Health Equity for Black Communities with Dr. Onye Nnorom

On everyday experiences that decrease Black communities’ trust: 

“It’s actually the context in Canada, in North America, of everyday life of Black people experiencing stereotypes and biases within the healthcare system, being ignored by the research system, not really valuing us and engaging us to be meaningfully involved in real studies.”

On why vaccine uptake has been low within Black communities:

“You mix the distrust and the history and the present-day experience of racism with the conspiracy theories, and you’ve got a perfect storm of people saying ‘No.’ Either ‘Not yet,’ or ‘No, never.’”

On increasing trust and respect within marginalized communities:

“A lot of people, after a certain time, they digest it, they might grow trust with us and they may get the vaccine. For our pop-up clinics, we’ve seen huge numbers of Black people and other racialized groups and differently-abled groups – other marginalized groups also coming out to get the vaccine and feeling that it’s a safe space and it’s an inclusive space and they’re going to be respected.”

On the importance of human connection:

“But it’s about you, as a whole person. There’s going to be music. We’re going to make sure you have food. We’re going to let you know about other community resources. We want to make sure that you are okay beyond just getting that shot in your arm.”

On the importance of having Black representation in roles of power, in all fields:

“I was just watching a documentary on Black filmmakers in the United States and they were talking about how – I think in the ’60s and things like that – when there would be a Black person in a movie, and they tell them how to walk in this really stereotypical way and talk. So the Black actors would be like, “But we don’t talk like that and we don’t do that,” and then the white director would be like, “No, this is how Black people act.”

On the need to address the past, before focusing on the future:

“Our history isn’t just something that was back then and this is now. It’s a lovely idea that we could just say, ‘Tthere’s not going to be any slavery anymore,’ and then along with it goes any anti-Black racism and that’s over, we just turn to the next chapter in our lives and everything moves on and it’s beautiful. That’s not quite the way that it happens.”

On the value of intergenerational wisdom:

“Know when we say intergenerational wisdom: number one, there’s a value in that, of just common sense that’s been passed down. It’s like not believing in love because you didn’t have the study. You know love exists because you’ve seen it. I know that racism and the harms from it impact health because I’ve seen it.”

On increasing access to resources that are proven to work in Black communities:

“So, listening to us, having the idea of ambassadors. Again, there’re so many programs that have been developed where there’s education happening in barbershops, in salons, in churches. We know those work from cancer screening, HIV – there’re so many studies already there.”

On the need for institutional anti-racism training:

“We need hospitals and research institutions, et cetera, to really undergo anti-racism training so that when there’s another issue, they’re starting to build the trust. They’re starting to understand.”

On taking a different perspective to understand the experiences of Black communities:

“So if that’s helpful for your listeners to think about… You remove race, put yourself in a situation where it’s another country where you’re concerned about their human rights legacy and present day approaches, but they’re the ones who have the magic bullet for the variant. What are you going to do?”

On optimism and steps for the future:

“[COVID-19] has amplified so many inequities of how we treat our elderly. I mean, it’s also exposed inequities for women as caregivers. Just so many factors that now everything’s up in the air: we can work towards a new normal. So I am optimistic about that, but it’s hard work. Changing things is hard work. So I’m hoping that we are dedicated towards this because a lot of people didn’t know. In all honesty, a lot of white Canadians, a lot of people from mainstream society were not aware, but so much has come to our awareness that I’m hoping it’s a critical time of change.”

Brooke Struck: Hello everyone, and welcome to the podcast of The Decision Lab, a socially conscious applied research firm that uses behavioral science to improve outcomes for all of society. My name is Brooke Struck, research director at TDL, and I’ll be your host for the discussion. My guest today is Dr. Onye Nnorom: equity, diversity and inclusion lead at the Department of Family and Community Medicine at the University of Toronto; president of the Black Physicians’ Association of Ontario; and host of the Race, Health & Happiness Podcast. You may know her there as Dr. O. In today’s episode, we’ll be talking about trust in the system, racialized communities, public health, vaccines and paths forward. Dr. Nnorom, thanks for joining us.

Dr. Onye Nnorom: Thanks for having me. Breakfast is awesome.

Brooke Struck: Please tell us a bit about yourself and what you’re up to these days.

Dr. Onye Nnorom: Oh, so a little bit about me. I think my identity as a Black woman of Nigerian and Trinidadian background, originally born and raised in Montreal but now living in Toronto, is certainly a part of my identity. Cisgendered, now a physician working in, as you said, family medicine and public health. And also, you didn’t have a chance to mention, but I’m at the Dalla Lana School of Public Health as well, because that’s relevant to this conversation. My work as associate program director: I train the medical officers of health of the future. And before this pandemic, nobody even knew what public health doctors did, but that’s my specialty and that’s who I train: the people who will run public health organizations or do work that I do in the community.

For me, a lot of my work is in teaching and focused on an understanding of how racism impacts health and even more how that affects Black health. What I’ve been up to since this pandemic and the uprising that occurred after the death of George Floyd was really helping people understand how all of those factors of anti-Black racism – or racism in general and forms of systems – how they end up impacting other marginalized groups, particularly Black communities, all kind of intersected because of the groups that have been affected by the pandemic. And then most recently, the groups that tend to be more reluctant to take the vaccine because of distrust. So that’s the kind of work that I do, and hopefully helping to change or bring us on this journey to the new normal. So my little slice of that is what I’ve been up to.

