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Ms Dhu findings show importance of teaching doctors and nurses about unconscious bias

Croakey has previously reported that the long-awaited, damning and ultimately disappointing findings into the 2014 death in custody of Yamatji woman Ms Dhu raise serious issues not just for governments and police, but also for health and medical systems and practice in Australia.

In the post below, Gregory Phillips, Associate Professor and Research Fellow in Aboriginal Health at the Baker IDI Heart & Diabetes Institute, considers the coroner’s recommendations in light of Australia’s “inability to deal with unconscious bias and racism”, in and out of the health system. He says our responses must go far beyond cultural awareness training and its implicit judgements:

Australian universities, medical schools and health systems grappling with how to include Aboriginal and Torres Strait Islander people in their institutions as participants and staff – and how to produce equality of outcomes – need to deal with both overt and systemic factors of racism.

The post was originally published at The Conversation and is republished here with permission as part of our ongoing #JustJustice series, to coincide with Guardian Australia’s Breaking the Cycle project (which has featured a number of #JustJustice articles), and to mark the publication of the second edition of the #JustJustice book.

Croakey readers may also be interested in these articles:


Associate Professor Gregory Phillips writes

In delivering her findings of the coronial inquest into the death of 22-year-old Ms Dhu during time spent in a Western Australian jail cell, state coroner Ros Fogliani was highly critical of some actions of police and medical staff.

She reportedly said Ms Dhu’s medical care in one instance was “deficient” and both police and hospital staff were influenced by preconceived notions about Aboriginal people.

Ms Dhu died on 4 August 2014 from staphylococcal septicaemia – a severe bacterial infection – and pneumonia, which were complicated by a previously obtained rib fracture. Released CCTV footage showed Ms Dhu moaning from pain, saying it was ten out of ten.

It was reported an emergency doctor considered her pain real but exaggerated for “behavioural gain”. Another doctor also noted Ms Dhu suffered from “behavioural issues” while a constable thought she was “faking” her suffering.

Ms Dhu’s case is not the first instance of mistreatment of an Aboriginal person in custody or a medical setting, nor is it likely the last. And while coroner Fogliani’s recommendations included mandatory, ongoing cultural competency training for police officers, to assist with health issues and other dealings with Aboriginal people, this isn’t enough.

For thirty years, Australian institutions have implemented cultural awareness programs. The thinking was if they taught staff about Aboriginal and Torres Strait Islander cultures, it would result in better lecturers, clinicians and policy-makers – and magically produce equity.

But this assumes Aboriginal culture is the problem. Like a deaf student in an all-hearing classroom, it is not the deaf student or their needs that are the problem, but a system that thinks an all-verbal and all-hearing teaching style is equal. The idea of equality itself entrenches systemic discrimination.

Unconscious bias

In April, Darwin Hospital staff were under fire for allegedly leaving Aboriginal singer Gurrumul Yunupingu to bleed internally for eight hours. Media reported hospital staff noted Gurrumul’s liver damage was self-inflicted (a result of repeated heavy alcohol use) rather than being due to his chronic hepatitis B infection he had since he was a child.

We don’t know whether these allegations are true, but we do know unconscious bias exists in Australia. It refers to the instant judgements we make about other people and situations based on our own values, experiences and cultural and gender beliefs. These judgements impact significantly on hiring and promotion decisions, how medical students make decisions, and in public discourse.

Regardless of merit or facts, research shows black or Indigenous people are more likely to be seen as less trustworthy; women to be risky prospects, and overweight people as irresponsible. Those with power and privilege judge those with less power for their inability to compete on terms set by the powerful.

So how is unconscious bias different to racism?

Like an iceberg, unconscious bias is said to represent the beliefs, values and experiences (below water) that give rise to overt expressions of discrimination (above water).

There are two problems with these definitions, however. They don’t reveal how beliefs, values and experiences got into the subconscious in the first place. They may also imply it is not the responsibility of those with unconscious bias to change their implicit beliefs and explicit actions.

In Australia, the inability to deal with unconscious bias and racism has serious health effects on Aboriginal and Torres Strait Islander people. These include increased stress, mental ill-health and suicide, systemic racism in education, sports, justice and the public sector.

