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Racism as a determinant of indigenous health and wellbeing
Professor Yin Paradies Deputy Director
What is racism?
n Racism is the inequitable distribution of opportunity, benefit or resources across ethnic/racial groups
n Racism occurs through avoidable and unfair actions that : (i) further disadvantage minority ethnic/racial groups; or (ii) further advantage dominant ethnic/racial groups
n Racism is expressed through attitudes, beliefs, behaviours, norms and practices and may be either intentional or unintentional (Paradies et al. 2009)
What is racism?
n Racism is treating someone unfairly because of where they come from, the colour of their skin and their accent
n Racism is about what people think, believe and their emotions such as fear and anxiety. It is also about the way our society operates beyond individuals.
n Anyone can engage in racism and anyone can experience racism. By no means is it the case that only White people can be racist!
Internalised racism Interpersonal racism Systemic racism
Acceptance of attitudes, beliefs or ideologies about the inferiority of one’s own ethnic/racial group
Interactions between people that maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups
Requirements, conditions, practices, policies or processes that maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups
Believing that Indigenous people are naturally less intelligent than White people
Being racially abused when walking or driving in the street
Indigenous Australians are 2-3 times more likely to be arrested and charged with an offence
But what is racist?
Not racist
Actions that distinguish people based on their race – but not in a negative or hurtful way – are not considered racist
Somewhat racist
Many people are undecided about actions which could be seen as racist, but were in some way justified
Racist
Actions labelled as racist are seen to involve an intent to cause harm, or the unjust treatment of people based on their race
Actions that were seen to disadvantage Anglo-Australians are also seen as racist
NOT RACIST/ DISCIRMINATORY
RACIST/ DISCRIMINATORY
Telling a Muslim woman that she is exotically
beautiful
An African taxi driver is assaulted
by two Anglo-Australian men
Universities must enrol a certain number of Indigenous students
Asking a colleague to speak on behalf of their whole culture
Saying “he’s a good runner because he’s
black”
Someone missing out on a job because they
are Aboriginal
Indigenous people are more likely to be
stopped and questioned by police
Ringing the bank to complain that the call centre is staffed by
Indian people
(Sweeney Research 2010)
What is direct racism?
n Telling someone to go ‘home’ to their country when Australia is their home and sometimes they were even born in this country
n Security guards following people around in shops and searching their bags just because they are Black
n Thinking that someone is stupid because they can’t speak English very well
What is indirect racism?
n Not letting school students wear head coverings
n Thinking that everyone should speak English in public places
n Having mostly or only white people on TV shows and in computer games etc.
American Review of Canadian StudiesVol. 41, No. 3, September 2011, 293–307
Tolerated, but not Preferred: Troubling the Unconsciousof Televisual Multiculturalism
Nafissa D. Thompson-Spires
Vanderbuilt University
Canadian televisual exports make up at least 30 percent of the original content on UScable television. And from many angles, Canadian youth-television series look morediverse, more positive, and more attentive to interracial and interethnic issues than dosimilar US series. This article explores Canadian representations of interracial rela-tionships and situates them within readings of Canada’s official multicultural policy. Itargues that much of this surface-level positivism about race reveals unconscious anxi-eties that ultimately manifest in drastic ways of treating “diversity” or “multicultural”subjects.
Keywords: multiculturalism; Canada; television; Instant Star; Degrassi
In Canada, the party line goes, there are no racists save those who watch too muchAmerican television. (Clarke 1997, 101)
“I didn’t even know Canada was diverse,” my students say. “Why are there so manyminorities in these shows?” they ask. Virtually every semester, when I teach a comparativesegment on US and Canadian television, the questions end up here. Despite Canada’s offi-cial multicultural policy, many US viewers have no idea that “there are a lot of minorities”in Canada, nor do they realize that many of the minorities they see on “American” televisionare indeed Canadian actors appearing in Canadian series. As of 1996, Canadian televisionexports supplied at least 30 percent of the original content on US cable television (Attallah1996, 182) and an even higher percentage of US youth television.1 While televisual flowfrom the United States to Canada has historically proven problematic for Canadian identityand industry,2 televisual flow from Canada to the United States has proven profitable forUS television.
Part of the reason for this popularity lies in Canadian youth television’s approachto representation, including visual diversity, relevant didacticism, and realistic storylinesthat attract international viewers. Popular Canadian exports such as the Degrassi series,Edgemont (Atkins 2001), and Ready or Not (Rosenberg 1993) have left imprints on USyouth culture through their exploration of interracial issues and their avoidance of overtstereotyping, making major strides in troubling the myth of a “white Canada.”
Yet, under closer examination, many of these series reveal anxieties about multicultur-alism that only appear as sub- or unconscious dynamics beneath the surface of apparentracial harmony. Beneath their positivism, in fact, they continually reveal hierarchical con-structions that expose apprehension about diversity’s place in society, distinguish authenticCanadian identity from “diversity,” and link minorities to white suffering. Many of theseyouth texts even associate interracial interactions with death. This article situates Canadian
ISSN 0272-2011 print/ISSN 1943-9954 online© 2011 ACSUSDOI: 10.1080/02722011.2011.594518http://www.informaworld.com
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Privileges of whiteness
§ Can you identify with this list?
