Understanding racism in the Australian health system
Racism, as defined by the Australia Human Rights Commission, involves prejudice, discrimination or hatred directed at someone based solely on their colour, ethnicity or national origin. These beliefs portray themselves through people’s actions and attitudes, and sometimes are not transparent. Racism can be internalised or experienced at an interpersonal, institutional or systemic level. Internalised racism perpetuates negative self-images through self-devaluation and acceptance of perceived and reinforced inadequacy. Interpersonal racism involves increased exposure to predjuice, discrimination, disrespect and mistrust.
Systemic racism operates across political, legal, economic and social systems and is the pre-determinant of Institutional racism. Moreover, Institutional racism is the collective failure of an organisation to provide appropriate and professional service to people based on their colour, culture or ethnic origin. In the health setting, both systemic and institutional racism result in assumptions and attitudes that lead to bias in safety and quality of care, and can result in poorer health outcomes for Aboriginal and Torres Strait Islander people.
“There is a need to address systemic racism and enhance cultural competency.” Ken Wyatt
Impacts of Racism
Racism and discrimination towards Aboriginal and Torres Strait Islander peoples is a reality that is exacerbated by a history of abuse, dispossession and intergerational trauma occurring from and continuing since colonisation began.
‘33% of Aboriginal and Torres Strait Islander people over the age of 15 reported experiences of unfair treatment during the past 12 months because of their Indigenous origins.’ 2014-2015 National Aboriginal and Torres Strait islander Social Survey
Experiences of racism are associated with risky behaviours such as substance use. Additionally, fear of racism can lead to avoiding places, situations or people, such as not seeking medical care when needed, which can have a profound effect on a person’s socioeconomic outcomes and health status.
‘Aboriginal and Torres Strait Islander peoples’ lives, health and wellbeing cannot be put at risk because of underlying racism and prejudice.’ Australian Indigenous Doctors Association
What does racism in healthcare look like for First Nations Peoples?
Institutional racism is embedded in governance structures and processes, as well as in the delivery of services and in workplaces. It can be seen in attitudes, behaviours or processes which amount to discrimination through prejudice, ignorance, thoughtlessness, racist stereotyping, and unsafe physical spaces that further disadvantage minority groups. Racism directly impacts the health of Aboriginal and Torres Strait Islander peoples, who are entitled to access culturally responsive health services.
These experiences can lead to poorer-self reported health status, lower perceived quality of care, underutilisation of services, delays in seeking care, failure to follow recommendations, distrust, interruptions in care, and avoidance.
‘Systemic racism in the health system directly influences Indigenous Australians’ quality of and access to health care services.’ Australian Indigenous Doctors’ Association
Racism experienced by First Nations health practitioners
Racist remarks and behaviours also burden practitioners operating within the health system. Systemic racism and inadequate reporting has a detrimental effect on the growing number of Aboriginal and Torres Strait Islander health practitioners.
‘Indigenous doctors are 5.5 times more likely to report bullying as a major source of stress, 10 times more likely to experience racism, and 27% of Indigenous health students reported being very stressed by racism.’ Australian Indigenous Doctors’ Association
Despite the shocking extent to which Aboriginal and Torres Strait Islander health professionals experience racism, according to AHPRA’s 2019/2020 annual report 7,637 health practitioners identify as Aboriginal and or Torres Strait Islander. This exceptionally low rate demonstrates the extent to which institutional racism may influence the number of Aboriginal and Torres Strait Islander people wanting to enter the health system. It also demonstrates a key issue within the health system regarding cultural competence, as a limited number of First Nations practitioners impacts upon the cultural safety procedures and knowledge implemented.
‘Naming and acknowledging racism as a major factor impacting both Indigenous health outcomes and the number of Aboriginal and Torres Strait Islander medical students and doctors working in the health system, is a crucial step towards tackling it and achieving real progress towards a culturally safe health system.’ Australian Indigenous Doctors’ Association
Do healthcare workers get cultural safety training?
Within NSW, Respecting the Difference training is mandatory, with the minimum requirement being a two hour program and six hour workshop. The Australian Health Practitioner Regulation Agency (AHPR) reminds all practitioners that they are required to comply with their professional code of conduct, condemning discrimination or racism.