Brooke Struck: Great. Let’s start unpacking now. There’s so much in there. So you mentioned the challenges of racialized communities throughout the pandemic. There’s certainly a health angle to that, but there’s more to it as well. Let’s think about vaccine uptake now for a moment, and zoom in on that. We’ve heard a lot about lower levels of vaccine uptake among racialized communities and Black communities in particular. That’s certainly within Canada, but not limited to Canada. What are some of the drivers that you’re seeing behind these low uptake rates?

Dr. Onye Nnorom: The drivers – I’ll speak to some of the data, but also just my own lived experience as a Black person living in Canada. The first signal we got, because as the president of the Black Physicians’ Association, we heard from the Public Health Agency of Canada in November of 2020 before the vaccines even came out – that they had done studies of different demographic populations and they had identified that Black people were least likely to want the vaccine. This was before it was developed or made available, and one thing that surprised the most: even less so than Indigenous communities, that we know there’s a legacy of intergeneral trauma and distrust towards healthcare.

I don’t think I have to explain that: we know about residential schools and colonization. But it was a surprise, I think to them, that amongst all groups, Black people seemed to be – based on that survey – less willing to get it. Now we’ve seen that improve over time, because at that time it was an imaginary vaccine. It was a hypothetical question. But ultimately, the factors have been, with regards to the distrust, some of it is historical. People talk about big studies in the United States where Black people had been mistreated, like the Tuskegee experiment where they didn’t provide syphilis treatment, but observed people basically dying of syphilis and documenting it.

But most people don’t know about that in today’s world, and particularly in Canada. It’s actually because, for people in their countries of origin, Europeans have come in with vaccines and other pharmaceutical companies have come in and taken advantage of Black communities historically and very recently into the ’90s as well. But more than that, I would say it’s actually the context in Canada, in North America, of everyday life of Black people experiencing stereotypes and biases within the healthcare system, being ignored by the research system, not really valuing us and engaging us to be meaningfully involved in real studies. Government – so where we might be in protests about police brutality. Where we might be saying, “There’s not enough social programs in our schools,” and Government is ignoring us. Then all three of those groups come together and say, “Here, you need to take this new vaccine.”

Well, based on our intergenerational knowledge, it is not a good idea where mainstream European society says, “Here, come take this new thing.” Historically, that has not gone well as far as how we’ve been used in studies. So there’s that, that comes from the mothers, the grandmothers. That’s the intergenerational wisdom of – it’s not to just say “No” flat out, it’s to observe and make sure we’re not being used as guinea pigs. And so that’s the wisdom. 

But the other factor is our everyday lives.In Toronto, there had been requests at the beginning of the pandemic: “Can we have more buses in some of the low-income neighborhoods?” Where people were essential workers, still had to go out, and wanted to socially distance.

My understanding, again anecdotally, was that that was not provided. For a lot of Black people who are overrepresented in essential healthcare work – like being personal support workers, working among term care homes – being denied PPE or not having enough personal protective equipment. So it’s even in the pandemic, asking for help saying, “Can you help us because we’re getting sick?” And the government ignores that and people ignore it. And then “Here’s a vaccine. Let us inject this into you.”There’s so much of that.

So as Black physicians, we’re able to navigate that space a little bit, understanding healthcare, understanding the racism that exists in healthcare, but still to look at the community and say, “You know what? This is still our best defense against this virus that’s disproportionately affecting our community because of all of these social injustices that have made us more likely to be essential caregivers or people who can’t socially distance, or people who can’t just stay home or have access to sick leave.”

It’s like this perfect storm of social neglect and distrust that then gets further amplified by social media myths. So all of the false news, all of the conspiracy theories. You mix the distrust and the history and the present-day experience of racism with the conspiracy theories, and you’ve got a perfect storm of people saying “No.” Either “Not yet,” or “No, never.” So we’ve been working more with the “Not yet,” as opposed to the people who are like, “Never.”

Brooke Struck: Yeah, it’s interesting. The way that you’ve described that, makes me think about the challenges around the AstraZeneca vaccine and how much the public discourse and public discussion about problems around blood clots was essential for policy changes to take place. There was stuff going on within the community that had not been observed or had not been observed to that magnitude in clinical trials. That kind of thing happens often when you go from giving a vaccine to a few tens of thousands of people to millions of people.

So it’s normal that we start to see more things happening in the population setting than in the clinical setting. But if those reports from people in the community are not taken seriously, then all of a sudden we don’t have these policy changes. We don’t have these revised discussions.

Dr. Onye Nnorom: Exactly.

Brooke Struck: So putting aside the issue of whether governments ought to have changed course around AstraZeneca, I don’t want to get into whether-

Dr. Onye Nnorom: No, no. Yeah, yeah.

Brooke Struck: But that discussion of the fact that the community might have legitimate concerns to raise and that we need to be listening to those communities – that seems really, really at odds with the kind of thing that you’re talking about, with more busing and the need for personal protective equipment and all of these kinds of measures that, earlier on in the pandemic, communities were calling for and not receiving or not sufficiently receiving in order to take the protective actions that they were hoping to take. And that in fact, the public health authorities were urging them to take, as well.

