Viewpoints

Missing Data: Canada's inability to properly measure and address health inequalities

By Stacey Butler

Canada may have a universal healthcare system, however the treatment Canadians receive is far from equal. Canadian rapper, John River, was experiencing shortness of breath and severe headaches, yet these symptoms were dismissed by hospitals in Toronto, simply because of his appearance and skin colour. Instead of his complaints being taken seriously, he was stereotyped, viewed as uneducated, and assumed to be faking symptoms to obtain drugs. This case of systemic racism resulted in significant delays in treatment and left John River in severe pain for months on end.1

Stories like this bring to light the health inequalities experienced by racialized individuals in Canada. Despite culture and race (or more accurately, racism) being recognized by Health Canada as important social determinants of health,2 our healthcare system does not routinely collect data on race or ethnicity, with the exception of indigenous identity. Failing to collect race or ethnicity-based data in Canada is a major limitation that negatively impacts the quality of our research and our healthcare system. It prevents us from understanding the diversity of our patients and from being able to detect inequalities that we know exist as a result of systemic racism.3

The terms race and ethnicity are often used interchangeably, despite having different meanings and contexts. Race is a social construct that categorizes people based on visual traits such as the colour of their skin.4 Ethnicity refers to groups with a shared culture, ancestry, language, or belief system.4 Race has been used both historically and currently to discriminate against, exclude, or marginalize a group of people, and results in unequal opportunities. It is crucial to understand how both race and ethnicity contribute to health inequalities in Canada. Data on race can be used to identify health inequalities that exist due to bias and racism. While data on ethnicity can be used to understand and identify cultural barriers to healthcare.4

Since individual-level data on race or ethnicity is not routinely collected in Ontario’s healthcare system, population health studies have resorted to using alternative methods to measure health inequalities. Typically these methods rely on neighbourhood, or area-level data available from the Canadian Census. For example, the Ontario Marginalization Index (ON-Marg) addresses race and ethnicity by identifying areas of Ontario with a high ‘ethnic concentration’, defined as areas with a high proportion of the population who identify as a visible minority or are a recent immigrant (arrived to Canada in the past five years).5 The ON-Marg tool is limited by its use of aggregated, area-level data, as opposed to data on each individual’s ethnicity. An additional limitation is the so-called ‘healthy immigrant effect’, where recent immigrants are generally healthy but their health deteriorates over time. Furthermore, in the case of diabetes, this deterioration is greater for immigrants who belong to a visible minority group.6 Nonetheless, the ON-Marg tool is still useful to study several social determinants of health in Ontario at the neighbourhood level.

Given the limitations of area-level data, epidemiologists at ICES, a population health research institute in Ontario, have gotten creative with their approach to addressing ethnicity. They have developed a tool that uses surnames to identify people of South Asian and Chinese ethnicity.7 Using this method, researchers have uncovered differences in the risk of several diseases and in the severity of mental illness.8 However, the surname algorithm is only able to categorize people into two distinct ethnic groups (South Asian and Chinese) and lumps the remainder into a ‘general population’ category. Thus, it cannot measure health inequalities in other ethnic groups that exist within the Ontario population, reiterating the need for individual-level data on ethnicity.

The COVID-19 pandemic has put race and ethnicity in Canada in the spotlight, as aggregate, neighbourhood level data draws our attention to the disproportionate rates of infection and mortality among racialized communities.9 Visible minority groups are seven times more likely to have

"The COVID-19 pandemic has put race and ethnicity in Canada in the spotlight, as aggregate, neighbourhood level data draws our attention to the disproportionate rates of infection and mortality among racialized communities.9"

COVID-19 than White Torontonians.10 These observations have created a call to action for the collection of individual-level race or ethnicity-based data in our healthcare system. Local public health units began collecting race-based data for patients with COVID-19 in the spring of 2020 and by the summer, information on race, income, household size and language was being collected across Ontario.11 This is a positive step forward, but it should not have taken a pandemic to propel us to collect this information and begin to address health inequalities in Canada that have existed for decades.

Although there are difficulties in navigating the collection of race or ethnicity-based data, it is essential to collect this information in order to properly measure and address health inequalities in Canada.3 We must ensure that this data is used to improve the health of racialized individuals and not to further marginalize or segregate them. It is also essential that privacy and confidentiality is maintained.4 The Canadian Institute for Health Information (CIHI) recommends working with community groups that represent racialized individuals, in order to identify relevant research priorities.4 Simply collecting the data is not sufficient if the results are not communicated to the public and policy-makers. Most importantly, any findings of inequalities must be addressed with targeted interventions to create substantial change.

Lastly, it is important to recognize that many social determinants of health are inter-related and changes outside of the healthcare system are needed to have a widespread impact. Systemic racism affects opportunities and access to employment, education, housing, clean water, healthy food, and a safe environment.3 We can all do our part in addressing these social determinants of health by acknowledging our privilege and getting involved with underserved communities. The Wellesley Institute (https://www. wellesleyinstitute.com/) and FoodShare (https://foodshare.net/) are two great examples of local initiatives that strive for health equity in Toronto.

