Sociology of Health & Illness Vol. 37 No. 5 2015 ISSN 0141-9889, pp. 698–714 doi: 10.1111/1467-9566.12236

‘Underclassism’ and access to healthcare in urban centres Sannie Y. Tang1, Annette J. Browne2, Bill Mussell3, Victoria L. Smye4 and Patricia Rodney2 1

School of Nursing, York University, Toronto, Ontario, Canada School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada 3 Sal’i’shan Institute Society, Chilliwack, British Columbia, Canada 4 Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada 2

Abstract

In this article, we draw on findings from an ethnographic study that explored experiences of healthcare access from the perspectives of Indigenous and nonIndigenous patients seeking services at the non-urgent division of an urban emergency department (ED) in Canada. Our aim is to critically examine the notion of ‘underclassism’ within the context of healthcare in urban centres. Specifically, we discuss some of the processes by which patients experiencing poverty and racialisation are constructed as ‘underclass’ patients, and how assumptions of those patients as social and economic Other (including being seen as ‘drug users’ and ‘welfare dependents’) subject them to marginalisation, discrimination, and inequitable treatment within the healthcare system. We contend that healthcare is not only a clinical space; it is also a social space in which unequal power relations along the intersecting axes of ‘race’ and class are negotiated. Given the largely invisible roles that healthcare plays in controlling access to resources and power for people who are marginalised, we argue that there is an urgent need to improve healthcare inequities by challenging the taken-for-granted assumption that healthcare is equally accessible for all Canadians irrespective of differences in social and economic positioning.

Keywords: Indigenous peoples, Canada, healthcare access, urban health, poverty, racialisation, social inequity, healthcare inequities, ‘underclass’

Introduction Health and wealth are closely related, and their distribution is organised by complex social and political processes. In the current context of neoliberal globalisation, we are witnessing a growing gap in wealth and health not only between nations, but also within Western countries, including Canada (Cushon et al. 2010). One of the manifestations of wealth inequalities in Canada is increasing polarisation of income among urban dwellers, including concentrated poverty in the already impoverished inner-city neighbourhoods (Raphael 2011). Class and race intersect with urban poverty in complex ways; the inner-cities of large Canadian metropolitan areas, such © 2015 Foundation for the Sociology of Health & Illness. Published by John Wiley & Sons Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Maiden, MA 02148, USA

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as Toronto, Montreal and Vancouver, tend to be highly racialised with disproportionate concentrations of Indigenous peoples1 and immigrants from non-European countries (Statistics Canada 2008; Peters 2009; Peters & Andersen 2013a). An urban ‘underclass’ comprising racialised social groups in Canadian cities can neither be reduced to personal failure nor explained by the racialising logic of cultural differences or assumed racial/ethnic inferiority. Rather, we need to understand urban poverty as a symptom of global capitalism and its neoliberal policies that result in unaffordable housing, reduced government spending in social and welfare services, and an increasingly competitive and exploitative labour market, to the disadvantage of many unskilled or semi-skilled workers (Coburn 2004; Wallis & Kwok 2008; Peters 2009; Peters & Andersen 2013a). These conditions of social inequity2 borne by the urban poor, including substandard housing, homelessness, poverty, and other conditions associated with social and economic marginalisation such as crime and substance use, also have profoundly negative effects on health, putting people at risk and creating healthcare needs that are often unmet. Despite the proclaimed right to universal access to healthcare for all in Canada’s publicly funded healthcare system, emerging evidence suggests that people from low socioeconomic and racialised backgrounds are subject to access barriers including discrimination and marginalisation within the mainstream healthcare system (Tang and Browne 2008; Institute of Medicine 2009; Reutter et al. 2009; Canadian Institute for Health Information 2010, 2012; Browne et al. 2011a; Wallace and MacEntee 2011). Negative experiences from healthcare encounters often stem from providers’ assumptions about patients’ presumed ethno-cultural background or low socioeconomic status, or perceptions of patients as ‘difficult patients’ or ‘frequent users’ (Koekkoek et al. 2011; Nelson et al. 2011). Negative healthcare experiences can also stem from patients’ encounters with every day and institutional forms of discrimination and dismissal. Stereotyping and Othering of patients can result in moral disengagement by healthcare providers from the patients and their needs (Rodney and Varcoe 2012); these processes can deter patients from seeking and utilising health services in the future. Given the persistent inequities in healthcare access for some populations, we need to ask if and in what ways healthcare is playing a complicit role in reproducing existing social inequalities by controlling access to resources and power for those who are vulnerable to the effects of structural inequities, marginalisation and poverty. In this article, we critically examine the healthcare experiences of mostly Indigenous patients who were urban residents seeking healthcare in an inner-city neighbourhood, to elucidate some of the complex processes by which race and class inequalities operate and are reproduced within the institutional space of healthcare delivery. We challenge the common understanding of poverty as the consequence of individual actions, inaction, or irresponsibility. Instead, we conceptualise experiences of poverty as inextricably influenced by structural processes, including public policies that legitimise the increasingly meagre allocation of social and economic resources in society (Wallis & Kwok 2008; Raphael 2011), and long-established federal policies and associated practices such as the Indian Act and related regulations that continue to classify and divide Indigenous peoples in Canada, as well as existing race/ class/gender relations that subject some populations to bearing a disproportionate burden of social and economic woes. These existing relations are compounded by persistent negative public perceptions and discourses about Indigenous peoples and other racialised groups in Canada (Newhouse 2000, 2006; Tator and Henry 2006; Peters and Andersen 2013a). In research pertaining to Indigenous peoples in urban areas, it is particularly important to view patterns of urbanisation in a socio-historical context. There has been a dramatic increase in the proportion of Indigenous peoples living in Canadian urban centres (Statistics Canada 2008); however, patterns of urbanisation for Indigenous peoples are not like those of other © 2015 Foundation for the Sociology of Health & Illness

