RACGP National Faculty of Aboriginal and Torres Strait Islander Health

Submission to Australian Human Rights Commission

National Anti-Racism Partnership and Strategy

May 2012

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Correspondence and enquiries should be directed to:

Associate Professor (Dr) Brad MurphyChair, National Faculty of Aboriginal and Torres Strait Islander Health

orMs Lauren CordwellManager, National Faculty of Aboriginal and Torres Strait Islander Health

Royal Australian College of General Practitioners1 Palmerston CrescentSouth Melbourne VIC 3205

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IntroductionThe Royal Australian College of General Practitioners (RACGP) is a membership-based organisation for general practitioners, with over 19,000 Australian-registered GP members. In April 2010, it established the National Faculty of Aboriginal and Torres Strait Islander Health (‘the faculty’) to ‘advocate for culturally appropriate health delivery systems that will improve health outcomes for Indigenous Australians’.1

This submission to the Australian Human Rights Commission National Anti-Racism Partnership and Strategy has been prepared by the National Faculty of Aboriginal and Torres Strait Islander Health. Whilst its responses apply specifically to aspects of racism experienced by Aboriginal and/or Torres Strait Islander patients in the general practice context, many comments are also relevant to experiences of other cultural groups, and to other environments.

Background Shortly after its formation, the faculty developed a RACGP position statement on Aboriginal and Torres Strait Islander Health, which includes the sentence:

The RACGP deeply regrets the degree of covert racism and stereotyping of Aboriginal and Torres Strait Islander people and calls on Australian general practitioners to challenge racism especially within the context of general practice.2

It followed up with a number of initiatives to correct possible misperceptions by GPs and their practice team of Aboriginal and Torres Strait Islander culture, health and life circumstances, and health services. These initiatives include:

The development of an online activity: Introduction to Aboriginal and Torres Strait Islander cultural awareness in general practices for GPs and practice staff wishing to register for the Practice Incentives Program Indigenous Health Incentive

The development of introductory cultural protocols and guidelines for RACGP members and staff working with Aboriginal and Torres Strait Islander individuals, communities and organisations

The preparation of a paper to be accessed from the faculty website (not yet published), identifying commonly held myths and misconceptions held by primary health care professionals and countering them with facts

The establishment of a ‘What you are saying’ section on the faculty website, where general practitioners and other health professionals talk about their experience of working in Aboriginal and Torres Strait Islander health, developing culturally safe work practices and identifying Aboriginal and Torres Strait Islander people

In addition, the faculty has engaged in a number of initiatives to encourage working at the RACGP to ensure that their work positively affects Aboriginal and Torres Strait Islander health, consistent with a commitment made in the RACGP position statement. Many staff who participated in any of these initiatives have told us that their understanding of issues affecting Aboriginal and Torres Strait Islander health increased substantially. We believe that word of mouth within the RACGP can positively influence the knowledge and attitudes of staff who did not attend.

At the same time, we are aware, anecdotally as well as from research, that Aboriginal and Torres Strait Islander patients and communities experience various forms and degrees of racism in their access to, and experiences with, primary health care services.

1 RACGP National Faculty of Aboriginal and Torres Strait Islander Health website, http://www.racgp.org.au/aboriginalhealth2 RACGP National Faculty of Aboriginal and Torres Strait Islander Health website, http://www.racgp.org.au/policy/Aboriginal_Health_policy.pdf

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We know that some reception and administration staff, as well as some GPs, may be responsible for Indigenous patients’ experiences of racism, and perhaps without being aware of being so. We believe that the influence of all general practice staff on Indigenous patients’ continued use of, and achievement of health benefits from, primary health care services can be profound.

For example, a medical receptionist is usually the ‘gatekeeper’ to the GP, and will influence the powerful first and last impression that a patient will have of their encounter with a health service. A negative experience can result in the complete cessation of practice visits. In addition, some GPs hold very strong views, often amounting to stereotyping, about Aboriginal and Torres Strait Islander people. As research shows, this attitude can filter through to the nature and quality of the health care provided, with direct and indirect effects on health outcomes of their Aboriginal and Torres Strait Islander patients.

The knowledge and opinions of non-Indigenous health professionals are quite likely to be no different to those of their equivalents in any other profession. We believe that people can act in racist ways as a result of limited relevant educational opportunities, little or narrow experience with Aboriginal and/or Torres Strait Islander communities, peer group and media influence, or sheer lack of interest. From our experience, if these people have the opportunity to form different attitudes when presented with facts, opinions or personal experiences that challenge these assumptions, many will respond positively. Other people, of course, clearly have a fixed position on the status of ‘other’ people, are committed to racist opinions and philosophies, and are therefore greatly resistant to change.

We put forward suggestions to address the different degrees of racism described above.

In addition, we refer to the concept of institutional or systemic racism, defined as ‘Requirements, conditions, practices, policies or processes that maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups’.3

We believe that this concept is very relevant to many primary health care organisations, particularly those who have, or believe they have, few or no Aboriginal or Torres Strait Islander patients in their practice. We therefore put emphasis on system change within general practices in our responses below, and focus less on interventions at the individual or community level.

