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A public health approach to racism.

katinadonise


The way people perceive racism is clearly divisive. There are heated parliamentary debates, frequent discussion in traditional and social media and substantial debate regarding the anti-racism movement internationally. There are differing views of what racism is, disagreement on various matters being racist or not, and also the presence of racism itself in Australia. For public health, while the differing perspectives is acknowledged, there is a well-accepted approach that can be applied, based on a substantial literature on racism and shifting behaviour across the population.  


A public health approach to racism offers value to this discussion. I have previously written a blog about how I think about a public health approach. Here I apply that approach to racism, highlighting the areas of evidence for the issue being of public health importance (using epidemiology), system approaches (legislation, policy), community partnerships, data and evaluative thinking.  


Racism as a public health problem

Racism can be considered a public health problem, as racism is a determinant of health, and it is highly prevalent – that is, it is an important health issue at the population level. Racism has a profound effect on mental wellbeing and mental health illness, in addition to the ongoing experience of stress, which translates into physiological damage and physical illness that can be intergenerational (Selvarajah).  We also know that the experience of racism is common. For example, in a representative sample of South Australians, one in two Aboriginal people compared to 15.2% of non-Aboriginal people had experienced discrimination (OCPSE).  In addition to the reported experience of racism, there are clear measures of continual disadvantage on a number of measures including life expectancy, educational attainment, employment, and housing (Productivity Commission). The data are clear that racism does exist, and it is a major public health issue.


System approaches

A public health approach includes working with system level influences of behaviour as routine practice. Take for example the approach to tobacco control. Rather than solely focus on behavioural approaches with individuals to stop tobacco use (e.g. education that smoking is bad for your health), a series of legislative and policy interventions were sequentially introduced which made the environment less conducive to smokers, leading to reductions over time in prevalence of smoking. Critical in this example is the combination of interventions including education approaches through the health care system and mass media which collectively led to changes in behaviour of individuals across the population. Systemic changes led to individual behaviour change. It is the understanding that individuals are substantially influenced by the environment in which they live that is applied to racism. Many systems of our society work together to ensure discrimination, based on race, remains intact. This is true even of the health system in Australia and internationally, with vast numbers of studies documenting the experience of racism and its negative influence on use of the health system (Selvarajah et al, Hamed et al).


Legislation to support behaviour change is an effective system level strategy. It is the case, however, that existing anti-discrimination legislation is not sufficient, as I have written about in a previous blog. In summary, system level racism (referred to as institutional racism or systemic racism) is embedded in institutions. Many people cannot see this racism and further it is accepted as “normal” from the dominant cultural narrative. In being harder to identify, institutional racism is therefore harder to limit through enforcement of legislation.


Policy and strategy of organisations can contribute to filling this enforcement gap. For example, well considered and implemented Reconciliation Action Plans can lead to examination of the systems in place in an organisation that perpetuate racism, alongside intent to make changes. The South Australian Anti-racism strategy looks to human resources policy systems to shift the systems that hold institutional racism in place (OCPSE).


Interventions to reduce socio-economic disadvantage do not directly affect racism but can reduce the impact of racism on populations. For example, there is a large body of evidence about the benefits of high-quality early childhood education on improving educational outcomes and also a range of other beneficial socio-economic outcomes. This can extend to health behaviours, for example in a study I led that found that people who had attended a Kindergarten Union preschool in South Australia had a reduced risk of uptake of smoking, among other benefits (D’Onise et al). Increasing access to early childhood education with a focus on quality care is an important anti-racism intervention.


Community partnerships

It is critical to work with communities to ensure any intervention is effective. This means starting with community voices, community leaders and community champions. Interventions led by or in partnership with the community are more likely to be effective and sustainable and will also go some way towards redressing the power imbalance that currently exists with many communities and government/the state (Haldane et al). Self-determination in all matters relating to Aboriginal and Torres Strait Islander people is fundamental to wellbeing and is important for anti-racism.


Data and evaluative thinking

The majority of the intervention evidence I have presented relates to the substantial knowledge base about changing the behaviour of populations. There is a wealth of evidence on the effects of racism on population health, however there is limited direct evidence in what works to reduce or eliminate systemic racism. While this should not limit antiracism interventions, an explicit evaluative approach is needed for any work in this area. High quality data systems and evaluative thinking are needed to build a comprehensive evidence base, including knowing what works and what does not.


In summary, a public health approach to racism involves multiple levels of interventions (legislation, policy, strategy, programs, education, data), across the whole of society, incorporates life course thinking, shares or cedes power and monitors effectiveness of any intervention over time. I have included some references below which I encourage those interested to read and consider.

 

 

References

D'Onise K, McDermott R, Lynch J. Can attending preschool reduce the risk of tobacco smoking in adulthood? The effects of Kindergarten Union participation in South Australia. Journal of Epidemiology and Community Health, 2010;65(12):1111-1117.


Haldane V, Chuah FLH, Srivastava A, et al.  Community participation in health services development, implementation, and evaluation: A systematic review of empowerment, health, community, and process outcomes. PLOS One, 2019;14(5):e0216112.


Hamed S, Bradby H, Ahlberg BM, et al. Racism in healthcare: as scoping review. BMC Public Health, 2022;22:988.


Office of the Commissioner for Public Sector Employment. Anti-racism strategy 2023-2028: Equipping the South Australian public sector to fight racism. Adelaide, Government of South Australia, 2023.


Productivity Commission. Closing the Gap information repository dashboard. Australian Government. Accessed 9 September 2024. Dashboard | Closing the Gap Information Repository - Productivity Commission (pc.gov.au)


Selvarajah S, Maioli SC, Deivanayagam TA, et al. Racism, xenophobia, and discrimination: mapping pathways to health outcomes. Lancet, 2022;400:2109-2124.

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