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migrants in cities in Canada (Peters 2007, 2009; Peters and Andersen 2013a). First, unlike many other urban residents, Indigenous peoples often maintain strong ties with rural and/or reserve communities, moving back and forth on a regular basis to maintain vital and purposeful community relationships (Peters and Andersen 2013a). Second, while Indigenous peoples have a greater chance of living in low income neighbourhoods (Peters and Andersen 2013a) because of structural conditions and policies, and systemic racism, which create conditions of economic marginalisation, Indigenous peoples are increasingly found in a wide variety of locations in urban areas, challenging the notion of inner-city ghettos as the location of urban Indigenous peoples. Third, ideas about the presumed incompatibility of Indigenous peoples and city life reflect colonial discourses that continue to shape assumptions of government, policy makers, and members of the public that cities are places of loss of culture and community for Indigenous peoples (Peters and Andersen 2013a, 2013b). Indigenous scholars argue otherwise; many Indigenous peoples are building cultural identities and communities in urban areas that are shaped inter-generationally (Newhouse 2000; Peters 2011; Peters and Andersen 2013a). While it is impossible to deny the reality of socioeconomic and cultural challenges that shape the quality of life of many urban Indigenous peoples, Peters and Andersen (2013a: 11) and others emphasise ‘the complexity of urban Indigeneity in Canada and abroad and, more specifically, the co-constitutive influence of urban locales on the production of Indigenous identities’. It is against this backdrop that we put forward the notion of ‘underclassism’ as a lens through which to understand how healthcare systems and practices intersect with classism and discrimination to contribute to marginalising conditions for Indigenous peoples and non-Indigenous peoples in urban contexts. Explicating conceptualisations of ‘underclassism’ Before presenting our analysis in this study, it is important to clarify our use of the term ‘underclassism’ – to emphasise the intersecting nature of factors such as discrimination, poverty, stigma, racism, and social exclusion, among other facets of oppressive social relations. Like many hospitals located in Canadian inner-cities (also known as ‘core areas’), the ED in this study served a complex mix of clientele living or working in the neighbourhood, including residents from the near-by inner-city, people who were homeless or who were inadequately housed (e.g. in single room occupancy hotels that are typically unsafe as residences), as well as office workers, business people, and occasional tourists. The diverse socioeconomic status among people seeking healthcare in the ED rendered it impossible for us as researchers to ignore the visibility of class and social differences within the institutional space of that hospital. In an ideal situation of egalitarianism where everyone is expected to be treated the same irrespective of their background, class differences should not make a difference to the quality of healthcare provided. In reality, however, judgments about individuals’ social class seemed to matter in shaping a patient’s experiences in accessing and utilising healthcare, and many patients in our study were conscious of the social (de)values attached to their physical appearance. As one patient-participant reiterated, half-jokingly, he would make sure that he wore his ‘designer clothes and cologne’ when attending the ED so that he could bypass what he interpreted to be the potential dismissal he expected to experience when viewed as someone who was ‘poor’ and from a racialised background. In our fieldwork, we also noticed the ways that some healthcare staff responded to and interacted with patients coming from the downtown core area are reflective of larger societal attitudes of disapproval and indifference towards that population. These emerging observations challenged the assumption that everyone experiences equal access to healthcare or perceives that healthcare © 2015 Foundation for the Sociology of Health & Illness

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is equitably accessible. In order to examine existing healthcare inequities against the ideological blind-spot of egalitarianism (Tang and Browne 2008), we anchored our analysis in the concept of ‘underclassism’ to highlight how unequal social positioning operates to structure inequitable access to healthcare between people who are perceived to be from the ‘dominant, normal, privileged class’ and those who experience social and economic marginalisation. It is important to emphasise that our focus on ‘underclassism’ – an interpretation that emerged from our critical reading of collected data – does not imply that we looked specifically for an ‘underclass’ in the data as if it objectively existed or was readily discernible based on some assumed characteristics of particular ethno-cultural or social groups. Rather, we conceptualise the ‘underclass’ – which often invokes stigmatising images including extreme poverty, welfare dependency and crime in public consciousness – as an ideological product associated with the neoliberal politics of economic and socio-political changes which give rise to, and intensify economic and social dislocations, particularly among the most vulnerable and historically disadvantaged populations such as the racialised poor in inner-city neighbourhoods (Wilson 1992). Contrary to those conservative discourses that explain the ‘underclass’ in terms of a ‘culture of poverty’ and individual inadequacy, we concur with Wacquant and Wilson (1989: 25) that ‘underclass’ has to be understood and used as a structural concept that speaks to the unjust and oppressive consequences of capitalism, including ‘the cumulative structural entrapment and forcible socioeconomic marginalization resulting from the historically evolving interplay of class, racial and gender domination’. Thus, the notion of ‘underclassism’ does not imply that oppressive social relations are created or sustained along singular axes. From an intersectional perspective, multiple forms of vulnerability stemming from material conditions, racialisation, or gendered inequities (among others) are experienced simultaneously, in ways that are mutually reinforcing and continually shifting depending on context (Mullings and Schulz 2006; Weber 2006; Hulko 2009; Browne et al. 2011b; Hankisvky 2011). Similarly, the notion of ‘underclassism’ cannot be understood in isolation from other simultaneous and intersecting forms of social position and locations, which converge to fundamentally structure and sustain complex power relations and unjust social hierarchies. Although the everyday material effects of socioeconomic exclusion are real for those who live with poverty and social deprivation, Bourdieu and Wacquant (1999) remind us that the ‘underclass’ is a ‘fictional group’ that which, like other social categories such as race, class, and gender, is a social construction. In other words, the ‘underclass’ represents neither fixed subject positions nor a real group of people. While the term ‘underclass’ has been commonly used to refer to people experiencing long-term unemployment and/or homelessness, people with problematic drug-dependencies, people living on social welfare, people in the justice system, and so on, we consciously put the terms ‘underclass’ and ‘underclassism’ in quotation marks to remind readers of its politically and socially constructed nature. Further, we do not wish to imply that those who are seen as members of the ‘underclass’ are without their own agency and expertise. However, this understanding of the ‘underclass’ as manufactured rather than given in social reality (Bourdieu 1990) gives us the needed analytic currency to unmask the obscure, yet productive process by which the hierarchies of positional inferiority versus positional superiority between different social groups are structured and reproduced in healthcare. Thus, although healthcare providers who participated in our research did not use the label ‘underclass’, we illustrate the processes through which ‘underclassism’ can manifest, often unintentionally, and the role that healthcare can play in constraining peoples’ access to needed resources for health. © 2015 Foundation for the Sociology of Health & Illness