§ Do you agree with this list?
§ Do only White people get these privileges?
§ How do these privileges relate to class, nationality, gender, sexuality etc.?
Self-reported racism
Study Location Measurement Prevalence of racism %
NATSIHS 2004-5 National single item 16 NATSISS 2002-3 National single item 18 WAACHS 2001-2 WA single item 22 NATSISS 2008 National multi-item 27 Dunn et al. 2003 Qld/NSW single item 30 LSIC 2009 National single item 31 Larson et al. 2007 WA single item 40 Paradies et al. 2008 Darwin multi-item 70 Forrest et al. 2007 National multi-item 79 Ziersch et al. 2008 Adelaide multi-item 93
Interpersonal Racism Against Indigenous people
§ 5000 respondents in the 2001 NSW/Qld Racism
Survey and 4000 respondents in the 2006 Victorian Racism Survey were asked:
§ Would you be concerned if a close relative were to marry an Indigenous person?
§ 28% in NSW/Qld and 25% in Victoria expressed concern at such an occurrence
Employment
n Booth et al. (2009) sent over 4000 fictional resumes to employers in response to job advertisements with ethnic-specific and Indigenous names
n The study found that in order to get as many interviews as an Anglo applicant, Indigenous, Chinese and Middle Eastern applicant must submit 35%, 68% and 64% more applications, respectively
92.3 85.8 84.1 81.9 79.9
67.4 66.0
54.7
0
10
20
30
40
50
60
70
80
90
100
Names, teasing or comments
Ignored Sworn at/verbally abused
Less intelligent
Left out Spit or something
thrown
Don't belong
Property vandalised
Per
cent
of
resp
onde
nts
Experiences of racism in last twelve months
Settings of racist experiences in last twelve months
66.9
58.5
50.9 47.8
42.1 40.4 35.2 33.6 33.5
29.3 23.8
20.3
0
10
20
30
40
50
60
70
80
Per
cent
of
resp
onde
nts
3
healthcare systems (as noted earlier, these include the possibility that minorities are dis-proportionately enrolled in lower-cost health plans that place greater per-patient limits on healthcare expenditures and available services), the types of incentives in place to contain costs (e.g., incentives to physicians to limit services), and where minorities tend to re-ceive care (e.g., minorities are less likely to access care in a private physician’s office, even when insured at the same level as whites).
The second set of factors emerges from the clinical encounter. Three mechanisms
might be operative in healthcare disparities from the provider’s side of the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or health of minorities. Patients might also react to providers’ behavior associated with these practices in a way that also contributes to disparities. Research on how patient race or ethnicity may influence physician decision-making and the quality of care for minorities is still developing, and as yet there is no direct evidence to illustrate how prejudice, stereotypes, or bias may influence care. In the absence of such research, the study com-mittee drew upon a mix of theory and relevant research to understand how these proc-esses might operate in the clinical encounter. Clinical Uncertainty
Any degree of uncertainty a physician may have relative to the condition of a patient can contribute to disparities in treatment. Doctors must depend on inferences about sever-ity based on what they can see about the illness and on what else they observe about the patient (e.g., race). The doctor can therefore be viewed as operating with prior beliefs about the likelihood of patients’ conditions, “priors” that will be different according to age, gender, socioeconomic status, and race or ethnicity. When these priors are consid-ered alongside information gathered in a clinical encounter, both influence medical deci-sions.
Doctors must balance new information gained from the patient (sometimes with vary-ing levels of accuracy) and their prior expectations about the patient to make a diagnosis and determine a course of treatment. If the physician has difficulty accurately understand-ing the symptoms or is less sure of the “signal” – the set of clues and indications that
Any degree of uncer-tainty a physician may have relative to the condition of a patient can contribute to dis-parities in treatment.
Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. SOURCE: Gomes and McGuire, 2001 Smedley et al. 2002
Quality of healthcare
Racism and ill-health
(Paradies et al. 2013)
Australian adult health
§ Poor self-assessed health status, psychological distress, diabetes, smoking and substance use in the NATSIHS (Paradies 2007)
§ Depression, poor self-assessed health status and poor mental health in the DRUID study (Paradies & Cunningham 2006, 2012)
§ Mental ill-health in the Adelaide Indigenous Urban Location and Health project (Ziersch et al. 2011)
§ Reduced general physical and mental health in a rural Western Australian town (Larson et al. 2007)
LEAD: racism & mental health
Australian child health
n Alcohol consumption, cigarette and marijuana use as well as emotional/behavioural difficulties and suicidal thoughts in the Western Australian Aboriginal Child Health Survey (Zubrick et al. 2005)
n Anxiety, depression, suicide risk, mental ill-health and poor oral health in the Aboriginal Birth Cohort study (Jamieson et al. 2011; Priest et al. 2011)
n Poor general/mental health and depression among Indigenous youth in Victoria (Priest et al. 2011)
U.S. findings
n Self-reported hypertension (Kaholokula et al. 2010) and lower average cortisol (Kaholokula et al. 2012) among Native Hawaiians after adjusting for confounding
n Longitudinal association with substance abuse among Navajo adolescents (Galliher et al. 2011) and diabetes among among two ‘American Indian tribal groups’ (Jiang et al. 2008)
n Longitudinal problem alcohol use via decreasing positive school attitudes and increased feelings of anger and perceived delinquent friendships among North American Indigenous adolescents (Cheadle & Whitbeck 2011)
NZ findings
n Lower cervical and breast cancer screening rates among Maori women (Harris et al. 2012a)
n Lower mental health, chronic mental, health disorder, poor/fair general health, lower physical health, CVD, smoking, drinking (Harris et al. 2012b)
n Depression and cigarette smoking among Maori high school students (Crengle et al. 2012)
Canada/Norway findings
n PTSD and problem gambling among Aboriginal, Metis and Inuit adults in Edmonton, Canada (Currie et al. 2012)
n Poorer self-reported health (Hansen et al. 2010) and psychological distress (Hansen et al. 2012) for Sami
n Twice as likely to report CVD due to marginalisation, including ethnicity-based discrimination (Eliassen et al. 2013)
Implicit Association Test
What is implicit race bias? n Implicit bias is a form of subtle bias that occurs
automatically, with little conscious control, sometimes despite well-intentioned efforts to be nonracist. It occurs more often in high pressure and ambiguous situations.
n For example, the sight of a dark-skinned person may trigger beliefs about aggressiveness or criminality, which act as filters through which that person’s actions are interpreted
n Implicit bias affects most people in societies across the world
(Nier et al. 2011)
Implicit racism
n Implicit bias is associated with teacher’s differential expectations for students depending on their race/ethnicity
n Students who displayed a ‘Black’ walking style were perceived by teachers as lower in academic achievement, highly aggressive, and more likely to need special education
n IAT predicted mock jurors views of the evidence while 87% of 85 White judges displayed a strong White preference in the IAT Black judges had no clear preference
(Staats 2013)
Implicit racism
n Unconscious healthcare provider bias has been found to lead to poorer clinical decisions for African Americans (Green et al. 2007)
n Poor visit communication and poor ratings of care (Cooper et al. 2012)
n An implicit association of certain diseases including obesity and drug use with African Americans (Moskowitz et al. 2012)
(Shavers et al. 2012; Paradies et al. 2014)
Healthcare provider racism
n Healthcare provider racism can lead poorer self-reported health status, lower perceived quality of care, under-utilisation of health services, delays in seeking care, failure to follow recommendations, societal distrust, interruptions in care, mistrust of providers and avoidance of health care systems
n Unconscious healthcare provider bias has been found to lead to poorer clinical decisions for African Americans
(Shavers et al. 2012; Paradies et al. in press)
The Health Sector (Oz)
§ Five studies have shown disparities in medical care experienced by Indigenous patients in Australia
§ These studies found that Indigenous patients with the same characteristics as non-Indigenous patients were about a third less likely to receive appropriate medical care across all conditions (Cunningham 2002) as well as for lung cancer (Hall et al.
2004) and coronary procedures (Coory & Walsh 2005) in particular
§ Indigenous patients were only one-third as likely to receive kidney transplants (Cass et al. 2003)
The Health Sector (NZ)
§ ‘Non-clinical factors’ may be contributing to ethnic differences in caesareans for Maori women (Harris et al. 2006)
§ Hospital care received by Maori is marginally poorer than that received by other (Davis et al. 2006)
§ Lower intervention for Maori cardiac patients compared to others (Westbrooke et al. 2001)
Healthcare provider racism
n In the 2004-5 NATSIHS, 4.2% of Indigenous adults reported that they received worse treatment when seeking health care in last year compared to non-Indigenous people while 4.3% in the 2008 NATSISS reported discrimination by doctors, nurses or other staff at hospitals or surgeries in the last year
n 5.0% of Maori adults reported racial discrimination in the 2006/07 NZ Health Survey (Harris et al. 2012) while 7.1% of American Indians/Alaskan natives reported healthcare discrimination (a quarter due to race/ethnicity) in the 2001 California Health Interview survey (Johansson et al. 2006)
Healthcare provider racism
n Emerging evidence from the Localities Embracing and Accepting Diversity (LEAD) program in Victoria indicates that Indigenous people who experiencing racism in health settings are almost twice as likely as those experiencing racism in other settings to suffer from high or very high psychological distress
(Kelaher et al. MJA provisionally accepted)
Conclusion
n Racism is an established determinant of health
n Indigenous people experience high levels of racism in a range of key settings
n There is considerable evidence that contemporary forms of racism are associated with ill-health for indigenous peoples in a number of countries