Dr. Onye Nnorom: Exactly. Exactly. So asking people to stay home and socially distance when they don’t have the means to, because of their living situation or because of their work, but then the personal protective equipment is not provided, does not help build trust. And even in some of the lower-income neighborhoods, initially having access to testing was also a problem, and then also access to vaccines initially was. So all of these things get compounded, but I would say AstraZeneca becomes a good example. As you said, we’re not going to get into the politics of it necessarily, but that’s an example of where I say, for Black communities, it’s that intergenerational wisdom.

We have been used as guinea pigs enough times to know that when a brand new thing comes out, that you’re supposed to put in your system when you’re otherwise healthy – it’s totally different if you’re sick and have no other choice. But you are functioning perfectly fine, and then somebody says, “Come and take this.” Because we’ve, again, through intergenerational wisdom, been at the forefront of research as being tested on, the wisdom is, “Wait,” when they come and say, “Line up here.” My mother grew up in Trinidad and she remembers vans of European people coming to her school, giving kids injections and some kids died.

The advice from my grandfather to my mother was, when you see the van of white people, do not take the vaccine. Now, I got my childhood vaccines, but it’s just this need to make sure that a vaccine or treatment or whatever it is, has demonstrated safety and efficacy before you jump forward to get the vaccine. I can say even for me, as a healthcare provider, I did wait a little bit. Not a huge amount of time, but I wasn’t first in line, and I know for other Black people who work in the pharmaceutical industry not necessarily creating vaccines, it was the same thing. Because that has been passed down to us, that you just wait.

And so AstraZeneca, actually, we ended up using that as an example to the community and saying, “That was the wisdom to wait a little bit, but enough data has been collected, enough people have gotten the vaccine that we’ve been able to identify where the problems are and address it.” So that actually helped with trust because they were like, “Okay, there was a problem, and it looks like it was taken care of, not swept under the rug,” which is what we as Black people are used to. When we file a complaint, it’s swept under the rug. So it’s a really great example of something being well-managed, but also why that intergenerational wisdom exists, due to experience.

Brooke Struck: Yeah, it’s interesting. You mentioned that you need to have confidence that these kinds of concerns are not going to get swept under the rug. In the case of AstraZeneca, they weren’t. The public discourse did ingest this new data that was coming in. But for the Black community, I could well imagine, putting themselves in that position and saying, “Well, if we need our voices and our voices alone to be heard in this, we’re in a much more vulnerable situation than something that’s population-wide.”

Dr. Onye Nnorom: Correct. Correct. So that was also the hesitance to being first in line and just waiting. But, again, where we’ve been able to have webinars, we have community ambassadors from the Black community on the ground, people speaking at churches. Then we helped to say, “You know what? Look, aside from mainstream society not always taking us seriously or the way we experience it, really devaluing our lives…” That’s where the statement Black Lives Matter comes from. It’s a counter narrative to our lived everyday experience of either being ignored, neglected, or mistreated from a systems-first standpoint.

Then it’s like, “Well, no, this is what’s happening to the community. This is what the data looks like. It’s actually us who are overrepresented in the ICUs. We need to advocate for change. We need to advocate that these hospitals and research organizations and government agencies start to address the issues of anti-Black racism, because that’s the core reason there’s the distrust. So let’s get it out the route. But right now, this is still our best defense and we care about you.” And so we do not provide the message, “You have to get the vaccine.”

For the Black Physicians’ Association of Ontario, we created a physician statement that included a recommendation that people do consider getting the vaccine, but also get the appropriate information. But most of our document was actually focused on mainstream society addressing the issues, engaging in anti-oppression training and having collection of race-based data, other things that are required by the community and addressing living situations. Social determinants of health is where we mainly focused it, but we don’t take the position, “You have to have the vaccine.” Or if we have a conversation with somebody and they say, “I don’t trust it.” We say, “Okay, you know what? You have good reasons not to trust it. These are reasons why you should consider. This is what’s going on. If you have more questions, we’re here for you, because we care about you, because we value your life.”

And so what we’ve seen is, a lot of people, after a certain time, they digest it, they might grow trust with us and they may get the vaccine. For our pop-up clinics, we’ve seen huge numbers of Black people and other racialized groups and differently-abled groups, – other marginalized groups also coming out to get the vaccine and feeling that it’s a safe space and it’s an inclusive space and they’re going to be respected. And we have people that are answering questions, so it’s been a really beautiful thing in that sense because we’ve been able to kind of bridge some of that gap. So where the trust is there and access is there, we have seen Black people come out to certainly get the vaccine.

Brooke Struck: It’s interesting the way that you frame this around, not just Black people and not just racialized communities, but the level of discourse between a healthcare provider or a public health representative and a patient. What you’re describing sounds like a situation where, what the doctor or the public health worker is expressing is a care for the patient, not necessarily a care for the vaccine. Like, “I’m not here to talk to you about the vaccine, I’m here to talk to you about you”

and that is something that cuts across racial lines and lines of ability and this kind of thing. So I can easily imagine that: creating a space where people who feel marginalized from the system would all find themselves much more comfortable regardless of the directionality of their sense of marginalization.

Dr. Onye Nnorom: Yeah, and I would push that term. So the sense of marginalization means that it’s not occurring. But in fact, our country was built on a premise of oppression of Indigenous people and then bringing in slaves and that kind of thing. So these are equity deserving groups. These are groups that are experiencing marginalization. But yeah, at the individual level, some people will still go to the mainstream centers. Of course, it’s an individual thing. But I just want to make sure that it’s not – I know you have international listeners.It’s not just a perception, but it’s everyday life where people are not being treated with dignity because of their identities, whether that is the color of their skin, or because they are trans or because they’re differently-abled.