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Methods: overview of context and design This article presents our analysis of ‘underclassism’, one aspect of the findings of a large ethnographic study, which was a collaborative research endeavour of university researchers and community-based leaders in Indigenous health (Browne et al. 2011a). This study was designed to explore experiences of healthcare access from the perspectives of Indigenous and non-Indigenous patients seeking services in the non-urgent division of an urban Emergency Department (ED) located in a large hospital in a Western Canadian city. In Canada, non-urgent divisions of EDs (sometimes referred to as fast tracks) are designed to provide healthcare to those patients whose health conditions are triaged as stable and non-urgent according to standardised assessment criteria. Primary care and acute care services, including ED care, is provided to Canadians without any fees collected at the point of care. Although EDs are not typically designed as primary care access sites, an increasing number of people in Canada and other nations are using EDs for health issues triaged as stable and non-urgent. This is because healthcare reforms have resulted in a diminishing number of community health services and primary care providers who are available to work with patients whose health is influenced by intertwining health and social issues (Browne et al. 2011a; Nelson et al. 2011; Browne et al. 2012; Canadian Institute for Health Information 2012). Recent data from Canada shows that non-urgent and less urgent use of the ED for primary care issues that could, ostensibly, be treated in community or walk-in clinics accounts for an estimated 45 per cent of all ED visits (Canadian Institute for Health Information 2014). In Canada, peoples’ ethnicity is not tracked as part of administrative data; therefore, data on the use of the ED by ethnicity is not available. In this study, data were collected over a 20 month period of immersion in the fast track clinic of the ED. The data collected included: (1) indepth, open-ended interviews with 44 patients (34 or 77% of whom self-identified as Indigenous, and 10 or 23% of whom self-identified as Euro-Canadian); (2) indepth, open-ended interviews with 38 staff members who worked in the non-urgent division and in the larger ED, including, nurses, doctors, social workers, admitting clerks and security staff; and (3) participant observation of clinical encounters between patients and providers and the general ED environment. The hospital in which this study was conducted is located adjacent to a downtown core area recognised as one of Canada’s poorest neighbourhoods. Like other urban inner-cities across Canada, this particular neighbourhood has been profoundly shaped by neoliberal social policies driven by reduced government commitment to the welfare state. These policies have resulted in increasing and extreme social inequities including a concentration of people experiencing the negative health effects of living far below the poverty level, unemployment, inadequate housing and other forms of structural violence (Harvey 2007; Culhane 2009; Farmer 2009). Among our sample of patient-participants including 25 men (76% Indigenous and 24% Euro-Canadian), 18 women (78% Indigenous and 22% Euro-Canadian), and one person who identified as transgender, many lived in single occupancy rooms in core area hotels, boarding rooms, hostels, transition houses, or on the street; and the majority existed on meagre social welfare or disability payments, or had no income. The majority of the data in this study were collected by three research associates who identified as Indigenous peoples and more specifically, as affiliated with Northern Cree, Haida, and Okanagan First Nations. Each was experienced in qualitative data collection and skilled at connecting with the patients in meaningful ways. Most patient interviews lasted 30–60 minutes and took place in private areas of the ED where confidentiality could be maintained. Interviews with healthcare providers usually lasted 15–30 minutes as most staff-participants had to fit the interview into their heavy work schedule. Written informed consent was obtained from each participant, who was ensured of the voluntary nature of their participation and their right to withdraw from the study at any time. Confidentiality of participants was protected by a © 2015 Foundation for the Sociology of Health & Illness

