Chapter 1 | Health impacts of racism

• Integrate reflexive practice into continuing professional development, including reflecting on how your own cultural perspective, privilege, power, assumptions and biases may impact on the delivery of healthcare for Aboriginal and Torres Strait Islander patients, their families and communities.⁵ One example of a guide to help you do this is the ‘8 ways’ identity mapping exercise.
• Ensure staff receive training about trauma and its impacts, as well as cultural safety.^15,30
• Build your practice’s capacity to attract, recruit, retain, support and develop Aboriginal and Torres Strait Islander staff, for example using guidance from the Barring Djinang Aboriginal cultural capability toolkit.
• Check that people know their rights and support them to speak up if their rights are not being respected.¹⁵ For example, refer them to the Human Rights Commission or a racism register (eg ‘Call It Out’), or offer to register the incident on their behalf. Display posters or other communications materials from anti-racism and human rights campaigns, such as ‘Call It Out’ and Racism. It stops with me.
• Build partnerships with Aboriginal and Torres Strait Islander organisations to provide better support, including referrals to programs, and improve culturally safe care.¹⁵
• Communicate clearly in trauma-informed ways, taiored to the person: use plain English and translators when needed and explain the processes and actions involved in an assessment or treatment, including asking permission before doing anything involving touch. Try to make people feel comfortable, taking time to build trust.¹⁵
  • Where possible, allow additional time for providing healthcare to people who have experienced trauma (eg Stolen Generations survivors).¹⁵
  • Be aware that family members may also be experiencing the impacts of trauma and may need support.¹⁵
  • Be guided by each person as to whether they want to talk about their traumatic experiences (including experiences of racism) and, if people do share their stories, consider how this can be included in their care plan.
  • Validate people’s feelings when they share their stories of racism or other trauma. Provide perspective, for example by explaining it is not their fault. Provide tools for empowering and healing. Avoid making dismissive statements about people’s trauma.
• Avoid making assumptions about people’s needs and health based on race. Treat the specific circumstances and risk factors experienced by the individual patient.
• Support self-determination by engaging meaningfully in shared decision making. For example, use the ‘Finding your way’ model to guide and improve conversations with Aboriginal and Torres Strait Islander people.

Key guidelines and statements

• CARI guidelines: Recommendations for culturally safe and clinical kidney care for First Nations Australians
• AIDA position statement: Cultural safety
• National Health Leadership Forum: Position paper on institutional racism
• RACGP position statement: Racism in the healthcare system
• RACGP: Standards for general practices, 5th edition 

Reporting racism

• Human Rights Commission
• Racism. It stops with me
• ‘Call It Out’ First Nations racism register

Addressing racism

• Ending racism video and Check Up tools
• Anti-racism kit
• Guide to bystander intervention
• Bystander anti-racism project
• Institutional racism matrix template (Appendix 1)

 Culturally safe practice

• AIDA cultural safety training
• Barring Djinang Aboriginal cultural capability toolkit
• ‘Finding your way’ shared decision-making model
• Systems assessment tool developed by the One21seventy project

 Trauma-informed care

• Healing Foundation factsheets for GPs: Working with the Stolen Generations
• Blue Knot training courses and resources, including information on becoming trauma-informed and talking about trauma
• We Al-li culturally informed trauma integrated healing approach training
• Closing the Gap Clearinghouse resource sheet: Trauma-informed services and trauma-specific care for Indigenous Australian children

Background

What is racism?

Racism can be defined and conceptualised in various ways, including by reference to the modes through which it operates (eg structural, institutional or interpersonal forms of racism).^31,32 Each of these various forms of racism is a manifestation of ‘systems within societies that cause avoidable and unfair inequalities in power, resources, capacities and opportunities across racial or ethnic groups’.³³ Such systems are based on social categories of ‘race’ that have no biological basis,^28,34–36 yet are invoked by dominant groups to ‘devalue, disempower, and differentially allocate valued societal resources and opportunities to groups defined as inferior’.³⁷