We as the Black Physicians’ Association of Ontario got a lot of our advice and guidance actually from Indigenous physician groups and Indigenous communities because they had started their vaccine clinics earlier on. But that idea that you described, where I was thinking about the full person…As physicians, we often are at the top of the hierarchy of medicine, but we know through a term called “Indigenous cultural safety” that was actually developed by Indigenous peoples in Australia, but it’s where you come in with, what’s called cultural humility.

So you’re not coming in with that judgmental tone that yes, doctors have, but also nurses or anybody in healthcare can have, where you’re above the patient. But really coming with a sense of humility. And for us, for BPA, we also incorporated our own African concepts. It’s not Pan-African, but South African, which is Ubuntu. “I am, because we are. We are all interconnected as humans. My existence is interconnected with your existence.” And it actually very much applies to the pandemic where your health is very much interconnected with my health.

So when we provide the vaccine, we take the time to talk to people. We look people in the eyes, which I’ve heard does not always happen in the mainstream vaccine clinics. It’s like, “Just move, move.” It’s kind of factory-like. But it’s about you, as a whole person. There’s going to be music. We’re going to make sure you have food. We’re going to let you know about other community resources. We want to make sure that you are okay beyond just getting that shot in your arm. Very important for it. When we work with the Jamaican Canadian Association, there’s food baskets. There’s a Play-Doh that you can take for your kids, take that home. Really it is about a much more holistic approach that we care about you.

So when other groups come in, they feel that inclusivity and that warmth,so they come to our clinics too. So it’s a beautiful thing where we use that Afrocentric lens. Yes, primarily, it’s designed by and for the Black population, but we welcome so many others who want to feel that when they get their vaccines as well.

Brooke Struck: I like that. It’s not just about the recipient as a person, it’s also about the healthcare worker themselves as a full person. It’s not just that you, as the person coming to get a jab in the arm, need to feel that there’s this sense of community. That sense of community also includes me as this person who’s here.

Dr. Onye Nnorom: Correct. Correct. So we make sure our volunteers, our physicians, everybody – particularly when we have the pop-up clinics – that they have food, they’re well hydrated. They are well so that they can bring wellness and their demeanor when they see the patient coming for the vaccine. So yes, it’s all interconnected. Why? Because we’re all human beings. I get my vaccine too. In that case, I’m the patient. At the clinics, I’m the provider, but it’s all full circle. So we want to see that for everybody who comes to the clinic: that they leave feeling a sense of wellness. That’s what it’s supposed to be. It’s health.

Brooke Struck: I really like that. Let’s shift gears a little bit now and talk about different stages of the vaccine rollout. So in a previous conversation, I really liked something that you helped to clarify for me. I hadn’t really thought about it in these terms before: that you have these different layers of access through the different phases of a vaccine campaign. So the first is around a supply-access question. “Is there a vaccine to be had?”

Then there’s the second logistic step. We now have enough vaccines that some people are starting to get access to it, but can I, as an individual, get access to it? In virtue of where the clinic is located and the clinic’s hours, and the ability for me to take time off of work, and the ability for me to get someone to watch my kids, or to bring my kids with me and play with some Play-Doh? But whatever that is, there needs to be a solution for your kids and for your work and for your transit and all that kind of thing. So that’s the second stage, is that logistics stage.

And then the third stage is this trust stage where we’ve passed through phases one and two. There’s enough vaccine. It’s kind of distributed around enough that people can go and get it if they want it. Now the question is, do people believe strongly enough in this that they’re going to go and get the vaccine, even though we’ve made it as easy and as smooth and frictionless as we can?Can you talk us through a little bit of how those stages have been experienced by Black communities in Canada as we’ve gone through the phases?

Dr. Onye Nnorom: Sure. In November of 2020, it was the concept of a vaccine. I think at that time, only 30% of Black Canadians were interested in this hypothetical vaccine. So it wasn’t here yet. But once it was available in Canada, I would say, those of us who are from the Black community tables around vaccine decisions – and there’s very few of us at those tables, but at least advocating or having access to those who were at those tables – we were advocating for Black communities to be prioritized, because we already knew the data coming out of places like Toronto Public Health where 83% of the COVID-19 cases were Black and racialized people in Toronto. So there was that.

At the same time, we didn’t have vaccines. So to speak of access, we just didn’t have vaccines in Canada, actually. So in the United States, it was happening and you were seeing the hesitance among Black communities in the United States and in the UK, but they had vaccines. So we were left trying to figure out as Black physicians, like, “Okay, how do we help the community with regards to information about the vaccines?” as they were being developed and the ones that were available here in Canada. So we were doing webinars and trying to get funding for community members on the ground and having a vision towards it being like barbershops and things like that when things would open up.

So there was that phase. And that’s where there were  a lot of conspiracy theories because the vaccine wasn’t even here. So it was very much the boogeyman – I think for a lot of different groups, not specific to Black communities. And also, even when we were encouraging the community, a lot of us hadn’t gotten access ourselves to the vaccine. So it’s a tough message to say, “I recommend you get the vaccine,” when many of us ourselves didn’t have access to it. So then we started to have a lot more vaccines, April, May in Canada, which is really later than the other western countries.