Despite these measures, racism still permeates the health system as existing standards insufficiently ensure culturally safe care for Aboriginal and Torres Strait Islander patients. More must be done to remove racism, as the continued bias in safety and quality of care will continue poorer health outcomes and mistrust. The impacts of racism have a flow on effect throughout the social determinants of health; the economic and social conditions that influence individual and group differences in health status. A prime example is poor health and poverty - poor health contributes to a reduced income that exacerbates other determinants such as access to safe and healthy housing, which continues to perpetuate disparities.
The responsibility for eliminating racism from the health system does not rest solely on individuals, it requires strong commitment and collaboration with organisations, communities, action from non-Indigenous Australians, and mainstream services and systems.
What is being done to address racism in the health system?
Peak Aboriginal and Torres Strait Islander health bodies argue that boosting culturally safe clinical care may substantially contribute to Indigenous health improvements. Moreover, help address the gaps in health and wellbeing between non-Indigenous and Indigenous Australians. The 2020 National Agreement on Closing the Gap has recognised the importance of listening to the voices and aspirations of Aboriginal and Torres Strait Islander people, and has implemented this as a foundational measure in the new approach to address inequalities between First Nations people and non-Indigenous Australians. This new approach recognises the need for community controlled organisations in order to deliver best services and outcomes, and the urgency for government agencies and institutions to address systemic racism and promote cultural safety, and transfer power and resources to communities. Both of these critical elements have been adopted as priority reform areas two and three of the Agreement.
The central role of community controlled services (CCHS) is transferring control to community members to ensure the health and wellbeing of the local community is addressed. Parties within the Agreement have acknowledged that CCHS are better for First Nations people, achieve better results, employ First Nations people, and are often the preferred service type.
Where CCHS aren’t available, it is critical that mainstream services provide care that is culturally safe. Culturally safe health care involves understanding a patient’s culture, acknowledging differences and being actively mindful and respectful of these, understanding theory of power relations, having an appreciation of historical contexts, and acknowledging racism at an individual and institutional level and its impact on First Nations peoples.
Culturally safe health care is defined by the users experience regarding the care given, and the ability to access services and raise concerns. The Australian Institute of Health and Welfare has developed the cultural safety in health care for First Australians Monitoring Framework, which underpins the National Aboriginal and Torres Strait Islander Health Plan 2013-23. The AIHW monitoring framework helps enable the 2013-23 plan to reach its aim of producing a health system that is culturally safe, free of racism and inequality, and one where access is available to services that are effective, high quality, appropriate and affordable.
‘This Health Plan provides a clear focus on strategies to address racism and to empower people to take control of their own health.’ Hon Warren Snowdon MP
The extent to which racism permeates the health system has also been acknowledged and reflected in the 2020 National Close the Gap Agreement, within priority reform area 3: Decrease the proportion of Aboriginal and Torres Strait Islander people who have experiences of racism. Government parties and partnering stakeholders have committed to undertaking system-focused efforts to address features of systems that cultivate institutionalised racism.
APHRA which regulates the 750,000 Australian registered health practitioners have set out a 2020-25 Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy, with the aim to eliminate racism from the health system. Through setting education standards, and producing consistency and quality improvements, the aim is to make cultural safety norms for Aboriginal and Torres Strait Islander patients.
‘You cannot have an aboriginal flag or piece of artwork or a totem attached to your facility and then think you’re culturally safe and responsive to the health needs of that community.’ Jamie Newman, CEO of Orange Aboriginal Medical Service
What more can be done?
Under the Racial Discrimination Act 1975, it is unlawful to discriminate against a person based on race, colour, descent, national or ethnic origin, or immigrant status. This protects people from racial discrimination in public life, for example getting or using services, but clearly this isnt enough.
‘Aboriginal and Torres Strait Islander peoples’ lives, health and wellbeing cannot be put at risk because of underlying racism and prejudice.’ Professor Fiona Stanley
The Australian Government announced its support of the United Nations Declaration on the Right of Indigenous Peoples in 2009. This Declaration is an international instrument on the rights of Indigenous peoples and has established a universal framework of minimum standards for the survival, dignity and well-being of Indigenous peoples. Despite Australia’s voting in support, it is obvious that several Articles within the framework have not been met, for example;
Article 2 ‘Indigenous peoples and individuals are free and equal to all other peoples and individuals and have the right to be free from any kind of discrimination, in the exercise of their rights, in particular that based on their Indigenous origin or identity.’