Racialisation is a social phenomenon by which people are categorised into ‘races’ based on phenotypic characteristics, ancestry and/or culture, which are assumed to confer essential innate characteristics or differences.^32,38 Although racial science has been discredited, and race is considered ‘neither useful nor scientifically valid as a measure of the structure of human genetic variation’,²⁸ racialisation persists along with racist attitudes, behaviours, worldviews and social structures that act to perpetuate each other.^31,38 Racist social structures include ‘the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice…[which] in turn reinforce discriminatory beliefs, values, and distribution of resources’.³⁸ Although race has no basis in biology, racism has biological consequences for racialised peoples by undermining the determinants of health and inflicting trauma and stress through racist systems and discrimination.¹

Central to racism is the use of power and privilege by certain groups within society, and the subsequent oppression, cultural suppression and inequity experienced by other racialised groups.^32,38 In Australia, British settler-colonists racialised and dehumanised Aboriginal and Torres Strait Islander peoples as part of legitimising invasion and theft of land, territory and resources, and concomitant attempted genocide. Prior to British invasion and colonisation, Aboriginal and Torres Strait Islander peoples practised a diversity of cultures that sustained the health and wellbeing of communities and Country — land, waters, air, plants, animals and their and their inter-relatedness – through reciprocal relationships of care between people and Country.^39,40 Country, culture and community are central to the health and wellbeing of Aboriginal and Torres Strait Islander peoples. An important aspect of many Aboriginal and Torres Strait Islander cultures is kinship. Kinship establishes a system of shared obligations and duties that define social roles and community belonging, and provide a form of governance that supports the harmonious thriving of families and communities.^41,42 Since colonisation, these systems of ensuring wellbeing have been impacted by ongoing and compounding waves of violence and trauma.⁴³ This has had devastating effects on the health and wellbeing of Aboriginal and Torres Strait Islander peoples both directly and indirectly, through damage to the cultural systems that help communities thrive.⁴⁴

Health inequities currently experienced by Aboriginal and Torres Strait Islander peoples result from the ongoing impacts of colonisation. This includes racism inherent in contemporary societal structures and ideologies that suppress Aboriginal and Torres Strait Islander cultures and perpetuate political exclusion and ‘differential access to risks, opportunities, and resources that drive health’.³⁷ Historical and ongoing processes of colonisation and racism are forms of trauma. They have violently disrupted connections with Country, culture and community for Aboriginal and Torres Strait Islander peoples, and introduced health risk factors that have ongoing and intergenerational effects. For example, government-sanctioned removal of children from their families has caused and continues to cause complex trauma for Aboriginal and Torres Strait Islander individuals, families and communities.⁴⁵

How does racism impact health?

Racism can affect health through multiple pathways,^1,33,38,46 including through exposure to physical, psychosocial, socioeconomic and legal stressors, which can co-occur, interact and compound over life courses and generations, in addition to the effects of coping behaviours in response to these exposures.³⁸ Racism impedes access to protective social, cultural, environmental and economic determinants of health and wellbeing, such as nutritious food, clean drinking water, adequate housing, neighbourhood infrastructure, education and employment opportunities, financial security, connection to Country and self-determination.^2,33,38,47 Beyond preventing access to positive determinants, racism also introduces negative determinants through stress, trauma and the risk of physical injury and death from exposure to racially motivated violence.^1,33,38 Furthermore, racism contributes to inequitable access to healthcare and legal services, which serves to exacerbate or entrench poor health outcomes and limits access to supports and behaviours that are protective of health and wellbeing.¹⁸

One direct pathway between racism and health is through stress. Experiencing or anticipating racism activates the fight-or-flight response, as is the case with any threat that a person perceives.¹ This involves activation of the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, which produces a state of alertness with elevated heart rate, blood pressure, blood glucose and inflammation.¹ When these stress response pathways are repeatedly or chronically activated, alterations occur in numerous bodily systems, including the cardiovascular, gastrointestinal, endocrine, metabolic, neurological and immune systems, with long-term immunosuppressive effects.⁴⁸

