“It’s time we listened to the truth and act together as one” — Michael Yunupingu

TODAY is the last day of National Reconciliation Week. The theme for 2019, “Grounded in truth: walk together with courage, aims to bring attention to the fact that reconciliation efforts cannot be achieved unless Australians are willing to engage in challenging conversations about our nation’s colonial past and present. These conversations need to acknowledge the ongoing impact of colonisation and recognise that, for Aboriginal and Torres Strait Islander peoples, sovereignty has never been ceded.

In an act of reconciliation, we (a non-Indigenous doctor and an Indigenous doctor) collaborated to write a constructive piece about how non-Indigenous Australians can show respect, solidarity and better engage with Aboriginal and Torres Strait Islander peoples. While it is promising that many readers will take heed of these messages and resources, unfortunately, a handful of responses demonstrated that underinformed views remain among some members of the medical community. This only highlights the urgent need for truth-telling and its essential companion: listening.

The Australian Medical Council’s Aboriginal, Torres Strait and Māori Health Statement 2018 mandates the inclusion of Aboriginal, Torres Strait Islander and Māori health in medical education to achieve health systems that are equitable and free of racism. These last three words are critical: free of racism. We have to become comfortable with saying the “r” word and teaching medical students about the presence of racism in our health system and the negative impact this has on health outcomes for Aboriginal and Torres Strait Islander peoples.

When teaching First Nations Health to medical students, the term “cultural safety” is often misunderstood to mean teaching about “culture”, when in fact it is not about teaching culture at all, but instead about unpacking racism and bias. As Professor Gregory Phillips, a medical anthropologist, writes:

… unless curricula specifically trains health professionals to unlearn their unconscious bias or racism, then they are less able to effectively learn about Aboriginal cultures and good health outcomes. Cultural safety is an essential part of clinical safety and patient safety, not something extra – one can’t be clinically safe if one is racist or unconsciously biased”

With the support of organisations such as the Leaders in Indigenous Medical Education (LIME) and in response to the Australian Medical Council standards for accreditation, all medical schools and medical specialty training colleges must demonstrate that teaching cultural safety, or cultural competency as defined above, is a core part of their curricula (here and here).

Institutional racism does exist, including in our health systems, and is a major contributor to the health gap between Indigenous and non-Indigenous Australians (here and here). Institutional racism:

… refers to the ways in which racist beliefs or values have been built into the operations of social institutions in such a way as to discriminate against, control and oppress various minority groups”

Aboriginal and Torres Strait Islander peoples are less likely to receive appropriate care for coronary heart disease, less likely to receive some cancer treatments, less likely to be offered a kidney transplant, and wait longer for elective surgery. These are all examples of how institutional racism leads to poor health outcomes.

Incarceration rates are evidence of institutional racism. The interconnectedness of institutional racism and incarceration was exemplified by the tragic case of Ms Dhu. Ms Dhu was imprisoned for unpaid fines in Western Australia and 48 hours later died in custody, as a result of what the coroner described as “unprofessional and inhumane” handling by police and “deficient” care from hospital staff. The coronial inquest found that police and hospital staff had been influenced by prejudiced ideas about Aboriginal people. A medical expert, Professor Sandra Thompson, explained that if Ms Dhu had been a middle-class white person, “there would have been much more effort made to understand what was going on with that person’s pain. So that’s what institutional racism represents”. Ms Dhu’s death in 2014 amplified calls to honour the 339 recommendations of the 1991 Royal Commission into Aboriginal Deaths in Custody, one of which was an end to issuing arrest warrants for unpaid fines. This recommendation is yet to be enacted in all Australian states and territories.

