Episode 34: Liben Gebremikael, TAIBU Community Health Centre

Episode 34: Liben Gebremikael, TAIBU Community Health Centre

(Access show transcript) TAIBU CHC was created to meet the specific healthcare needs of the Black Community. Executive Director Liben Gebremikael is optimistic that by addressing long-term systemic issues, the system will eventually be working for everybody.

Show Summary

Today we’re talking with Liben Gebremikael, the first Executive Director of TAIBU Community Health Centre in Toronto. He’s held the position since 2008. Liben is a social worker with over 25 years of experience in the primary healthcare sector, social services, and mental health field.

TAIBU was created to meet the specific healthcare needs of the Black Community – and as it’s evolved, addresses all the social determinants of health including, education, income, lifestyle, and housing. 

Their philosophy of care is built around a Zulu word ‘Ubuntu’, which means, we don’t exist as individuals, we exist as a family and as a community. All issues at TAIBU are addressed from that lens and that philosophy.

For Liben, there’s excitement and a sense of satisfaction at developing a culturally appropriate approach to specific illnesses that affect the Black community – illnesses like sickle cell disease and diabetes for example. 

The larger issue that preoccupies Liben and his colleagues at TAIBU is the necessity of systems change. Eliminating barriers to care for racialized populations means big changes are needed at the systems level. As Liben explains, it begins with the four ‘As’.

Mentioned in this Episode

Transcript

Imagine you could step inside the minds of Canada's healthcare leaders, glimpse their greatest fears, strongest drivers, and what makes them tick. Welcome to Healthcare Change Makers, a podcast where we talk to leaders about the joys and challenges of driving change and working with partners to create the safest healthcare system.

Ellen Gardner: Welcome to Healthcare Change Makers, a podcast produced by HIROC. I'm Ellen Gardner with Philip De Souza and Michelle Holden.

Today we're talking with Liben Gebremikael, the first executive director of TAIBU Community Health Centre in Toronto. He's held the position since 2008. Liben is a social worker with over 25 years of experience in the primary health care sector, social services and mental health field. 

TAIBU was created to meet the specific healthcare needs of the black community. And as it's evolved, addresses all the social determinants of health, including education, income, lifestyle, and housing. Their philosophy of care is built around a Zulu word called Ubuntu which means, "We don't exist as individuals, we exist as a family and as a community." All issues of TAIBU tie are addressed from that lens and that philosophy. 

For Liben there's excitement and a sense of satisfaction at developing a culturally appropriate approach to specific illnesses that affect the black community. Illnesses like sickle cell disease and diabetes for example. The larger issue that preoccupies Liben and his colleagues at TAIBU is the necessity of systems change. Eliminating barriers to care for racialized populations means big changes are needed at the systems level. As Liben explains, it begins with the four As. 

Well, hi Liben, welcome to Healthcare Change Makers.

Liben Gebremikael: Thank you for having me. It's a great pleasure and honour.

Ellen Gardner: You were TAIBU's first executive director, accepting the position in 2008. What were those early days like?

Liben Gebremikael: First few, maybe months or weeks, I really was asking myself, "What am I doing here? Why did I choose to be here?" It was exciting, but overwhelming at the same time, particularly because it was establishing the organization from scratch. So that was both a learning opportunity, excitement, but also a lot of work coming within the city sector. But also, the mandate of the organization has a heavy weight to address the systemic barriers and health inequities of the black population across the greater Toronto area. So it was exciting and overwhelming at the same time. And it was through our engagement and relationship with stakeholders like the Black Health Alliance, who was the sponsoring agency for the establishment of TAIBU. A lot of CHC sector leaders at the time who were very excited that TAIBU was being established, who lent their time and support and guidance, the founding members of the organization who were very keen in making sure that we started in the right way.

Ellen Gardner: What was it that attracted you to the position? Had you worked in community health before?

Liben Gebremikael: At the time I had about 20 years of experience working in both in primary care, but also in community health and particularly mental health. My background is social work. So I have done a lot of work predominantly in the UK, working with racialized communities, refugees, asylum seekers, and providing a culturally appropriate care, whether it's mental health care or addressing any of the social determinants of health whether it's housing or income. And so that was the background I had. And when I came to Canada, I continued to work with families around the mental health field. And when I saw the position being advertised, I knew really this is where my passion and where I wanted to engage in and make a difference.

Ellen Gardner: In your position now, I guess as a leader, you have to juggle administration with... Do you do any direct care in the position or is it mostly administration that you do?