The cumulative physiological burden related to repeated and chronic activation of stress pathways is known as allostatic load.^1,48 Biomarkers associated with allostatic load include salivary cortisol, insulin-like growth factor-1, C-reactive protein, fibrinogen, immunoglobulin E, interleukin 6, high-density lipoprotein, low-density lipoprotein, glycosylated haemoglobin, blood pressure, heart rate and urinary noradrenaline, among others.^1,48,49 Higher allostatic load and overload are associated with poorer health outcomes across a range of conditions in clinical and general populations, including all-cause mortality, cardiovascular disease, diabetes, cancer, psychological distress and periodontal disease.^48–50 A study of Aboriginal adults (n=336) in urban and regional areas of Australia found that higher levels of exposure to childhood stress and trauma were significantly associated with dementia diagnosis.⁵¹ A recent international analysis of a large sample (n=5062) of older adults found that allostatic load explained the excess risk of all-cause mortality among those experiencing discrimination.⁵² A study of Indigenous peoples in Canada found that the frequency of discrimination in childhood was significantly associated with adult allostatic load, even after adjusting for age and income.⁵³ That study also found that engagement with Indigenous culture buffered the adverse effects of childhood discrimination on adult allostatic load.⁵³

Internationally, there is not an agreed method for measuring exposure to racism. Most research to date has focused on measuring experiences of interpersonal discrimination, which can be captured using survey instruments. Exact quantification of the prevalence of experiences of racial discrimination is difficult given the inability to comprehensively capture experiences of racial discrimination. This is compounded by differences in study populations, study designs and measurement instruments used across studies. However, it is well established that experiences of interpersonal racial discrimination are common among Aboriginal and Torres Strait Islander peoples in everyday life and in healthcare settings.^2–4 It is also well established that there are strong links between experiences of interpersonal discrimination and negative health and wellbeing outcomes, both from international studies^33,54 and studies specifically with Aboriginal and Torres Strait Islander populations.^2–4

A recent national study involving over 8000 Aboriginal and Torres Strait Islander adults found a significant dose–response relationship between discrimination and various measures of social and emotional wellbeing, health behaviour and health outcomes.⁴ For example, compared with those who reported experiencing no discrimination, those who had experienced moderate or high discrimination had a higher prevalence of:

• psychological distress, low happiness, low life satisfaction, frequent experience of pain, doctor-diagnosed depression, doctor-diagnosed anxiety
• ow control over life, choosing not to self-identify as Aboriginal and/or Torres Strait Islander, feeling torn between cultures, feeling disconnected from Aboriginal and/or Torres Strait Islander culture
• ever having alcohol dependence, being a current smoker or gambling in the past year
•  poor or fair general health, diabetes, heart disease, high blood pressure and high cholesterol.⁴

A separate study of Aboriginal and Torres Strait Islander men found that discrimination was associated with a higher prevalence of suicidal thoughts.⁵⁵

Racism occurs within many institutions in Australia; healthcare settings are no exception.^9,56 Furthermore, experiencing interpersonal racism in healthcare settings is associated with ‘increased psychological distress over and above what would be expected in other settings’.⁹ The importance of eliminating racism in healthcare settings and government institutions has been recognised in the National agreement on closing the gap and the National Aboriginal and Torres Strait Islander health plan 2021–2031.^17,22 Both these documents set priorities to identify, monitor and address all forms of racism in order to improve health outcomes for Aboriginal and Torres Strait Islander peoples. Both documents also recognise that strong Aboriginal and Torres Strait Islander cultures are fundamental to improved health and wellbeing.^17,22 At the general practice level, racism should be considered in any interaction with Aboriginal and Torres Strait Islander people, not only as a potential cause of the symptoms patients present with, but also in terms of the risk of the practice and practitioners within it exposing patients and others to racism.

All practitioner–patient interactions exist within a sociopolitical context, and it is imperative that non-Indigenous healthcare practitioners recognise the power dynamics at play within such interactions and how their own cultural assumptions and worldviews can affect the experience and outcomes of their Aboriginal and Torres Strait Islander patients and colleagues.⁵⁷ While eliminating racism requires systems-level reform across the health, legal and other sectors,¹⁸ GPs and practices can play important roles in the collective effort required to heal from the trauma of racism and prevent its perpetuation.

Several Australian clinical guidelines deal directly with the primordial prevention of racism, as do position statements of peak bodies and partnerships such as the National Health Leadership Forum, the Australian Indigenous Doctors’ Association and the RACGP.^5,6,58,59 Within this guidance material, approaches to preventing racism include ensuring the provision of culturally safe care and addressing institutional racism at multiple levels.

