poor racialized families who were often struggling with homelessness, mental health issues, and had a history of substance use. I did not use my cis privilege to intervene every time Two spirited and trans* peoples were misgendered while attempting to receive care in the emergency departments of hospitals. I was immobilized in the face of verbal abuse towards undocumented women being forced to pay money prior to receiving any health services related to their pregnancies.  The contrast between “do no harm” and the real world practice of medicine has left me with a high degree of cognitive dissonance. Rather than being taught about the apartheid history of medicine, our roles and responsibilities as settlers, medical students are taught to see themselves as experts on health of all people. This uncritical educational model and an admissions process that works to uphold colonialism and intersecting class, race, gender and other forms of power in society sets up a vicious cycle of medical violence. A crucial aspect of holding the mirror up onto ourselves requires us to accurately name problems, because if we cannot name them then we cannot recognize them and if we cannot recognize problems then we do not have the capacity to solve them (Crenshaw, 2017). In addition to accurately naming the problem, building an anti-oppressive practice requires us to uncover the mechanisms through which dominant groups in society including medicine unjustly exercise power and to unlearn the explicit ideologies oppressive systems use to justify oppression.

We have been taught about cultural safety training and the need for cultural competency curriculum in medicine. We have also been taught about the social determinants of health and their upstream role in shaping poor health outcomes for people. Both of these models require physicians-in-training to learn about the other: people with different cultural backgrounds whether religious or spiritual or linguistic or racial and also people from dispossessed communities including poor people, people who are precariously housed or homeless or incarcerated, or transgender or gender nonconforming people. The pedagogical lens always remains on the other in an attempt to expand the healthcare providers’ understanding of the people around them that do not belong to their class or racial or gender backgrounds. Though this pedagogical approach could possibility mend some of the negative day-to-day interactions and microaggressions people experience within the healthcare system, I believe its ahistorical and non-relational dimensions do little to uproot power and privilege that create the conditions of poor health in the first place. It is for this reason I have developed the following framework as one tool that can aid in shifting the practice of primary care.

AN INTEGRATED ANTI-OPPRESSION FRAMEWORK FOR PRIMARY CARE PRACTICE:

1) Uprooting Medical Violence

“When people get used to preferential treatment, equal treatment seems like discrimination.” - Thomas Sowell

Any study of oppression necessitates the study of relationships: wealthy people’s existence shapes the realities of the poor; racialization demands the existence of Whiteness; European and now the American empire would not exist was it not for the historically looted Third World. This is why medical education needs to go beyond teaching cultural competency and instead needs to directly address the relationship between colonization and medicine, race and medicine, and heteropatriarchy and medicine to start. Our current educational paradigms continue to perpetuate the false belief that medicine has and continues to do no harm and that members within medicine are inherent leaders and knowledge bearers for others. It is for this reason I believe an ideological shift is needed, one where professionalism means acknowledging and undoing social injustice, and the ways it manifests within medicine. Rather than neglecting our history, we should study it head on with humility and move through the discomfort it produces rather than avoid it. In doing so, we have to recognize the self-serving nature of guilt. We have to ensure that our reflective process allows us to move away from a place of inaction due to shame to a place of responsibility. Our patients and the communities we serve are already surviving from our unjust society; they need us to address our role in perpetuating harm against them and working to undo it. They need us to fight against the violence of erasure and forgetting.

2) Understanding Intersectionality and Centering The Margins

“Intersectionality is the best chance for an effective diagnosis and ultimately an effective prescription” (Hancock, 2007, p. 73)

Intersectionality, as coined by critical race theory scholar Kimberlé Crenshaw (1989), is a framework that allows us to understand that oppressive systems such as racism, sexism, ableism, transphobia, xenophobia, and classism impact individuals in an interconnected way and create interdependent forms of privilege. As Hankivsky (2014) reports, an intersectionality framework tells us that inequities are never the result of single, distinct factors but rather an outcome of intersections of different social locations, power relations and experiences. It is for this reason that individuals’ social locations cannot be separated from one another and examined in an isolated manner. It gives us the understanding necessary to study social problems in ways that capture how policies and systems unfairly impact all members of society rather than a few distinct specific groups of people. It calls on us to center on those pushed most to the margins in society because if we do not, we risk building tools that liberate some people at the expense of others. Centering on the margins does not mean building diversity and inclusivity as “tokenistic, objectifying, voyeuristic inclusion is at least as disempowering as complete exclusion” (Crenshaw, 1994). Instead centering on margins requires us to focus on a multitude of ideas, experiences and voices of marginalized people rather than homogenizing groups based on their class, race, gender or sexuality. Mohanty (2003) states that we must anchor ourselves analytically in the lives of the most marginalized communities because this provides the most inclusive paradigm for thinking about social and environmental justice. Centering on the teachings of the most marginalized allows for more concrete and expansive visions of universal justice because though privilege leads to unjust advantages, it also “nurtures blindness to those without the same privileges" (Mohanty, 2003).