Liben Gebremikael: It's mainly administration, but whenever I have the time I really engage with clients or with our community workers. If there is any visits to be done and they need an additional pair of person to go and visit, I volunteer because I think that connection with people is very important when you do administration work, it's always good to be connected to the ground. Sometimes the role that we are when you are in leadership is very strategic, it's a lot of planning, but I believe that you need to really continue to put your feet on the ground and listen to people and hear people that will help you either to influence your decision, but also understand what is happening on the ground. So they say, "Once a social worker, always a social worker." It's very difficult to get out of that.

Ellen Gardner: The name TAIBU means “be in good health”. And as you define the vision of the organization, it's to improve, promote and protect the health and well-being for black populations through culturally designed primary healthcare services. This implies a different kind of health care delivery, one that's more culturally sensitive. How did you and your team come up with different approaches on how to reach the black community?

Liben Gebremikael: That's a very important question. I think we have to go back to why TAIBU was established in the first place. And where did that come from? And I said earlier on that it is the Black Health Alliance that sponsored the establishment of TAIBU community health center. The Black Health Alliance is an organization comprising of both black health professionals, community leaders and organizations. And it's mandate is really to address the systemic challenges that the black community faces and the founder of the Black Health Alliance, Dr. Christopher Morgan, together with other black health leaders at the time started the conversation as to, we know that there are health inequities within the black population, and these are very systemic. And we're seeing it, whether it is through chronic disease, a disproportionate rate of chronic disease or educational attainment, challenges, community safety issues, mental health.

And they started having this conversation as to what is the solution for such health inequities that is existing in the society. And it took them a few years through different engagement. They did research in early 2000 that looked at how black youth were accessing healthcare system in Scarborough. And there was some recommendation out of that. They participated in the consultation for Canada's Medicare, which later on became the Romano report. And so through those engagements, they really understood and highlighted all these challenges. And then the next step was we need to stop this conversation and discussion. We need to move into action. And one of the proposals for the action was to create a centre that is focussed on the health of black communities and bringing about solutions. So that's how the idea of having a health center that is dedicated to the black population came about, as we all know the system was never designed with the racialized, marginalized, indigenous peoples in mind.

People talk about a broken system. We say that the system is not broken. The system is working perfectly, as it was designed. The challenge is it was not designed for certain populations. And so our work is to really find where those gaps are and bringing about a different approach as you asked in the question is the approach is really having the anti-black racism, Afrocentric lens as one big piece. And the second piece is also making sure that the social determinants of health are at the centre of what we do because the healthcare system sometimes can be too medical in its approach. And it's looking at people from their physical health issues without taking into consideration some of the other aspects.

Many CHCs, as you probably know, do that but our focus is more intensified when it comes to black communities and our understanding from that basis, what is the impact of anti-black racism? We have a project called the Ubuntu Village Project. Ubuntu is a Zulu word and it means I am who I am because of who we all are. And we don't exist as individuals or as a unit. We exist as a family and as a community. And so when we are addressing health issues, it has to be from that lens and that philosophy. And then, as I said earlier on, is focusing on some specific issues.

Ellen Gardner: Liben, can you give me an example of Ubuntu in action when you've engaged the community in a particular problem, and what the outcome was?

Liben Gebremikael: I can give you one example, sickle cell disease, for example, is a blood disorder that disproportionately impacts people of African descent. And what we did when we started the relationship with the Sickle Cell Association of Ontario and also the sickle cell community was that there was a huge gap once people reached 18 and they were discharged from SickKids Hospital. SickKids Hospital has a very great program for sickle cell disease up to the age of 18, once you're 18 and you’re discharged, there's nothing out there. And so people rely on the emergency department and the hospital for their sickle cell crisis situation. So, when we did a needs assessment with the community, we found out that there was this huge gap in the community where people would not go to their family physician because the family physicians would ultimately tell them, go to Emerg.

So they would wait until the pain is unbearable and then they would go to Emerg. And then they would face barriers when they go to Emerg because they're considered to be a pain medication-seeking people, and they are not believed, all this kind of impact of anti-black racism and discrimination and prejudice. 

So we designed a pilot project that is community-based where we had a hematologist physician who would come to TAIBU on a weekly basis and would see people before they are in crisis or when they are developing symptoms of crisis so that they can be seen before they need to go to the emergency department. And that pilot that we ran for about four years demonstrated that number one, there was a lot of education that members received through genetic counseling and education about their own disease.

We had a team that was supporting them with a nutritionist, a social worker, and a nurse. So they will not just be seen for their sickle cell, but also other issues of housing, income, education, workplace situation, that the social worker was able to support them. And so when we did the evaluation for that pilot, we were able to see that number one, the quality of life of those people who participate in that pilot was significantly increased. They were able to reduce the incidents of crisis happening by at least 50 per cent. People who used to go to emergency department three, four times a year would have gone only once a year, which is expected if you're living with sickle cell disease. We also had a partnership with one of our local hospitals here, where we had established a protocol at the emergency department.

