Analysis: There is undeniable racism in health, as demonstrated by differential outcomes. So why are some of the country’s most senior doctors in denial?
It was 15 years ago when Dr Matire Harwood researched the treatment received by those presenting at hospital with an acute coronary syndrome.
When Harwood began her research she was told it was a waste of time: ‘we treat every patient the same’ was the common response from cardiologists.
Harwood’s research found Māori were 40 percent less likely to receive the interventions regarded as best practice, even after accounting for things like co-morbidities and which hospital they were treated at.
When she presented that data to cardiologists some stormed out of the room.
“I’m sick of you accusing us of being racist,” one said.
Harwood said she was sick of seeing inequitable outcomes; sick of seeing people dying.
Being presented with data that disproved their assumptions about their practice, elicited an emotional response from doctors, and it still does.
More than a decade later, there are frequent and open discussions about inequity in access to healthcare and health outcomes. Systemic racism is part of those discussions.
The recent review of the health and disability system looked at the institutional racism within the system, and recommended ways to combat racism.
Following the review’s reports, former health minister David Clark acknowledged this systemic racism, and committed to good policy responses.
It seemed the country was now acknowledging institutional racism. But a string of incidents show some of the country’s most senior doctors, including cardiologists and renal clinicians, are still in denial.
Now a group of healthcare leaders are calling out racism, in the hope of showing concrete examples that will help move the conversation onto how to address the bias.
Sir Jerry Mateparae, who recently became chair of the Healthier Lives National Science Challenge and the governance board’s Kahui Māori, told Newsroom he was “aghast” at racist comments made by reviewers of a New Zealand Medical Journal article.
The article was the world’s largest and most comprehensive study of cardiovascular risk profiles, using data gathered in New Zealand.
The authors wanted it to be published in a New Zealand journal. The study had the ability to expose inequities, and help inform best practice that would lead to better treatment and more equitable health outcomes.
Without research like this, racism and inequity isn’t exposed, and the cycle continues.
But the peer reviewers, who were New Zealand cardiologists, responded with a series of negative reviews.
They repeatedly asserted racist beliefs, including that the existence of institutional racism was an opinion, not a fact; that there were no indigenous people of New Zealand; and that Māori experienced development, not colonisation.
Mateparae said the fact that these reviewers were some of the country’s senior cardiologists indicated the problem was more pervasive than previously thought.
He and Healthier Lives director Professor Jim Mann decided to speak out to support the researchers, in the hope of raising awareness.
Now those researchers are speaking to Newsroom about their experiences with racism in health, and where to from here.
University of Auckland professor of epidemiology Rod Jackson says he was shocked by the “overtly racist” comments.
“I was absolutely incensed. There is no way they were going to win, from my perspective. I just refuse to take this,” he said.
Jackson, along with fellow researchers Matire Harwood, Vanessa Selak and Jamie-Lee Rahiri, pushed back against the comments, and penned an editorial calling out the racism.
“When I saw these reviews, I just thought ‘f**k you’. There’s no way you’re going to get away with this. We need to get this [research] out there…
“I’m the most senior practising cardiovascular epidemiologist in New Zealand, and there’s no way I’m going to let some racist cardiologist stop us getting this important information out there.”
More recently, Jackson and Harwood were in a meeting where senior renal clinicians opposed the idea of making treatment decisions based on ethnicity, despite a slew of scientific data showing ethnicity in itself was a proxy for risk.
The country’s top experts in risk assessment say being Māori or Pacific is a major risk factor for poor outcomes for diabetes. Medically, knowing someone’s ethnicity was scientifically as good as a blood test when it came to understanding risk.
This knowledge was used to form the basis of the proposal to give Māori and Pasifika restricted access to a new, unsubsidised glucose-lowering diabetes drug.
But those proposing Māori and Pasifika get restricted access were told by one senior clinician at Counties Manukau DHB that they shouldn’t be making clinical decisions based on ‘race’.
All of those who spoke to Newsroom also pointed to National Party leader Judith Collins’ assertion that obesity was a personal choice. They said this showed denial of the impacts of racism, colonisation and social determinants reached the highest levels.
Any society that has substantial measurable differences in health outcomes, by ethnicity, has systemic racism. Full stop, nothing about it.”
As someone who had been focusing on solutions to dealing with racism and inequities for more than a decade, Jackson was disappointed to see senior leaders still denying the existence of systemic racism.
On top of that, it seemed many people continued to grapple with the difference between equity and equality, with many doctors declaring themselves ‘colourblind’.
“I thought we’d moved on from acknowledging [racism], to actually what we’re going to do about it…
“These last few months, I’ve been shocked, actually. I really have been devastated by this very point.”
If the country wanted to address inequitable outcomes, it first needed for everyone to accept the “undeniable fact” that racism existed. That meant flipping the framing on its head.
