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E āku rahi, e āku iti tēnā ra koutou katoa.
Unacceptable and intolerable inequalities exist between Māori and non-Māori across a range of social, economic and many major health measures. Discrimination is unhealthy – it shortens lives and wastes potential. There are multiple forms of discrimination and different ‘isms’ which interlock and sustain one another in shifting ways. This article examines ‘racism’ and the pathways along which it leads to ill health.
An 8–year difference in life expectancy between Māori and Pākehā is particularly galling to most of us. For some conditions, Māori have similar or slightly higher risk of getting the disease, but much higher chances of dying from it. This indicates a failure of our health care system to deliver equally effective health care to all citizens. For example, Māori are only 9% more likely to develop cancer, but 77% more likely to die from cancer than non-Māori. Heart disease deaths, although decreasing, remain over twice as high among Māori males, while admissions to hospital are only 40% higher and receipt of heart operations similar to non-Māori receipt. Māori are more than twice as likely to have diabetes but more than seven times more likely to die from diabetes than non-Māori. Cervical cancer, a particular focus of many Māori community health services, provides an important contrast, with gaps in mortality and survival decreasing substantially over the last two decades.
Health inequalities are driven by:
- Differential access to the social and economic resources required for health, leading to differences in disease incidence. In Aotearoa this is manifest in the different distributions of Māori and non-Māori living standards, imprisonment rates, school leaver outcomes, occupational classes, wages per level of education and experience, and residence in socioeconomically deprived or affluent areas.
- Differential access to and through health care. Examples include Māori being less likely to be first admitted to a tertiary hospital with acute heart problems, affecting access to diagnostic procedures such as angiography and the surgical treatments that follow; slower pathways through care (longer times to colposcopy for cervical cancer, longer times to surgery for breast cancer, longer times to heart surgery); higher reported levels of unmet need for health care, especially dental care.
- Differences in the quality of care received. A study of colon cancer treatment found that Māori patients were less likely to be offered and receive chemotherapy compared to their non-Māori counterparts, and more likely to wait longer than two months to start chemotherapy. Other studies show Māori patients first admitted to hospital with a heart attack or unstable angina were less likely to receive cardiac surgical procedures than non-Māori (after taking relevant factors into account); Māori women are less likely to receive pain relief in childbirth; Māori hospital patients are more likely to experience adverse events, and Māori are more likely to have teeth removed than restored.
This picture is symptomatic of systemic or institutionalised racism: requirements, conditions, practices, policies or processes that maintain and reproduce avoidable and unfair inequalities across ethnic groups. This includes acts of omission as well as acts of commission.
Other types of racism (underpinned by systemic racism) include interpersonal racism: interactions between people that maintain and reproduce avoidable and unfair inequalities across ethnic groups. It involves prejudice (differential assumptions about the abilities, motives and intents of others according to their ‘race’/ethnicity), and discrimination (racist behaviours and practice).
One of the clearest examples of interpersonal racism in New Zealand was demonstrated in ‘paired mystery shopper’ research where Māori and Pākehā with similar characteristics applied for the same rental house and Māori were more likely to be refused. The 2002/03 New Zealand Health Survey showed that 34 percent of Māori had experienced racist discrimination in their lifetime (across a number of situations), and 15 percent had experienced discrimination in the previous 12 months. Discrimination in renting or buying a house was the most frequently reported type of discrimination reported by Māori and was associated with a higher risk of smoking and poor mental health. Discrimination in health care was the second most commonly reported type.
How might racism operate in health care? Sometimes discrimination might occur when the clinician feels they are not discriminating but doing their best for their patient. “If they look like they haven’t the money, I downplay the treatment. I say, maybe they’re not missing out on much. I don’t want to upset them.” Māori families are more likely to experience such interactions than Pākehā families. While perhaps well-intentioned, this behaviour breaches patients’ rights to full information about their options, and must be vigorously challenged. All patients and families have the right to decide for themselves how best to proceed, based on full information.
It is important for whānau to stay engaged with health care – not to avoid it for fear of discrimination. We all have the right to good quality health care. But we must all be vigilant – families and patients need to be watchful and alert, pay attention and ask questions. If something feels wrong, it can be questioned or challenged. It is better to act than to not act– we regret the occasions when we did omitted to act more than the occasions when we do. Sometimes we can be taken by surprise by discriminatory behaviour, become paralysed with shock – but we can always learn from that situation and follow it up if appropriate, and at least be better prepared for next time.
Health professionals must be attentive to their own practice and be ready to act if they observe others offering less than best practice. This requires learning to recognise discriminatory practice – both at the interpersonal level and at the institutional level, and being prepared to act against it.
The right to the highest attainable standard of health applies to all peoples. Discrimination has no part to play in a healthy society.
Nā Bridget Robson, Ngāti Raukawa, Ngāti Tuarā/Ngāti Kea
Te Rōpū Rangahau Hauora a Eru Pōmare,
Te Whare Wānanga o Otago, Te Whanganui-a-Tara