When people come with a sickle cell crisis, how they should be processed and engaged, and evidence had shown that if they can be seen within half an hour, they're given pain medication. And they're given some hydration and in the likelihood that they needed some oxygen, if they are given oxygen they could be discharged within an hour without being admitted in the hospital. We traced that engagement with the hospital, and we saw that we were able to decrease the number of people attending the emergency department by 65%. 

I'm just giving you this as an example, to show that if there are different ways of addressing issues that the black community faces, whether it's sickle cell, whether it's chronic disease, diabetes, hypertension, these are the kinds of disproportionate impact of chronic disease and mental health.

So we have used the same thing when we're doing with seniors engagement, youth engagement, through the COVID pandemic in terms of reaching out to our clients and making sure number one, people are trusting the system. That's a big issue within our communities. Two, they have proper access, whether it's physical access or other kinds of access, culturally appropriate access services. And three, that they are part of decision-making, one of the African principles of self-determination. So that they also participate in design, in decision-making, in planning of services. I think those are the critical ingredients when we're talking about culturally appropriate approaches and services.

Ellen Gardner: Is a lot of it seeing the problem and developing an approach as you go that you see different problems, you have to figure out, "Okay, how are we going to find the resources? How are we going to manage and help our community with this particular problem?"

Liben Gebremikael: People are really engaging with the issue of equity, which is promising, but it requires a lot of work because it’s very difficult to change the system quickly. So the system takes time, but we have to continue to do this work and bring about small changes as we go along. Usually, the focus has been, "Oh, let's make sure that we have good enough representation on our board, for example, or on a leadership circle." It's not so much about the numbers. It's so much about what's happening in that space, whether it's the governance space or the leadership space, and whether the voices that are being supported are being represented either physically, but also when those places don't have representation, it is the responsibility of the system to be asking those questions when needed to be asked to respond to the questions when they're asked and then create a pathways to change.

Just having an EDI training session is great. You can pick a box to say, "Okay, our organization or our board has participated on a training." But if nothing comes out of that, and there is no change, even if it's one thing that the organization changes. So, changing the system is a big challenge. 

That’s where we are now focussing, even in our programs, we are moving from just doing programs and we are incorporating the concept of systems change in all that we are designing, moving forward. We have changed the title of one of our teams, we used to be called the community team. And now we've called it, the community services and systems change team, and all our programs would have component of systems change in them.

Ellen Gardner: Liben, can you talk about where specifically in Toronto, we need to see systems change?

Liben Gebremikael: One of the programs we have under the systems change is addressing the disproportionate impact of suspension and expulsion of black students in schools. Studies have shown that in Toronto, for example, in the Toronto district school board, about 12% of the pop student population are black, but they account for in 2017, it was 42 and 48% of the school suspension and expulsion rates. I think it's calmed down over the years, maybe it's in the 30%, still high, 30% is still high as a disproportionate impact when it is three times the rate of the representation in that student. So what we have done is we started with a program to address those issues and supporting black students who are facing these kind of challenges, including supporting them with legal advice and representation.

But if we were just to do that and support black students through a program, we will continue to do this year after year. And we will be looking for resources year after year, if nothing has changed within the school system. So our approach is, as we are trying to address these issues, whether it's school, whether it's mental health, whether it's employment with youth, we are also designing a component in that program to make sure that we are engaging the system. So we can work with them to say they need some change. You need to change some of the things that you're doing? If it is prejudice, then we need to address that. If it is creating a different system or understanding of how disciplinary measures are being imposed on racialized black indigenous students, then we need to look at that because if the school does not change, then the percentage of suspension and expulsion would remain the same. And we would need a program that would need grants to continue the program.

We're changing the situation of how we want to do this and incorporate a system component in our programs so that as we do the program and helping emerging cases, we are also working with the system so that they can change their position. 

So that in the long term, and I say this to our board, I say this to our staff, in the long-term TAIBU's objective is to put TAIBU out of business. If everything works in the system, there is no need to have a TAIBU, right? Because the system would address the issues, cultural sensitivity, anti-black racism. We needed a TAIBU and the Black Health Alliance started this process of conceptualizing and establishing a centre that is dedicated to the black population because we have a systemic issue. If we continue in the long-term to address the systemic issue, then every CHC, every healthcare facility, every youth-serving agency will be meeting the needs of those racialized and marginalized communities. And the system would be working for everybody.