This framework also pushes us, as healthcare providers, researchers, policy makers and or activists to consider our own social positions, roles, and power and this critical reflection is termed reflexivity. As intersectionality also explicitly calls upon us to work towards transformation and social justice, I believe this theory can provide valuable insight into the ways our medical curriculum and practice needs to be changed. People often have a difficult time incorporating new facts that challenge their worldviews, so I believe the intersectionality framework can help us learn from the beginning that we are not inherent leaders simply by becoming medical students and that we now also carry the legacy of medical abuse.

3) Practicing Allyship and Solidarity as Health Care Providers

“Education does not change the world. Education changes people. People change the world.”- Paulo Freire

Allyship is an active process, not a declaration, which works to recenter Indigenous worldviews and respects leadership from Indigenous and other oppressed communities. This means colonial institutions such as Western medicine and non-Indigenous peoples cannot lead struggles for Indigenous self-determination. This means a commitment to self-education about the cultural, spiritual, economic, linguistic and political impacts of colonization. It means a commitment to re-centering our understanding of health and wellness, and recognizing the limited role Western biomedical paradigms play in the health of individuals and communities. It means listening to our patients with the intent to understand not with the intent to reply. It means we have a responsibility to speak up more vocally against institutions and people within healthcare who perpetuate medical violence (Metzi and Roberts, 2014). It does not mean speaking on behalf of others but rather speaking to “relinquish some piece of privilege in order to create justice” (Jones, 2013). It means an ongoing commitment to health and wellness for all dispossessed communities, and doing so through building of long-term relationships to ensure accountability.

“Not being racist is not some default starting position. You don’t simply get to say you’re not a racist; not being racist – or a sexist or a homophobe [or ableist or classist] – is a constant, arduous process of unlearning, of being uncomfortable, of eating crow and being humbled and re-evaluating” (Demby, 2010). We are often told that the practice of medicine must be one that is patient centered yet we have practiced medicine in a way that does not respect consent and bodily autonomy. So shifting our framework to one of allyship requires us to see ourselves as consultants with a specific set of knowledge, skills and beliefs that we can share with others and do so with compassion rather than judgment or frustration in allowing others to make decisions for themselves including the right to refuse the care we can offer.  

4) Growing Health Justice by Supporting Grassroots Resistance

"If you have come to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together."

                              - Lila Watson, a Gangulu Indigenous Elder from what is present-day Australia

I believe in highlighting and supporting resistance and resilience to be just as important a task as documenting the negative health impacts of oppression. As I’ve studied the history of colonialism and conquest, I’ve become aware of the importance of broad-based popular resistance to hegemonic cultures and institutions such as Western medicine. While talking to an audience of psychologists and psychiatrists, US civil rights activity Stokely Carmichael (1968) stated that “…society either pretends it does not know of institutionalized racism, or is incapable of doing anything meaningful about the conditions of institutionalized racism. And the resistance to doing anything meaningful about institutionalized racism stems from the fact that western society enjoys its luxury from institutionalized racism, and therefore, were it to end institutionalized racism, it would in fact destroy itself.” Hence resistance to the medical industrial complex, defined as a system focused on profit first rather than health, and a system connected historically and presently to eugenics, capitalism, colonization, slavery, immigration, war, prisons, and reproductive oppression, must come from individuals both within and outside of it in order to build sustainable change (Mingus, 2015).