Attitudes towards Australia’s black history that consider cultural and physical genocide to be a myth are unfortunately not uncommon in modern Australia. This speaks to a bigger issue about the lack of First Nations history in our education system from primary school, throughout tertiary education and beyond (here, here, here and here). There are multiple sources of evidence to debunk “myths” surrounding the occurrence of genocide, including countless oral histories from the stolen generations (here and here) and further testimonials from the original settlers as evidenced in their journals (here and here). When these sources of evidence were not considered proof enough and research became privileged as the most credible body of knowledge, numerous works have been written to detail our nations’ true history (here, here, here, here, here and here). In a visual display of the atrocities of the frontier wars, an Australian academic is working to systematically map out all the massacres that took place — events that are often omitted between stories of bush rangers and gold rushes.

Not only are challenging truths often denied, other tactics may be used to quiet potentially uncomfortable discussions. We wonder if male doctors would be advised to “stick to their knitting” as we were in response to our last article? The use of belittling claims which attack one’s integrity are unfortunately well known silencing mechanisms in public discourse around Indigenous issues. As doctors, with experience in medical education and Aboriginal and Torres Strait Islander health, our views are salient and should not be dismissed as uninformed, incorrect or irrelevant. These sorts of comments are a reflection of the privilege that manifests as superiority, when others assert that they know more about our areas of expertise or experience than we do.

These attitudes were also demonstrated recently by a response from a college CEO, who discounted and disputed an Indigenous doctor’s writing about their exposure to racism in the health system and during their specialty training program. Dr Kristopher Rallah-Baker, Australia’s first Indigenous ophthalmologist and the current president of the Australia Indigenous Doctors’ Association, described how he had experienced several instances of overt racism, often from superiors. Dr Rallah-Baker further reported how he believed racism and a lack of cultural safety has affected recruitment of Indigenous trainees into medical specialty training colleges. The dismissive response to Rallah-Baker’s article prompted a letter of support for Rallah-Baker from a wide group of health professionals, academics and members of Aboriginal and Torres Strait Islander communities and health services. A number of discussions ensued, resulting in the Royal Australian and New Zealand College of Ophthalmologists (RANZCO) and Rallah-Baker subsequently releasing a joint statement, with RANZCO committing to:

“… ensure a positive environment for Aboriginal and Torres Strait Islander trainees and to improve cultural safety amongst college members”

A true demonstration of reconciliation.

There is an urgent need for truth-telling about Australia’s colonial past and its impact on Aboriginal and Torres Strait Islander peoples’ present. We are encouraged by other readers who not only rejected negative comments, but were willing to call out these “antiquated” and “deeply held racist views”. People inherently dislike being called racist. However, racism only exists as a negative label if people fail to use it as an opportunity to self-reflect on their values and prejudice, and how these may influence their patient interactions and the wider health system.

The need for truth-telling in Aboriginal and Torres Strait Islander discourse carries on, and NAIDOC week continues the campaign with the theme “voice, treaty, truth”. It is not expected that this article will change years of entrenched racism; however, we must walk together with courage to tell the truth. Whether an individual wants to acknowledge the presence and negative influence of racism or walk past it, it is undeniable that health outcomes are inextricably worsened by racism.

Medical professionals are key stakeholders in the health system and need to take a leadership role in truth-telling by acknowledging the ongoing impact of Australia’s colonial past, striving to be culturally safe and demonstrating understanding, kindness and compassion. We as a medical community must work together to improve health outcomes, especially for Aboriginal and Torres Strait Islander peoples, and ensure that we do not let our own personal biases colour the care we provide.

We respectfully acknowledge the Traditional Owners and Custodians of the Country on which we are fortunate to work, live and continue to learn on. We also pay respects to all the Ancestors past, Elders present and influential First Nations Peoples with us today that have walked with courage and spoken truths before us. We are guided by their wisdom and inspired by their resilience in communciating this message.

Dr Alyce Wilson is a public health registrar at the Burnet Institute working in global maternal, child health and nutrition. Alyce has practical clinical and public health program experience working reciprocally with Aboriginal and Torres Strait Islander communities in Victoria, Cape York, the Torres Strait and the Northern Territory. She holds an appointment as a lecturer in First Nations’ Health and nutrition within the Department of Medical Education at the University of Melbourne.

