‘Patients trust us more than any other doctor’: GPs perfectly placed to deal with systemic racism

Matt Woodley

26/06/2020 12:58:55 PM

Aboriginal and Torres Strait Islander people are the most incarcerated people in the world and have health outcomes equivalent to developing countries. But GPs can help.

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Aboriginal and Torres Strait Islander people are 15 times more likely to end up in prison than non-Indigenous Australians.

The 12th Closing the Gap report, released in February this year, laid bare the lack of progress Australia continues to make with regard to improving Aboriginal and Torres Strait Islander health, education and employment outcomes.
Child mortality is twice that of non-Indigenous children, the life expectancy gap remains at about eight years (and equivalent to developing countries like Palestine and Guatemala), and there is a burden of disease 2.3 times greater than that of non-Indigenous Australians.
According to the Coalition of Peaks, which this week released what it called a ground-breaking report into the development of a new National Agreement on Closing the Gap, a change in approach is required to ‘truly close the gap in life outcomes between Aboriginal and Torres Strait Islander people and other Australians’.
It advocates for more Aboriginal and Torres Strait Islander involvement across the board, and calls for mainstream service delivery – including the health sector – to be reformed to address systemic racism, promote cultural safety, and to be held ‘much more accountable’.
Associate Professor Peter O’Mara, Chair of RACGP Aboriginal and Torres Strait Islander Health, told newsGP that differences in health outcomes are ‘absolutely’ linked to systemic and institutionalised racism in Australia, as is the subsequent trauma it inevitably produces.
One of the greatest sources of trauma for Aboriginal and Torres Strait Islander people, according to Associate Professor O’Mara, is their interaction with police and the criminal justice system.
‘The system is against us in so many ways,’ he said.
‘I went up to a town in the Northern Territory many years ago and when I got to the community a young fella had just been taken across to Darwin where he was spending two weeks in incarceration [due to mandatory sentencing laws].
‘What had happened is, he and his mates were playing cricket on the street … and this young fella had the bat, hit a big shot, and smashed a streetlight.
‘Someone has complained and said, “I’m calling the cops”. He waited and did the right thing, he said, “Look, I’m really sorry, it was an accident, we were playing cricket. I’m sure my parents will try and help pay for the light”, but he got locked up for two weeks.
‘Just for something silly like that – they were playing cricket on a dead-end street in Australia.’
Associate Professor O’Mara says instances like that only tell part of the story.
‘[For example], there’s the fact that Aboriginal and Torres Strait Islander people are more likely to suffer hearing disorders – often as a result of things like chronic suppurative otitis media – and the evidence is there to say that when you have a hearing disorder, you’re more likely to be incarcerated,’ he said.
‘Some of the things that we do as GPs, like working on that trying to improve ear health for children, and particularly for Aboriginal children, can have a direct impact.’
Dr Penny Abbott, Chair of the RACGP Specific Interests Custodial Health network, said GPs are at the frontline for people who are in contact with the criminal justice system.
‘The reasons people end up in prison usually include health issues, such as mental health or substance-related problems, and social problems like homelessness and lack of community-based support networks,’ she told newsGP.
‘Addressing these issues before people get to the point of being sent to prison can happen at a primary care level where we are good at treating the whole person in their context.’
Dr Abbott also said once a person is released from prison it is a ‘perfect time’ to consider if an Aboriginal health check, mental health plan, or chronic disease management plan is urgently needed.
‘[GPs] can make a real difference to Aboriginal and Torres Strait patients by being aware of the kinds of health, social and system issues that their patient comes up against when leaving prison – a precarious time where people are at high risk of relapse to drug use, death, hospitalisation, and returning to prison,’ she said.
‘For example, GPs can ensure continuity of healthcare started in prison, manage health issues that weren’t addressed in prison, and look afresh at issues that may be cropping up post-release. Substance-use disorders are of course a big issue to be on top of.’

Associate Professor Peter O’Mara, Chair of RACGP Aboriginal and Torres Strait Islander Health, said differences in health outcomes are ‘absolutely’ linked to systemic and institutionalised racism in Australia.