But once we had it, there was actually quite a bit of safety data coming from the UK and the US. And the ones that were problematic had been flagged (issues with AstraZeneca, et cetera), by the time it hit the general population. So that’s when we started to have the pop-up clinics. But again, that’s where there was hesitance, because number one, when the vaccine was first available, let’s say through pharmacies, it went to the affluent areas. So it wasn’t accessible. And then even for Black communities, it wasn’t done in a way that people felt comfortable or safe. So it might be a clinic in, what they said, a “priority neighborhood” that came later. It went to the rich places first. But there was some hesitance there. And then, “Do you trust it?”

So that’s where we started to have more conversations with the hospitals, with public health agencies, to have what are called Black community-led vaccine clinics -which I’m going to be very honest, was a huge struggle. I was just watching a documentary on Black filmmakers in the United States and they were talking about how – I think in the ’60s and things like that – when there would be a Black person in a movie, and they tell them how to walk in this really stereotypical way and talk. So the Black actors would be like, “But we don’t talk like that and we don’t do that,” and then the white director would be like, “No, this is how Black people act.” This odd thing where the white directors who  have the power would say, “No, this is what Black people are.”

It resonated for me with regards to what happened with the vaccines, where we would go to hospitals and health units and say, “We need to do it in this way. We need to not rush it.” Because there was this need to get everybody vaccinated everywhere. And we’re like, “Because of trust, we need to move,” there were Black leaders saying, “Yes, be efficient, but we need to do it the right way to build trust.”

And a lot of institutions, which are Eurocentric institutions, would not listen. They were like, “No, this is the way we do it. You vaccinate, vaccinate, don’t look.” They don’t say, “Don’t look the person in the eye,” but it’s like, “We use this approach.” And they’re like, “This will work in your community. It worked in other racialized communities.” And we were like, “No, it’s not going to work in the Black community.” So it’s that sense that even though we are Black people living in our skin, these people who hold power and privilege, even within healthcare providers, are telling us how we should engage our communities.

And So that was a power, I don’t want to call it struggle – but maybe dance, that we had to enter. And fortunately for a lot of the centers, we were able to dance altogether. And there were some sites where we had to say, “Maybe you sit this one out, honestly,” because they really didn’t understand how to be culturally safe for our community.

Brooke Struck: And what about among healthcare providers and public health workers themselves? So I’m thinking particularly of people of color who find themselves, much like you, in this situation where they live this existence that is also partially inside of the institution that their community struggles with. In terms of sensitization or training, how is it that you get healthcare workers or doctors of color to be ready to walk into that kind of situation, where they are giving a different kind of care than they might be accustomed to giving in a different institutional setting?

Dr. Onye Nnorom: So for your listeners – under normal circumstances, vaccines are usually predominantly given by nurses. But for this pandemic, because a lot of operating rooms and other things were shut down and other politics that are above my level of understanding, physicians have been the main vaccinators. So for the Black Physicians’ Association of Ontario, we created a Black vaccinator network, but also invited allies to work with us.

But we do explain the need to be culturally safe and all the leads are Black physicians.So we do ask about their background, like Caribbean or something where they might have an understanding of the community, but when they come, we try to orient and say, “This is the way we do it. We are taking time to speak to people and answer their questions and formally introduce ourselves.” I got my vaccine at a mainstream place: the person who vaccinated me didn’t introduce themselves like, “Oh, what is your name?” We naturally do that. We say, “Hi, my name is…” as a human being.

So we make sure they have that orientation at the beginning, aside from the technical pieces of the online registry and that kind of thing. But that hasn’t been very challenging because we call it the Black vaccinator network: the people who are non-Black who have selected to work with us are usually people who are in solidarity with us and who are allies. So it hasn’t been that difficult. I know for our Indigenous colleagues, they have the benefit of having formal Indigenous cultural safety training. So they would make sure that allies took that training before being vaccinators.

We don’t have that yet in the Black Canadian context. We’re actually working on it – many of us working on that – but in the meantime, we just made sure that there was that understanding. And so it’s been a beautiful thing. Again, it’s solidarity because for quite a few of our clinics – as Black physicians we’re underrepresented in medicine for the same systemic reasons that have put us at risk for COVID-19, it’s all interrelated – allies have really stepped up and been really great. And where there has been a possibility of nurses being able to vaccinate, again, our non-Black nurses, Black nurses, it’s been wonderful to get that kind of support and  community. I would say that has not been a challenge where people have selected to work with us.

Brooke Struck: Yeah. There’s definitely a self-selection effect that’s going to be at work here.

Dr. Onye Nnorom: Yes.

Brooke Struck: I want to pivot a little bit now, towards the future. But before doing that, I want to address the past. So you talk about intergenerational wisdom, and we can – I think pretty easily – pull up some of these examples of really flagrantly terrible things that have happened in the past… But we’re living the past all the time, right?

Dr. Onye Nnorom: Yes.

Brooke Struck: Our history isn’t just something that was back then and this is now. It’s a lovely idea that we could just say, “There’s not going to be any slavery anymore,” and then along with it goes any anti-Black racism and that’s over, we just turn to the next chapter in our lives and everything moves on and it’s beautiful. That’s not quite the way that it happens and the way that you talk about intergenerational wisdom, I was really reminded by the way that you described it, of what I consider to be something that I think in a lot of higher educational institutions finds a very natural home.