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strict procedure of data management that removed from the dataset all identifying information such as the names of people, places, healthcare settings and communities, and replaced them by corresponding codes. Two forms of qualitative data were analysed in this study: observational data recorded as field-notes, and interview data transcribed verbatim from audio-recorded conversations with patients, healthcare providers and hospital staff. Data analysis followed an interpretive thematic analysis approach that involves critical interpretation of empirical data (Thorne 2008). Interview transcripts and observational notes were repeatedly read by members of the research team to identify patterns in the data and possible linkages to theoretical perspectives. Nvivo© (QSR International, Melbourne) was used to code the interview data, and as coding categories were refined, the analysis shifted to a more abstract and conceptual representation of the themes reflected in the data. Credibility of the analysis was continually discussed and evaluated with our team including scholars in Aboriginal health and an Aboriginal Community Advisory Committee. Specifically, we situated our analysis within a social ontology that understands everyday actions and interactions not merely as personal or interpersonal events, but as reflective of and implicated by material and social conditions that organise our social reality and our experiences in it (Smith 1999). Our use of a downtown urban hospital for data collection – a hospital perceived as a hospital of choice for Indigenous peoples from the inner-city – was not meant to evaluate the performance of that particular hospital. Rather, the purpose of our analysis was to examine the larger question of access to healthcare for patients experiencing the effects of structural violence and inequities in the urban context. As such, any clinical sites serving residents in a downtown core area would have been equally valid points of entry for our ethnographic exploration. Research continues to show that healthcare providers’ interactions with Indigenous peoples are shaped by their assumptions about Indigenous identity, which in turn intersect with broader social discourses in Canada about Indigenous peoples’ credibility and deservedness as medical subjects (Browne et al. 2011a; Fiske and Browne 2006). In this article, we examine how the construction of ‘underclass’ patients intersects with racialised assumptions about Indigenous peoples’ identity and deservedness as patients seeking care in the Fast Track of the ED.

Findings Constructions of ‘underclass’ patients through a productive space of visibility and invisibility Healthcare Provider (HCP 28): People with sores, addiction . . . physically presenting signs of having used [substances], motor movement . . . looking haggard, sort of looking like life has been really difficult. HCP 11:

A lot of them are on welfare or drug pushers, or I mean I am assuming. They don’t seem to have jobs, not well dressed, dirty, unkempt, using drugs, not taking care of themselves.

HCP 14:

Whiney people, needy people . . . they are such trying, it feels like that’s all we see, and it’s not. © 2015 Foundation for the Sociology of Health & Illness

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Furniss, E. (1999) The Burden of History: Colonialism and the Frontier Myth in a Rural Canadian Community. Vancouver: UBC Press. Harvey, D. (2007) Neoliberalism as creative destruction, The Annals of the American Academy of Political and Social Science, 610, 1, 21–44. Hankisvky, O. (ed) (2011) Health Inequities in Canada: Intersectional Frameworks and Practices. Vancouver: UBC Press. Hulko, W. (2009) The time- and context-contingent nature of intersectionality and interlocking oppressions, Affilia, 24, 1, 44–55. Institute of Medicine (2009) Race, Ethnicity, and Language Data: Standardization for Healthcare Quality Improvement. Washington DC: The National Academies Press. Kingfisher, C. (2007) Discursive constructions of homelessness in a small city in the Canadian prairies: Notes on destructuration, individualization, and the production of (raced and gendered) unmarked categories, American Ethnologist, 34, 1, 91–107. Koekkoek, B., Hutschemaekers, G., van Meijel, B. and Schene, A. (2011) How do patients come to be seen as ‘difficult’? A mixed-methods study in community mental healthcare, Social Science and Medicine, 72, 4, 504–12. Mullings, L. and Schulz, A. (2006) Intersectionality and health: An introduction. In Schulz, A. and Mullings, L. (eds) Gender, Race, Class, and Health: Intersectional Approaches. New York: Jossey-Bass. Nelson, K., Connor, M., Wensley, C., Moss, C., Pack, M. and Hussey, T. (2011) Review article: People who present on multiple occasions to emergency departments, Emergency Medicine Australasia, 23, 5, 532–40. Newhouse, D.R. (2000) From the tribal to the modern: The development of modern Aboriginal societies. In Laliberte, R.F., Settee, P., Waldram, J.B., Innes, R., Macdougall, B., McBain, L. and Barron, F.L. (eds) Expressions in Canadian Native Studies. Saskatoon: University of Saskatchewan Press. Newhouse, D.R. (2006) From woundedness to resilience, Journal of Aboriginal Health, 3, 1, 2–3. Peters, E.J. (2007) First Nations and Metis People and Diversity in Canadian Cities. Montreal QC: Institute for Research on Public Policy. Peters, E.J. (2009) Aboriginal Peoples in Urban Areas. Don Mills: Oxford University Press. Peters, E.J. (2011) Urban Aboriginal Policy Making in Canadian Municipalities. Montreal QC: McGillQueens University Press. Peters, E.J. and Andersen, C. (eds) (2013a) Indigenous in the City: Contemporary Identities and Cultural Innovation. Vancouver: UBC Press. Peters, E.J. and Andersen, C. (2013b) Introduction. In Peters, E.J. and Andersen, C. (eds) Indigenous in the City: Contemporary Identities and Cultural Innovation. Vancouver: UBC Press. Raphael, D. (2011) Poverty in Canada: Implications for Health and Quality of Life. Toronto: Canadian Scholars’ Press. Razack, S.H. (2013) Timely deaths: Medicalizing the deaths of Aboriginal people in police custody, Law, Culture and the Humanities, 9, 2, 352–74. Reutter, L.I., Stewart, M.J., Veenstra, G., Love, R., Raphael, D. and Makwarimba, E. (2009) ‘Who do they think we are, anyway?’: Perceptions of and responses to poverty stigma, Qualitative Health Research, 19, 3, 287–311. Rodney, P. and Varcoe, C. (2012) Constrained agency: The moral structure of nurses’ work. In Baylis, F., Downie, J., Hoffmaster, B. and Sherwin, S. (eds) Healthcare Ethics in Canada, 3rd edn. Toronto: Nelson. Smith, D.E. (1999) Writing the Social: Critique, Theory, and Investigations. Toronto: University of Toronto Press. Statistics Canada (2008) Aboriginal Peoples in Canada in 2006: Inuit, Metis and First Nations 2006 Census. Ottawa: Statistics Canada. Tang, S.Y. and Browne, A.J. (2008) ‘Race’ matters: Racialization and egalitarian discourses involving Aboriginal people in the Canadian healthcare context, Ethnicity and Health, 13, 2, 109–27. Tator, C. and Henry, F. (2006) Racial Profiling in Canada: Challenging the Myth of ‘a Few Bad Apples’. Toronto: University of Toronto Press. © 2015 Foundation for the Sociology of Health & Illness

