Taking up the challenge of eliminating racism in health care through talking about race (and culture)

Abstract

This perspective article offers a framework for the formulation of an Indigenous antiracist training approach that has been devised through the work of the Queensland University of Technology (QUT)‘s Carumba Institute and Children's Health Queensland Hospital and Health Service (CHQ). Our methodology engages with Indigenist pedagogy, critical race theory, and Indigenous critical race theory to attend to the structural dimension of race; foregrounds Indigenous life worlds, knowledges and experiences; favours institutional transformation over participant satisfaction; and fosters communities of continuing antiracist practice.

All authors of this perspective article are scholars at QUT's Carumba Institute, a world class Indigenous research educational environment that foregrounds Indigenous sovereignty. The Carumba Institute is led by the lead author of this article, Munanjahli and South Sea Islander woman Professor Chelsea Watego, who was born and raised on Yuggera country. She is an Indigenist health humanities scholar, prolific writer and public intellectual, and is one of Australia's leading experts on race and racism. Kevin Yow Yeh is a Wakka Wakka and South Sea Islander man, born and raised on Butchulla/Badjala country, and an educator and researcher interested in race, racism and the pursuit of justice. Dr David Singh, Dr Helena Kajlich and Dr Saran Singh are all non-Indigenous settlers working on the unceded lands of the Turrbal and Yuggera people. Their research is intersectional and focuses particularly on the intersection of race, racism, law and health.

The CONSIDER reporting criteria checklist for health research involving Indigenous peoples¹ was completed for this article and can be found in the Supporting Information.

Despite the Australian Government insisting that it aspires towards a health system “free of racism“,² there is a contradiction between these grandiose claims and the failure to meaningfully respond to the pervasive crisis of racism within the Australian health system. The aspirational urge to “eliminate” racism disguises the foundational nature of race as a structure of oppression, and the widespread refusal to attend to racism. This persisting refusal to address race and racism in a meaningful way is evidenced in a range of health educational efforts and interventions designed to ameliorate it.

We note the refusal of the Medical Journal of Australia (MJA) to publish evidence illuminating how Indigenous peoples experience racial violence within the health system, specifically in regards to how medical rationalisations are deployed to deny the existence of racism.³ Inexplicably, an invited editorial on racism in the MJA special edition on Indigenous health was excluded due to a “defamation risk”, a claim not supported by the independent legal advice the authors obtained. This was not dissimilar to the decision by the University of Queensland's School of Medicine to “scrap” an assessment item on institutional racism owing to student dissatisfaction with their results. The central concerns of students were “that a fail on this subject could be the difference between getting an overall high distinction or a distinction which could impact postgraduate employment”.⁴

The concerns of the medical profession are frivolous when contrasted against the violence and death experienced by individuals at the very bottom of the racial hierarchy due to substandard care (see the recent Inquest into the deaths of “RHD Doomadgee Cluster” [2023];⁵ the Inquest into the death of Ms Naomi Williams [2019];⁶ the Inquest into the death of Ms Tanya Day [2020];⁷ and the Inquest into the death of Mr Dougie Hampson JR [2024]⁸). Coroners often concede “systemic errors” but never “systemic racism”.⁹ This refusal to interrogate how race functions means that Indigenous peoples are deemed complicit in their own deaths.^{9, 10} Preventable deaths are quickly cast as “inevitable” through the same violent racist logics that deem victims undeserving of care in the first place. A structural approach to understanding racism makes clear that it is impossible to “eliminate” racism from health systems. However, antiracist efforts in health remain hamstrung by the refusal within health sciences to deal with the structural nature of race and racism.

It is promising that the Queensland Government has introduced groundbreaking legislation requiring, for the first time, that hospital and health services (HHS) “develop and implement Health Equity Strategies” with Aboriginal and Torres Strait Islander stakeholders, which includes the requirement of “actively eliminating racial discrimination and institutional racism within the [HHS]”.¹¹ However, we are concerned as to how the HHS will meet their legislative requirements when there is such a limited understanding of racism (as evidenced in their plans), and such staunch resistance to structural approaches to race and racism. Furthermore, there are currently few Indigenous antiracist training programs for health services in Australia. Therefore, in this perspective article, we offer a framework for the formulation of an Indigenous antiracist training approach devised through collaboration between QUT's Carumba Institute and CHQ.