For instance, we don’t educate people to say, “Oh, well, you should believe this, you shouldn’t believe that.” What we’re trying to teach is some kind of critical skills, right?

Dr. Onye Nnorom: Mm-hmm.

Brooke Struck: And what you’re talking about with intergenerational wisdom, is not this kind of blind, “Do it or don’t do it.” It’s really just asking people to be critical and I feel that the way that the message is packaged is so important in the way that people are receiving it, right?

Dr. Onye Nnorom: Mm-hmm.

Brooke Struck: If I were to go out and talk to people about the need for intergenerational wisdom around vaccines, I would definitely get a very different response than if I talked to people about just needing to be open-minded and think about evidence, for instance. Even if those two things are very similar in the kinds of end results that they bring about. So I was really interested to see the way that the language around the narrative will influence the way that some people receive it. That some people might look at intergenerational wisdom, and for people who are of a certain type, they might just roll their eyes to that kind of thing.

Dr. Onye Nnorom: Of course.

Brooke Struck: But they would never roll their eyes at this idea, “Well, you should just think critically. You shouldn’t be dogmatic, no matter which position you’re committed to. You should always have an open mind.” One gets a hard eye roll, the other doesn’t, even though they can be very similar in the way that they play out. Dr. Onye Nnorom:

So let’s say you’re going to be evidence-based and critical about something. But how does the evidence get generated? Who decides what kind of data enters a study or is valid or whatever? So a lot of things that happen to us that we observe and get passed down to us as far as experiences of racism, as far as just knowing that when, for instance… 

I grew up, again, in Montreal. A Black child gets shot in a drive by shooting. Not that much happens. I’m a kid. I’m a kid growing up in Montreal and Black. I see this. It doesn’t even really make the news.

And then a white kid – particularly when I was in Montreal, was that very tragic shooting on Yonge Street, a white girl – and legislation has to change. Everything has to change. So at a very young age, you start to do the math and understand how society values your life. I’ve been talking to some of our Black community social workers who want to help the Black youth who might have addictions and things like that feel better. Some of them live in affluent neighborhoods and say, “Oh, you have a sauna in your building. Why don’t you go and just do some deep breathing there.” And you’ll have a Black boy saying, “I’m sorry, I can’t go and sit in the sauna in my building because as a young Black man, if I enter that space, everybody tenses up.”

So that is our knowledge. That is our everyday, what we call “wisdom,” because it’s not going to be put in the study, because guess what? I do research. Half of the things that we want to study don’t get funded. I can tell you, even for the Black Physicians’ Association of Ontario, I’m going to be real right now. We applied for government funding to evaluate the impact over the clinics that we have. I don’t know who they gave the funding to, but they certainly didn’t give it to us. So what ends up being translated into the type of knowledge that is valued by mainstream, Eurocentric, white society or power – even if you wanted to research it, doesn’t often see the light of day because it’s not in alignment with what you’re saying, the values or experiences of those who have the power.

So it’s like, “What’s this study possibly going to show?” Because you don’t fully understand the context that we’re living in. Know when we say intergenerational wisdom: number one, there’s a value in that, of just common sense that’s been passed down. It’s like not believing in love because you didn’t have the study. You know love exists because you’ve seen it. I know that racism and the harms from it impact health because I’ve seen it. But even when we want to do the studies so that it is seen as formal knowledge, there are so many barriers.Not only are we not accepted to medicine, not only do we not get the opportunities to be in research, blah, blah, blah, blah, blah, but even when we are, we don’t get the grants. We submit it to a paper, it doesn’t get published.

There’s so many layers that prevent that from becoming the kind of knowledge that perhaps mainstream society would value anyways. So it’s two different things. One is, there’s a value in that knowledge, period. If you don’t have a study on love, it doesn’t mean love doesn’t exist. Same for the experiences of racism. But also, even when we want to translate it into  something that would be used for, I guess, a critical analysis of decision-making, there’s barriers there for us too.

Brooke Struck: For sure. For sure. All right. Let’s get into that topic of what it is that we can start to do to address these issues of trust. I mean, a lot of what you’ve been discussing there, is these big systemic issues around research. Around who sets research agendas and once research questions are set, how the data gets collected and who collects the data and thinking about the face of the person collecting the data actually having an influence on what it is that you collect and the way that you interact with people. There’s so much of that. Let’s focus on COVID specifically now, and perhaps around vaccines and public health measures and how we can use the responses that we’re making to this pandemic, as a step forward in this larger project of addressing these inequities.

Dr. Onye Nnorom: Yes. So I think that a lot of the steps that have been described by so many groups, including the Black Physicians’ Association of Ontario, has been really to make sure that there are resources invested in what we already know works in Black communities. So, listening to us, having the idea of ambassadors. Again, there’re so many programs that have been developed where there’s education happening in barbershops, in salons, in churches. We know those work from cancer screening, HIV – there’re so many studies already there. There needs to be investment in that for providing the facts around the vaccine.

We need hospitals and research institutions, et cetera, to really undergo anti-racism training so that when there’s another issue, they’re starting to build the trust. They’re starting to understand. So that’s huge. The institutions also need to undergo their own training and their own change. But the collection of race-based data is huge and I was part of the group advocating for that. That’s why we’re able to say, “Wait a minute, these are the groups that need vaccines. These are the neighborhoods where we need to focus on. This is where the deaths are happening.”