The tools and skills used to build resistance from within medicine can range from pushing for curriculum changes and equitable admissions processes, conducting peer led trainings (see Appendix B), learning more about the information highlighted in this report and beyond (see Appendix C), forming health contingents for different forms of civil disobedience, sharing our skills with local street medic collectives, providing care and holding these conversations in our own communities, and contributing to grassroots communities who don't have the same level of financial and social capital we may hold. Imagine if our medical school admissions processes mirrored those for the Escuela Latinoamericana de Medicina (ELAM) in Cuba where people from around the global South who are from low-income backgrounds are prioritized for admission with the only non-binding requirement of committing to practicing medicine in underserved areas in their own communities or others like theirs (Fitz, 2011).  Walia (2013) reminds us that in order to transform hegemonic power relations, we need to engage in a perpetual process of analysis, organizing and reflection. It means amplifying social and environmental justice movements that are also grounded in an unwavering commitment to Indigenous struggles for decolonization. Ultimately we are successful when our work transforms systems of power while also transforming the consciousness of those participating in movement, including us as healthcare providers (Walia, 2013).

CONCLUSION

“Look for where your privilege intersects with somebody’s oppression. That is the piece of the system that you have the power to help destroy.” - Ijeoma Oluo

Ultimately, we have to recognize that the pledge to tackle oppression does not simply improve the care we provide to others who consensually use the healthcare system. An anti-oppressive approach also has the ability to improve the culture of medical practice for the betterment of all those who participate within it. Given the high rates of depression and suicide among medical trainees and physicians (Riches, 2016; Muller, 2017), we have to recognize that the culture of competition and disposability embedded within our economic system is alive in medicine. It is imperative that we recognize the benefits of undermining our privilege and destroying the systems that create it. When we provide care in a way that recognizes the need to celebrate strength not power, we can shift our own culture to one that rewards cooperation. When we challenge our culture of disposability and individualism, we can celebrate each other’s achievements rather than view them as threats to our own livelihoods. When we work towards ending medical violence and dehumanization within healthcare, we can grow our own capacities to respect each other’s humanity. When we undo our enormous contributions to building income inequality, we give ourselves the permission to live full lives rather than living to sell our labour to meet our ever-growing wants while other people's material needs are left unmet.

In summary, I believe our goal of building health and wellness in communities means working towards decreasing and where necessary eliminating the reliance on institutionalized Western medicine so that its unjust structures as well as its racist, classist, and sexist interests cannot impact oppressed communities. Simultaneously, we need a radically altered medical education program that aligns itself with communities rather than its oppressive past and present practices. I dream of a medical education program that leads graduates to commit themselves to strengthening social movements that work to eliminate social injustices rather than pathologizing or converting such injustices into sickness. If we’re committed to the practice of allyship, then our work rests on ensuring that our careers and an industry is not built from paternalistic researching and “treating” of poverty, homelessness, gender violence and mental resiliency often described as mental illness. Our commitment to addressing our complicity within these institutions as future physicians as well as settlers on Indigenous lands lies in actively, and vocally, opposing the violence committed by and through the institution of medicine. It also lies in the total transformation in the way we think, learn, and unlearn with humility and with a deep sense of responsibility. I believe that our commitment remains two-fold: 1) radically transforming medicine, both the education we receive and the very institutions within which we work while 2) simultaneously supporting grassroots movements for healing and self-determination. Ana Clarissa Rojas Durazo asks the question I hope we all ask of ourselves and each other: “Let’s…re-invigorate a grassroots movement…that doesn’t shy away from asking, or isn’t paid to forget to ask “what’s it really gon’na take to live lives free of violence?” (Durazo, 2006)

As I finish this educational academic project surrounded by the unspeakable violence Indigenous communities around me face, the words of Dr. Omi Osun Joni L. Jones (2013) ring loud and clear:

“Do not tell anyone, in any oppressed group, to be patient. Doing so is the sign of your own privilege and unconscious though absolute disregard for the person with whom you are speaking…Patience is not a political strategy. It is a diversionary tactic. It is a patronizing recommendation made only by those that do not believe that oppression is killing us all.”

Acknowledgements: N. Rai would like to thank Abeer Majeed, Lauren Pragg, Malika Sharma, Zainab Amadahy, Nadia Kanani, Gunjan Chopra, Drs. Lisa Richardson and Janet Smylie for their inspiration in thinking about these issues.

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APPENDIX A

Definitions

Ableism

“A system of oppression that includes discrimination and social prejudice against people with intellectual, emotional, and physical disabilities, their exclusion, and the valuing of people and groups that do not have disabilities.” (Social Justice Terminology, 2017)

Assimilation

The forced integration of people into dominant ethno-religious ideologies and economic systems. In Canada, assimilation has been an explicit policy of the Canadian government and has focused on forcibly “integrating” Indigenous peoples into dominant (European-Canadian) culture. Duncan Campbell Scott, the superintendent of Indian Affairs said in a speech to a parliamentary committee in 1920: "I want to get rid of the Indian problem. .. Our objective is to continue until there is not a single Indian in Canada that has not been absorbed into the body politic, and there is no Indian question, and no Indian Department…” (Cairns, 2000).