Our methodology brings together the conceptual expertise of the Carumba Institute, and its political and historical analysis, with the frontline experiences and first-hand knowledges of CHQ management and health care workers. Not only does CHQ set the foundation of paediatric health for all of Queensland, but given the clear need for antiracist interventions in paediatric health care,¹² and that paediatric care often represents patients’ first encounters with the health system, partnering with CHQ provides the opportunity to make the most substantive commitment to addressing racism in health care. Our methodology is innovative because it insists upon the structural operation of racism — and specifically, the racism that is deployed against Aboriginal and Torres Strait Islander people as both “first human [and] first raced”.¹³

Although health organisations like to “commit” to addressing racism, there has not yet been a shared understanding of terms such as “race” and “racism”, and there is even less evidence of an understanding of the ways race is complicit in the production of health inequalities beyond overt forms of racial discrimination. To compound matters, those organisations charged with providing explicit antiracist guidance have struggled to do so beyond good intentions. For instance, the Australian Human Rights Commission¹⁴ introduced a National Anti-Racism Framework “concept paper”, in which they offered no conceptual clarity as to what constitutes “race”, “racism” and “antiracism”. It is this persistent lack of conceptual clarity that this methodology aims to remedy, by creating a shared and rigorous understanding of race and racism to inform antiracist interventions across health services.

Current educational interventions in health services, particularly in Queensland, focus on compulsory cultural capability training and concepts of cultural safety. These frameworks were developed in Aotearoa New Zealand,¹⁵ and, in their original conceptualisation, advanced Indigenous-led definitions of the structural roles of racism and power. However, over time, this original model of cultural safety — which were critical interventions for addressing harms caused by racism in health systems — have become co-opted and watered down to the point where they are no longer fit for purpose. They either fail to address race and racial power explicitly, or are interchangeably described as cultural “awareness, capability, competency, humility, safety and sensitivity”. This lack of conceptual clarity is dangerous because it risks legitimising educational frameworks that are not clear in their objectives and understanding of race, increasing the likelihood of these frameworks being unsafe for Indigenous participants.

Furthermore, these frameworks assume an innocence that can be remedied through building competency or cultural knowledge, implicitly suggesting that harms arise at an interpersonal level. There have been attempts to address race through the Courageous Conversations about Race series,¹⁶ although this series has been imported from elsewhere (the United States), and as such it fails to conceptualise Indigeneity and race in the context of the Australian settler colonial state, and the distinct working of racial power that dispossess and erase Indigenous peoples who are also raced as Black.

We offer a meaningful and substantive response to the current aspirational policy goal of eliminating institutional racism. Our methodology is grounded in Indigenist pedagogy, critical race theory, Indigenous critical race theory, and antiracist political education. We engage with this scholarship to propose a methodological framework that attends to the structural dimension of race; foregrounds Indigenous life worlds, knowledges and experiences; favours institutional transformation over participant satisfaction; and fosters communities of continuing antiracist practice.

Race is neither “ahistorical” nor “unchanging”. Race is instead a “floating signifier”; it is “subject to an endless process of being constantly resignified, made to mean something different in different cultures, in different historical formations and at different moments of time”.¹⁷ As critical race scholars Delgado and Stefanic¹⁸ argue, race is socially constructed, meaning racism is not exceptional but rather an ordinary and everyday experience for most people. Racism advances and preserves the dominance of a white majority, but, crucially, racialised “status brings with it a unique voice and understanding of race and racism because of experiences of oppression within a system based around white racial dominance”.¹³ This conceptualisation necessitates an understanding of racism as being already inherent to the Australian health system, not an aberration, and affirms that solutions, strategies and antiracist practices for resisting racism must be developed by individuals who possess a lived experience of race and racism.

A desktop audit found that fourteen health equity strategies (excluding CHQ) have been implemented in Queensland to eliminate racism from the health service. Although all strategies are clear in their intentions to address racism, none make clear what they understand “race” to be. How is it possible to eliminate something one cannot define? We make this observation to demonstrate the uniqueness of our partnership with CHQ. As cultural theorist Stuart Hall¹⁹ reminds us, dealing with race entails dealing with both “real, concrete social, political, and economic issues” and structures that are “intrinsically difficult and complicated”. Race is an intellectual project, and, therefore, it is unserious to make commitments to address racism without first rigorously conceptually defining race.¹³ It is well and good to “want” antiracism, but only CHQ have demonstrated an understanding of the partnerships and scholarship required to work towards material and substantive antiracism.