So we need to hear voices, but we also need the data. And the data helps when it’s working, because, although Black communities were the number one affected group in Toronto, we’re somewhere like number four now, because measures were taken. Largely by the community, but also with the support of institutions like Toronto Public Health. So we need those things. We need voices to be heard. We need white or mainstream institutions to have the training. And then we need resources put in, so that those of us who are trying to do vaccination in a culturally appropriate way, can do that. And for us to do that, we need to know that there are resources available. So like I said, when we do it, we have food baskets. We make sure there are other providers there. We make sure people know where they can receive care.

So although your question is, “How can we just get the vaccine to people?” Realistically, to build trust, again, you need to think about the whole person much more than that. We need vaccines: first layer of accessibility. Vaccines still need to be available. It needs to be in the neighborhood. It needs to be an inclusive matter and there needs to be a way that Government and others can show that they actually care. So it is the housing question. It is making PPE available. It is all of those factors that caused the distrust – slowly starting to address them.

And a lot of communities are also advocating for more Black-focused community health centers. So centers that are designed to serve the Black community in different regions. There’s already one in Toronto called TAIBU Community Health Centre, but that’s been another big push because there is the need for culturally-safe care. So those are some of the big pieces, the right now pieces, but it does require investment.

I know people are like, “What can I, as a single person do?” But really it’s, “Can you support some of the Black organizations that are actually doing this work with regards to financial resources?” Or, “Can you be part of writing letters to Government saying, ‘This needs to change?’” Because it’s not going to just be something that happens because you read a book or something. Ultimately, it is about systems. It’s systems that are causing the distress, but we each make up the system. So working with groups that already exist or writing those letters or those emails supporting the organizations that are on the ground. Huge.

Brooke Struck: Yeah. Yeah, that’s great. And I will very, very briefly shamelessly promote another episode of this podcast where we talked with Lasana Harris about debiasing. That conversation was fascinating. I’ll make sure that there’s a link for people who want to follow on to that. One of the things that you said earlier, Dr. Nnorom, was about this kind of balance of sitting down with somebody and talking to them about the vaccine, but your final objective in that conversation is not like, “Okay, and now you’re convinced you’re going to get the vaccine.” Right?

Dr. Onye Nnorom: Yeah, yeah.

Brooke Struck: That you sit down with the objective of helping someone to make an informed decision and also to feel cared for as a person. And if this individual who feels cared for and has the information at their disposal in a language that they understand – it’s not jargon and all this kind of thing – a person in that situation ought to be able to make a decision about whether they want to get a vaccine or not. And you kind of pointed it out – to draw on our common Montreal heritage here – it’s like, “There’s no room for reasonable people to disagree about whether or not to get a vaccine. You’re sitting down across from me and you haven’t already decided to get a vaccine. What does that say about my perception of you as a person?”

Dr. Onye Nnorom: Exactly.

Brooke Struck: How do we navigate that difficult tension of the fact that vaccines really are the best protection that we have right now against this virus and we do want people to be getting vaccinated for everybody’s sake?. But at the same time, we acknowledge that people have the agency and the freedom to choose for themselves whether they’re going to get it or not?

Dr. Onye Nnorom: Whenever you tell somebody, “You have to do this,” their instinct is to say “No.” Just think of a two-year-old – that’s one of the first words. That’s our self-determination. And so in Black communities where – and they’re different communities, we’re not a monolith – but where I’ve worked, for instance, that type of community health center, we’ve been able to increase rates of cancer screening, influenza virus uptake, just continuously being like, “Okay, can I talk to you about this? Is it okay we have this conversation?” And providing information, but also listening to the reasons.

And you know what? I’m going to flip this and take this away from race. Let’s say… This is an imaginary situation. There’s another variant of the virus, and the only country that has the vaccine is a country that Canadians don’t trust. Because right now there are some vaccines going in countries, and I’m not going to name the countries, but is a country that Canadians don’t trust. But the evidence shows that it helps. But the problem would be for Canadians, that you might not even trust the data because you don’t trust that country. You don’t trust its history and its legacy of how it treats its people. And you don’t trust that the vaccine is going to be safe.

You might think that this is a way for them to gain power, or they might even put different elements in the vaccine for the Canadian population even if it’s working in their own country. So what would that conversation be like between you and I? I would ask you, “What are your reasons?” And I would try to understand that. Then I might say, “Okay, even though there’s a history of not trusting this country, right now, this new variant is killing us here in Canada and they are the only ones that have it. We have Canadians who have been involved and are looking and watching what the process has been and are in every aspect of it. So it’s not what we used to know historically about the country.” You might say, “Uh huh,  Dr. O, that’s nice. See you later.” And then I’ll be like, “Okay, cool. Cool. Alright, no problem.”

And I might say, “Brooke, can we just talk a little bit more? Because I care about you. I don’t want you to get this variant.” And you might say, “No, I’m done.” And I accept that. Or you might say, “Okay, let’s talk about it some more. I’m going to read up some more.” Then you come back and then we have another conversation. And then you might be seeing other people around you getting that vaccine, from that other country that you don’t trust because of its history and present day legacy of human rights violations, because the United Nation has already flagged their concern about the human rights situation for Black Canadians. But now we’re just talking about Canadians being concerned internationally about the human rights violations of another country. But you see some of your colleagues getting it and they’re okay and they’re able to go about their lives.