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One Indigenous patient from the downtown core area told us about his perception of being essentialised by healthcare providers as ‘one of them’: Patient 18: They treated me like nothing but a [explicative] ‘Indian’ on drugs who doesn’t deserve the respect of all other patients that were around me. Assumptions of Indigenous patients as drug-seeking can play an important function of gatekeeping or denying some patients from accessing the healthcare they need, even if they come to the hospital for legitimate reasons (Tang and Browne 2008; Browne et al. 2011a). One patient-participant recalled his observations of how Indigenous peoples were treated in the ED of a downtown hospital: Patient 1: I have seen Natives, in particular, yelling and screaming when they are getting escorted out of the hospital because the doctors or nurses just think they are there because they want to get high on their medications or whatever. These actions, perceived as ‘disciplinary’ particularly by patients who experience frequent dismissal can reinforce prevailing assumptions about ‘underclass’ patients and feed into popularised images of such people as potentially dangerous, deviant, or less deserving members of society. Elsewhere, we have described how patients in our study made decisions about where to seek healthcare based on neighbourhood boundaries that often exist between the poor inner-city and the gentrified neighbourhoods located in close proximity, highlighting the taken-for-granted awareness of social and class boundaries shaping where patients from the inner-city perceive themselves as deserving to seek healthcare (Browne et al. 2011a). Ironically, the visibility that subjects people experiencing poverty and racialisation to the spotlight of scrutiny and suspicion also minimised them as being invisible (i.e. less important, undeserving) clients of healthcare.3 The implications of invisibility for the ‘underclass’ patient, such as being kept waiting for treatment, tended to be dismissed by healthcare staff as subjective misperception on the part of the patient when filtered through an uncritical lens of egalitarianism that assumes that ‘everyone who seeks healthcare is treated the same’ (Tang and Browne 2008). A few patients who identified as Indigenous in our study challenged this assumption by speaking to what they perceived to be a hidden process of social triaging in the ED, whereby decisions about who gets seen first seemed to them as based less on triaged clinical priorities but on the social positioning of the patient, as if some people were by nature more deserving of health services than others: Patient 23: There’s somebody who was in serious pain and I was after him, and this other person got in front of him . . . I mean we are getting more affected like, ‘oh, a junkie or hard alcoholic, living in an alley’, you know. Patient 29: There are a lot of other people, some of them don’t have major injuries but they will go in fast . . . I notice every time I go to see a doctor, I’m waiting for a long time. Like my knee I handled that for about a week and a half before I even decided to go (for treatment), because I knew the waiting time was just going to be a long time, making you wait. The perception of being kept waiting, as shared by the two Indigenous patients above, cannot be explained away as a coincidence or as merely a reflection of their individual disgruntlement. Many patients in this and other research have reiterated their concerns about being viewed, and treated, on the basis of an intersecting set of negative stereotypes – particularly those that construct Indigenous peoples as necessarily prone to irresponsibility and dependence (Furniss 1999; Tang and Browne 2008; Browne et al. 2011a, 2012; Razack 2013). Patients © 2015 Foundation for the Sociology of Health & Illness

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who, because of their socio-historical positioning, and mental health and addiction issues, experience dismissal in many sectors of society, including the healthcare, justice, and social service sectors, are particularly sensitive to the mannerism and messages conveyed to them by staff working in such sectors. In intricate ways, those interpretive lenses that Indigenous patients residing in the inner-city core areas bring to understanding their healthcare encounters are expressive of the larger systems of colonialism and neo-colonialism. These colonising systems operate in Canada through the policies and practices embedded in the Indian Act, and the justice and educational systems, including the racialising and classist assumptions and stereotypes that constitute the ideological ‘underclass’ and organise the ways that healthcare providers may read and interact with patients affected by poverty and social marginalisation. The experiences of patients from low income inner-city neighbourhoods do not merely reflect societal misperceptions or biases of some healthcare providers that can simply be corrected through re-training or educational programs. Expressed in those experiences are hidden processes through which the state controls and manages people from lower socioeconomic positions – whereby control is not so much exercised by force, but by the actions of healthcare providers who work within systems that are inequitably structured. We shall now turn to discussing this process of ‘ruling’ (Smith 1999) – a process we refer to as ‘underclassism’. Underclassism: social marginalisation of the ‘underclass’ in healthcare Reducing healthcare as a right to healthcare as welfare According to the Canada Health Act, healthcare is a right that every Canadian is entitled to enjoy irrespective of the (in)ability to pay. Despite the principles of universality and accessibility, the perception of who should enjoy the ‘legitimate’ right to healthcare seems to be largely determined by the social status of the person as tax-payer or non-tax payer as perceived and assumed by the service provider. Some healthcare providers and other staff members expressed resentment in relation to patients who were perceived as dependent, unmotivated or as personally responsible for their own demise. As we have written elsewhere, such resentment reflects much wider social discourses that are prevalent in Canada (Browne 2007; Browne et al. 2011a). For example, this healthcare provider spoke to an implicit entitlement to healthcare for different groups based on their social and economic status: HCP 11: I try to treat everyone the same. I have no patience for people who waste taxpayers’ money . . . What if my family member needed an ambulance and couldn’t get one because all these other people call them when they don’t need them. It’s a $400 taxi ride for these people. They get here and they say, ‘give me a sandwich, get me a drink’. You don’t get anything if you are in here expecting it, like it’s your right . . . By and large the people that come here are treated very well. But if you come in expecting something, entitled to something, things will go badly. Prevalent in our data was a paradoxical discourse of entitlement that proclaims the value of egalitarianism while at the same time endorses inequitable access to resources for different populations. The ways that entitlement was interpreted seem to be based on a hidden hierarchy of positional superiority of ‘deserving’ citizens versus positional inferiority of non-taxpayers. For those patients who rely on the social safety net for everyday sustenance, their right to healthcare is further reduced to another form of welfare within the dehumanising package of social assistance. This is accomplished by government policy and the public discourse towards welfare recipients, that swiftly transform what is supposed to be social entitlement to © 2015 Foundation for the Sociology of Health & Illness