Dr Ngaree Blow is a Yorta-Yorta, Noonuccal woman and doctor. She is currently working as the Director in First Nations’ Health at the University of Melbourne, as well as completing research in the intergenerational health team at the Murdoch Children’s Research Institute. She completed both her Masters of Public Health and the Doctor of Medicine degrees concurrently and has a keen interest in public health and paediatric medicine. She has been a member of the Australian Indigenous Doctors Association since 2011 and has been involved in many First Nations health and education roles.

 

 

 

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.


Poll

Racism exists throughout the Australian health care system








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11 thoughts on “Truth-telling fundamental to reconciliation

  1. Saul Geffen says:

    The authors clearly outline the many challenges faced by indigenous Australians and the responsibility we all hold to try and improve their outcomes.

    However would a truthful account not recognise that due to colonisation Indigenous woman are now emancipated? Have access to contraception, obstetric care, sexual health medicine? That First Nation people’s children now have the benefits of immunisations, treatments for streptococcus and nutritional advice?

    The wrongs perpetuated by colonial powers hundreds of years ago need not define our country and are not the only cause for poor Indigenous health outcomes.

    The clinics I run in Indigenous health centres I often see patients whose problems are color / race blind. If I close my eyes and just listen I could be speaking with Australians of any race or creed. The problems of smoking, arthritis, chronic pain and spasticity are not the fault of poor treatment of their ancestors

  2. Steve Trumble says:

    Really pleased to hear that RANZCO has now engaged with AIDA (the Australian Indigenous Doctors’ Association) to promote cultural training within the college. Actively addressing racism within our profession is to be congratulated, and other colleges should follow this lead.

    And speaking of congratulations, it’s wonderful to read such a clear, coherent piece written by two emerging academics. These two are worth watching. Every negative comment they receive only strengthens their message.

  3. Anonymous says:

    If 100% of the population accurately identified with the truth that Australia was invaded and Aboriginal people were dispossessed of their lands and cultures, there would still not be reconciliation in this country. That is because the reconciliation agenda has been hijacked by the likes of the authors of this article, who don’t actually understand what the term means. There are two prerequisites for reconciliation to occur – justice to repair the wrongs of the past, and forgiveness on the part of those wronged of the rest of us. To achieve true reconciliation, the perpetrators and the victims have to agree on these two points – what would constitute justice, and if delivered what would constitute forgiveness.

    In our country, forgiveness will mean abandoning the grievance industry that is represented in this article, it will mean taking personal responsibility for the things all citizens of a single unified nation take responsibility for as part of the implicit responsibilities of citizenship.

    In little more than a generation the political and medical left, of which I was a proud member, has been transformed by the woolly thinking resplendently displayed in this article. The old political left had faith that an Aboriginal child had the potential to be anything, regardless of the disadvantage they suffered. We worked towards the aim that overcoming material disadvantage would enable the full potential of all to be realised. For this we are apparently now uninformed and racist.

  4. Michael Keane says:

    1) Please, please, please can MJA Insight publish a liberal view on indigenous issues. (That’s small l liberal not Liberal Party). It seems only views that are based on the politics of identity are published by Insight.

    2) The authors would do well to verse themselves in the many arguments that show that disparate impact is NOT necessarily a sign of structural racism. One-sided conversations without a discussion of legitimate, academic opposing views does not achieve anything. There is intense debate about what disparate impact represents.

    3) The authors would do well to read detailed critiques of concepts such as unconscious bias.

    4) Yet again, the authors would do well to head the salient advice of the chief justice of the US Supreme Court who warned that if you want to stop racial discrimination, you have to stop discriminating on the basis of race.

    5) I thoroughly agree that our policy and actions should always be guided by kindness. And that kindness has to extend to all people and the many, varied and difficult circumstances that people find themselves in at the individual level. That is the liberal tradition.