References

1. Amin F. Falling through the cracks of Canada’s healthcare system: the John River story. City News. 2019 Dec 4; Available from: https://toronto.citynews.ca/2019/12/04/canada-healthcare-system-john-river/ 2. Health Canada. Social determinants of health and health inequalities [Internet]. 2020 [cited 2021 Jun 8]. Available from: https://www. canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html 3. Nestel S. Colour Coded Health Care The Impact of Race and

Racism on Canadians’ Health. Toronto, ON; 2012. 4. Canadian Institute for Health Information. Proposed Standards for

Race-Based and Indigenous Identity Data Collection and Health

Reporting in Canada [Internet]. Ottawa, ON; 2020. Available from: https://www.cihi.ca/sites/default/files/document/proposed-standard-for-race-based-data-en.pdf 5. Public Health Ontario. Ontario Marginalization Index (ON-Marg) [Internet]. 2018. Available from: https://www.publichealthontario. ca/en/data-and-analysis/health-equity/ontario-marginalization-index 6. Adjei JK, Adu PA, Ackah BBB. Revisiting the healthy immigrant effect with diabetes risk in Canada: why race/ethnicity matters.

Ethnicity and Health. 2020;25(4):495–507. 7. Shah BR, Chiu M, Amin S, Ramani M, Sadry S, Tu J V. Surname lists to identify South Asian and Chinese ethnicity from secondary data in Ontario, Canada: A validation study. BMC Medical Research

Methodology. 2010;10. 8. Chiu M. Ethnic Differences in Mental Health and Race-Based Data

Collection. Healthcare Quarterly. 2017;20(3):6–9. 9. Subedi R, Greenberg L, Turcotte M. COVID-19 mortality rates in

Canada’s ethno-cultural neighbourhoods [Internet]. 2020. Available from: https://www150.statcan.gc.ca/n1/pub/45-28-0001/2020001/ article/00079-eng.htm 10. IMS Magazine. Answering the call for COVID-19 research: PUB-

LIC HEALTH & EPIDEMIOLOGY. IMS Magazine. :8–9. 11. McKenzie K. Race and ethnicity data collection during COVID-19 in Canada - If you not counted you cannot count on the pandemic response. The Royal Society of Canada. 2020;1–12.

Drug Use for Grown-Ups: A Radical Discussion on Drugs

By Dorsa Rafiei & Stephanie Tran

Earlier this year, Dr. Carl Hart, a neuroscientist and professor at Columbia University, released a book entitled Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear,1 arguing for people’s freedom to alter their consciousness with drugs. The book’s provocative topic certainly ruffled some feathers in both the general public and academic communities. Meanwhile, the book received glowing reviews from publications such as NPR and the New York Times, to name a few.

In Drug Use for Grown-Ups, Hart points out the way society has demonized drugs as well as users—particularly black and brown drug users—leading to policies that have contributed to social injustices, such as the disproportionate incarceration and harsher sentencing of black and brown people compared to white people for nonviolent drug offences.2 An important step in providing a solution to this problem, Hart argues, is the decriminalization and legalization of all drugs, which allows for regulation and quality control of substances. However, we believe Hart’s argument becomes dangerous when he provocatively muses about his recreational use of heroin and states that he is a better person because of drugs, claiming that if he can use drugs safely, so could other “grown-ups.” Therefore, readers inability to satisfactorily predict who will develop the illness state once they have first been exposed to the substance. It’s difficult enough to determine even the prevalence of substance use disorders, despite our having descriptive criteria.”4

In addition to user variability, there are innate differences in drug properties that cannot be overlooked. Hart resents the more accepting attitude of the public toward some drugs, such as psilocybin, versus the negative attitude toward “harder” drugs, such as heroin: “I had grown increasingly annoyed with the mental gymnastics that some psychedelic users perform in order to distance themselves from other drug users.”1 While psilocybin is a powerful psychoactive substance, it is physiologically safer than heroin.5 Psilocybin overdoses may include vomiting, paranoia, psychosis, and seizures and are rarely life-threatening. On the other hand, heroin can cause respiratory depression and overdose, which can be lethal. Although Hart’s intentions are to increase unity among drug users by emphasizing the positive effects of drug use, he fails to adequately address the different neurophysiological effects of drugs.

An overwhelming emphasis in Drug Use for Grown-Ups is on the positive effects of drugs which fails to highlight disparities in the social and biological predispositions of

should be cautioned for the book’s lack of acknowledgement of variable social and biological predispositions for addiction, innate discrepancies of drug properties, and limitations of current scientific evidence.

