Real Consequences of Valuing Cultural Diversity

JOE CAHILL:

Welcome everybody. My name is Joe Cahill. I am the Chief Customer Officer for the Project Management Institute. Welcome to our podcast today. 

For some, concepts like “diversity and inclusion” reflect goals and values to which one might aspire. To others, they literally mean the difference between life and death. In project management, we talk about stakeholders – those who are or perceive themselves to be impacted by the project’s outputs and who can affect that outcome. 

But in practice, are the voices of people who feel marginalized, disempowered, and neglected actively sought out, heard, and incorporated into our work efforts and ways of working? How can we build the capabilities to hear, engage, and learn more effectively? Today’s podcast is sure to give us lots to think about as well as some action steps we can take to embody a mindset of diversity and inclusion.

With us today is Dr. Marcia Anderson. Marcia is a Cree-Anishinaabe whose roots go back to the Norway House Cree Nation and Peguis First Nation in Manitoba. She graduated with her M.D. from the University of Manitoba in 2002, and has since served in a variety of leadership roles, including as head of the Section of First Nations, Métis and Inuit Health; medical officer of health for the Winnipeg Regional Health Authority; a past president of the Indigenous Physicians Association of Canada; and executive director, Indigenous academic affairs, Ongomiizwin-Indigenous Institute of Health and Healing.

Dr. Anderson is an advocate, researcher, and leader in the areas of Indigenous health, primary health care, and medical education. In 2016, she presented a TED Talk on Indigenous Knowledge to Close Gaps in Indigenous Health which has received about 70,000 views. In 2018, she was named as one of Canada’s 100 Most Powerful Women by Women’s Executive Network.

Welcome Dr. Marcia Anderson. Thanks for joining us here for the discussion. Your background goes far beyond just being a physician. Would you share with us a bit about your learning journey and how your passions influenced that journey?

DR. MARCIA ANDERSON:

Thank you for that question. So I'm Cree-Anishinaabe. I grew up in the city, I would say relatively disconnected from my cultural identity due to the impacts really of colonization on our family. So for me one of the unexpected blessings of medical school was a reclamation of that identity. And this is a really critical aspect of my learning journey. 

After my first year of medical school, I was able to go and spend some time in some different Inuit communities in the far north. After my second year of medical school, I spent time in Norway House, which is the home community of my grandpa, even though no one in my family had been to Norway House for a few generations. 

And that connection to land, to territory, to culture really started to inform my understanding of myself as well. And that was so necessary for building a resistance to the stereotypical messages that were part of the teaching at the time. It allowed me to see the strengths, the beauty of the culture, the language, the knowledges, which I think is a real act of resistance when we consider different forms of racism and how that is reenacted. 

Throughout my learning journey, I was also able to connect with other indigenous physicians and medical learners, and they were really a critical part of the support team throughout my medical learning journey. Really strong mentorship. We did a lot of our own work to teach each other about indigenous health and to support each other, not just through our learning journeys, but through our actions and system change. 
Unfortunately, while I was a resident, in my second year of specialty training, my dad had a severe heart attack and almost passed away. And it was an incredibly difficult experience, not just because of his critical cardiac illness, but because he experienced significant racism in a way that was life threatening for him, and in which I was fortunately able to intervene, which I wouldn't have been able to do if I had not been a medical resident at that time on a cardiology rotation. 

That became formative for the rest of my career because it crystallized how systemic and individual racism operate within the healthcare system and became the fuel for change moving forward.

CAHILL:

So I just want to understand the situation that you were in. Within a healthcare situation where your father was in cardiac arrest, you're saying that in that situation, he was not getting the care that he that he should have? And if you weren't there, it would have been a much different situation?

ANDERSON:

That's exactly what I'm saying. Yeah.

CAHILL:

That's kind of scary. So I did listen to your TED talk on indigenous knowledge and healthcare. One of the things that struck me was your focus on language, which is key to meaning and understanding. I think it's important to start another discussion here. 

You talk about epistemic racism, as it's a unconscious way of evaluating the knowledge and ways of one group of people and having that be more superior to another group of people. You then give examples to illustrate that point. So can you share with the audience an example and the key insights that you gleaned?