Aside from the incarcerated person, Associate Professor O’Mara said it is also important to be aware of the vicarious trauma that families can suffer, especially if the family member is assaulted while imprisoned, or worse, dies in custody.
Since the 1991 Royal Commission into Aboriginal Deaths in Custody, imprisoned Aboriginal and Torres Strait Islander people have died at a lower rate than non-Indigenous prisoners – although there are no reliable statistics that can be used to calculate death rates in police custody.
A key finding of the royal commission was that Aboriginal and Torres Strait Islander people ‘do not die at a greater rate than non-Aboriginal people in custody’, but rather ‘what is overwhelmingly different is the rate at which Aboriginal people come into custody, compared with the rate of the general community’. 
Yet, in the subsequent years, the proportion of Aboriginal and Torres Strait Islander people in Australian prisons has nearly doubled from 14% to 27%. As a result, 437 Aboriginal and Torres Strait Islander people have died in custody in the past 29 years, as opposed to 99 in the 10-year period investigated by the royal commission.
The high incarceration rate means Aboriginal and Torres Strait Islander people are 15 times more likely to end up in prison than non-Indigenous Australians, and thus more likely to die there as well.
Dr Abbott said deaths in custody are a great burden on Aboriginal and Torres Strait Islander communities.
‘We need to remain vigilant and committed to avoiding people being sent to prison in the first place, as well as providing quality care in prison and after release,’ she said.
‘We also need to continually reflect on the root causes of deaths in custody and over-incarceration of Aboriginal and Torres Strait Islander people, the social determinants of poor health and inequities, and the systemic racism that our patients continue to experience.
‘There are many things which will help, such as more programs to divert young Aboriginal and Torres Strait Islander people from prison, and a larger workforce of Aboriginal and Torres Strait Islander people in health and prison health.’
But, as pointed out in the Coalition of Peaks report, institutionalised racism is not restricted to the justice system, and remains a common experience among health professionals and within the health system as well.
Associate Professor O’Mara highlighted disproportionately high rates of Discharge Against Medical Advice (DAMA) events experienced by Aboriginal and Torres Strait Islander people as one by-product of discrimination in the health system, but said GPs are well-placed to help prevent such episodes from occurring.
‘This is a great example, unfortunately, of what happens to our people,’ he said.
‘I’ve seen a gentleman in the clinic in the Aboriginal Medical Service who had chest pain, and I thought that he was having a heart attack – a myocardial infarction. So I started treating him for that and called the ambulance, which took him to a local hospital that … within the health services is known to be blatantly racist.
‘This gentleman goes into the emergency department. He’s quite happy to be there and he’s thankful that he’s receiving the treatment, but some things are said in that environment that are so toxic to him that he decides to pull the ECG leads off, take the IV lines out and walk out the front door.
‘That happens all too commonly in this setting and then at that point, the doctors and nurses, the health professionals will wash their hands of it because we say, “We told them not to go, they chose to go, they signed this [DAMA form]”.’
Associate Professor O’Mara said he can recount ‘hundreds’ of similar experiences and that ‘every Aboriginal person’ would have comparable stories – Aboriginal ethnicity is the strongest predictor of DAMA and occurs at a rate eight times that of the non-Indigenous population.
However, he is trying to encourage health services to take more responsibility by getting them to ‘look at it in a different way’, as be believes it is incumbent upon health professionals, including GPs, to lead the fight against racism.
‘[I want them] to think what is so toxic about this environment … [where] they know if they walk out that front door they could die and they’d rather do that than stay in here,’ Associate Professor O’Mara said.
‘Everyone in the health system should be advocating for their patients, but GPs are perfectly placed to do that.
‘Our patients trust us more than any other doctor that they see and they have an intimate, ongoing relationship with us that they don’t necessarily have with any other health professional.
‘Creating a safe environment for our patients is exactly our responsibility … it’s just about showing an extra level of care for patients and ensuring that they’re comfortable in order to help make a wider change.’
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Dr Ian Stanley Truscott   27/06/2020 9:06:20 AM

My experience with the DAMA is different from this. I’ve almost never seen a reason to blame hospital staff.

Dr Julie Anne Copeman   27/06/2020 11:55:20 AM

My experience also differs - please refer HREOC 37/2007. A medical workforce was decimated by poor management and abuse of staff both indigenous and non indigenous. The indigenous health service lost their most trusted and knowledgeable workers. Racial abuse happened when people didn’t get what they wanted and was perpetrated by the clients not the staff. This is the issue not being addressed and why continuity of care is lacking and advances in health outcomes aren’t being realised.

Dr Evan Ackermann   27/06/2020 1:35:46 PM

I must disagree with Peter on the claim that our health services are systemically racist – I do not believe they are, I do not believe the arguments forwarded support the proposition. I think it unfair and inappropriate to maintain a judgement that our health services are systemically racist.
The health system at both State and National levels all have clearly articulated anti-discrimination policies and rules. They all have specific programs, training and support to address the health issues experienced by indigenous populations – all with substantial budgets and resources. There are dedicated indigenous health services and aboriginal and torres strait islander community controlled services across Australia. They have had these programs for decades. Most of these health institutions obsess about their racial values; no one has the luxury of being even unconscious about racism. The notion that these systems would tolerate racism in their institutions is ludicrous.

Dr Evan Wayne Ackermann   27/06/2020 1:36:42 PM

Response continued ..2
It may well be there are racist people in these institutions – but that is not being systemically racist. That would be a failure of local leadership to take action to support the values of the system. Similarly, if a hospital is “is known to be blatantly racist” – the question is why haven’t local leaders taken action? – because it would be counter to all stated objectives of the hospital system.
Similarly, the reference given does not support aboriginality as the strongest predictor of “discharge against medical advice” and its does not occur at 8x non indigenous rates. The comparative rates are 2% and 1.4% for children admitted to a paediatric hospital in Sydney. The low absolute difference in rates of DAMA (0.6%) does not support a notion of systemic racism in services.
DAMA may well be an indicator of responsiveness of health services to Aboriginal and Torres Strait Islander Health populations – but that does not mean it is an exclusive indicator of racism.

Dr Evan Ackermann   27/06/2020 1:37:18 PM

Response ..3
We may have an imperfect health system, and certainly it is not responsive to everyone and can be improved; but saying there is systemic racism within the health system is false and not supported by any data or activity.
I would value Peters insights and response to this.