How racism plays out in public health

The idea of “equity” is everywhere in our public health system.

But what’s missing, write Dr Belinda Loring and Dr Elana Curtis, is an examination of the common behaviour and daily practices that create racial bias and unequal outcomes.

Here, Belinda and Elana explain how racism is perpetuated by daily workplace decisions in our public health organisations.

 

The fallacy of neutrality

Mainstream public health practice often fails to acknowledge that it has its own ethnic origin, positionality, and bias.

Mainstream public health practice in Aotearoa is not ethnically neutral, but rather grounded strongly in British colonial understandings and approaches. A failure to acknowledge this in-built positioning leads to false perceptions by public health practitioners that they are objective and that they don’t unfairly privilege anyone on the basis of ethnicity.

This causes difficulties when advocating for efforts to address health inequities as these are seen, erroneously, as measures which “prioritise” or favour Indigenous groups. In fact, they are measures to rebalance the priority shown to the dominant New Zealand European population, who overwhelmingly benefit from the efforts of public health institutions which are conceived, led and delivered in ways that align with their cultural background.

A recognition of the cultural bias built into our public health institutions is critical for a more honest appraisal of the biased starting point we must actively work to overcome.

Equity as a box — performative non-performativity

“Equity” is everywhere in public health practice in Aotearoa. Commitment to Indigenous health equity is embedded in Te Tiriti o Waitangi, legislation, policy documents, job descriptions, and project plans.

We have frameworks and strategies that unfailingly include a box highlighting how equity is a core overarching priority or objective. Yet beyond the preamble or the equity section in the template, the content of the strategy, plan, or analysis fails to articulate how this commitment is being enacted, or to prioritise Māori in any meaningful way, and thus continues to privilege the dominant ethnicity.

This is often accompanied by a failure to acknowledge underlying inequities by ethnicity when considering public health issues and how to address them (that is, by tailoring a response which assumes a level playing field between Māori and non-Māori).

Expressing a commitment to equity is not the same as embodying or internalising a commitment to equity in the focus of policy or programme activity. Public health practitioners must be alert for, and challenge, empty rhetoric on equity, which does nothing more than provide a false sense of security alongside racist approaches and outcomes.

Inauthentic and unfair partnership

The importance of partnering with Māori in public health activities is generally but variably understood. It’s often regarded as a bureaucratic requirement rather than a necessity for good public health practice.

Partnership is reduced to consultation, or seeking sign-off at a late stage once the problem has been defined, the priorities identified, the service/research designed, or the policy drafted without an acknowledgment that racism is introduced at each of these stages.

Response timeframes are most often racist as it is the mainstream system that controls when in the process Māori are engaged, and this routinely gives Māori less time to consider and respond.

Public health practitioners hold the power in deciding when, with whom, and how much engagement occurs with Māori, and this entails an inherent racial bias.

The balance of power in decision-making processes maintains the privileging of power to the dominant ethnicity. Even when a public health issue disproportionately affects Māori, a meeting will include a lone Māori representative (rather than all necessary Māori contributors), and the inadequacy of this practice is normalised and unchallenged.

Frequently, engagement is with an inappropriate person — using an “othering” lens that Māori ethnicity alone is the only required attribute. For example, using a Māori manager or iwi representative to contribute to a technical public health issue, rather than seeking Māori technical expertise.

Related to this is an inability or unwillingness to embrace multiple Māori perspectives. More “traditional” mātauranga Māori or cultural expertise is played off against other forms of Māori knowledge that may provide a critical analysis of power, racism, privilege. The role of public health institutions in deciding which singular Māori “view” is palatable or legitimate is a further mechanism by which public health helps maintain racist balances of power.

The palatable Māori view is frequently the view that doesn’t directly challenge the status quo of the mainstream public health practice, but rather proposes a “cultural” solution or endorsement, which can be more easily incorporated as an adjunct without requiring any significant deviation or reorientation of the mainstream public health approach.

This serves to perpetuate rather than remedy the inequities built into the status quo. Public health professionals further exercise this power and bias by “Māori shopping” — sequentially approaching individual Māori until someone provides the desired sign-off or perspective.

Public health professionals frequently fail to recognise Māori Indigenous rights (which exist independently of any excess health “needs”) by regarding Māori as a stakeholder at the same level as other marginalised groups. The inclusion of an ever-increasing cast of “priority” minority groups fails to recognise that the fundamental problem is the disproportionate privilege public health practice affords to the white majority. This maintains the dominant ethnic power base by focusing the issue on the competing interests of minority groups.

True partnership requires humility, an acknowledgment that mainstream public health has incomplete understandings of the problem and the solutions. Partnership also requires receptiveness to what the subject of scrutiny should be — including how public health practice needs to be altered to remove its racial bias.

Focusing on cultural competency rather than cultural safety

Public health institutions frequently conflate cultural safety with cultural competency. While both are important for achieving health equity, cultural safety requires public health professionals and institutions to examine themselves and the potential impact of their own culture, biases, attitudes, assumptions, stereotypes, prejudices, structures, and characteristics that may affect the quality of public health practice.

