Racism in Healthcare - What Every Nurse and Midwife Needs to Know

Cheri: Welcome to the Nursing and Midwifery Health Program Victoria podcast series, where we will be diving into issues that impact the way nurses and midwives navigate today's ever-changing world. I'm Cheri Huggins, a Registered Nurse and senior clinician at the Nursing and Midwifery Health Program Victoria, and host of this podcast. The Nursing and Midwifery Health Program is a support service which provides care and assistance to nurses, midwives, and students by experienced nurses and midwives.

NMHPV provides a space where our colleagues can bring with them any sensitive health issues impacting their well-being. It is free to access, confidential, and independent. 

Todaywe're really pleased to welcome Giridharan the Race Discrimination Commissioner at the Australian Human Rights Commission. Thanks so much for joining us today, Giri.

Giridharan: Thanks for having me.

Cheri: So, we really appreciate you being here, and we wanted to have this conversation because we're hearing more and more about the impact racial discrimination has on nurses and midwives, particularly from diverse backgrounds. We know it affects individuals' well-being, career opportunities, and sometimes even patient care. So, it's important for us to understand this better and to talk about what can actually change. So my first question to you is, you've been advocating against racism in the healthcare sector recently, including working closely with nurses and midwifery organisations such as the New South Wales Nurses and Midwives Association, what motivated you to begin this advocacy?

Giridharan: Well, Cheri, the consultations that led to the National Anti-Racism Framework identified health as a really critical issue. And for those that don't know, the National Anti-Racism Framework was a document that the Human Rights Commission released about a year and a half ago. It was the first-ever whole-of-government, whole-of-society plan to tackle racism. It came off the back of really significant consultations with people all around Australia, Aboriginal and Torres Strait Islanders, other people that are affected by racism and we talked to about 300 community organisations or got submissions from them.

And consistently, health was identified as a key issue. And put really simply, racism makes people get sick, stops them getting better. In the worst-case scenario, it kills. I mean, there are diseases that are killing Aboriginal and Torres Strait Islander people that were eradicated in the rest of the population 30 years ago and responsibility often gets really dispersed with no one putting their hand up to be accountable. So looking at all of that, I thought that there was a real opportunity to advocate and to bring people together and to try and work on change together.

Cheri: So racism really has a significant and detrimental impact, not only on the individual, but the community as a larger community and also society.

Giridharan: Absolutely. The individual, of course, whether it's the employee or the patient, can be affected. The employee might be dissatisfied, might be unhappy, might be anxious, stressed, unwell. The patient is the same and then the community at large is affected because if a person in a community isn't getting good help, the rest of the community can see that, and they feel a lack of trust in health systems, or they don't want to engage with health systems, which means that that community doesn't get the health assistance they need. And as a society, we all are detrimentally affected by that because we have less people who are able to be productive. We have more pain and angst in our society generally. As a whole, it's all negative.

Cheri: Makes sense. That makes perfect sense, doesn't it? So for listeners who may not be familiar with your role, Giri, could you tell us a bit more about what you do as the Race Discrimination Commissioner, and how do you generally explain what racism is?

Giridharan: So my role is one that was created under the Race Discrimination Act, an act that was passed 51 years ago. It had a different name when it was passed, but it's changed over time, and it's become the Race Discrimination Commissioner. And the act says that my job is to advocate and to educate and to build knowledge about racial discrimination within Australia. So it's not an easy job.

Cheri: No, it sounds as if it's multilayered. It's not just one thing.

Giridharan: No, it's many things. It's whatever I can get to in the time that I've got, really. And when I talk about racism, I try and talk about racism, firstly, in a way that people understand. And I'm sure we'll come back to that. But secondly, I try and talk about it as being about power and privilege because I say that at the end of the day, there's actually very, very little difference in the DNA between me and you, Suri, and the rest of Australia. Race is a concept that was created, really, as often a means of doing terrible things like stealing land or genocide or massacre or whatever it might be. And so racism is the way in which some people have exerted privilege or power over others, and they've often used race as a means to do that. So in that sense, it's a social construct, but it's felt very real by all of those that are disenfranchised or disadvantaged by it.

Cheri: So is it fair to say, Giri, it's a bigger issue than just how we speak to each other on an interpersonal level?

Giridharan: Yeah, absolutely, it is. And I think that when you think about racism as just interpersonal, it becomes really easy to avoid responsibility because you can just say, "Oh, well, I'm not saying something racist to someone. I haven't seen someone say racist things to someone. Therefore, it's not happening. I don't have a responsibility to change." If you think about it as a structural or a systemic thing, then you always have an obligation to change because you've got an obligation to try and change those systems or structures for the better to make them fairer and more equitable for everyone.

