Health professionals' duty of care includes combating racism in society as well as in health care settings
The Australian Government's proposed changes to the Racial Discrimination Act 1975 and the repeal of section 18C has transfixed national debates on legally defining racial discrimination.1 Under these changes, racial discrimination would no longer include acts that “offend, insult, humiliate or intimidate” a person based on the person's race, colour or national or ethnic origin and instead be limited to acts that “incite hatred” or “cause fear of physical harm”.2 These proposed changes have been framed in the context of enabling “free speech”, yet, evidence presented in this issue of the Journal shows that they have potential to cause harm. In this issue, Kelaher and colleagues highlight the prevalence of racism as experienced by Indigenous Australians and its deleterious effects on mental health.3 Alarmingly, almost every Aboriginal Victorian participating in this study reported an experience of racism in the preceding 12 months, which included jokes, stereotypes, verbal abuse and exclusionary practices. The experiences of racism reported here neither incited hatred nor caused fear of physical harm, yet resulted in harm such as psychological distress, especially when meted out in our health care system. These findings are a stark reminder that racism is indeed an important health issue, and as health professionals, our duty of care extends to contributing to these broader policy discussions.
This study also highlights the importance of addressing racism in the health care services that we work in, as the association between racist encounters and increased psychological distress was even more pronounced within our own settings. The mandated shift in medical training to be inclusive of Indigenous health is a critical step forward in enabling culturally competent practice.4 Yet tackling racism is a complicated task; not least because, paradoxically, it requires us to “remain conscious of race while at the same time challenging the common sense presuppositions of racial rule”.5 The debunking of race as a biological construct6 has not deterred sociological meanings of race, which infiltrate everyday explanations of physical, social and cultural differences, and form many of the racist encounters Indigenous people experienced in this study. Addressing racism thus requires us to see race and think critically about our own imaginations of racialised bodies rather than purport to be “race or colour blind”. Unpacking one's own cultural values and assumptions can be an uncomfortable experience, but health practitioner discomfort should not inspire inaction. Culturally safe care through practitioner reflexivity is a vital instrument of good medical practice.
As the Journal celebrates 100 years, the Inala Indigenous Health Service in Queensland is on the eve of celebrating 20 years of service, and provides a powerful example of the importance of culturally safe health care for Indigenous Australians. In 1994, the Inala Health Centre General Practice, a mainstream practice, was not accessed by the local Indigenous community because they felt humiliated and insulted by staff.7 People did not feel cared for and therefore did not access the health care on offer. Under the stewardship of Noel Hayman, the service responded by critically reflecting on its culture and engaging in honest, albeit uncomfortable, conversations about its “treatment” of Indigenous people. Resulting changes included employing and collaborating with Indigenous people, alongside systematic cultural awareness training that was taken seriously. Since 1995, the Inala Indigenous Health Service has increased from 12 to over 10 000 registered Indigenous patients and has become a Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care.8 Improved health through improved access to health care came about through improved relationships between health practitioners and Indigenous people. Quoting from one patient of the service,
we got the best doctors in the world here . . . Not talking down to us, talking to us, do you understand? This is what a black fella can't take, he can't take it when a man talks down to him . . . he'll get up and say, “Yeah, yeah, yeah,” walk out and do the same thing. But when you sit down and talk with him, talk to him, he takes notice. That's what these fellas do here honestly, I tell you the best staff in the world here . . . 9
Both the Inala example and the study by Kelaher et al highlight how influential culturally safe health care is in addressing Indigenous health inequality. While race and racism operate as powerful ideological and structural tools of oppression within and outside of the health setting, there remains tremendous capacity in our health system and within the scope of individual health practice to mitigate the effect of racism on Indigenous health outcomes.
Provenance: Commissioned; not externally peer reviewed.
- 1. Griffiths E. Racial Discrimination Act amendment: federal government leaves open possibility of altering proposed changes. http://www.abc.net.au/news/2014-03-25/racial-discrimination-act-changes-george-brandis/5343464 (accessed Jun 2014).
- 2. Australian Government Attorney-General's Department. Amendments to the Racial Discrimination Act 1975. http://www.ag.gov.au/consultations/Pages/ConsultationsonamendmentstotheRacialDiscriminationAct1975.aspx (accessed Jun 2014).
- 3. Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities. Med J Aust 2014; 201: 44-47. <MJA full text>
- 4. Mackean T, Mokak R, Carmichael A, et al. Reform in Australian medical schools: a collaborative approach to realising Indigenous health potential. Med J Aust 2007; 186: 544-546. <MJA full text>
- 5. Sturm C. Blood politics: race, culture and identity in the Cherokee nation of Oklahoma. Berkeley: University of California Press, 2002.
- 6. Pearce N, Foliaki S, Sporle A, Cunningham C. Genetics, race, ethnicity, and health. BMJ 2004; 328: 1070-1072.
- 7. Hayman NE, White NE, Spurling GK. Improving Indigenous patients' access to mainstream health services: the Inala experience. Med J Aust 2009; 190: 604-606. <MJA full text>
- 8. Hayman NE, Askew DA, Spurling GK. From vision to reality: a centre of excellence for Aboriginal and Torres Strait Islander primary health care. Med J Aust 2014; 200: 623-624.
- 9. Bond C, Brough M, Spurling GK, Hayman NE. “It had to be my choice” Indigenous smoking cessation and negotiations of risk, resistance and resilience. Health Risk Soc 2012; 14: 565-581.
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