Instead of undertaking this critical work, public health institutions focus predominantly on the cultural competence type of activities. This results in meetings that start and finish with a Māori karakia (prayer), yet contain participation, discussions, and decisions that prioritise non-Māori.

Māori language sub-headings or graphic design are used liberally throughout policy documents and strategies which are fundamentally racist in their framing and impact.

The need to ensure culturally safe public health workforces and institutions is becoming increasingly recognised by professional and regulatory bodies in Australia and New Zealand.

Behaviours relating to white fragility

White fragility refers to the defensiveness and discomfort of white individuals, when presented with evidence or perspectives that challenge their unacknowledged racialized beliefs about the world. In response to these challenges, they withdraw, defend, cry, argue, minimise, ignore, and in other ways push back to maintain equilibrium.

In public health practice, these individual behaviours serve to systematically paralyse or impede institutional pro-equity change. The importance of regular practice review and quality improvement is embedded into healthcare professionals, yet when the issue of performance by ethnicity is on the agenda, personal defensiveness frequently derails the discussion.

The centring of white individuals’ feelings in meetings discussing Māori population health need holds back public health institutions from undertaking any rigorous review or improvement of performance for Māori.

A related behaviour is tone-policing of Māori feedback, labelling Māori feedback as “aggressive” or “angry” in a way that serves to dismiss the content. In contrast, non-Māori feedback is often regarded more favourably, or even thanked, emphasising the privileged voice that white allies have in public health.

Despite holding this privilege, white public health professionals frequently stay silent and defer to the lone Māori colleague to give the critical feedback, and this white silence further perpetuates racism in our public health institutions.

Recognising and overcoming the behaviours associated with white fragility is a responsibility of all white or dominant ethnicity public health professionals.

Controlling Indigenous approaches

Public health institutions share power with Māori reluctantly and only when facing significant risk of failure. Typically, the mainstream public health service designs or delivers a mainstream approach, then adds a Māori clip-on to adapt the approach to try and compensate for the in-built bias against Māori, rather than designing an approach that works for Māori from the outset.

This enables the mainstream public health institutions to maintain full control and does nothing to disrupt the racist power imbalance.

However, when the mainstream approach is in trouble, such as we saw when mainstream public health approaches were losing control of Covid-19 spreading among Māori communities, Indigenous-led solutions are sometimes sought out and supported. What we have observed in this situation, however, is a distrust and discomfort with Indigenous leadership, and there is a tendency to try and manage this fear by exercising other means of control.

The requirement for evaluation or monitoring is not evenly applied in public health practice — a much higher degree of scrutiny is applied to Māori-led solutions than to the performance of the mainstream system. Moreover, a mainstream lens is used to evaluate Indigenous models, reinforcing racist bias about whose perspectives are legitimate and deserve priority.

Racist use of data

Collecting, analysing, and presenting data is a powerful public health tool — however, data never speaks for itself, and epidemiological “objectivity” has historically been weaponised against Indigenous people.

When it comes to ethnic health inequities, data can be collected and analysed in ways that either conceal or diminish inequities — or reveal them. For example, presenting non-age-standardised Covid-19 data gave the impression that Māori mortality and morbidity were lower than those of non-Māori, yet when appropriate age-standardisation was used (18 months into the pandemic), this pattern reversed to reveal that Māori had twice the Covid-19 mortality and morbidity as non-Māori.

Racism in data includes the acceptance of poor-quality ethnicity data that systematically undercounts Māori in key health datasets, the selection of inappropriate comparison groups, or inappropriate methods of analysis, or the failure to critically interpret what ethnicity data is actually telling us, and then connect that to policy and programme changes.

There is a normalisation of graphs showing persisting ethnic bias in the effectiveness of public health interventions and yet a failure to translate this to commensurate action or consequences. Total population analyses will always privilege the numerically dominant ethnicity, and bias the policies and decisions made in their favour.

Far from being unbiased and neutral, mainstream public health practice in Aotearoa is inherently racist, and this bias is currently under-acknowledged by public health professionals and institutions.

To be truly anti-racist, public health needs to move from its arms-length role as an observer of racism to a critical inward reflection on its role in the everyday (re)production of racism.

We have attempted to describe some of the ways that racism is perpetuated in everyday public health practice, with the intention of offering public health professionals and institutions a starting point on which to reflect and improve their cultural safety and contribute to anti-racist, equitable, and effective public health.

This is a lightly edited version of a paper which first appeared in Australian and New Zealand Journal of Public Health, Volume 48, Issue 4, August 2024, 100167.

 

Dr Elana Taipapaki Curtis (Ngāti Rongomai, Ngāti Pikiao, Te Arawa) is a Māori public health physician and Director of Taikura Consultants Ltd. She is an Associate Professor in Māori health and continues to teach, research and work in Māori health as a consultant.

Dr Belinda Loring is a non-Māori specialist public health physician, with 15 years’ experience working on health equity and health policy at local, national and international levels. She held roles in noncommunicable disease prevention and control, social determinants of health, health equity and national health policies at the World Health Organisation. She is a senior research fellow at Te Kupenga Hauora Māori, University of Auckland, and has supported Māori health equity work at Te Aka Whai Ora, the Ministry of Health, district health boards and public health units.