No international clinical guidelines were found that explicitly address racism. A review of clinical guidelines by the US Preventive Service Task Force (USPSTF) in 2021 found that although many guidelines in the US addressed racial disparities, none addressed racism directly.³⁵ The USPSTF review also found that although many organisations have issued statements and commitments around racism in healthcare, few have provided substantive guidance on operational steps to address the effects of racism.

Given that racism functions on multiple levels, interventions to address racism must also occur at multiple levels. A scoping review on antiracism interventions in outpatient healthcare settings identified the following aspects required for successful antiracism action:

• leadership buy-in and commitment with dedicated resources, support and funding
• a multilevel approach beginning with policy and organisational interventions
• transparent accountability mechanisms for sustainable change
• long-term meaningful partnerships with racialised communities
• ongoing mandatory tailored staff education and training.⁶⁰

These aspects are consistent with those put forward by the World Health Organization (WHO) in their research brief Strengthening primary health care to tackle racial discrimination, promote intercultural services and reduce health inequities.⁶¹ These aspects are also reflected in many of the recommendations made in clinical guidelines developed by Aboriginal and Torres Strait Islander organisations regarding racism and cultural safety, outlined below.

Many clinical guidelines and related materials emphasise the need for care to be culturally safe.^5–7,58,59 The RACGP Standards for general practices (5th edition) includes Criterion C2.1 ‘Respectful and culturally appropriate care’, which must be met in order to achieve and maintain practice accreditation.¹⁹ The Australian Health Practitioner Regulation Agency (Ahpra) National scheme’s Aboriginal and Torres Strait Islander health and cultural safety strategy 2020–25 acknowledges that ‘Cultural safety is a critical component of patient safety, and cultural safety must be defined by Aboriginal and Torres Strait Islander Peoples’.⁸ Ahpra offers the following guidance on how health practitioners can ensure culturally safe and respectful practice:

• Acknowledge colonisation and systemic racism, social, cultural, behavioural and economic factors that impact individual and community health
• Acknowledge and address individual racism, [individual] biases, assumptions, stereotypes and prejudices and provide care that is holistic and free of bias and racism
• Recognise the importance of self-determined decision making, partnership and collaboration in healthcare that is driven by the individual, family and community
• Foster a safe working environment through leadership to support the rights and dignity of Aboriginal and Torres Strait Islander people and colleagues.⁸

Box 1 contains a description of cultural safety offered by the National Health Leadership Forum, a collective partnership of Aboriginal and Torres Strait Islander national organisations relating to health and wellbeing.

A recent systematic critical synthesis of the cultural safety education literature in the context of Indigenous health in Australia, Aotearoa New Zealand, Canada, and the US found that although there is a growing body of literature exploring best practice approaches to cultural safety education, this tends to focus on curriculum content and structure rather than the effectiveness of teaching methods or how to assess it.⁶² That review also noted that reflexivity is seen as a central skill for cultural safety; however, there is a lack of clarity around reflexivity as a concept and how best to teach or assess it.⁶²

Although currently there is insufficient evidence around how best to teach reflexivity, relevant guidance on how to practice aspects of reflexivity and cultural safety exist, including resources developed by or in collaboration with Aboriginal and Torres Strait Islander people, such as the 8 ways identity mapping exercise, cultural safety training developed by the Australian Indigenous Doctors’ Association (AIDA), the Barring Djinang Aboriginal cultural capability toolkit and other materials listed in the Useful resources section. Strategies under the National Scheme’s Aboriginal and Torres Strait Islander health and cultural safety strategy 2020–25 include work to ensure consistent definition of cultural safety across the National Scheme, consistent incorporation of cultural safety into health professions’ codes of conduct and the development of continuous professional development and an upskilling strategy for the registered health workforce.⁸

An important part of cultural safety includes providing feedback mechanisms so that patient experiences can inform continuous quality improvement regarding cultural safety. This is particularly important because cultural safety can only be assessed by those experiencing the care (not the providers of care). Feedback mechanisms must be safe, effective and accessible for Aboriginal and Torres Strait Islander patients. The need for such complaints processes is recognised by the National Aboriginal and Torres Strait Islander health plan 2021–2031 (objective 8.3).¹⁷ General practitioners can support this by providing Aboriginal and Torres Strait Islander patients with information about their legal rights to access culturally safe healthcare,¹⁸ and how to provide feedback about care they have received, either to their practice or other relevant agency, such as the Human Rights Commission (see Useful resources). 

