Racism and patients receiving emergency care

Opinion

When elected in October 2023, the NDP identified reducing emergency room wait times as a primary goal for health system improvements.

Recently, a report issued by Shared Health concluded that Black and Indigenous patients have longer wait times than white patients to see a physician when they visit emergency rooms (ERs). Since ERs are the highest-stress unit in a hospital for both patients and health-care staff, and a primary gateway for health care, bias in the allocation of health care can have significant adverse consequences for the well-being of Manitobans.

The central feature of emergency care is the triage process. The Canadian Triage and Acuity Scale (CTAS) utilizes five levels to allocate scarce resources to the patients who are most seriously ill. Triage does more than guide treatment by a physician. It also manages access to tests and allocation to beds. CTAS Level 1 signifies patients who may die without immediate attention, while Level 5 patients are those who could be treated elsewhere, other than an emergency department.

The pivot point of the CTAS system is the triage nurse, who uses a combination of visual examination, vital sign measurement, and patient complaint to categorize incoming cases. A comatose individual arriving by ambulance or a “walk-in” complaining of chest pain, dizziness and sweating profusely, would probably be a CTAS Level 1. A cut requiring stitches may be a Level 3 or 4, depending on its severity.

I have read the public report in detail. While it makes a case that, compared to other ethnic and racial groups, Black people and Indigenous persons often experience longer wait times to see a physician, it is not universally the case. Analyzing the data by the location of the ER and CTAS level reveals instances where other ethnic groups experience poorer service compared to Black and Indigenous people.

Academics can nitpick research to death. A more important issue is with the policy response that mandates “anti-racism” training for ER workers.

This policy assigns responsibility for the higher wait times experienced by Black and Indigenous persons to the attitudes of individual health workers. This is unfair, risks unintended consequences, and, most importantly, may result in little or no change in the pattern of care. It may worsen outcomes if the triage process prioritizes ethnicity over health status.

Policies to mitigate systemic racism too often focus on trying to correct individual failings rather than addressing systemic causes of the adverse outcomes. And what systemic issues might account for the high use of ERs by Indigenous persons? The Shared Health report takes pains to address a common notion that Indigenous persons overuse ERs, arriving with minor complaints and languishing at CTAS Level 5. But its explanation is unconvincing.

A lesser-known trend among the First Nations population of Canada is its increasing urbanization. Some estimates indicate that around 60 per cent of all First Nations persons now reside, at least for part of the year, in cities. Winnipeg certainly typifies this trend.

About a decade ago, I conducted a series of focus groups for a federal government department to explore the challenges faced by young First Nations migrants from remote reserve communities during their transition to Winnipeg, where they arrived for school or to improve their lives. Of course, we used elders to create trust and elicit deep insights … I lurked in the background.

An important finding was that for these young people, moving from a remote reserve to Winnipeg was akin to migrating to Canada from another continent.

Compared to immigrants from abroad, whom I was also studying at the time, many of these young First Nations people had few family or social contacts in the city. In contrast, the Filipino and Indian communities have robust community networks that offer support to immigrants, including access to both health care and religious and cultural associations that provide a range of support services. First Nations are only now starting to develop these community-based systems.

Many First Nation migrants from reserves to cities leave an environment where federally funded nursing stations offer primary care. That system is unavailable in urban areas, resulting in First Nations having reduced access to various forms of primary care. This could explain why they use emergency rooms at high rates; they have no alternatives.

The Shared Health study overlooks a crucial aspect of our health-care system. Anyone who has been in a hospital or used an ER realizes that having a family member or friend to be their advocate ensures more timely service. This is indirectly evident in the Shared Health data, which shows negligible differences in the care received by children, regardless of ethnicity. Most children visiting an ER have an advocate … their parent. The study data apparently did not include whether the adult patient was accompanied.

This suggests a program of advocates whose role is to move among those in the ER, ensuring they are not forgotten. This team must be ethnically and racially diverse. It is also important not to create advocates who support only one ethnic group. Finally, advocates must be integrated with the medical team to avoid interfering with the triage process.

Such advocate teams would be easy to recruit as hospital volunteering has a long history. Advocates would also encourage patients to remain until they see a physician. The report notes that both Black people and Indigenous people leave before seeing a physician more frequently than other ethnic groups.

Such advocacy teams do not replace community-based health care that supports those lacking a family physician. But in the short term, such teams could be a cost-effective enhancement to ERs that avoids blaming front-line ER workers for the systemic failures of our health-care system.

Gregory Mason is an associate professor of economics at the University of Manitoba.