In addition, we are aware that racism and unequal access to health care exists in all parts of the health care system. We draw attention, for example, to reports of Indigenous hospital patients receiving lower levels of stroke identification or early intervention in cardiac treatments and other conditions, of racism expressed towards pregnant Aboriginal and/or Torres Strait Islander women affecting the birth weight of their babies, and leading to ongoing health complications.

While our focus is on primary health care, we believe that the patient experience is derived from all points of contact in the wider health system. Because the whole ‘patient journey’ requires safe and high quality health service delivery along the whole health care continuum, we recommend that a broader investigation or inquiry be conducted into institutionalised racism towards Aboriginal and Torres Strait Islander people in the wider health system. This could include a focus on:

Allied health services, pharmacies, diagnostic services etc Specialists Hospitals Support services such as Medicare Locals

3 Paradies, Y., Harris, R. & Anderson, I. 2008, The Impact of Racism on Indigenous Health in Australia and Aotearoa: Towards a Research Agenda, Discussion Paper No. 4, Cooperative Research Centre for AboriginalHealth, Darwin.

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This submissionThis submission has been prepared by the faculty with a view to responding to selected relevant questions posed by the HREOC in the context of staff working in general practice.

Objective 1: Create awareness of racism and how it affects individuals and the broader community

1. What information would be useful to include in a campaign to prevent and reduce racism?

We would support the communication of information to primary health care staff designed to enhance their awareness of racism and its effects in the primary healthcare environment. This is consistent with the Ottawa Charter for Health Promotion, a key document in the public health arena, which states:

The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.4

We believe the information needs to be communicated in an engaging way that promotes dialogue and avoids confrontation and blame. Because of the scale and effects of racism in primary health care, a targeted campaign is recommended, tailored to the general practice environment.

Information and communication strategies could include:

Well-designed wall posters, available from HREOC free of charge to any general practice or community health service and hospital, advising that patients from all cultural backgrounds are welcome, thus ensuring practice staff, as well as patients, receive the message.

Videos and online educational activities on racism and its effects, accessible free of charge from the HREOC website. These could be considered for incorporation into relevant Quality Improvement and Professional Development (QI&CPD) points for health professional organisations.

Development and distribution of a document describing common myths and misconceptions about Aboriginal and Torres Strait Islander people in the health care context, and authoritatively countering each of them with facts. This could be provided to general practices, hospitals and other health services to use for induction and refresher programs for staff.

General awareness-raising campaigns (for example, through television and print advertising) to bring to people’s attention the facts about racism and its effects on health.

Presentations at major primary health care conferences and articles in regular medical publications, reporting key research activities conducted on racism in primary health care and its effects.

Communication of a more specific nature to primary health service boards, service directors, CEOs and executive management teams, on issues relating to institutional racism and how to develop systemic cultural competency across the organisation’s policies, processes and people.

4 Ottawa Charter for Health Promotion, http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf,

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2. How could we better acknowledge the contributions to Australia of Aboriginal and Torres Strait Islander peoples and culturally and linguistically diverse communities?

We believe that many non-Indigenous Australians are unaware of the many cultural and other achievements of Aboriginal and Torres Strait Islander people, and of significant historical events since colonial settlement. This is evident from comments in the (over 800) participant evaluations of the RACGP online cultural awareness activity, referred to earlier. Our recommendations to GPs, made in our introductory cultural protocols and guidelines paper, are relevant here:

Although it is vital that GPs are aware of the health circumstances of Aboriginal and Torres Strait Islander people, it is important that this view does not dominate or drive their overall knowledge of, or attitude to, Indigenous people. Educational and other communication materials for GPs should focus on alternative dimensions of strength and achievement, including health-seeking behaviours. This would emphasise a ‘strengths based approach’ to communities, acknowledging their resilience and health care approaches that work well, that is a holistic approach to health care

Ensure GPs are aware of, and encourage them to celebrate, relevant national and state Aboriginal and Torres Strait Islander events, such as ‘Close the Gap’ Day, Reconciliation week, NAIDOC

Encourage GPs to include ‘Welcome to country’ or ‘Acknowledgement of country’ as appropriate, in major events, such as conferences, workshops and significant meetings

Encourage GPs to participate in the increasing number of Aboriginal and/or Torres Strait Islander cultural activities that are available, and to learn more about Australian history from an Indigenous perspective

Encourage GP participation in face-to-face cultural awareness training and ongoing engagement with their local community, for example, seeking advice from community elders who can suggest a possible ‘cultural mentor’ for the health professional

Objective 2: Identify, promote and build on good practice initiatives to prevent and reduce racism

1. What are the priority areas in which we should be addressing racism (for example: employment, education, sport, the media, cyber-racism?)

Given the reports of the high incidence of racism experienced by Aboriginal and Torres Strait Islander people when accessing primary health care, and what we now know of its effects, including on health, we believe that primary health care services – and the entire health care system - should be one of the priority areas.

At the same time, because of the widespread, pernicious, often institutionalised and frequently subtle nature of racism in Australia, we also believe that much more research, education and discussion of a more general kind needs to be conducted in the area.

