To overcome health inequities between Indigenous and non-Indigenous peoples in Australia and New Zealand, health professionals and their institutions need to take a long, hard look at themselves and their biases, according to public health physician Dr Rhys Jones.

Health professionals, health care organisations and educational institutions must commit to the lifelong, transformative ‘unlearning’ processes of decolonisation, he says.

Jones is a Senior Lecturer at Te Kupenga Hauora Māori, University of Auckland, and below is an abridged version of his Redfern Oration at the RACP 2014 Future Directions in Health Congress. The article was first published in RACP News and is cross-posted here with permission.

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But I treat all my patients the same…

Rhys Jones writes:

Indigenous health in Australia and New Zealand is characterised by inequities in health outcomes, in the determinants of health, in access to and quality of healthcare, and in representation in the health workforce. These inequities are unacceptable and represent a breach of the right to health for Indigenous peoples. 

Health inequalities between Indigenous and non-Indigenous populations are not natural or inevitable; they are created and maintained by our societies’ structures, systems and institutions. 

As people who operate within these systems and institutions, it’s important that we ask the difficult questions – about the roles we play in perpetuating health disparities, but also about the roles we can play in reducing and eliminating them.

Examining these questions highlights the need to decolonise medical education and practice, which in turn requires us to decolonise ourselves.

Health care disparities

It is evident from a wealth of international literature that racial and ethnic disparities in healthcare are widespread. In New Zealand, for example, Māori patients tend to receive less care than non-Māori patients – shorter consultations, fewer referrals for investigation and management, and less effective treatment. 

This is despite generally having much greater need for healthcare, due to a substantially higher burden of disease, and facing greater barriers to achieving optimal healthcare outcomes.

Research shows that racial and ethnic inequalities in healthcare can be attributed to characteristics of the health system, patient or population differences, and health professional factors. 

In other words, while other factors also play a role, health professionals contribute to unequal outcomes for Indigenous patients. When confronted with evidence of our contribution to disparities, the response is often denial: ‘But I treat all my patients the same.’

While we may be quite happy to admit that there is a problem, we’re generally much less willing to admit that we might be part of the problem. 

So how do we account for this gap between perception and reality? What explains the discrepancy between our intent (to treat all patients as well as we can) and the outcome (some patients receiving better care than others)?

Implicit and explicit bias

The key to explaining the divergence between intent and outcome is recognising the role of unconscious processes and how they can influence our practice. It has been shown that unconscious biases and stereotypes can affect our thoughts and actions irrespective of how egalitarian our conscious attitudes are.

A theoretical model developed by US researchers shows how clinician factors, patient factors and characteristics of the setting and wider society interact to ultimately produce different quality care based on the patient’s ‘race’ or ethnic group.

None of us are immune to implicit biases – our perceptions and judgments of others are shaped by social values, beliefs and discourses from a very young age.

In settler societies like Australia and New Zealand, representations of Indigenous peoples can be traced back to colonial ideologies about Western superiority and Indigenous inferiority. We internalise these associations, which are then reinforced through medical education and training.

So, going back to the comment, ‘I treat all my patients the same’, based on the preceding discussion our default assumption should be that we will treat patients inequitably. That is, unless we do something fundamentally different.

What does this mean for us as healthcare practitioners?

The fact that biases and stereotypes are the result of social conditioning (that affects everyone) does not absolve us of the responsibility to do something about them.

There are tools that can help us to identify areas where we may have ‘blind spots’ – in other words, where implicit bias may betray our overt attitudes and beliefs – such as the Implicit Association Test (IAT).

Being aware of our own biases is important because it allows us to do something about them. In the short term, we can correct for or consciously override potential biases. In the longer term, there are strategies that can help us ‘rewire’ cognitive connections that result in the expression of bias.

In order to address biases, experts suggest that we should be engaging in lifelong, transformative ‘unlearning’ processes. 

A really important message is that we can’t do this alone – if we only reflect in the solitude of our own thoughts, we will only ever come up with analyses and solutions from our own (biased) frame of reference. This highlights the need for social reflective processes.

What does this mean for medical education and training?

Medical curricula need to be redirected away from cultural ‘awareness’ or ‘sensitivity’ towards much more transformative educational processes.

The objective of the exercise is not to learn about Indigenous culture(s); it is to learn about ourselves and our positioning with respect to Indigenous peoples.