Cultural safety training has been put forward as one mechanism to work towards improved cultural safety within healthcare, as well as other settings. However, concerns exist that some forms of cultural safety training have become exercises in ‘ticking the box’ rather than meaningfully engaging in high-quality content that is integrated into ongoing practice.¹³ This concern is reflected in the CARI Guidelines Recommendations for culturally safe and clinical kidney care for First Nations Australians⁶ and the AIDA position statement on cultural safety,⁵ which recognise the need for cultural safety training to be well credentialed and designed by Aboriginal and Torres Strait Islander people. One example of the integration of cultural safety training within a broader intervention is the Ways of Thinking, Ways of Doing (WoTWoD) program, which involves a half-day cultural respect workshop, practice support from a cultural mentor and a toolkit to guide activities to embed cultural respect into routine practice.⁶³ This mixed-methods evaluation of the WoTWoD program with 10 practices in south-western Sydney found that participation improved cultural strategic thinking among practice staff (as measured by the Cultural Quotient, which measured three capabilities: cultural strategic thinking, cultural motivation and cultural behaviour). It also led to changes within the practices in physical settings and organisational processes, as well as increased engagement of the practices with Aboriginal organisations.

Another aspect of ensuring cultural safety for Aboriginal and Torres Strait Islander patients includes embedding trauma-informed approaches in healthcare services.^13,14 This recognises that respectful, culturally safe practice requires understanding the role that historical, collective, intergenerational and other trauma plays in the lives of Aboriginal and Torres Strait Islander peoples and communities. Understanding trauma and how it impacts individuals, families and communities is key to clinicians providing trauma-informed care.¹² Trauma-informed care promotes and prioritises safety by ensuring cultural competence, developing trusting relationships, sharing power and governance, supporting patient control and decision making and providing integrated care to improve accessibility and continuity of care.^7,12,64

Clinicians can implement trauma-informed care by building trusting and egalitarian relationships, engaging in open communication, minimising distress and maximising patient autonomy. This could include asking for consent to perform procedures; being flexible and allowing time for breaks or stopping procedures if the patient is distressed; collaborating with patients and their families to develop plans of care; and multidisciplinary collaboration and referrals. ⁶⁴ The Healing Foundation has developed resources to support trauma-informed care for Stolen Generations survivors, which are broadly relevant for all Aboriginal and Torres Strait Islander peoples.¹⁵ Other resources and training are listed in the Useful resources section. Evidence on the effectiveness of specific trauma-informed changes in practice is limited. However, a recent synthesis of literature on trauma-informed care found that it could be beneficial for all patients, regardless of trauma history, in terms of feeling more respected, in control and comfortable during healthcare interactions. ⁶⁴ 

The need for structural transformation in order to eliminate institutional racism is emphasised in the CARI Guidelines Recommendations for culturally safe and clinical kidney care for First Nations Australians,⁶ Priority Reform Area Three of the National agreement on closing the gap²² and recommendations from several peak bodies such as the AIDA and the National Health Leadership Forum.^5,21 In order to address institutional racism, it needs to be recognised, routinely measured, monitored and acted upon at multiple levels. A tool developed to monitor institutional racism in public hospitals health systems, known as the ‘Matrix’, sets out key indicators and criteria across five domains: participation in organisation leadership/governance; policy implementation; service delivery; recruitment and employment; and financial accountability and reporting.³⁰ Some of these areas are applicable to general practice (eg reporting on recruitment and employment of Aboriginal and Torres Strait Islander staff at all levels). A Systems Assessment Tool developed as part of the One21seventy project may also be useful in helping general practices assess opportunities to improve the functioning of their practice systems to deliver quality care for patients.⁶⁵

An important part of addressing institutional racism is ensuring that the design and delivery of healthcare services reflects community priorities.⁵ Both AIDA and the National agreement on closing the gap (Priority Reform Area 3) recommend working in genuine partnership with Aboriginal and Torres Strait Islander communities to achieve this.^5,22 However, practices must be mindful to avoid overburdening community; prior to reaching out to community organisations, practices should draw from existing literature and guidance developed by Aboriginal and Torres Strait Islander peoples.