Capitalism

“An economic system based on private ownership and control. Produces profits for individual rather than collective needs.” (SPAN, 2008)                                                    

Colonization

It is a process of dehumanization in order to justify the exploitation of Indigenous people and the land. It is a violent process of domination and conquest to take peoples lands, resources, and their labour or life if they are deemed disposable which at times has lend to the extermination of an entire nations. Hence, it generally occurs through three large processes: genocide, removal or termination and forced assimilation. Loomba (1998) also states that: "Colonialism was not an identical process in different parts of the world but everywhere it locked the original inhabitants and the newcomers into the most complex and traumatic relationships in human history…”

Cultural competency

Cultural competence describes "skills, knowledge, and attitudes to safely and satisfactorily deliver CulturalCare”, which is defined as "health care that is culturally sensitive, culturally appropriate, and culturally competent” (Spector, 2004).

Environmental Racism

“... is a form of discrimination caused by government and private sector policy, practice, action or inaction which intentionally or unintentionally, disproportionately targets and harms the environment, health, biodiversity, local economy, quality of life and security of communities, workers, groups, and individuals based on race, class, color, gender, caste, ethnicity and/or national origin.” – Clayton Thomas-Muller

Imperialism

A state’s ability to enact power and domination, especially by direct territorial acquisition or by gaining political and economic control, of other areas either through military force or through more subtle yet equally unjust forms of policies and practice.

Indigenous

While recognizing that there is not one “official” definition of what it means to be Indigenous and that Indigenous peoples have the right to define themselves using their own languages and meaning, the Indigenous Physicians Association of Canada defines the term Indigenous as: “communities, peoples and nations…which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or part of them. They form, at present, non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as a basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal system” (pg 6, First Nations, Inuit, Métis Health Core Competencies, 2009).

Marginalization

When the dominant group(s) in society establish and maintain a social division based on lines of power and consider themselves to be the ‘centre’ and push non-dominant individuals or group(s) of people outside the realm of normal, to the ‘margins’ of society. In doing so they take away power from those on the margins because those who exist at the social, political, and economic edges of society do not have the same access to life opportunities and resources that members of the dominant group have.

Microaggressions: see page 24 of the report.

Oppression

As per the Merriam-Webster dictionary, it is defined as the unjust or cruel exercise of authority or power. Safehouse Progressive Alliance for Nonviolence (SPAN), 2008 expands the definition with this table:

Power

Having access to resources (social, cultural, and economic) and decisionmaking to obtain what you want and to determine someone else’s reality.

Privilege

A system of unearned freedoms, rights, benefits, advantages, and access afforded (to) members of the dominant group in a society. This is usually taken for granted by individuals as they are taught not to see it (McIntosh, 1988). Being disadvantaged in one area does not negate the privilege in other spheres.

Prejudice

“It is an irrational feeling of dislike for a person or group of persons, usually based on stereotypes. Virtually everyone feels some sort of prejudice, whether it’s for an ethnic group, or for a religious group, or for a type of person like blondes or large people. The important thing is they just don’t like them - in short, prejudice is a feeling, a belief. You can be prejudiced, but still be a fair person if you’re careful not to act on your irrational dislikes.” - Hepshiba (2015)

Discrimination

“It takes place the moment a person acts on prejudice.  This describes those moments when one individual decides not to give another individual a job because of, say, their race or their religious orientation.  Or even because of their looks (there's a lot of hiring discrimination against "unattractive" women, for example).  You can discriminate, individually, against any person or group, if you're in a position of power over the person you want to discriminate against.  White people can discriminate against black people, and black people can discriminate against white people if, for example, one is the interviewer and the other is the person being interviewed.” - Hepshiba (2015)

Racism

“This differs from discrimination because racism describes patterns of discrimination that are institutionalized as "normal" throughout an entire culture. It's based on an ideological belief that one "race" is somehow better than another "race".  It's not one person discriminating at this point, but a whole population operating in a social structure that actually makes it difficult for a person not to discriminate” (Hepshiba, 2015) or benefit from the discrimination of other people.  