ANDERSON:

Yeah, absolutely. So this is rife in the medical system, for example. So we have a very specific way of evaluating knowledge and evidence in which we're told the gold standard is a randomized, double blind, placebo-controlled trial. And there's a whole lot of stuff around that, around objectivity, around neutrality, around generalizability. 

So within the medical system as an example, that form of Western knowledge, production, and evaluation is considered superior to any other form of knowledge creation and evaluation. We tend not to be super open to other types of knowledge around health and healing. 

However, as a Cree-Anishinaabe woman, with connections into community, who has seen firsthand how people have benefited from those cultural connections, ceremonial practices, traditional medicines, and from an understanding that there is actually no reason to consider Western knowledge superior to indigenous knowledge. 

One example I would give is, I was at a conference where a program that was grounded and inclusive of indigenous healing methods and indigenous knowledges was being described. There was a respected physician from the U.S. there who stood up and made a comment about how happy he was that as part of the evaluation, we would be evaluating indigenous traditional knowledge around maternal-child health care.

I said that it's not the position of Western knowledge to evaluate indigenous traditional knowledge. What we would be looking to evaluate in a program such as this is the ability of the Western healthcare system to adapt, make space for indigenous peoples to exercise their right to access Western or indigenous methods of health and healing, and to use either and or both as they see fit. 

So we have to be really careful in how we frame those evaluations. Like I said, it's not the position of Western knowledge to evaluate indigenous knowledge. Because assuming that we need Western knowledge in order to… Western methods in order to validate our own knowledges is itself a position of epistemic racism.

CAHILL:

So a big assumption, that's for sure. Can you share some examples of deliberate efforts to remove epistemic racism and sexism, and it tell us about how it really worked?

ANDERSON:

In a very practical sense, a lot of my brain space these days is occupied with COVID-19 as a public health physician. Early on, going back to January, there's an incredibly limited COVID-19 vaccine supply. And one of the groups that was prioritized very early on, and quite understandably, was healthcare workers. 

The part of the epistemic racism that we addressed here was, it is not just Western healthcare providers, including doctors, nurses, respiratory therapists, etc, who should be included in that. Rather, our indigenous traditional healers and knowledge keepers are also important and frontline healthcare workers promoting and supporting the health of indigenous peoples in communities. 

And therefore, an action to disrupt epistemic racism is to include them in who we see as important healthcare workers and ensure they are also prioritized for that early access to vaccines. And so our partners in the province agreed with that, and we're the first province in the country to include traditional healers and knowledge keepers in our vaccine rollout.

CAHILL:

It really leads you into the thought process of identifying these gaps. So this Center Stage podcast is part of PMI’s Knowledge Initiative, and it focuses on building dynamic knowledge and learning capabilities. 

You also talk about knowledge and wisdom. You define wisdom as knowledge based on lived experience by people willing to learn from the choices they make. I really, really liked this definition and I want to talk more about it. 

First, you suggest that such a definition embraces equality by recognizing that each person's lived experience is valid. Practice though, in the real world in practice, perhaps more easily said than done for some, right? In this conversation we're actually having right now, how might unconscious biases influence how I and others hear your story and incorporate it into their own understanding?

ANDERSON:

One thing particularly I just want to clarify first, that was not my definition of wisdom. That definition of wisdom came from the Women's Advisory Council for the Manito Ikwe Kagiikwe Project. That Advisory Council was made up of women who had experience either parenting or being pregnant and using substances because that's who the program was designed to serve. So that was really their definition of wisdom. 

And in practice, part of how I think this is difficult, or that wisdom is not equally respected… wouldn't practicality be different for women like that compared to me? Because people might see my credentials as a physician with over 14 years of practice experience now and some pretty senior titles in an academic institution, as equivalent to their own forms of knowledge, right? 

Whereas, and I'll just note, too, that systematically, indigenous peoples in general have not had the same opportunities I've had to get those degrees, build that experience, be in the roles that I’ve been. That systematic racism means that we are actually less likely to have those opportunities, which means we are less likely to get invited to the types of tables and decision-making committees that really impact our lives and our experiences. 

One of the ways that organizations have tried to address this is by inviting people in with lived experience. However, very often what we find, and what the experience is, is that even in those spaces, their wisdom is not considered equal to the knowledge of people who are there with formal titles and formal authority. 