Ellen Gardner: Were there some specific things that TAIBU did to overcome some of the barriers to care and vaccine hesitancy during COVID in the black community?

Liben Gebremikael: At TAIBU we really started quite early, I think it was September of last year when we really thought that this was going to be an ongoing challenge. We knew our communities were impacted already because we had started an advocacy at the start of the pandemic with other black health leaders and CHCs, like from Parkdale Queen West CHC, Angela Robertson, Black Creek CHC, Rexdale. All the black health leaders really got together with the Black Health Alliance and advocated for the race-based data collection for impact of COVID. We knew what was happening in the States. And we knew that was also the same thing here, but we had no way of demonstrating. So we pushed for the race-based data collection for COVID. And we were successful both at the beginning with public health, but later on with the ministry as well.

That really showed us what we have been saying all along and also emphasizing that COVID it comes on top of what was already existing before in terms of the inequities and underlying conditions. I usually say, COVID is like the x-ray. It really showed us how broken the bones were and how many places the bones were shattered beneath right through the ongoing generational disparities that existed. 

So, as we knew this was happening, we really knew that black communities historically have distrust. I mean, we don't call it hesitancy within our sector because it's not about being hesitant. It's about not trusting the system and not trusting what is being provided and given as information. We knew this is one area we needed to do some work. 

At TAIBU we partnered with our local hospital here and started a communication engagement awareness campaign under three teams.

The first one being, get the facts. So we knew there was a lot of misinformation out there within our communities. So we were encouraging people to get the facts and we were providing those clinical information. The second theme was get tested. There was a huge disparity and access to testing for racialized communities. Partly because there were some additional issues that people were facing that if they got tested and they tested positive, would they be losing their job? And how would they manage, sustaining and maintaining their livelihood and caring for their families? So we said, "No, get tested." And then we also said the third theme was get support. So get the facts, get tested and get support. We knew that as people were going to be tested, and if they were testing positive, then we were there to support them through financial means, whether it was income support, housing situation, transportation, we even support the people who had to travel to their workplaces.

As you know, when pandemic hit and people were allowed to work from home. Many of our communities, racialized people cannot work from home because the type of work they have to do does not allow it for them to do that. So they would be traveling and using public transportation to go to work. And that's where they would get exposed to risk of COVID-19. So there was significant work that we needed to do, and we will continue to do. We have partnered with the city of Toronto and establishing the Black Scientists’ Task Force on vaccine equity. So black scientists who have experience in development of vaccines and other doctors research have come together to form this task force so that they can go to the community and educate and bring awareness. We've done a lot of town halls and community events to get people to understand the seriousness of the virus and also understanding their neighbourhood status.

A lot of people when I get to speak to them, when I see them in our parking lot here, or I see some of our clients out there in the community, most of them did not know, for example, that Scarborough and Malvern was a hotspot. They didn't know that one in four black community members were impacted by COVID-19. So those kinds of engagement education encouragement was very important. The second part was the vaccine rollout and making sure that as spaces where black communities find themselves comfortable to go to, they have some relationship, were also part of the vaccination spots. So that's why we really put our hand up first when we approached to see if we would be a community clinic site. So we have been doing that. And then later on also starting to do mobile testing or mobile vaccination sites and mobile testing sites as well, working with different communities, whether it's schools, whether it's housing complexes, churches, mosques, where we know people congregate and are comfortable in that space. Bringing the service, bringing the information and bringing capacity to those spaces has made a huge difference.

Ellen Gardner: It's been a difficult and intense time for anyone working in healthcare during the past 20 months. It does sound like your team really took a very proactive approach to helping your community through this difficult time, but I'm sure your team was probably stretched in many, many different directions. I just wonder, did anything change in the way your team delivered care and how did you support them during this time?

Liben Gebremikael: Equity work by itself is very challenging, time-consuming, emotionally taxing because a lot of people who are in this field are there because they personally believe in the cause and the mandate of the work and organization. You're not like a pay cheque situation. People are here and involved in this kind of work because they personally are invested emotionally and personally. So, when COVID hit last year, it was challenging, but it became even more challenging with the George Floyd incident and post that traumatic event that really triggered a lot of emotional challenges. I'm pretty sure this is for many of black communities, but certainly we felt it here at TAIBU. We had to create a space for people to be able to process that. On the one side, it's unpack the work that they do, but on the other side, it was very personal.

Despite all this happening to staff and with the extra support that that has been provided, we also don't want to miss that we are also a resilient community. The community at large will have gone through this huge impact of COVID-19 and we're still functioning as a community, but our staff and as an organization, and many other CHCs would also share this view is that we need to hang on to this resiliency. We have pivoted to a virtual care and virtual program immediately.