No existing clinical guidelines were found that include recommendations around screening patients for experiences of racism. No evidence was found relating to the effectiveness of screening for racism in preventing or mitigating harm from racism. There is a risk of causing harm if questions about experiences of racism are asked without the capacity to respond appropriately, or in the absence of cultural safety and respectful trusting relationships. We can learn from the evidence around screening for complex trauma, noting that not all experiences of racism are experienced as complex trauma. Research on community preferences regarding complex trauma screening for Aboriginal and Torres Strait Islander parents showed that the ‘majority of stakeholders supported the importance of assessing each of the proposed complex trauma domains with Aboriginal parents. However, strong concerns were expressed regarding where, by whom and how this should occur’.²³ The researchers of that study concluded that:

…assessments to identify Aboriginal parents experiencing complex trauma should only be considered when the prerequisites of safety, trusting relationships, respect, compassion, adequate care, and capacity to respond are assured. Offering choices and cultural and strengths-based approaches are also critical. Without this assurance, there are serious concerns that harms may outweigh any benefits for Aboriginal parents.²³

This aligns with WHO criteria identifying when screening for a condition/factor is warranted, one of which is whether the screening procedures and appropriate interventions are acceptable to the population being screened.²⁴ As one example, one Aboriginal Community Controlled Health Organisation (ACCHO) has included questions about discrimination/racism in their annual health assessment (715 health check). This ACCHO is understood to be viewed as culturally safe by its patients and to have strong links with the local community. All practitioners who deliver this assessment completed a multiday training course on ‘courageous conversations about race’. No evidence exists to date on the effectiveness of this approach.

Many current risk algorithms include Aboriginal and Torres Strait Islander status as a ‘risk factor’ for disease; that is, an Aboriginal and/or Torres Strait Islander patient is assigned a higher score strictly on the basis of being Aboriginal and Torres Strait Islander. However, Aboriginal and/or Torres Strait Islander identity in itself is not a risk factor for disease.²⁵ The assumption underpinning the inclusion of Aboriginal and Torres Strait Islander status in a risk algorithm is that, at the population level, Aboriginal and Torres Strait Islander people are more likely than non-Indigenous people to experience disadvantage across social, environmental and other factors that may pose an increased risk of the disease outcome. However, the use of Aboriginal and Torres Strait Islander status as a risk factor conflates individual-level risk with population-level risk. Exposure to risk and protective factors vary widely within the Aboriginal and Torres Strait Islander population, and assessments of risk are only accurate if they are based on an individual’s own risk profile, rather than the risk profile of the population.

The Recommendations for culturally safe and clinical kidney care for First Nations Australians from CARI Guidelines strongly recommend ‘removing Indigenous status as a risk factor for chronic kidney disease because the increased risk is explained by adverse social determinants of health, leading to a greater burden and progression of chronic kidney disease’.⁶ It is acknowledged within the literature that the use of race-based algorithms can risk exacerbating inequities.^26,27 That is, algorithms that assign a higher risk score on the basis of race perpetuate the fallacy that race is a biological rather than social construct, which, in turn, distracts from the need to address the social and structural issues causing racial inequities. Conversely, algorithms that require racialised patients to meet a higher threshold of illness severity to receive comparable care to non-racialised patients can reproduce or entrench health disparities.²⁷ Although the removal of race from such algorithms needs to be addressed at the level at which these algorithms are developed, at the practice level clinicians can be mindful about their the use of these algorithms and use them only when the ‘race correction’ is warranted as a compensatory mechanism for the structural issue causing the racial difference in outcome.

Clinicians should recognise that there are diverse experiences, socioeconomic situations and exposure to risk factors and protective factors among Aboriginal and Torres Strait Islander people. Gaining a holistic understanding of a patient’s individual risk profile can be supported by comprehensive health checks and inform appropriate responses to the specific needs of individual patients.