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assistance (including healthcare) to social blame for being dependent and destitute (Wallace et al. 2006). This implicit but powerful discursive mechanism of marginalising welfare recipients is, at least partly, enabled by the classist and neoliberal assumptions of able-ism and individualism that put the ultimate responsibility for achieving self-sufficiency on the person. If the notion of rights implies a sense of respect and worthiness, the label of welfare implies being unproductive and abusive of the generosity and the hard work of others. The social devalues attached to welfare recipients can reinforce the marginalising treatment that ‘un-deserving’ subjects such as welfare recipients often experience in clinical encounters. One healthcare provider spoke to the inherent biases in the ways her colleagues tended to read what might be stigmatised as misuse in the case of ‘underclass’ patients could be left unquestioned when a patient perceived to be middle-class is involved: HCP 28: We see people who are coming from lower SES, struggling with poverty and those kinds of issues, who are coming with social issues and certain health issues that aren’t urgent. I guess the sense and the perception is that this group comes and sort of invents a reason to come that may not be really existent, whereas they (HCPs) probably don’t question the other group . . . There are other people that come for a cold or sunburn that it’s thought to be ridiculous but there isn’t the same stigma that they have about misusing the ED the same way as the other (i.e., those from lower SES). When healthcare is reduced from a right to welfare for the recipients of social assistance, the egalitarian ideal of equal respect that underlies citizenship rights is subject to be replaced by an ‘exalted value of compassion’ (Thobani 2007) that raises tax-paying subjects to a higher moral standing as potential providers for the unfortunate members of society. The inherent power differentials between those who are in the privileged position to exercise compassion, and those who are at the mercy of someone else’s help and understanding, set up an expectation of patients to demonstrate reciprocity by behaving in ways that abide by their positional inferiority in relation to ‘first-class’ citizens: HCP 14: We’ll meet all of their needs, and when that doesn’t happen, there is a great deal of frustration on their part which makes it almost confrontational at times, it can be incredibly challenging to remain compassionate and non-judgmental about patients we see, when that kind of situation arises. When you see that kind of behaviour, often there is a lack of gratitude, and not that we need to be thanked, but it’s always nice to be appreciated for the work we do and that we are not there as servants, we are there to provide a service, our mission is to provide healthcare. Contrary to the perception of some healthcare staff that patients tend not to appreciate the care and hard work of health professionals, a patient we have interviewed said otherwise: Patient 40: They are really nice to me . . . they all know me . . . it’s a really good patientdoctor relationship, and I feel really kind of ‘homey’ sort of thing. On the surface, compassion constitutes part of the moral platform upon which the liberal welfare state is built, representing a social commitment to provide for all citizens and to protect their social entitlement to the basic necessities of life (Thobani 2007). At closer scrutiny, however, the rhetoric of compassion draws upon and feeds back into the existing hierarchy of differential entitlement that defines who is deserving of help and who is not, including those who are seen as members of the ‘underclass’. On the one hand, healthcare providers can justify their judgmental behaviours by shifting the blame onto the ‘undeserving’ patient who is perceived as over-demanding and ungrateful, and thus responsible for not receiving respectful care from © 2015 Foundation for the Sociology of Health & Illness