Another way to understand this is to differentiate between what Stokely calls individual racism (discrimination) and institutional racism (most accurate definition of racism):

"It is important to this discussion of racism to make a distinction between the two types: individual racism and institutional racism. The first type consists of overt acts by individuals, with usually the immediate result of the death of victims, or the traumatic and violent destruction of property. This type can be recorded on TV cameras and can frequently be observed in the process of commission.

The second type is less overt, far more subtle, less identifiable in terms of specific individuals committing the acts, but is not less destructive of human life. The second type is more the overall operations of established and respected forces in the society, and thus does not receive the condemnation that the first type receives.

Let me give you an example of the first type: When unidentified white terrorists bomb a black church and kill five black children, that is an act of individual racism, widely deplored by most segments of the world. But when in that same city, Birmingham, Alabama, not five but 500 black babies die each year because of lack of proper food, shelter and medical facilities; and thousands more are destroyed and maimed physically, emotionally and intellectually because of conditions of poverty and discrimination in the black community, that is a function of institutionalized racism." - Stokely Carmichael (1989)

Social Location

“The groups people belong to because of their place or position in history and society. All people have a social location that is defined by their gender, race, social class, age, ability, religion, sexual orientation, and geographic location. Each group membership confers a certain set of social roles and rules, power, and privilege (or lack of), which heavily influence our identity and how we see the world.” - UVic Cultural Safety Module Glossary Definition

Stereotypes

Generalizations about a group of people whereby we attribute a defined set of characteristics to that group. (Allport, 1954)

Structural Violence

“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency.” - Farmer et al. (2006)

Whiteness

It is a racial identity created by upper class colonialists to distinguish themselves from indentured servants and slaves. It provides a guarantee against being enslaved and a strategy to secure White wealth and domination.

The following references were used for this appendix:

Allport, G. (1954) The nature of prejudice, Reading, MA: Addison-Wesley

Bishop A. (2002). Becoming an ally: Breaking the cycle of oppression in people (p. 160). Halifax: Fernwood Publishing.

Cairns, A. C. (2000). Citizens plus: Aboriginal peoples and the Canadian state (p.17). Vancouver, BC: UBC Press.

Farmer, P., Nizeye, B., Stulac, S. and Keshavjee, S. (2006). Structural Violence and Clinical Medicine. PLoS Medicine, vol 3, no 10: e449.  

Hepshiba. (2015). Why there's no such thing as "Reverse Racism". Daily Kos. http://www.dailykos.com/story/2010/7/15/884649/-

Loomba, A. (1998). Colonialism/Postcolonialism. (p. 2). London and New York: Routledge.

McIntosh, Peggy. (1988) White privilege: Unpacking the invisible knapsack.

http://www.antiracistalliance.com/Unpacking.html#top

Safehouse Progressive Alliance for Nonviolence (SPAN), 2008, Building a Multi-Ethnic, Inclusive, & Anti-Racist Organization.   http://wp.safehousealliance.org/wp-content/uploads/2012/10/Tools-for-Liberation-Packet-SPAN.pdf

Social Justice Terminology, 2016. Suffolk University, Boston. http://www.suffolk.edu/campuslife/27883.php

Spector, R. (2004).  Cultural diversity in health and illness. (6th ed., p. xii). Upper Saddle River, NJ: Pearson Education.

The Anti-Oppressive Network. 2016. Terminologies of Oppression: A Comprehensive List of Working Definitions.

https://theantioppressionnetwork.wordpress.com/resources/terminologies-of-oppression/

The University of Victoria Cultural Safety Module Glossary. http://web2.uvcs.uvic.ca/courses/csafety/mod1/glossary.htm

 APPENDIX B

Draft Anti-Oppression Training Structure & Resources:

Part 1: Warm-up exercises

Part 2: Introductions

·           Opening remarks - why is this important for healthcare practitioners? - CANMeds, historical accountability

·           Agenda (including trainers’ objectives), ground rules & parking lot of questions and group objectives

·           Introductions including definitions

Part 3: Integrated Anti-Oppression Framework principles (participatory methodology):

·           Locating Oneself: Power, Privilege, Reflexivity (invisible knapsack exercise)

·           An incomplete Oppressed Peoples’ History of Canada: Building a historical timeline together that will remain posted around the room for the remainder of the workshop

·           Uncovering Medical Violence: jeopardy game (themes include: matching the year to the action, people’s names to what they’ve done, and assigning true or false to statements collectively)

·           Centering the Margins: Intersectionality

Part 4: Anti-Oppressive Theory: concepts discussed and learned include allyship and solidarity (theatre of the oppressed) as well as change theory principles and tools

Part 5: Growing Health Justice: Resist and Reimagine

·           Sharing examples of grassroots health justice movements

·           Putting the skills into practice: group activity/strategy session on reimagining a just healthcare system  

Part 6: Check out Reflections / Evaluations

Note: Should consider having counsellors or active listeners available (in person or over phone) to speak to individuals if needed during exercises/training session.