And whether that is unconscious or conscious is kind of irrelevant, because the impact is the same. That voice is not heard. It's not given equal weight. It's easily overruled by someone who rattles off their resume, or what the latest trials or guidance is around a particular topic. 
And this is stuff that I see over and over again and then hear from people I work with, about their experiences in other places. So I think it requires actively us considering, who am I paying more attention to in a meeting room? Who am I paying less attention to? What knowledge am I considering equal and valid here? 

And one of the things I really encourage people, as someone who practices Western medicine and public health in large mainstream institutions, but from an indigenous community member perspective, is that we bring the best of our professional knowledge and experience to the table. And also on the table is the wisdom that our members with lived experience, the knowledge and wisdom of traditional healers and knowledge keepers who may be around the room, are also put on the table. 

But when that program or decision is meant to serve primarily indigenous peoples, it should be primarily indigenous peoples who decide which knowledge, wisdom is the most important and should be given the most weight in the planning and decision making that occurs.

CAHILL:

That certainly makes sense. You know, the other part of the definition of wisdom, it said “learning from the choices we make,” right? That was part of the sentence. That's equally as powerful. So why is learning so critical to convert knowledge to wisdom?

ANDERSON:

Yeah, it's a really good question. And to me, it has to do with a growth orientation. I can read all the books in the world that I want, read all of the journal articles, memorize the references. But if I'm not actually willing to learn about how that impacts me in my life, if I'm not willing to learn from the experiences that I have… If I'm at a meeting and that's the only information that I can see, and it means that I'm alienating other people in the room, then, to me, that's not a growth-oriented mindset or a growth-oriented process. And that will keep us stagnant in the status quo. 

When I think about some of the really big challenges that we have around anti-racism, around closing gaps in health for Black and indigenous and People of Color. I know for a fact that our current systems are not working to do that. 

So if we want to have different outcomes, we have to have different systems. And that differences also have to happen at the individual level. We have to have enough people on board with doing things differently. And to me that comes back to us being willing to learn and grow.

CAHILL:

So you mentioned growth, and I want to ask you, do you see the distinction between growth and development in this in the topic here? There's a balance between the two? Do you see those two things going hand in hand?

ANDERSON:

Yeah, yeah. So you know, we think about professional development and professional development activities. To me, I think about that as some educational interventions. But the growth is the piece that changes our practice, that makes the learning into impactful changes that we can see. And certainly that does require the right support and systems around it.

CAHILL:

So we want to highlight how diversity, inclusion, and knowledge affect people's lives. COVID and the responses to the virus globally, nationally and locally have varied significantly. There have been extremely negative impacts on marginalized communities in every country around the world. On a global scale, how could we have used knowledge from past epidemics to orchestrate a better response to COVID?

ANDERSON:

You know, it's a great question and it's probably one of the things I find the most frustrating or even distressing around this, because I know that we have had evidence of unequal impacts from respiratory illnesses and from pandemics going back to the time of the Spanish flu. So over a century we've had this evidence and knowledge. 

And yet what I didn't see heading into 2020 and even into 2021 in our response to the pandemic, was any clear commitment to not have that same outcome of large inequalities and how we're being impacted by COVID-19. 

I did not see any clear commitment to addressing those gaps, to preventing those gaps. And so I don't think there was a commitment to learn from past pandemics so that we could have a more equal society or more equal outcomes when it comes to COVID-19. 

And when I think about, why are we willing to learn from some past experiences but not others, and I think about the impacts of the Spanish flu, of H1N1, of tuberculosis on indigenous communities. And I have to think that the reasons have to do with underlying system systemic racism, and the founding of our country, and would suggest that when we think about the impacts of COVID-19 on Black communities, whether that's in Canada or the U.S. or even globally, that the underlying reason is actually the same. 

When a significant part of our society thinks that these health gaps are the natural state, that they are unavoidable and that they are acceptable, then we're not going to put the investments and effort into closing those health gaps. 

I was a practicing public health physician in 2009 when H1N1 was circulating. There’s significant unequal impacts on First Nations communities. We talked a lot about how that was rooted in overcrowded and inadequate housing. Ten, 11, 12 years later, we’re in the exact same situation and that is driving the unequal experience.