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healthcare providers. On the other hand, as a ‘white’ moral ideal, the ‘exalted value of compassion’ (Thobani 2007) tends to gloss over systemic inequities that keep some populations at the social and economic margin of society, thus locking them at the receiving end of our compassion and our generosity as the real contributing members of society. The ‘victim mentality’ that one healthcare provider has alluded to, feeling as if ‘the world and us and the hospital and society owe them a large amount of something’ (HCP 8), may be speaking less to a ‘false consciousness’ of the patients but more to their lived reality of social inequities, including their frustration and anger about bearing a disproportionate share of the burden and suffering of an unjust society. Manufacturing dependency among socially and economically marginalised patients In addition to constructing ‘underclass’ patients as un-entitled to the rights of ‘normal’ citizens, the process of ‘underclassism’ also involves manufacturing dependency among those patients through healthcare. By dependency, we are referring to a state of constructed unequal power relationships, manufactured by human actions that put some people in a vulnerable position to be denied access to their needed services, such that they are kept in a state of partial deprivation as well as in a position of powerlessness in relation to those empowered by institutional policies and unspoken social rules to control the allocation of resources to the social Other. This process is no less hegemonic, even if the exercise of power over another is limited, and even when the resources concerned are mundane. For example, on one fieldwork day, the attention of the researcher was drawn to a particular patient who was earlier seen for an urgent eye condition, and was waiting for consultation by ophthalmology. The researcher noticed that the patient appeared to be pacing nervously in the waiting area, looked fatigued and gaunt, and was dressed in worn-looking clothes. The researcher asked a staff member in the ED if she could bring the patient some juice and a sandwich while he waited for the specialist. The following exchange occurred between the researcher and the staff member: Field-notes (re. Patient/HCP interaction #32): I noted that the unit wasn’t incredibly busy, though she (the staff member) was in the process of sorting through some papers. She turned to me and said in an elevated tone of voice and with an annoyed look on her face, ‘We just can’t give away food to those people, you know. All we’re going to do is make it so that they come back here, they’ll just keep coming back over and over . . . We’re trying to put a stop to all of that, and if we just keep giving them food, they are going to come back.’ The interaction above was not representative of all healthcare staff in our study. However, this example speaks vividly to the notion of manufacturing dependency, when patients experiencing the effects of structural inequities, such as economic marginalisation, poverty and racialisation are subject to punitive treatment by those who have the power to provide (or withhold) access to needed resources. The visibility of the ‘underclass’ patients or what the staff member called ‘those people’, who are seen as abusing the ‘care’ of ‘normal’ citizens, justifies the marginalising and unwelcoming treatment. Even when most patients from the inner-city come to the ED for legitimate clinical reasons, their healthcare needs tend to be obscured by providers’ stereotypes of people as over-users and in some cases, abusers of scarce resources. Constructions of the ‘underclass’ patient as undeserving justify institutional policies such as those around nourishment for patients – policies supposedly necessary for © 2015 Foundation for the Sociology of Health & Illness

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improving the efficiency and cost-effectiveness of the ED by off-loading ‘those patients’ who are seen as using the hospital services inappropriately. The problem of inappropriate use illustrates how the pressure of healthcare efficiency can intersect with the devaluing of people who are experiencing poverty and its related social impacts. As one healthcare provider told us: HCP 28:

I think there is a perception that somebody who is coming from (name of a low income neighbourhood) is looking for something, with an agenda. There is talk here now that they are not going to give out sandwiches and kind of things to try to weed those people out.

The common sense images about ‘underclass’ patients put them in an inferior position for being mistrusted by healthcare providers, who have the power to believe or not believe the presenting symptoms of the patient and his/her motive for seeking care in the hospital. This invariably sets up an unequal relation of power between the healthcare providers and the patients, who are dependent on the healthcare provider for clinical help. One patient who identified as Indigenous recalled an experience where her grief reactions over the death of her father were interpreted by healthcare providers as behaviours related to drug use that (erroneously) stemmed from her visibility as a member of a racialised group, and as someone living in poverty: Researcher: When you went in (to the psychiatric unit), you said they thought you were on drugs. So were you (on drugs) or it’s just something they assumed? Patient 14: No, it was just something they assumed and like the way I looked and everything like that. They thought I was high on drugs. That’s how bad it was, how bad I was. In particular, ‘dependency’ is manufactured by the differential treatments that healthcare providers convey to patients who are marginalised, who are often denied access to pain medications, versus the ‘normal’ citizens from middle class backgrounds, who are granted power to exercise autonomy, including the right to self-medication of narcotics at home based on their needs. We want to illustrate this point by contrasting two cases, including the experience of one man who identified as Indigenous (Patient 1), and who resided in an inner-city neighbourhood, and one self-employed Euro-Canadian man (Patient 2) who resided in a near-by middleclass neighbourhood. In the case of this patient of Indigenous descent, he described feeling that his health issues were inadequately addressed, rendering him relatively powerless in relation to the help he was seeking: Patient 1: (The doctor) came in and saw me and goes, ‘just put a tensor bandage on it and send him home with a couple of Ibuprofen’ and that’s all he said. He didn’t give me a chance to explain to him . . . I tried to talk to him, but he was busy talking to (another patient) and he didn’t even look at me, he thought I was just coming in to try to get something to get high or something like that . . . You come off the street and they figure that you want something to get high. In contrast, the middle-class patient we interviewed, who had a chronic condition that resulted in chronic pain and the administration of oral pain medication on a regular basis, was allowed to exercise autonomy by self-medication: Patient 2: I am at a point now where with my (chronic infection) I take self-medicated Morphine at home, and only when I am vomiting at the point where I can’t take the Morphine or other medications then I come (to the hospital). ‘Dependency’ or constructed unequal power relationships occurs when some patients are allowed to exercise their autonomy while such rights are denied to others. Substance use is not © 2015 Foundation for the Sociology of Health & Illness

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restricted to the ‘underclass’. As existing literature indicates, it is equally a problem among people in the middle or upper classes. However, patients coming from lower socioeconomic backgrounds are kept at the rank of the ‘undeserving dependents’ whose need for support are often denied and subject to stigmatisation. As Young (1990: 54) argues, ‘[b]eing a dependent in our society implies being legitimately subject to the often arbitrary and invasive authority of social service providers and other public and private administrators, who enforce rules with which the marginal must comply, and otherwise exercise power over the conditions of their lives’. Even though many healthcare providers may see themselves as powerless players within the hierarchical structure of policy making in healthcare institutions, paradoxically, they are given implicit permission by the institutions to exercise at least ‘some power in relation to others’ (Young 1990, p.56), including the power to regulate access to resources for members of different social groups based on the perceived social worth and ‘deservedness’ of the person who seeks care. Most healthcare providers enter their profession and do their work with the best intentions in mind. However, unless healthcare providers are cognizant of how their everyday actions and decisions have implications for reproducing an oppressive structure of race/class (and gender) inequalities, healthcare practices will continue to serve as a vehicle for the state to extend control over the ‘underclass’ by constraining their life opportunities, including the opportunity to restore and promote better health through access to respectful, timely and quality healthcare.