Our primary care interactions and contacts and visits have not been impacted as much. There has been some slow down, but we were back to our normal numbers in terms of encounters and visits and things like this.

Our programs did not stop for communities. We were able to continue and add new programs because there was some new fundings that were being provided. So as much as it was difficult and challenging, I think there's also lessons to be learned that we are a resilient community, a resilient staff, a resilient organization that we can continue to build on what has taken place so far. And yes, the journey is a long journey. It's a marathon, not a sprint. We will continue to do as much as we can, as we move forward.

Philip De Souza: We at HIROC are in awe of all our subscribers, including yourself and your team and how much you guys have done over this pandemic and not have done, but what you continue doing each and every day, we're just in awe and are so grateful to the work that our subscribers are doing right across the country. And I just wanted to acknowledge, I really liked how you talked about, how you really value having your feet on the ground and listening to not only to your team, but those who come for to seek support from you all.

If somebody's in a team or a healthcare organization or whatever the case may be, wants to start an equivalent of their own TAIBU in their community, or they want to make, like you said, that small change of changing the name of that for example, that committee, you had to systems change team so they can envision that change, that impact. What's one thing you think they could do to either get the ball rolling in creating an organization like TAIBU, or making that small change but so it's such an impactful change with having a committee name, et cetera?

Liben Gebremikael: So I think one or two things that comes to mind would be number one is, start with engaging the community that you want to serve. Maybe this is serving the Black community or changing the situation, it's starting that conversation and making sure that people are engaged to the extent that they feel they're going to be part of the solution. There is this word ‘consultation’ that has been used a lot in our communities and racialized communities, BIPOC communities are really tired of this consultation because what we have seen is people are coming, consulting and going, and nobody knows what's happened to that consultation. Or the consultants become the expert on the information they've gotten from the community.

I would not use the word consultation. I use the word ‘engagement’, so engaging with communities and really be transparent in saying, "We're here to listen. We're here to support. Lead the way, and we will support the change, would be a very significant approach." 

The other piece that we use in our black governance and leadership project is the path of four A's, which starts with acknowledgement. We need to start to acknowledge that there is a challenge, a problem, some inequity that we need to address, and also acknowledge that this is systemic, and we need to locate our self as an organization, whether we are mainstream organization or not, that we may be part of this challenge. So we need to also look inward and acknowledge where we are with ourselves. Then the second A, is the accountability. So once we know what we know, then we have to make ourselves accountable to doing something, and I usually use the example of CHCs.

We have an accountability agreement with what used to be called the LHIN, now Ontario Health, as part of our funding agreement. But when we as an organization start something to do and we want to be accountable, we have to let the community impose that accountability onto us. And that's a shift in our framework, in our mindset, in how we do things. So, there is a big paradigm shift that needs to happen in order to become accountable to community issues. 

The third A and the fourth A are kind of interlinked – it’s advocacy and ally relationship. So, advocacy, if once we are accountable, then in the short-term, we need to be advocates for those issues, because we know racialized communities or groups do not have the voice, the power or the space to advocate on behalf of themselves. So we have to step in and hold the space for those communities to advocate on their behalf. But our ultimate goal should be to become an ally, which means we don't have to hold a space anymore. We create the space for them so they can hold the space so that they can become advocate for themselves.

Ellen Gardner: One exciting thing that we learned about was a partnership that your team is formed with Peloton on their anti-racism initiative. And there's a number of other nonprofits involved. How did that partnership come about?

Liben Gebremikael: It was a surprise for us too, but we are really very appreciative of Peloton's engagement. They just looked for us on social media and contacted us and said, "We're doing this initiative. And we want to partner with TAIBU around this physical wellness and mental wellness program.” We were so delighted that we were the organization that was selected from the whole of Canada. That was huge for us. I think that at about six other organizations, I think some in Europe and some in the States, but we’re the only one in Canada. We were very privileged and delighted and elated that we were selected, but this was a great recognition and another opportunity really to bring about change within our communities.

Ellen Gardner: We will be watching for it, for sure. So really just want to thank you, Liben, for just an interesting conversation and also thank you and your team for, as Philip says, the amazing work that you're doing. We do wish you all the best as you continue to deal with all the things around COVID and helping your own community.

Liben Gebremikael: Thank you for the opportunity to share our stories and thank you for a very engaging conversation. I really appreciate it.

Ellen Gardner: You've just been listening to our interview with Liben Gebremikael, executive director of TAIBU Community Health Centre in Toronto, for more information about HIROC and to listen to other episodes of Healthcare Change Makers, go to our website, HIROC.com. Thank you for listening.

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