And at the end of the H1N1 pandemic, when we were doing a debrief, I very clearly recall saying, the most unfortunate thing to me will be when the next pandemic comes, if we didn't learn about the impacts of social determinants of health and act differently, so that we are in the same situation. But that's exactly what happened.

CAHILL:

So definitely made some improvements during the pandemic, but not quite anywhere near where we need to be. So tell us a little bit how the voices within the marginalized communities influenced the responses as the pandemic progressed.

ANDERSON:

My colleague  Melanie MacKinnon, who's a First Nations nurse, we've worked really closely together for the past 10 years, and she has many more years’ experience even prior to that in nursing and in health leadership. We talked very early on around how COVID-19 was going to impact First Nations communities, and what we needed to do in order to try to minimize those impacts. 

And so she really took the lead on developing our Manitoba First Nation Pandemic Response Coordination Team. First Nations leadership in the province - so the chiefs of the communities through the assembly of Manitoba chiefs - passed a state of emergency and passed a resolution that gave us the mandate to create the structure and to organize to lead the First Nations response.

That really positioned us differently with our provincial and federal counterparts. We have quite a quite a complex service delivery arrangement and jurisdictional arrangements here in Canada when it comes to First Nations Health. But creating that locus of control with mandate from our political leadership, that is the Chiefs, really underlied all of the responses we've had since then. So we've had the best First Nations-specific data across the country, quite possibly the best indigenous-specific data around the world, that's governed by an information-sharing agreement that protects indigenous rights and data sovereignty for First Nations people. 

But that evidence really has informed our policy advocacy as well, which has been quite effective. We've had direct communications using a variety of different means - radios, social media - to reach as many people as possible to become trusted voices and messengers. And then have participated in media briefings at key times for key announcements with our provincial counterparts as well. 

And so we've had high visibility throughout this response. One of the things we learned from previous experiences was, it's really important that First Nations people are seen as leading the response by and for other First Nations people, because that helps to counter the mistrust that there can be with government institutions, given our histories of colonization. 

And it's actually mutually beneficial. We share a healthcare system. If First Nations are experiencing high COVID rates and high severe outcome rates, that is straining our shared healthcare system. And so really, I think this has been seen as a win-win approach by our federal and provincial counterparts as well.

CAHILL:

What are some of the key takeaways from the situation that you expect to result in real change going forward? How can they actually be leveraged, how can  the learnings be leveraged to improve these broader inequities that you're talking about?

ANDERSON:

Yeah, I think we have long advocated for First Nations leadership in First Nations health, as have other structurally marginalized communities done for themselves. That is one of our collective rights as a community is to have leadership and decision-making authority over matters that impact us. 

And what COVID-19 has really created a space for, is not only is that a rights-based approach, but it's an expertise-based approach. We have expertise within our communities, that those organizations outside of our communities don't actually have. That expertise is completely necessary and results in improved responses and outcomes. 

And so I think the opportunity coming out of that is to look at how we structured our response in COVID-19, what the benefits were to the system as well, so that it can be replicated in other aspects of the healthcare system and even outside of the healthcare system. 

So that clinical expertise, the political mandate and community leadership support that we had. Understanding what the different layers and levels of autonomy were. So for example, we did a lot of work at the provincial level around planning, policy advocacy, decision making. At the community level, community leaders did a ton of work around enacting community-level measures to protect the community that included things like check stops, isolation spaces. 

Those were complementary activities that appropriately respected the autonomy at each level. The work we did at the provincial level was to support those community-level measures and community members in what they needed to do. And so I think those are the models we'll be looking to implement in other parts of the system as well

CAHILL:

It's always good to take the win and leverage it into something bigger and that sounds like that's what you're going to do. We've learned some important definitions tonight, right? We've talked about things like wisdom, and we talked about the real-world implications of diversity and inclusion. 

I want to shift the conversation to exploring the related leadership capabilities here. On the surface, many organizations, they have these statements of values, training programs, they have roundtables, resource centers, all revolved around diversity and inclusion. Do you think that's enough?