Our antiracist educational intervention is directly informed by the emergence of Indigenous critical race theory. Unlike critical race theory, which has its origins in the United States, Indigenous critical race theory marks the intersection of race and Indigeneity. It demands that race scholarship goes beyond theory to create spaces “for those negatively racialised to speak freely about race and how it makes and breaks them, but also to strategise how to make the perpetrators of racial violence pay”.²⁰

Our methodology is further informed by the work of Professor Lester-Irabinna Rigney²¹ who explains:

In Australia, racism is often abstracted through a broad historicisation of colonisation, which fails to attend to how colonisation continues to be embedded in institutions and practices.²² The insights derived from our methodological approach allow us to contribute to the growing body of research and practice that recognises the limitations of cultural safety and competency models that focus on racism as a problem of bias. As Watego, Singh and Macoun¹³ observe: “This understanding of racism as primarily attitudinal — related to racial hatred or to racial prejudices held by an individual or group — remains influential both popularly and academically”. These understandings of racism result in approaches to antiracist education that focus on “unconscious or implicit bias,” thereby prioritising the feelings, beliefs and fragility of white participants rather than intellectually engaging with race and racism as political structures. The effectiveness of antiracist strategies must be judged on their ability to disrupt and provoke transformative institutional change. Interventions that gauge effectiveness by how carefully strategies cater to white feelings and fragility — thereby obscuring white complicity — can never meaningfully address the foundational function of race and racism in shaping the health system.

The antiracism training we propose will bring together the tools of critical race and Indigenous theory to develop a shared vocabulary of racism in the health system and a set of strategies to enable antiracist practices within health systems. Our methodology prioritises Indigenous peoples’ sovereignty and their embodied knowledge of race and racism. Drawing on scholars such as Milligan and colleagues,²³ we emphasise that “institutional racism in Australian health care cannot be addressed without attending to the denial of Indigenous sovereignty and control of land, lives, and futures”. An Indigenist antiracist approach works to ground antiracist practices in an understanding of the material function of racism as a tool of continuing colonisation.

A key feature of racial knowledge is the notion of Indigenous intellectual inferiority. Our methodology centres Indigenous peoples as knowers, as theorists, agents of change, and architects of the transformation that institutions are commonly laying claim to.²⁴ Our method itself is antiracist, which is in stark contrast with the ways in which most educational approaches centre the non-Indigenous learner, leaving the workings of white racial power unnamed. Whiteness as ideology is predicated on the maintenance of dominant social consciousnesses that are taken for granted as “common sense”.²⁵ This ideology is prevalent within existing cultural safety training: every effort is made to avoid upsetting or confronting white fragility.

The ideology of whiteness is further evident in the steadfast resistance to shifting the gaze away from the “ailing Black body” to indicting individuals and institutions who are active agents in upholding racialised systems of power. The push for a “strength-based approach” within Indigenous health has not remedied this dilemma because it does not matter whether Indigenous peoples are constructed as marginalised or empowered if there is no accountability for the working of racial power. White settlers are always an invisibilised norm against which Indigenous peoples are assumed to exist. Whiteness as the norm is inherent to cultural safety training approaches, which often focus on interpersonal racism to develop educative modules that aim to uncover “unconscious bias” or “prejudiced” or “biased” views. Unconscious bias framing “psychologises racial prejudice” while “leaving racialised power relations untouched”.¹³

These interventions that seek to “measure” individual “biases” provide “an abstract and dehumanised account” of racism that fails to explain racial violence and does not “reflect or respect the material, embodied realities of racialised people”.¹³ As such, current interventions on racism rarely equip participants to engage in meaningful antiracist practice, particularly the kinds of collective antiracism that might precipitate institutional transformation.

Our training program instead makes Aboriginal and Torres Strait Islander participants the key arbiters of the content of the training. Cultural safety training often operates with an underlying “assumption that greater reflexivity by practitioners about their own culture and location will result in benevolent adjustments to health practice”.¹³ This assumption is predicated on the idea “that it is ignorance rather than the kinds of investments identified by critical race theory that generate racism,“¹³ but more importantly, it results in often compulsory training that is fundamentally unsafe for Indigenous peoples. Our methodology instead attends to the material consequences of a lack of cultural safety. This educational strategy is culturally safe for Indigenous peoples because it consists of Indigenous-only training for Indigenous participants, facilitators and colleagues. It also provides cultural supervision and support from Indigenous mentors who already possess a sophisticated understanding of how race operates. The kind of training that we propose and model is one that attends to how racial violence is perpetrated in teaching and learning spaces, and how its impacts might be minimised and resisted.