Anti-oppression training Resources:

• http://wp.safehousealliance.org/wp-content/uploads/2012/10/Tools-for-Liberation-Packet-SPAN.pdf
• http://www.oaith.ca/assets/files/Publications/Intersectionality/Practical-tools-intersectional-workshops.pdf
• http://aorta.coop/sites/default/files/ao_facilitation_resource_sheet_july_2014.pdf
• Allyship: https://theantioppressionnetwork.wordpress.com/allyship/
• https://www.energyactioncoalition.org/sites/wearepowershift.org/files/AO_Reader_2007.pdf
• https://organizingforpower.wordpress.com/power/anti-oppression-resources-exercises/
• Can apply variations of the heterosexual privilege checklist: http://www.oaith.ca/assets/files/Publications/Intersectionality/FrameworkARAO-Training.pdf
• Intersectionality 101: https://www.sfu.ca/iirp/documents/resources/101_Final.pdf

Graphics and video clips:  

• Privilege 101: https://brightside.me/article/what-you-should-think-about-before-you-judge-others-10155/
• Deaf not Dumb: https://www.youtube.com/watch?v=zK_G-h1uep8
• Income inequality 101: https://www.youtube.com/watch?v=uWSxzjyMNpU
• Unequal Opportunity Race (Privilege 101): https://www.youtube.com/watch?v=eBb5TgOXgNY
• Dominant culture, normative hegemony, microaggressions: https://www.youtube.com/watch?v=PMJI1Dw83Hc
• Police Violence and Abolition https://www.facebook.com/fusionmedianetwork/videos/1870625166296786/?pnref=story
• Undocumented, Unafraid, Unapologetic: https://www.youtube.com/watch?time_continue=117&v=jPNlpzykojE
• Microaggressions 101: https://www.facebook.com/fusionmedianetwork/videos/1342841949116382/?pnref=story
• Intersectionality 101: https://www.sfu.ca/iirp/documents/resources/101_Final.pdf and Kimberlé Crenshaw’s Ted Talk: The Urgency of Intersectionality https://www.ted.com/talks/kimberle_crenshaw_the_urgency_of_intersectionality
• Centering The Margins: I want a dyke for a president http://www.dazeddigital.com/music/article/33096/1/watch-mykki-blanco-read-i-want-a-dyke-for-president
• 6 Rules for Allies by Dr. Jones: https://vimeo.com/78945479
• 26 Ways to Be in the Struggle Beyond the Streets: https://issuu.com/nlc.sf.2014/docs/beyondthestreets_final

Documentaries:

·           Colonization Rd: http://www.cbc.ca/firsthand/episodes/colonization-road

·           The Stairs: http://www.thestairsdoc.com

·           Salud! https://vimeo.com/97738890

·           Revolutionary Medicine: Story of the First Garifuna Hospital: http://revolutionarymedicine.org

Online Education, steps in supporting Indigenous Sovereignty:

·           Cultural Safety modules by University of Victoria Nursing Program

·           Module 1: http://web2.uvcs.uvic.ca/courses/csafety/mod1/index.htm

·           Module 2: http://web2.uvcs.uvic.ca/courses/csafety/mod2/index.htm

·           Module 3: http://web2.uvcs.uvic.ca/courses/csafety/mod3/index.htm

·           Free Online course on Indigenous Canada: https://www.ualberta.ca/courses/indigenous-canada

APPENDIX C

In an effort to make this information more easily available, the ‘Know Your History: A Guide to Uncovering and Resisting Medical Violence’ was created by N. Rai. It has been circulated across a number of different social media forums. The resources are displayed in an easy to read format and the document continues to grow as new and old resources are uncovered. You can view this resource here: https://docs.google.com/document/d/1dpfLW-CeaM7ODpS6x5S039QC1-W9w8OAajvIpTG5Gao/edit?usp=sharing.