ANDERSON:

No, I don't think that's enough. And I think anytime that we make a statement or update our strategic plan, it's incumbent on us to define the measurable impacts and indicators that we are aiming for. I would have to say that within diversity and inclusion-based approaches, it's imperative that we're really explicitly talking about racism and anti-racism. That we're asking, what are we prioritizing here? 

I've reviewed a number of statements, or been asked for input, that really were prioritizing the comfort of those who are currently benefiting from the status quo. I think our diversity and inclusion work, if it's not explicitly talking about racism, if it's not making us uncomfortable, it’s not forcing us to grow and change, then we really have to question who that's actually for, and how likely we are to achieve meaningful impacts from it. 

So I think we have to have much stronger rights-based language, anti-racism language, and everything we do has to ultimately be measured against impacts and indicators that are meaningful to the community or population groups we are trying to be more diverse or inclusive of, for example. I think quite often organizations get tempted to stop at training programs, and those training programs are not actually expected to result in changed behavior or there's no accountability mechanism that links the training program to observed changes in behavior or changed decision making. 

And so I think, until it goes deeper into what are the policy changes we need to see, what are the resourcing changes we need to see, what are the hiring practices and changes that we need to see in order to achieve impacts. But those statements and values and training programs are never going to be enough. 

CAHILL:

So let me ask you, many of the people listening are in the project profession. And by virtue of being project managers, program managers, agilists, things of that nature in terms of their roles, they serve many stakeholders through projects. How can how can these individual leaders challenge themselves in this area? What can they do to improve what they have influence over?

ANDERSON:

I think that's a great question. The first thing I always encourage individual learners around is be very willing to be uncomfortable. You know, that discomfort is actually a critical part of learning in this area. Why are you uncomfortable? Like there's so much valuable learning in that discomfort. 

And it's only by interrogating our discomfort that we can start to understand the different ways that we might be participating in the very systems we say we want to disrupt. It's only when we interrogate that discomfort that we can understand and grapple with the ways the systems that we want to disrupt are actually benefiting us, and that we might lose some of that unearned benefit or unearned advantage if we actually disrupt them. 

And in that discomfort is the place where we put our own labor in instead of relying on the labor of others. So the first thing I certainly say is, be willing to be uncomfortable. If you're not uncomfortable, you're probably not pushing yourself to learn in this area.

CAHILL:

As we wrap up here, I want you to provide some positive examples of what's possible from your perspective. Which global or broadly known organizations are moving beyond these corporate statements and really embodying diversity and inclusion? What makes some of these organizations stand out to you?

ANDERSON:

So I will say there is a broader EDI policy committee work going on. But last year, we also passed a policy called the Disruption of All Forms of Racism Policy, and I appreciate that commitment to really dig into that work and to do some innovative things. Which of course, you know, passing a policy is really only the first step on a journey that you then have to enact. 

But that includes things like saying we're going to do racial equity impact assessments for all new policies in the faculty. It includes us training more investigators for complaint processes. It commits us to do regular and transparent reporting on experiences of racism within the faculty. 
So a lot of the ideals that I think become necessary as part of the change management around anti-racism, we have embedded in that policy.

So that is certainly one positive example. And then I've seen things change around here because of that. You know, I mentioned our September 30th day. Leading up to that, we had some ceremonies out in our traditional medicine garden, which is just outside my office where I'm sitting right now. 

There was a time even less than a decade ago, where it was hard for us to have a smudging ceremony within our buildings, and took quite a lot of work to get the right people on board around the ventilation and fire systems and things like that. 

When we decided we wanted to have these ceremonies leading up to September 30, and we wanted to have a sacred fire as part of this outdoors, our physical plant team was immediately on board telling us they'd help us get the fire permits, identify the best location for the fire pit and all of that. And so that might seem like a small action, but when I know the journey that we've been on, that means a lot to see the people we have rallying around us and supporting us in these activities.

Those are a couple of the examples that I would share about a broad policy change but also an individual action almost that was so important and encouraging.

CAHILL:

That's a wonderful way to end because it's a great message to everybody who's trying to make change. It's a critical ingredient to move things forward, particularly in diversity, inclusion because it's much harder change to drive through. 

Dr. Marcia Anderson, thank you so much for your time here today. Very insightful conversation. I personally would love to meet you someday, when that affords us we can get ourselves in a room together, but we appreciate your time. Thank you again.