The measure of success for our methodology is not white satisfaction but the emergence of communities of practice that support long term organisational disruption and resistance within health organisations. Strategies that focus solely on the level of individual bias are akin to removing desiccated leaves while leaving the rot that grips the stem and roots unattended; the superficial veneer of antiracism leaves the structural conditions of racism unaddressed.

Rather than attend to race politically, racism's “offending behaviours” are instead made “amenable to corrective training to align a practitioner's unconscious or implicit racial bias with their conscious or explicit commitments”.¹³ There is no consideration for the hostility that true antiracism will inevitably provoke, nor guidance for how vulnerable antiracists might navigate this resistance. Antiracist educational interventions must put forward clear strategies and theories for how change can be fought for and sustained. As such, our model focuses on supporting participants to become actively engaged in antiracist practice by providing participants with access to training tools and a training program pilot. The training program will include discussion of key concepts in race and racism, the structural and political functions of race in the health system. It will involve discussion of specific scenarios or strategies through problem-based learning exercises to develop a shared vocabulary of racism and a clear understanding of the structural dimensions of racism in the health system. By training participants to think of race and racism as structural, this methodology will provide tools by which communities of antiracist practice can depersonalise the backlash that invariably follows antiracist action and provides tools and resources with which strategic responses can be formulated.

This methodology provides the tools, language and support to do this work, and actively de-centres white resistance and fragility. In so doing, we aim to support the existing work of individuals who are engaged in challenging racism in the health system and advocating for justice for Aboriginal and Torres Strait Islander people by fostering a broader community of antiracist practice — one that will enact long term organisational transformation. Canadian scholars have critiqued cultural safety training for its universalising and flattening tendencies, and its presupposition of an endpoint where workers become “culturally safe”.²⁶ We reject this box-ticking approach²⁷ by instead foregrounding an antiracist education methodology that better honours the original conceptualisation of cultural safety. A methodology that, in its persistency and resistance to placating white discomfort, requires non-Indigenous health workers to consistently interrogate the complex entanglement between the seeming benevolence of health care and the violence inherent to the settler colony.

We do not imagine that we can eliminate racism in the health system through policy, regulation, or attitudinal change. We do not sustain the delusion of racism as only circulating through individual feelings, “bad apples”, and aberrant behaviours. Racism, as we conceptualise it, is inherent to the culture of an organisation, continually evolving and finding new expressions. To challenge this unhealthy culture, our methodology insists on the need to cultivate, support and educate strong communities of practice who will be at the forefront of change. Our methodology will not “solve” racism, but it will equip communities of Indigenist, antiracist practice with the tools necessary to challenge racism when and where it emerges.

Our methodology is premised on the understanding that racism is a structural feature of the health system that must be constantly disrupted and resisted. It is from this deeper commitment to building communities of Indigenist, antiracist practice that we see the possibility for meaningful transformation in the health system both locally and beyond.

Approaches to racism that do anything other than dismantle the structures of racism will only reproduce the crisis of racism that the Australian Government purportedly wishes to combat. Transformative change cannot be enacted without challenging the workings of racial power. To do this, health systems must adopt a broader antiracist strategy that complexly engages with the structural and lived realities of race and racism. Educational interventions are not a silver bullet. There is only so much that frameworks and methodologies can do to challenge something as complex, mutable and entrenched as racism, particularly in Australia. However, it is their capacity to build communities of antiracist practice that make educational interventions a critical foundation upon which an antiracist intervention can be built. Throughout this perspective article, we have offered a strategy for building and sustaining such communities. We believe that this methodology, which ensures that antiracist work happens at every level of the health system for both patients and workers, can be adapted and applied across health systems statewide and nationally.

No relevant disclosures.

Not commissioned; externally peer reviewed.

Watego C: Conceptualization, methodology, writing – original draft, writing – review and editing. Singh D: Conceptualization, methodology, writing – original draft, writing – review and editing. Yow Yeh K: Conceptualization, methodology, writing – original draft, writing – review and editing. Kajlich H: Conceptualization, methodology, writing – original draft, writing – review and editing. Singh S: Conceptualization, methodology, writing – original draft, writing – review and editing.