In reply: Lawson suggests that my conclusions1 are not justified, and that they may "cause more harm than good". I strongly disagree.
He suggests a number of alternative explanations, including "social" admissions for remote patients, and poor coding, but these do not account for the differences observed. Over half of the separations identified as Indigenous were of urban (19%) or rural (33%), rather than remote, area residents. Disparities in procedures for Indigenous and other patients were evident for each area. Almost half (46%) the separations identified as Indigenous were in principal referral or major hospitals, where coding should be of a high standard. Indigenous–non-Indigenous disparities existed within each hospital category. The results presented in my report1 were adjusted for area of residence, hospital category, as well as several other factors, and large differences in procedures remained.
Lawson also suggests that rejection of medical advice by Indigenous patients may play an important role. Rejection of advice certainly occurs on occasion, by both Indigenous and non-Indigenous patients. I question whether it is "common", as Lawson suggests, but that is not really the point. It would be far more productive to ask why and how this occurs, and how interactions between healthcare providers and Indigenous patients can be improved.
Lawson takes exception to my raising the possibility of systematic discrimination in the Australian healthcare system, referring to it as "alarming". In that we are in complete agreement. I, too, find it alarming. However, unlike Lawson, I choose not to deny it, but to accept it as an important challenge. My aim is not to make medical practitioners defensive, but to invite them to participate in finding ways to reduce disparities. Systematic discrimination can occur even when well-meaning people are trying to do the right thing. The systems in which we work can defeat our best intentions, even when we don't realise it. The reasons why a procedure was not performed on a particular patient may be perfectly sound given the circumstances. What we must ask ourselves is how those circumstances came to be, and what we can do to change them.
I agree with Lawson that some Indigenous people are sensitive about research, but I do not accept that they will "reject future investigations that are essential to their welfare". On the contrary, I expect that many Indigenous people would be happy to participate with healthcare providers in the development and implementation of creative solutions to improve the healthcare system.
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