Australia’s Race Discrimination Commissioner, Chin Tan, has launched a plan to establish a National Anti-Racism Framework and has called on the Federal governments support. Racism is an economic, social and national security threat to Australia and we need to treat it as such. Australia has not had a national anti-racism strategy in place since 2018 and federal funding ended for the plan in 2015.
‘The Black Lives Matter movement has focused community attention on issues of racial injustice, and there is now unprecedented community support to address these issues. Now is the time to implement a national framework dealing with racism.’ Commissioner Chin Tan
Heathcare initiatives to combat racism
St Vincent’s Hospital & Katherine Hospital
Sydney’s St Vincent’s Hospital recently went from being the worst in the state to one of the best when caring for Aboriginal and Torres Strait Islander patients in emergency, similar to the actions of Katherine Hospital in the Northern Territory.
‘A high number of Aboriginal people were coming in through our emergency department and were leaving us, not completing their treatment’ - Pauline Deweerd, Director of Aboriginal health at St Vincent’s
‘More than ¼ Indigenous patients left Katherine Hospital before completing treatment, often without informing staff.’ Simon Quilty, Physician
Scott Daley has been the person behind the scenes making change happen at St Vincent’s, implementing the new Indigenous Flexic-Clinic. The program ensures Aboriginal patients that come into emergency are quickly triaged, treated, offered support or care by an Aboriginal staff member and referred for ongoing care through the expanded Aboriginal health unit where possible. This approach allows for connections to be made and has made a big difference for outcomes and safety levels. One of the key successes has been expanding the Aboriginal health unit’s operating hours, ensuring patients are able to complete their treatment. Since the introduction of this program, the rate of incompleted treatment for Indigenous patients has reduced from 19.5 per cent to 1.6 per cent.
The NT Department of Health conducted an investigation into the staffing crisis at Katherine Hospital, and found significant deficiencies in nearly all essential dimensions of safe clinical service provision, with the root cause being that the unsustainable medical service model, progressively getting worse. Following this, a new general manager and group of doctors joined the hospital with the objective of turning the rate of incomplete treatment around. The rate of incomplete treatment by Indigenous patients in Katherine Hospital dropped from 11 per cent to 4 per cent with the introduction of specific measures by these new practitioners. Changes that improved the rate of incomplete treatment were, the implementation of highly trained specialist doctors invested in the community, interpreters, and consultations with families regarding complex treatment plans.
The challenges that St Vincent’s and Katherine Hospital faced around providing care for Aboriginal and Torres Strait Islander peoples aren’t unique, so these cases of community initiatives could be seen as blueprints for hospitals around the country.
‘The Matrix’ is a tool that rates the extent to which health care institutions are racist, with scores based on the following 5 measures: inclusion of Indigenous people in governance, implementation of relevant policies, rates of Indigenous employment, service delivery and financial accountability for Indigenous funding. It was developed by Henrietta Marrie; an Elder of the Gimuy Walubara Yidinji people of Far North Queensland and Director of the soon-to-be-established First Peoples Think Tank at Central Queensland University, and her husband Adrian.
‘When patients leave against medical advice, that means they got home still very ill and often death happens very quickly.’ Henrietta Marrie
The Matrix has been applied to hospitals and health centres within Queensland. The maximum score possible is 140, indicating no institutional racism. Findings showed that of the 16 facilities analysed, 10 scored less than 20 placing them in the extreme range of institutional racism, and 6 in the very high range. This tool quantifies institutional racism for policymakers, and gives health facilities concrete steps on how to reduce institutional racism.
The spread of COVID-19 to Aboriginal and Torres Strait Islander populations was predicted to have devastating outcomes, but at the end of 2020, cases of COVID-19 among First Nations peoples were 6 times lower than compared to the rest of Australia. This has been attributed to the leadership in First Nations communities, building trust in using community and individual solutions and promoting the Aboriginal Community Controlled sector. Moverover, implementing, strengthening and promoting culturally safe care, Aboriginal leadership and strengths based approaches stopped underlying racism and prejudice from impacting the health and wellbeing of Aboriginal and Torres Strait Islandr people.
Benefits of taking action
Culturally safe services within the health system reduce clinical variations, are cost effective and efficient forms of care, reduce racism and discrimination, and increase understanding and cultural capacity. Benefits for the Aboriginal and Torres Islander community include, improved patient perceptions and experiences of care, greater ability to have family involved, and improved wellbeing, access and equality.