    6) The authors claim that commenters on their previous article called out other negative comments. But the dissenting comments were very instructive. Indeed the personal attacks on dissenting views was quite disturbing. For the sake of discussion I have pasted my response to the previous article below

    Marcus, John and anonymous should be congratulated for contributing to an important debate. They give a more liberal perspective (in the classic sense of the word) to counter the article which is based on identity politics.
    What is concerning are the personal attacks against them by other people who wrote comments.
    The article by Wilson and Blow gives one socio-political view on the topic. You might believe and agree with that view or you might not.
    Marcus and co-responders give a valid, historically-informed and widely held view. The authors of the article would do well to inform themselves of the liberal tradition as espoused by Martin Luther King.
    A brilliant author who challenges the basis for identity politics is Heather MacDonald from the US. Once again the authors, Wilson and Blow, would do well to challenge themselves by reading her work.
    So there are different and legitimate positions. But to suggest that because Marcus and John hold a different position that “I hope they are not medical professionals but fear they are. I fervently hope they are not in positions of authority or teaching roles with respect to the doctors of the future.” is the very definition of intolerance. Or to borrow a phrase from Gilbert and Sullivan’s famous musical, it is the very model of the modern left’s intolerance.
    Marcus, John and anonymous offer a perfectly legitimate perspective that has a widespread historical and intellectual heritage. The target article offers a different perspective; an identity politics based perspective. Fair enough. Debate the underlying philosophical issues.
    On a wider note, rather than only publishing Indigenous-related articles that are in lock-step with the identity-politics based view, MJA Insight should publish some more liberal views.
    For instance, we urgently need to debate the scope and justification of Special Measures that are used to justify elements of indigenous policy. Special Measures (or equivalent) are used to obviate otherwise unlawful racially discriminatory policies.
    There’s a saying that in modern liberal democracies such as Australia that racism is in high demand but short supply. It’s a very salient saying!

