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Institutional racism – our duty of care to patients and staff

21 August 2020 Blog - Dr Julian Vyas

ASMS National Executive member and Auckland Starship Hospital paediatrician Dr Julian Vyas writes about how racial bias in the New Zealand healthcare system may not only affect health outcomes, but can also affect minority ethnic healthcare workers. He argues that tackling systemic racism requires action at both an organisational and individual level.  He asks all health staff to reflect on their own workplace, to be open to the possibility of subconscious bias existing and how it may affect colleagues.

If not now, when? 

Institutional racism in New Zealand – our duty of care to patients and staff

race (n):

  1. a class, or group, of people, unified by shared characteristics or traits.
  2. a competition between individuals or groups.

It is a curious coincidence that the English word for ethnic categorisation also refers to a contest where there is only one winning team, or person … and the rest are losers.

It is no revelation at all to state that a racial bias in health outcomes has been evident in New Zealand for a long time.  The troubling effects of this disparity are all too frequently seen by ASMS members in their daily clinical practice.  The recently published Health and Disability Review unequivocally describes the longstanding and disproportionate harm suffered by non-Pakeha and resource-poor people in New Zealand; let down by a system that seems incapable of ensuring equity of healthcare access and outcome.

Initiatives to improve aspects of planned care for disadvantaged groups might redress some effects of systemic racial bias in healthcare outcomes.  Yet whilst the underlying legacy of colonialism remains (e.g. denial of agency, poverty, inequity of opportunity, inadequate quantity, and quality of housing etc), they risk being little more than do-goodism.  Without rectifying the fundamental unfairness that exists in New Zealand healthcare  – that equity is compromised by ethnicity – prioritising some clinic and surgery waiting times would be akin to mistaking palliative care for a cure.  Only comprehensive, “root and branch” change gives any hope of properly tackling this problem.

At a time of examining a system that has allowed ethnic group outcome differences to persist, it is important to also consider how the self-same inherent racial bias might also affect the workplace environment for minority ethnic healthcare workers.  I am not referring to overt antipathy such as hate speech, but to more subtle forms of institutional racism in New Zealand healthcare, which up to now have received precious little attention.  When I have spoken with colleagues from ethnic minorities many can readily recount experiences where their ethnicity has prompted assumptions about them as individuals or determined the assignment of specific tasks.  ASMS’ observation is that throughout the New Zealand health sector, there is a paucity of representative ethnic diversity in leadership groups.  For healthcare workers who identify as being part of a minority group, the lack of leadership role models risks implicit signalling that “the system” has a lower expectation of achievement, and fewer opportunities.  For some, this can then dissuade ambition and blight confidence for career development as a health leader – even if such consequences are considered utterly unacceptable by existing leadership of all the health organisations.  More recently, more Māori and people of other ethnicities hold posts as senior leaders and managers, and such increased representation is welcome.  But much more is still needed; not just in DHBs, but also in all health professional councils, medical colleges, professional societies, the Ministry of Health, and health sector unions (including ASMS).

Tackling systemic racism is not just an organisational responsibility, but also needs to happen closer to home – with all of us also actively engaged in helping to solve this problem.  I don’t suggest that any colleague would knowingly exhibit discriminatory or racist beliefs towards others.  Rather, we all need to be mindful of a more insidious form of racism, when appearance and accent influence subconscious assumptions about a person’s character and abilities.  Episodes of this are described as “micro-aggressions.” These are events that to some of us, and when seen in isolation, may not appear offensive or derogatory.  However, it is accepted that repeated exposure can cause the recipient to suffer cumulative and incremental belittling, of undermining of their self-worth, and a mutual reduction in expectation of being respected by colleagues.

There are many types of micro-aggression including lower performance expectations, invalidation of competency or opinion, denying someone’s previous experiences of racism as them over-reacting to “teasing” or “banter.” Similarly, it can be considered racist when colleagues consider someone to be a spokesperson or archetype for their ethnic group rather than an individual.  If the occurrence of microaggressions persists, unchallenged, it can reinforce negative workplace behaviours and expectations – for everybody.  Whenever we recognise these pre-judgements, in ourselves or others, we must identify them for what they are, and consciously look to avoid perpetuating the occurrence of these microaggressions.  This requires a volitional change in attitude by individuals and organisations – to shift from having a multi-cultural perspective, to being actively anti-racist.

I have witnessed racism towards health staff in the UK, and in New Zealand.  Although I am of mixed race, I make no claim to have suffered from workplace discrimination to the extent that I perceive other colleagues to have.  Nonetheless, I have liked to consider myself sensitive to this issue.  Recently, I have begun to realise that I am not nearly as attuned to this problem as I would like to think.  I have found it “challenging” (an understatement!) to reflect on how I have benefitted from “white privilege.” And, to recognise my own feelings of defensiveness and fragility as I have come to understand the extent to which I have been privileged.  If any of us (myself included) are motivated to address the effects of racism in our workplaces, we can start by considering how institutional racism may have given us some career and life advantages over others.

To tackle systemic racism requires action at both an organisational and individual level.  We must all recognise that some of our colleagues and friends will regularly suffer racism, and for everyone’s sake we must all be part of the solution.  It is past time that healthcare agencies across New Zealand act fully, and in concert, to address the systemic injustice that persists.  The necessary methods to identify the existence of workplace racism, and palette of solutions to address it, are likely to be very similar for all healthcare-related agencies.  Governmental agencies (MoH, DHBs, TAS, PHARMAC etc), related NGOs (medical colleges, health unions, professional councils, medical and other clinical schools), and commercial healthcare providers (in primary and secondary care) should work collectively to understand the prevalence of workplace racism across the health sector.  A good starting point would be for these organisations to canvass all their employees/members about their own experiences of racism.

Historically some health leadership roles may have been appointed to because the applicant was “a good fit,” or someone was shoulder tapped to sit on a committee.  Going forward, there might be benefit, at a shortlisting or appointment stage, for routine external scrutiny of decision (e.g. by the Human Rights Commission).  An inter-organisational policy and practise of training and mentoring co-workers from diverse backgrounds is also needed – to support individuals to develop leadership skills, and to promote confidence that the system will equitably recognise and promote anyone with talents.  I would also encourage individual ASMS members to talk with medical and non-medical colleagues from non-NZ Pakeha backgrounds, to better understand their experiences of working in the New Zealand health system.

Although this article considers the experiences of colleagues from ethnic minorities, we should also seek the same understanding of the experiences of our workmates who identify with other minority groups e.g. those who have mobility limitations, or other disabilities.

At the risk of sanctimony, I believe we must all work together to tackle racism in all its forms; for the simplest of reasons – that it is unjust.  Regardless of this, I understand that what I am proposing may seem too difficult, complicated, or even painful a process for individuals and organisations to go through.  However, to continue to baulk would be wrong.  Human nature is strong enough that honesty about prior wrongs, accompanied by sincerity for remedial action, can bring justice to those who have been wronged.  Denial and obfuscation will not.

“See me, hear me.  Still you try to box me in.  You think you know my mind from the colour of my skin.”  – Box.  Asian Dub Foundation.  1995.