In a national survey of Aboriginal patients, 32.4% reported racial discrimination in medical settings most or all of the time. These people felt they had been treated unfairly (which included being treated rudely or with disrespect; being ignored, insulted, harassed, stereotyped or discriminated against) because they were Aboriginal or Torres Strait Islander.

Equality vs Equity

Public discussion about racism in Australia is often met with denial, discomfort and fragility.

Some blame AFL player Adam Goodes for calling out racism – shooting the messenger is a common reaction. Some stand with whistle blowers and defend their right to speak truth to power. Others completely deny racism’s existence, wishing it would go away because “we treat everyone the same”.

But the impulse to treat everyone the same confuses equality of inputs with equality of outcomes. As the below diagram shows, treating everyone with equal inputs (the same boxes) produces an inequality of outcomes (not everyone can access the game).

Courtesy: Interaction Institute for Social Change | Artist: Angus Maguire.” For online use please provide links: interactioninstitute.org and madewithangus.com.
Courtesy: Interaction Institute for Social Change | Artist: Angus Maguire.” For online use please provide links: interactioninstitute.org and madewithangus.com.

Alternatively, treating everyone differently, according to their needs and humanity is more likely to produce equality of outcomes where everyone can access the game. Equity deals not only with overt discrimination but the systemic factors that give rise to it.

Australian universities, medical schools and health systems grappling with how to include Aboriginal and Torres Strait Islander people in their institutions as participants and staff – and how to produce equality of outcomes – need to deal with both overt and systemic factors of racism.

Cultural awareness isn’t enough

Teaching health professionals about Indigenous health will effectively require teaching about unconscious bias and racism; one’s own culture, values and motivations. It requires training in “unlearning” preconceptions, regular reflections on one’s own practices; as well as education about Aboriginal and Torres Strait Islander cultures.

Most importantly, if the clinician cannot see themselves, their privilege and power as a potential problem, this will inadvertently re-establish racism and unconscious bias.

Educators have found patiently moving Australian medical students who were initially hostile to Aboriginal health curricula through their discomfort to reach the “a-ha” moment is a key teaching strategy in producing better prepared doctors.

Further, cultural awareness training assumes that even if we could train every individual staff member in a hospital to be perfectly culturally competent, they would then go on to magically produce better health outcomes.

But the systemic factors – workplace culture, policies, power, funding and criteria on which decisions are made – are critical if we want a culturally equitable society.

Improving outcomes for Aboriginal and Torres Strait Islander people includes moving from a goal of equality to equity; teaching about racism and unconscious bias, not just culture; and making explicit the deeper transformational work of institutional decolonisation. We need to ask: how can power be shared? On whose terms are decisions made? Who owns institutions and services? Whose criteria are used to judge effectiveness?

The answer is that Aboriginal and Torres Strait Islander definitions and measurement tools of success are more likely to contribute to producing better outcomes than those where unconscious bias and racism is implicit. The work of admitting and addressing institutional racism remains.

The #JustJustice team acknowledge and thank Western Sydney University for sponsoring stage two of the project, including a second edition of the book (with extra articles), the series at Croakey this week and related dissemination activities.

WSydUni

How you can support #JustJustice

• Download, read and share the 2nd edition – HERE.

Buy a hard copy from Gleebooks in Sydney (ask them to order more copies if they run out of stock).

• Send copies of the book to politicians, policy makers and other opinion leaders.

• Encourage journals and other relevant publications to review #JustJustice.

• Encourage your local library to order a copy, whether the free e-version or a hard copy from Gleebooks.

• Follow Guardian Australia’s project, Breaking the Cycle.

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PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
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Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016
#ATSISPEP
#AusCanIndigenousWellness
#cphce2016
#CPHCEforum16
#CRANAplus2016
#IAMRA2016
#LowitjaConf2016
#PreventObesity16
#TowardsRecovery
#VMIAC16
#WearablesCEH
#WICC2016
2017 conferences
#17APCC
#ACEM17
#AIDAconf2017
#BTH20
#CATSINaM17
#ClimateHealthStrategy
#IAHAConf17
#IDS17
#LBQWHC17
#LivingOurWay
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#OTCC2017
#ResearchTranslation17
#TheMHS2017