  5. Marcus Aylward says:

    Where to start? There are so many levels on which this needs to be unpacked.
    This article represents a particular world view which may not be said to be generally accepted and which may be challenged on points of fact as well as intent.
    This article – like its partner from a fortnight ago – seeks to further a particular political agenda by co-opting indigenous healthcare (a wholly motherhood issue) to the cause. There is no necessary connection between indigenous health outcomes and a treaty/reconciliation/’truth-telling’.
    Those who disagree with the authors’ viewpoints are apparently “underinformed”, and so people of goodwill who might be prepared to contribute to addressing healthcare disparities are driven away by the apparently symbiotic politicking.
    The fact of unequal health outcomes is being used as a surrogate for institutional racism, a mental gymnastic for which no evidence has been provided. There are lots of reasons for unequal health outcomes for indigenous patients – many wholly practical (location, cost, logistics) or cultural (a disinclination on the part of Indigenous patients to use or attend the service) which have nothing whatsoever to do with racial discrimination (as so gently outlined by Saul Geffen above). Non-indigenous rural and remote patients encounter similar disparities, but setting up cardiac transplantation service in Derby – to emphasise the point – may be neither justified nor a sound financial outlay. Per capita Human Services payments on behalf of indigenous citizens are already 4 times that for the non-indigenous: there are some gaps, in some locations, that simply can’t be closed.
    The deficiencies of the “unconscious bias” research and conclusions have been comprehensively catalogued by Heather MacDonald (amongst others) as cited here by commentator Michael Keane, but such a burgeoning miserablist industry is unlikely to go quietly despite being wholly scientifically discredited. And ‘feelings’ of racism – be it towards patients, doctors or trainees – do not constitute facts until appropriately tested (#MeToo notwithstanding).
    As to the authors’ broader project, the usual laundry list of grievance issues is included.
    Reconcile what?
    It is arguable that a great many people in this nation would need to be convinced that anything needs reconciling. There are a few who seek to stoke a simmering fire of historical grievance based on events now over 240 years old, all the participants in which are long gone (Serbia vs Croatia anyone?), where many would politely suggest that fixing the present and building the future would be better than trying to revise history, entrench separateness and manufacture discrimination through such projects as “The Voice”. Those people (and their assorted hangers-on, whose accretion would be the stuff of comedy were the issue not so potentially divisive) will not be placated, even if the rest of the nation were to prostrate itself (which it won’t).
    The ‘blood and soil’ narratives that have fuelled so many of the wars that have convulsed the world are anathema to Australians, whose ideals are founded on a simple egalitarianism. We would do well to see the wisdom in the American creed: E Pluribus Unum – “out of many, one”.
    This is a wonderful nation and a land of opportunity – as 6 or 7 million new immigrants who have no truck with or interest in Aboriginal/British altercations of two centuries ago have shown – and our task is to ensure that all Australians – here, now, and in the future – are embraced and able to make use of those possibilities, and within health care to provide first world health outcomes for all those who desire them.
    As to any treaty, the authors might be best served to familiarise themselves with a few aspects of International Law, on which they seem underinformed: a nation cannot make a treaty with itself (as Victoria’s recent fatuous grandstanding will show if/when challenged); in 1778, there was in this land (unlike in New Zealand) no sovereign entity that could be recognised as such in International Law, and no national structures of governance with which to negotiate (Bruce Pascoe notwithstanding). “First Nations” is an imported political term which seeks to aggrandise the status of the indigenous inhabitants in contrast to the international law as it then stood.
    And finally – for those who subscribe to the invasion trope – truth-telling requires you to know that acquisition of territory via invasion or annexation was only outlawed under international law by the Kellogg-Briand Pact in 1928, which is why all boundaries after WWII (but not WWI) were restored to their previous lines (with the possible exception of Eastern Poland which the Soviets pretended to have acquired by a legal 1939 treaty in the form of the Molotov-Ribbentrop Pact). So even if viewed as an invasion, the British settlers did not violate the law as it stood.
    If one wishes to go back and redesign such laws retrospectively – or on emotional terms to simply discard international law – there will likely be rather a queue of countries keen to revise their borders under whatever international precedent is set.
    How this relates to health care is entirely obscure.

  6. Uma Selvanathan -Orr says:

    Thought-provoking article with good points on cultural safety. The irrefutable statistics on the over representation of Aboriginal and Torres Strait Islander peoples with poorer health outcomes and the under representation of Indigenous Australians working as health professionals does speak volumes about how we are deficient in addressing this suitably. Intergenerational and lived experiences have far reaching impacts and presumably, sociologically harder to study,and
    exist if those affected tell us it exists. Discrimination on the basis of race and gender happens whether we are conscious of it or admit to it.

  7. Marcus Aylward says:

    (PS. Yes, yes: 1788 and 230.
    Went to school with Sarah Hanson-Young.)

  8. Glenn Rosendahl says:

    Your heading , TRUTH TELLING… is something of a euphemism. What is the ‘truth’, dare we tell it? I was told by a Kempsey patient with Aboriginal ancestry that in one event in the 19th century, as the white settlers moved north from Sydney, local Aboriginal women and children in the area of Crescent Head (on the coast, south-east of what now is Kempsey) at low tide were herded into a cave that faced out into the ocean – and pinned there until the tide rose, when the sea and surf flooded the cave and drowned them. This is indigenous folklore, I doubt it is written into ‘white history’. I assume that the male Aborigines had already been dealt with – savagely. The colonists sought to caress their consciences by dealing with the Aboriginal women and children in a more gentile manner.

    One can truly say that over the last two hundred and fifty years, the Aboriginal ‘Dreamtime’ became a nightmare.

    Wikipedia, under the title ‘List of massacres of Indigenous Australians’ has a download of 21 single-spaced pages of listings. Perhaps the most blatant and methodical is cited in the appendix (pp 30-31) near the end.