So then you and I will enter that conversation and maybe at some point, if I don’t look like I’m forcing you, if you don’t think I’m paid by that country to enforcethis vaccine on you, maybe you’ll get the vaccine. But maybe you won’t and your main reason will not be what was printed in the journal from that country that you don’t trust. It will be based on trust. It’s not just the data, but based on the legacy, history, and present day behaviors of that country, you might not trust it. It is not my position to say whether that is right or wrong. Personally, I don’t think it’s actually right, but I can understand it and so I empathize. And so we would have that conversation.

So if that’s helpful for your listeners to think about… You remove race, put yourself in a situation where it’s another country where you’re concerned about their human rights legacy and present day approaches, but they’re the ones who have the magic bullet for the variant. What are you going to do? And so it’s a conversation and it’s trust-building. And you want to know how many Canadians are involved in that kind of thing. So it’s the same thing.. We say it in the Black community, that Black people were involved in the vaccine, Black people volunteered to be participants, it’s been tested. But it’s a human reaction. It’s a human reaction to, where there’s a lack of trust because of, let’s just put it clearly, human rights violations. Where your life, you feel, is not valued by the person coming at you with the needle.

Brooke Struck: Yeah. It really emphasizes how much trust is a long game and public health is a long game. We’re focused so much on COVID and, “How can we get out of this situation?” But we are also building the foundation for whatever it is that we’re going to do in the future. We may or we may not convince the remaining twenty-odd percent of Canadians who are eligible and haven’t had a first dose. We may or may not succeed in convincing all of those people that the vaccine is the right thing to take, but there will be another public health crisis in the future. It may be soon, it may be far away, but there’s going to be another one, it’s just a matter of when. And we need to acknowledge that the conversations that we’re having now are not just short-game. You’re always playing both the short game and the long game at the same time.

Dr. Onye Nnorom: Exactly.

Brooke Struck: And no conversation is wasted, even if the outcome of that conversation is not that someone changes their mind on the spot and decides to roll up their sleeve.

Dr. Onye Nnorom: Yes, and that’s true even where I talk to people about racism – I think we watch too much TV. So somebody says something really insightful, and then the music changes in the background and then everybody in the room changes their minds and they all start to applaud. That is not what happens. We’re human beings, we learn. You have to have a conversation here, then you have a conversation at coffee, then you still speak to some young kids and they say a little something. Then you go do something, and then, boop. The light bulb goes off.

And for that person who might’ve talked to you after you’ve spoken to 17 other people says, “Wow, I changed your mind.” But in fact, it was all these other conversations and things you’ve observed. That’s what’s human, not what we see on TV that there’s just one conversation and then everybody’s minds are changed. So I think it’s the same with the vaccine and like you said, it is building that trust. And that’s why I am optimistic because this is a moment in time where Black healthcare providers whose voices had been largely ignored at different tables are able to say, “Look, this is the role that we can play, but you have to come to the table and come with humility and understanding.”

And for the Black community, we will address these issues, but there needs to be change. And I think that’s one of the things COVID-19 has done. It has amplified so many inequities of how we treat our elderly. I mean, it’s also exposed inequities for women as caregivers. Just so many factors that now everything’s up in the air: we can work towards a new normal. So I am optimistic about that, but it’s hard work. Changing things is hard work. So I’m hoping that we are dedicated towards this because a lot of people didn’t know. In all honesty, a lot of white Canadians, a lot of people from mainstream society were not aware, but so much has come to our awareness that I’m hoping it’s a critical time of change.

And specifically, for the vaccine, and I would say for anyone who’s thinking about shifting people’s minds… Then you’re going to get what we call the “early adopters,” but then you’re going to get what we’re calling, the “slow yes.” So we are not there for the people, like you said, the 20% who will absolutely not take it. That is their choice as human beings. That’s their self-determination, but there’s a lot of people who need a bit more information. They’re using their critical lens so we need to meet that need. And that’s “the slow yes.”

And we’ve seen that. I’ve seen it in my own family and it’s a beautiful thing when the person changes their mind out of their own volition and says, “Yes, now I do trust and I’m going to get the vaccine.” And as you said, that’s a huge investment for the future in advancing health, because now that person trusts, as opposed to forcing people. So I think it’s been, at times, a nightmare. But to quote Beyonce, “A beautiful nightmare,” in a sense, because I’m hopeful despite the challenges of this pandemic and the sorrow and the disconnection that it becomes a time of reconnection. Not just within families, but society itself. I’m hopeful for some progress in that direction.

Brooke Struck: I think that’s a wonderful note to end off on, that hopefulness for all of us feeling more and more connected moving forward. And I really liked that concept of the “slow yes.” That’s something I hadn’t heard before and it so nicely sums up so much of what’s just been kind of floating in my mind, but hasn’t crystallized yet. That’s such a perfect expression. So Dr. Nnorom, thank you so much for this conversation. It’s been great and I think that our listeners will also get a lot out of this, and I look forward to speaking with you soon.

Dr. Onye Nnorom: Thank you so much, and I hope that your listeners take a listen to my podcast as well, “Race, Health & Happiness.” The more podcasts, the merrier, I think. So please do tune in. Thank you for having me. This has been great.

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