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

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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Aboriginal and Torres Strait Islander health Closing the Gap incarceration racism