Discussion Our analysis of the healthcare experiences of urban poor people in inner-city areas challenges us to consider healthcare as both a clinical and social space. By social space, we refer to that invisible and contested space in which people from different social positions negotiate access to power and resources in their everyday reality. ‘Underclassism’ illustrates one of the ideological processes that take place within the social space of healthcare, whereby patients experiencing poverty and racialisation are prone to being marginalised and given lesser care in the mainstream health system. The ideological process of ‘underclassism’ serves an important function: surveillance and control of the social Other on behalf of the state. Our analysis in this article suggests that there are at least two ways that social control manifests in the ED. First, healthcare providers and staff members exercised at least some control over space, by taking actions to discourage the ‘underclass’ patients from coming and coming back to the ED for what are perceived as nonclinical needs (e.g. food, shelter). Such actions to enforce ‘territoriality’ (England 2004) by ‘weeding those people out’ are supported by, and work in tandem with institutional policies (e.g. policy to stop supplying sandwiches in the ED) that operate to maintain the desired social order or ‘clinical purity’ in the ED by regulating and controlling access for those who are seen as illegitimate users or ‘abusers’ of emergency care. Second, social control is partly enacted in the ED by keeping patients who are poor and/or experiencing racialisation at a positional inferiority, whose full citizenship rights to receive equitable healthcare are constrained by ‘disciplinary’ actions (e.g. keep the patients waiting or take their health concerns less seriously) that normalise and reinforce the marginal status of the ‘underclass’ patients as less worthy and un-belonging citizens in society. Even when healthcare providers are unaware of their participation in the oppressive system, healthcare as a social institution of the state plays an indispensable role in reproducing the existing structure of racial and class domination in the interests of the ruling. The ways that the social hierarchy of superiority and inferiority is reproduced through the healthcare encounter – as manifested in the process of ‘underclassism’ – challenge the assump© 2015 Foundation for the Sociology of Health & Illness

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tion that healthcare is equally accessible for all Canadians. In the hospital where we conducted data collection, it was generally assumed that it was a hospital of choice for Indigenous peoples and for people from the urban inner-cities because of its geographic proximity to the inner-city. In fact, many patients we talked to expressed a sense of familiarity with the hospital and the geographic convenience it brought them. However, many of the patients in this study delayed coming into the hospital until they could wait no more because of previous experiences that they perceived as demeaning, dismissive or discriminatory. This seems to suggest that even when health services are geographically close, they can remain socially distant. Accordingly, a critical examination of accessibility of healthcare must go beyond a linear, technocratic model that assumes that an increase in service provision will necessarily improve access. The technocratic approach to accessibility largely falls back on the ideology of individualism, whereby people are expected to take up the responsibility to seek and access health services promptly but appropriately. Such an approach fails to consider how access barriers such as discrimination, Othering, and social distance in terms of racialised and classed differences in symbolic capital (Bourdieu 1990), including income and social status, play out to organise help-seeking decisions as well as the quality of clinical encounters between the patients and healthcare providers. When we understand healthcare as a form of social relations, and as a social space, professional and public discourse about the principle of accessibility cannot focus only on maximising clinical efficiency (e.g. decreasing waiting time and increasing discharge rates), but also on strategies to reduce the social distance that keeps some patients from being able to access clinically effective care that is meaningful to them. Solutions to persistent inequities in health and healthcare for marginalised populations, such as Indigenous peoples, low income people of colour, people who are homeless, or people living with major mental health or substance use issues, would call for a critical renewal of the cultural and ideological basis of healthcare education and healthcare organisation. Only when we are willing to recognise and address how healthcare is playing an important role to normalizing and reproducing existing social inequalities, then will healthcare become a genuine healing place for the embodied, historical suffering that people have to endure as a result of the various forms of oppression in a racist, sexist, and classist society. Address for correspondence: Annette J. Browne, School of Nursing, University of British Columbia, T201 – 2211 Wesbrook Mall, Vancouver, BC, Canada, V6T 2B5. E-mail: Annette. [email protected]

Acknowledgements The analyses discussed in this article are part of a larger study funded by the Canadian Institutes of Health Research. We thank our colleagues Betty Calam, Nadine Caplette, Jane McCall and John O’Neil for contributing to the analytical insights reflected in this article. We also thank Greg Brass, Tanu Gamble, Andrea Martel and Rachel Olson for their excellent work as research associates on this project.

Notes 1 ‘Indigenous peoples’ refer to the original inhabitants of Canada including First Nations, Metis, and Inuit people. In Canada, ‘Aboriginal peoples’ is often used interchangeably with the term ‘Indigenous peoples’. © 2015 Foundation for the Sociology of Health & Illness

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2 For the purposes of this article, we define health equity as the absence of systematic and potentially remediable differences in one or more characteristics of health across populations or population groups defined socially, economically, demographically, or geographically (WHO 2008). Health inequity refers to differences in health or access to care that result from structural arrangements that are potentially remedial; in this sense, inequities are deemed unjust. 3 The paradox of visibility versus invisibility has also been problematised in other literature that examined how racialised residents in the inner-city space are disciplined by the strategic deployment of raced/classed/gendered representations that render those residents to be seen as highly visible ‘deviants’ (e.g. criminals, sex workers), while other times, minimise them as socially invisible and thus unimportant members of society (England 2004).

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'Underclassism' and access to healthcare in urban centres.

In this article, we draw on findings from an ethnographic study that explored experiences of healthcare access from the perspectives of Indigenous and...
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