    [Citation 161] ‘The massacre of Aboriginal people in a ‘war of extermination’ was widespread and relentless. As one of the early missionaries, R.D.Joynt, wrote (1918:7), hundred had been “shot down like game.” And possibility, however, that they might have succeeded in preserving their cultural integrity ended drastically around the start of the 20th century when a huge London-based cattle consortium The Eastern and African Cold Storage Company acquired massive tracts of land to carve out a pastoral empire from the Roper River north into Arnhem Land. Purchasing all stocked and viable stations along the western Roper River, they began moving cattle eastward. Determined to put down all Aboriginal resistance, they employed gangs of up to 14 men to hunt down all inhabitants of the region and shoot them on sight. With police and other authorities maintaining a “conspiracy of silence”, they staged a systematic campaign of extermination against the Roper River peoples (Harris 1994:695–700). They almost succeeded.’ Gerhard Leitner, Ian G. Malcolm, The habitat of Australia’s aboriginal languages: past, present and future, Walter de Gruyter, 2007 pp.143–4

    I consider ’truth-telling’ should tell the truth. We should be open, honest – explicit and specific – about our – Australia’s – past. Not simply massacres. Admit and acknowledge the loss of Australian culture. Over 50% of the world’s human population speaks two or more languages. Multi-lingual competence is best cultivated in early childhood – naturally – from the every-day parent to parent, in the parent to child – domestic multi-lingual conversation. This experience of learning provides a natural ease and ability to learn further languages. But no – Aboriginal children were taken from their parents, then restricted to speak only one language – English.

    Australia now has a rich multicultural immigrant heritage, second, third, fourth generation descendants who know of their European or Asian past – as these cultures are continually maintained in Europe and Asia. Immigrant – immigrant descendent – Australians can travel to those countries and experience the continuing richness and integrity of their other identity. Not so – Australians of Aboriginal descent. That richness and integrity is largely in the past – now hinted in the recollected stories of the ‘Dreamtime’. A matter of conservation – to be found in museums. And in the oral memory of the present survivors – with whatever Aboriginal language knowledge and skill they still possess.

    It is an incredible shame.

  9. Tony says:

    Why is it that whenever Miss Dhu is mentioned, her Aboriginal boyfriend who cracked her ribs is never mentioned? If he was non-Aboriginal it would be all over the news. IS that not a form of racism?

  10. Dr Neil E Hucker says:

    For most of my 72 years of life and medical career I have not had to personally consider the so called racial and discrimination issues relating to
    Australia’s aboriginal peoples increasingly put forward for me to address as a fourth generation Australian of English, Scottish and Irish heritage.
    Over the last twenty years I have increasingly become informed of the facts of Australia’s history of colonization/invasion/control of our continent
    and all our inhabitants.
    I am increasingly interested in understanding all sides of “”the truth”” of how modern Australia emerged from a small penal colony subsisting
    on a continent already populated by aboriginal people. The various points of view and facts enclosed in these insight offerings I have enjoyed and
    hope will be continued as we doctors bring to bare our experience and wisdom in the “Truth”” telling debates.
    One fundamental concern of mine though is the use of the racial terms Indigenous or aboriginal as if these terms denote homogeneity. In terms of
    health criteria and particularly evidence based approaches for research we are dealing with aculturally heterogeneous group of people. Even the genetic
    makeup has become heterogeneous.
    To my mind it has been of great value politically to use generalized terms but how I would treat a non school attender from Arhnam land
    or Noel Pearson, apart from maybe their genes would need me to be very discriminating about what sort of cultural Aboriginality I have to attend to.
    One more point. Even though colonial attitudes for a long time saw aborigines as non people, even flora and fauna I will not subscribe to a role reversal and be called a non indigenous Australian. I am culturally Australian first.

    otcomes

  11. Marcus Gund says:

    So 93% of respondents agree that racism exists throughout the Australian health system.

    A small sample, true, but we must address this problem. Several of the comments above give voice to its reality.

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