We should be aiming for what Kumagai and Lypson describe as ‘critical consciousness’: ‘the continuous critical refinement and fostering of a type of thinking and knowing – a critical consciousness – of self, others, and the world.’

What does this mean for medical colleges?

In the pursuit of ‘critical consciousness’, medical colleges need to provide opportunities for trainees and fellows to engage in transformative processes that can address the effects of implicit and explicit biases.

Further, these activities must be established as part of the formal curriculum during training and continuing professional development. They are critical for the development of core competencies and therefore cannot be left to individuals to engage in based on personal motivation. The implication is that such activities need to be explicitly incorporated into teaching, learning and assessment processes throughout the educational continuum.

But modifying the curriculum is only one part of the answer; in order to truly become part of the solution, systemic change is required.

Medical colleges themselves need to engage in decolonisation – identifying colonial baggage and engaging in reform to address factors that perpetuate disparities.

This requires systematic monitoring and assessment of equity, formally identifying and addressing structures and processes that limit Indigenous health development, introducing proactive policies to improve Indigenous participation and success, and training and performance monitoring for staff, supervisors and assessors.

Importantly, none of this will succeed if Indigenous stakeholders are marginalised in the process; effective governance arrangements are needed to give expression to Indigenous aspirations and solutions.

In conclusion

As health professionals, whether or not we like to admit it, we contribute to health care inequities between Indigenous and non-Indigenous populations in Australia and New Zealand.

This happens in part due to the way social environments shape our psychological makeup, manifesting as implicit and explicit biases. To achieve equity, we need to decolonise ourselves – by engaging in lifelong, social, transformative ‘unlearning’ processes.

We also need to decolonise healthcare organisations and medical education institutions including medical colleges. A fundamental ingredient for success is Indigenous partnership at all levels – not simply involvement or consultation, but genuine structural reform to ensure that Indigenous voices drive solutions.

Albert Einstein noted that ‘no problem can be solved from the same level of consciousness that created it’.

If we are to make real differences to Indigenous health outcomes, we are not going to do it with the same thinking and structures that got us to this point.

This requires a warts-and-all decolonisation process – not only for us as individuals but also for our educational institutions and healthcare organisations.

(The references embedded in the text above are at the bottom of the post.)

• Dr Rhys Jones (Ngāti Kahungunu) FNZCPHM. On Twitter: @rg_jones

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Note from Croakey: on related themes

• Journalists and our institutions can also learn much from these approaches, as argued recently: Decolonising practices: can journalism learn from healthcare to improve Indigenous health outcomes?  The article, which I co-authored with Professor Pat Dudgeon, Associate Professor Kerry McCallum and Professor Matthew Ricketson, was published by The Medical Journal of Australia.

• A report on decolonising HIV research in Canada, by Marie McInerney.

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References 

Australian Human Rights Commission 2005. Achieving Aboriginal and Torres Strait Islander health equality within a generation – a human rights based approach. In Social Justice Report 2005, Ch. 2.

Reid P, Robson B. Understanding health inequities 2007. In Robson B, Harris R. (eds). Hauora: Māori Standards of Health IV: a study of the years 2000–2005. Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare, pp. 3–10.

Bacal K, Jansen P, Smith K 2006. Developing cultural competency in accordance with the Health Practitioners Competence Assurance Act. NZ Family Physician; 33(5):305–309.

Smedley B, Stith A, Nelson A 2002. Summary. In Smedley B, Stith A, Nelson A (eds). Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academy Press, pp. 1–28.

Lurie N, Fremont A, Jain A et al. 2005. Racial and ethnic disparities in care: the perspectives of cardiologists. Circulation; 111(10):1264–1269.

van Ryn M, Burgess D, Dovido J, Phelan S, Malat J, Griffin J, Fu S, Saha S, Perry S 2011. The impact of racism on clinician cognition, behavior and clinical decision-making. Du Bois Review: Social Science Research on Race; 8(1):199–218.

Wear D, Kumagai A, Varley J, Zarconi J 2012. Cultural competency 2.0: exploring the concept of ‘difference’ in engagement with the other. Academic Medicine; 87(6):1–7.

Kumagai A, Lypson M 2009. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Academic Medicine; 84(6):782–787.

 

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