Aboriginal and Torres Strait Islander peoples are the First Peoples of Australia, and have diverse, rich and continuing connections to culture, Country, traditional languages, family and community. These connections are powerful drivers of health and wellbeing.1-3 A skilled general practitioner (GP) respects and incorporates Aboriginal and Torres Strait Islander cultures and languages, so that patients are empowered to maintain their cultural identity while benefitting from primary healthcare tailored to their unique beliefs, context and needs.
The source of health inequities
Aboriginal and Torres Strait Islander peoples continue to demonstrate resilience and determination. However, through intergenerational trauma and historical and ongoing dispossession and disempowerment, colonisation continues to have a profound impact on health outcomes.4 The existing health inequity is inexcusable, with an overall burden of disease among Aboriginal and Torres Strait Islander peoples more than double that of non-Indigenous Australians, and a life-expectancy gap that remains unacceptable.5
This health inequity reflects the relative privileges that non-Indigenous people benefit from in socioeconomic and healthcare access, in comparison to Aboriginal and Torres Strait Islander peoples. Colonisation and systemic racism lead to structural disadvantage across all domains of socioeconomic determinants of health for Aboriginal and Torres Strait Islander peoples, with disparity in income, employment and education being particularly significant.5 Racism additionally directly affects both physical and psychological health.6,7
Successive Australian governments have failed to adequately address the ongoing consequences of colonisation. Despite the implementation of some specific measures and a Commonwealth commitment to ‘Closing the Gap’ since 2007, there has been mixed progress towards equity in socioeconomic determinants and health outcomes.8 There remains a relatively significant underspend in health funding not commensurate to Aboriginal and Torres Strait Islander disease burden, and key health policy recommendations remain largely unfunded and unimplemented.9
Cultural safety in general practice
Cultural safety is determined by Aboriginal and Torres Strait Islander individuals, families and communities. Culturally safe practice is the ongoing critical reflection of health practitioner knowledge, skills, attitudes, practising behaviours and power differentials in delivering safe, accessible and responsive healthcare free of racism.10
Healthcare services are not immune from reinforcing colonisation-based power imbalances.4,11 Additional to structural discrimination, reported experiences of interpersonal racism are common in healthcare contexts.12 Regardless of workplace location, GPs will likely see Aboriginal and Torres Strait Islander patients. Where available, dedicated Aboriginal and Torres Strait Islander medical services provide a significant level of care. However, in major cities fewer than 15% of patients usually attend such services, and even in very remote areas only 75% of patients usually attend a dedicated service, accessing available mainstream services instead.5 As such, the provision of culturally safe care in all primary healthcare settings is essential. This requires healthcare providers to acknowledge and address their own biases, attitudes and assumptions, as well as systems and policies, that might reinforce the colonialism, racism and privilege at the heart of health inequities.4,13,14
Cultural safety also requires healthcare professionals and organisations to understand their own cultural lens and examine the potential impact of their own culture on clinical interactions and healthcare service delivery.13 The majority of primary healthcare services are founded on non-Indigenous social and cultural norms. For Aboriginal and Torres Strait Islander peoples whose lived experience is of different social and cultural norms, unfamiliarity, discomfort and an expectation that patients will conform to the system’s norms can act as a barrier to healthcare.15,16
Aboriginal community controlled health organisations provide care aligned with Aboriginal and Torres Strait Islander cultures, values and community-driven goals for health and wellbeing. Non-Indigenous primary healthcare providers can learn ways to improve cultural safety from these models.
Cultural learning and self-reflective practice
Seeking to understand the cultural, historical and social fabric of the local community – and tailoring communication to local cultural communication styles and linguistic realities – can assist in building therapeutic relationships with communities, families and patients.16,17 In recognition of the significant diversity in language and cultural practices between and within urban, rural and remote Aboriginal and Torres Strait Islander communities, a focus on lifelong learning will contribute to ensuring care meets the specific beliefs, values and needs of each Aboriginal and Torres Strait Islander patient, as defined by them. Partnership building with local Aboriginal and Torres Strait Islander Elders, health professionals and organisations is an essential component for developing relevant knowledge and skills.15,17
In undertaking this learning, it is important to remember that no practitioner can ever know everything about all Aboriginal and Torres Strait Islander peoples’ cultures and communities, because cultural identity is complex, evolving and experienced uniquely by each Aboriginal and Torres Strait Islander person. Too much of an outward focus on the ‘other’ can reinforce stereotypes, assumptions and misunderstandings. A self-reflective focus creates humility, curiosity and a lifelong willingness to learn.16,18 It is not lack of cultural knowledge of Aboriginal and Torres Strait Islander peoples that most contributes to poor therapeutic relationships, but rather a failure to understand the local colonial and sociocultural context in which healthcare encounters are occurring.4,13
Advocacy is also a required competency of the GP. Primary healthcare practitioners are uniquely placed to partner with Aboriginal and Torres Strait Islander patients, their families and communities, to advocate for support to mitigate barriers to equitable healthcare access. Additionally, GPs can be a powerful voice and ally in advocating for improved investment in culturally appropriate, structural responses to health inequity.