“If you have a country or a system where there are substantial differences in health outcomes by ethnicity or race, then don’t you, by definition, have a racist system?
“How can you argue against double the coronary mortality in Māori compared to Europeans?
“How can you argue about the six or eight years less life expectancy in Māori and in Pacific compared to Europeans?
“To me, that is the fact of racism. Any society that has substantial measurable differences in health outcomes, by ethnicity, has systemic racism. Full stop, nothing about it.”
People might argue about the causes, but they couldn’t argue about the outcomes.
“And so our challenge to deal with that, is we have to do whatever we can to reduce those gaps.”
“We’re now at a point where we need to challenge this inequity in the face, we need to get right up front, we need to put it in the faces of everyone who potentially can make a difference.”
While Jackson was surprised by the recent racism he’d seen across the health sector, he knew his Māori colleagues had experienced it before.
For Dr Matire Harwood, the negative feedback was “just another kick in the guts”, Jackson said.
Harwood said it was a Friday night when she received the feedback on the research submitted to NZMJ.
She was in her bedroom, away from the family, and remembers feeling sick, “and a bit embarrassed”.
After digesting the feedback, Harwood, Jackson and Vanessa Selak responded to the peer reviewers, offering further evidence to support their statements regarding institutional racism. The reviewers dug in; what came back was worse.
Like others, Harwood said she believed it was time to do away with the blind (anonymous) peer review process – something the New Zealand Medical Journal is not considering.
People should have the courage to stand behind their views, rather than hide behind anonymity, she said.
After Harwood and her colleagues published their editorial, calling out racism in health research, many of her Māori, Pacific and academic colleagues contacted her to offer support – they had experienced similar feedback when publishing on the areas of Māori health, Pasifika health and ethnic inequities.
But these experiences had not been made public before.
Harwood said people found the ‘r word’ challenging.
After presenting that data 15 years ago, she learned framing research in a non-threatening way could help people reflect on the wider issues of institutionalised racism.
This was when one cardiologist said: “I did freak out looking at the data… and I found it really overwhelming… But actually, it did make me think I don’t like this data. I do want to be an excellent doctor. And so I’m going to have to use it.”
That experience taught her the importance of focusing on solutions.
All doctors wanted to help people, and conversations needed to start from that point.
Harwood, along with her research colleagues, and Healthier Lives’ Mateparae and Mann, all said the first step to addressing racism in health was having the courage to call it out.
Then they needed to propose solutions.
“We’re now at a point where we need to challenge this inequity in the face, we need to get right up front, we need to put it in the faces of everyone who potentially can make a difference,” Jackson said.
“When you’re dealing with health, when you’re dealing with disease, you’re dealing with society. It’s never just a personal thing, it is part of politics.”
As well as advocating for an open and transparent peer review process, all of those who spoke to Newsroom said the New Zealand Medical Journal needed to create a position for a Māori co-editor.
And more broadly, Māori and Pasifika needed to be encouraged and supported into positions of health leadership.
Achieving this began with encouraging and supporting more Māori and Pasifika into health, through programmes like the University of Auckland’s Māori and Pacific Admission Scheme (MAPAS), and Otago’s Mirror of Society admissions scheme – something that had become controversial this year, after a father of an aspiring medical student sued Otago over its admissions policy.
Harwood said Māori and Pacifika students brought their experiences with them, and that made them better doctors.
And students coming through medical schools at the moment were self-aware and able to challenge and reflect on their biases.
But it wasn’t enough to wait for these students to become healthcare leaders. The inequities and avoidable deaths were happening now.
There was also a degree of unlearning, when students went into hospitals where they were exposed to overt and subtle racism.
Harwood called it the “hidden curriculum”, while Jackson spoke about the inextricable link between politics and health.
“Politics is just health on on a bigger scale,” he said, quoting German pathologist Rudolf Virchow.
“When you’re dealing with health, when you’re dealing with disease, you’re dealing with society. It’s never just a personal thing, it is part of politics.”
Both said everyone who worked in healthcare needed to acknowledge that. But this year had shown it was going to take significant education of senior doctors to get to that point.
“If you live in a bubble, then I don’t think we want you in healthcare. We can find other people who think differently, or are willing to try to think differently, and will do a better job,” Jackson said.
Harwood said she was hopeful things were changing.
Movements like #MeToo and BlackLivesMatter had helped give people the courage to call out injustice.
Like Jackson, she talked about following those declarations with explicit descriptions and solutions.
“If we can get more of this data out, people can’t question the fact that there’s racism happening. And we’ll be motivated to want to do something about it,” she said.
While there was a long way to go, it was important to acknowledge how far New Zealand had come.
“The fact that we can do this sort of research and speak to these issues in a mana-enhancing way, I hope, and critique each other in a mana-enhancing way, we need to be grateful for that,” she said.
