Institutional racism occurs when the prejudices and assumptions of individuals find their way into the rules and culture of institutions, so they produce outcomes that systemically put disadvantaged groups at further disadvantage.
Professor Tipene-Leach suggests thinking about some of the fundamentals of general practice: “Like, I expect you to come to me, I expect that you will be here at 9.15am, if you are late, you are out.”
How, he asks, does this work for people with two jobs, four kids, struggling to get food on the table? “Is it not just a way of denying access?”
DHBs decline to provide a renal transplant to anyone with a BMI over 35 but, says Professor Tipene-Leach, there is not a “skerrick” of evidence to support the 35 cut-off. Arguably, it’s designed “to keep brown people out and skinny white people in”.
“This is institutional racism and we need to be constantly alert to calling it out.”
In the 1970s, before cultural competency, there was cultural sensitivity, which Professor Tipene-Leach taught at the time.
Essentially, this covered being aware of ways of greeting, seating, eating, and treating the other person – the skills of any good Kiwi, he says.
Cultural competency is about the attitudes and skills health professionals need if they are to function effectively when providing care to somebody of a different culture.
The health professional is directly responsible for this competency. And it remains important: “This is not about cultural competence going out the door and cultural safety walking in.”
Cultural safety goes further than competency, however. It was born out of research by Irihapeti Ramsden, a nursing and midwifery educator from the 1980s through the 2000s.
Dr Ramsden called on health professionals to engage in self-reflection and to look at the power relationship that pervades a consultation.
As Professor Tipene-Leach puts it, she told professionals “to take your biases, your assumptions, your stereotypes and your prejudices and look and see what they do to you and, in doing something to you, what they do to the patient, client, whānau who are in [your] rooms”.
“She wanted us to think through what are the patient’s rights in a consultation and what are their rights to get treatment, and she predicated her approach to cultural safety on the basis of getting best outcomes for Māori.”
As Dr Ramsden saw it, cultural safety is saying, “actually you have got to account for these outcomes”. The Medical Council doesn’t go quite this far.
But Professor Tipene-Leach says it’s necessary to look at outcomes at a PHO, clinic and individual level and to systematically monitor them by ethnicity.