The target demographic of Drug Use for Grown-Ups are, well, “grownups”. Hart defines a grown-up as a healthy adult who is “autonomous, responsible and well-functioning” and fulfills their social, parental, and occupational responsibilities.1 But how do we distinguish between the grownups that can use drugs responsibly versus the grown-ups that cannot? Hart argues that many drug users (like himself) do not meet the criterion for impaired functioning and thus do not have a substance use disorder (SUD) or an addiction. In fact, Hart’s argument dismisses the role of genetic predisposition and the environment, two common risk factors for mental illness and addiction.3 So, while a “well-functioning” adult can choose to responsibly use recreational drugs, environmental or situational factors (e.g., acute stress or trauma) may trigger increased use, dependence or even abuse, which can in turn impact, as Hart would suggest, “responsible use”. Ultimately, as Dr. William Haning, editor-in-chief of the American Society of Addiction Medicine, so eloquently puts, the fulcrum is “our

different “grown-ups”. Hart cites his own studies that investigated cannabis, cocaine, and methamphetamine, to name a few. However, the majority of these studies consisted of small sample sizes (< 10 participants) and looked at acute shortterm effects (< 2 weeks).7,8 Hart draws on evidence suggesting that the majority of drug users do not become addicted and are able to function normally. However, the number that do become addicted is no small number. In 2017 alone, the global estimate of opioid overdose deaths was 109 500, of which 43% were in the USA.9 Even in new heroin users, approximately 30% of people become dependent within the first year.10 According to Hart, “the opioid problem is not really about opioids” but rather a problem of “ignorance.”1 He argues that fatal opioid overdoses have been largely overstated, citing that the majority of overdoses are a result of contaminated opioid drugs or opioids combined with another downer (e.g., alcohol). Hart’s solution for ignorance is better educating the public about how to use drugs to increase desired effects and reduce adverse effects; however, this approach hasn’t worked with other drugs. For example, many “grown-ups” know they shouldn’t take a benzodiazepine with alcohol… but they do it anyway. People know they shouldn’t abuse alcohol, but alcohol-related incidents still make up a large proportion of emergency room visits.11 In fact, alcohol is the cause of 5.3% of deaths worldwide every year.12 Therefore, as we have seen with alcohol, education will not solve the issue of “ignorance” and the risk of addiction should not be overlooked to solely focus on the positive effect of drugs.

All in all, it is our opinion that illicit drugs should be decriminalized and legalized to allow for better therapeutics for people with SUDs, without the stigmatization and risk of incarceration—but there are dangers in Hart’s method of advocacy. He states that the book is “unapologetically not about addiction.” But to talk about drugs without considering the neuropsychopharmacological outcomes is simply irresponsible. Nevertheless, Hart’s radical opinions are an important part of the discussion to be had regarding reforming drug policies and de-stigmatization of drug use. References

1. Hart CL. Drug use for grown-ups chasing liberty in the land of fear.

New York: Penguin Press; 2021. 2. Vogel M, Porter LC. Toward a Demographic Understanding of

Incarceration Disparities: Race, Ethnicity, and Age Structure.

Journal of Quantitative Criminology. 2015;32(4):515–30. 3. Vink JM. Genetics of Addiction: Future Focus on Gene ×

Environment Interaction? Journal of Studies on Alcohol and Drugs. 2016;77(5):684–7. 4. Haning W. American Society of Addiction Medicine [Internet].

Editorial Comment 1/19/2021: Drug Use for Grown-Ups. [cited 2021May6]. Available from: https://www.asam.org/Quality-Science/ publications/asam-weekly/asam-weekly-archive/asam-weeklyeditorial-comment/2021/01/19/editorial-comment-1-19-2021drug-use-for-grown-ups 5. Nichols DE. Psychedelics. Pharmacological Reviews. 2016;68(2):264–355. 6. White JM, Irvine RJ. Mechanisms of fatal opioid overdose.

Addiction. 1999;94(7):961–72. 7. Comer S, Hart C, Ward A, Haney M, Foltin R, Fischman M. Effects of repeated oral methamphetamine administration in humans.

Psychopharmacology. 2001;155(4):397–404. 8. Haney M, Rabkin J, Gunderson E, Foltin RW. Dronabinol and marijuana in HIV+ marijuana smokers: acute effects on caloric intake and mood. Psychopharmacology. 2005;181(1):170–8. 9. James SL, Abate D, Abate KH, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.

The Lancet. 2018;392(10159):1789–858. 10. Santiago Rivera OJ, Havens JR, Parker MA, Anthony JC. Risk of Heroin Dependence in Newly Incident Heroin Users. JAMA

Psychiatry. 2018;75(8):863. 11. Myran DT, Hsu AT, Smith G, Tanuseputro P. Rates of emergency department visits attributable to alcohol use in Ontario from 2003 to 2016: a retrospective population-level study. Canadian Medical

Association Journal. 2019;191(29). 12. Addiction Statistics - Facts on Drug and Alcohol Use. Addiction

Center. [updated 2021 March 24; accessed 2021 July 14]. Available from: https://www.addictioncenter.com/addiction/addictionstatistics/.