How can we involve young people in addressing racism?

We recommend that the curriculum at all medical schools should include a substantial component on racism and its effects, and opportunities to develop cultural competence. The concept of cultural competence in perceptions and action is explored more fully in the doctoral thesis by Shaun Ewen, Cultural competence in medical education.5

5 Ewen, S. C. (2011). Cultural competence in medical education: a university case study. Doctorate, Centre for the Study of Higher Education, Melbourne Graduate School of Education, The University of Melbourne.

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We also draw attention to the work of the Committee of Deans of Australian Medical Schools (the CDAMS Indigenous Health Curriculum Framework, http://www.limenetwork.net.au/files/lime/cdamsframeworkreport.pdf , which demonstrates a thoughtful and comprehensive approach to medical student training. We recommend that this is extended to teaching in other health disciplines

We believe that young people also need to have the opportunity to develop skills to identify and deal with overt and covert racism that they encounter. This could be provided in educational institutions at all levels. These opportunities would have more effect if they were offered in the context of university/school/college policies and procedures to deal with racism at all levels.

2. How could these experiences be shared to help promote good practice? (For example: a best practice website, clearing house, seeding funding for pilot programs, changing criteria for Government grants programs?)

Any of the above would be useful. For ‘time-poor’ GPs, having an accessible and easily searchable best practice website would be important. For this reason, the faculty recommends the use of an existing and known website dedicated to primary health care practitioners (such as Australian Indigenous HealthInfoNet, http://www.healthinfonet.ecu.edu.au/?gclid=CKjhmqHM9K8CFYYepAod33pLEw). Objective 3: Empower communities and individuals to take action to prevent and reduce racism and seek redress when it occurs

1. What strategies or approaches can be used to help individuals and communities who experience racism to speak up or take action? If you have experienced racism, what would have helped you to speak up or take action?

We recommend that the engagement of peak bodies such as the National Congress of Australia’s First People, ANTAR and the National Aboriginal Community Controlled Health Organisation (NACCHO) and its state and territory Affiliates in this issue should be sought in relation to this question.

At the same time, we believe that racism is everyone’s business, and that racism in health care is the business of health care practitioners, whether Indigenous or not. For GPs and practice staff advocating alongside Aboriginal and Torres Strait Islander people for their right not to experience racism and discrimination can be a powerful way to give voice to the individuals and communities who experience racism.

However, in order for the above to be effective, there needs to be a process that both empowers people who experience racism to speak up and/or take action, and promotes confidence that their voice will be heard. This process needs to be clear, safe, simple and accessible to victims of racism. There are precedents for bodies of this kind, particularly in respect of workplace-related complaints such as bullying, and we recommend that an organisation be established to hear complaints and experiences of racism and to respond effectively.

2. What strategies or approaches can be used to help bystanders address racism where and when it occurs?

We believe that strategies to empower and skill primary health care professionals to recognise racism when it occurs in their workplace and to address it appropriately are very important in working towards reducing its incidence in the longer term. We believe that this should start with an awareness-raising and information campaign as identified above. This could then be followed up by a campaign directed to those ‘bystanders’ who wish to act, suggesting possible responses to racist comments and

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behaviours. This could be augmented by case studies on video or interactive online educational programs.

The ‘speaking up against racism’ section of websites such as All Together Now (http://www.alltogethernow.org.au/ and ANTAR (http://www.antar.org.au/issues_and_campaigns/health/racism ) provide useful information and resources to help people to address instances of racism appropriately, safely and effectively. These would be readily applicable in the primary care context and possibly more realistic than comprehensive organisational change strategies.

We believe this approach, while challenging people to express their ‘moral courage’, could be highly effective because:

It is non-confrontational, in that the call for change is to the ‘bystander’, not the perpetrator, who may be resistant to direct appeals to change their behaviour, but more responsive to social sanction

It assumes the best intentions of the bystander, ie that people who do not overtly exhibit racist behaviours are not racist, and so should be supported to do something about racism when they observe it

It helps address the ‘bystander effect’, where if racist behaviour occurs in a group context, each individual is less likely to react because of the perceived influence of the group or the expectation that someone else will intervene

It offers a way forward for people who feel outraged at racist behaviour but fail to act because of fear, embarrassment, or lack of confidence in their skills

It brings the topic of racism into workplaces and other institutions, thus helping to undo the sense that racism is a taboo subject

Over time, it may lead to a critical mass of people who willingly and confidently take action when they witness racism, and thus start to extinguish the sense that racism is tolerated in our country

Final commentsAustralia is often described as a tolerant country, and many of its citizens would say that they don’t treat anyone differently. At the same time, the arguments in the media and in politics about the rights of groups such as refugees and Aboriginal and Torres Strait Islander people, and about the validity of multiculturalism as an ideal, quite possibly give people implicit ‘permission’ to voice racist views. These views are often expressed in a subtle way, often introduced by the phrase ‘I’m not racist, but...’. We believe this kind of racism is becoming more prevalent, possibly because people are confused about whether racism is acceptable in this country or not. We believe that a national dialogue on racism would be a powerful way to send a clear message to us all.

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