Cheri: So, you've mentioned structural racism. Because it sounds a little bit like an abstract kind of concept that we do hear, but we don't necessarily know what that really means. Can you talk to that a bit more?

Giridharan: Yeah, absolutely. I don't think it is a well-understood concept, so it's a good question to ask. I often think about it like this. Interpersonal racism or tackling interpersonal racism is like papering over the cracks, but the faulty structure remains if you tackle systemic or structural racism for that. And so, if you think about it in the perspective of, say, a nurse, how does structural racism impact upon a nurse? Well, it could impact them, let's say, from let's say they're a migrant. So, from the moment they arrive in this country, some qualifications get recognised and others don't. Some people are forced to sit English proficiency tests and others are not. 

I remember hearing a really sad story about a nurse who'd studied at James Cook Uni in Queensland, got her degree, but then was told, "If you actually want to practise as a nurse, you need to sit an English proficiency test." And to do that test she was from Nepal, originally. If she'd come from the United Kingdom, Canada, America, New Zealand, she wouldn't have to sit that test. And to sit that test, she'd have to travel to Brisbane. And so to take time off work to find carers for her children to pay for the test itself, the flights, all of that, it was going to cost her about 8 grand.

Cheri: My God.

Giridharan: So she just couldn't do it. And that's structural racism. That's systemic racism at play. So not having your qualifications recognised, being forced to sit an English proficiency test, having an interview where people use colloquialisms and idioms that only a native English speaker would understand, not being culturally safe within the workplace, not having strong anti-racism policies or complaints mechanisms, not progressing within work because you're not seen as the cultural fit of leadership. And women of colour, in particular, cop that a lot. Having to code-switch, having to act or assimilate in a way that's more culturally acceptable than your own culture. None of what I've just described to you is interpersonal racism, slurs or name-calling. That's all structural. And from a patient's perspective, it could be from how does your community interact with the health sector? Do they actually come out to you? Are you in an area where there's very few services? 

And often, there's an overlapping between race and class there and socioeconomic status all compounding to reduce your ability to access healthcare. Do you understand what information gets put out about health services? Is it actually in a language? Is it translated to the language that you understand? When you go to see the service, are you believed? I remember hearing a terrible story of a young Aboriginal woman who was in shocking pain due to rheumatoid heart disease and was just given Panadol and told to go away. She eventually died. When you go in to get the health service, are you culturally safe? Is there a translator available? All of those things are not accidental. They're decisions made by health services, and they are based in part on what is acceptable as far as race and culture goes and what is not. And all of those things are systemic. They're not about slurs and name-calling, but about how systems disadvantage some people.

Cheri:  Those are such wonderful examples that you've given us there. And I think you've really, really wonderfully delineated between interpersonal and structural racism. And as you're speaking there, Giri, I get a sense of the inequity that runs through all of that. And that's inequity even between different cultures. You can be treated differently. You can come from a culture that's not an Australian culture and still be treated more fairly than if you come from yet a different culture.

Giridharan: Yeah, that's right. I mean, in a sense, if you want to understand structural racism or systemic racism, you need to build racial literacy. And it might be useful for me to explain what I mean by that because it will help illuminate a little bit more what I mean when I say systemic or structural racism. So I'll talk about myself. I'm a migrant. I'm from India. If I catch the plane to Chennai, India, the city I was born in, and I get off the plane in India, and I'm just Giri or Giridharan to a couple of relatives, get back on that plane, and I come home to Brisbane where I live, and get off the plane in Brisbane, and suddenly, I become multicultural or ethnic or diverse or even non-English-speaking background. I've caught that a few times. I'm exactly the same person that caught the plane to India and came home, but I've been made different by the society that I'm in here. And often, it's different by what is seen as acceptable or normal. And so understanding not me, but much more importantly, many others, how they're made different by society is racial literacy.

And then to tackle systemic racism, you have to understand, well, how do our systems and institutions, many of which were built during colonial times and then baked in during the wide Australia policy, how do they deem what's acceptable and what's not? For example, many of them will deem English to be the only acceptable language. For some communities, Aboriginal and Torres Strait Islander communities, they've been speaking language here for 60,000 to 80,000 years. And yet they're still not seen as acceptable, even though they've been on these lands for 80,000 years. How long do you have to be here? Or it might be that some religious beliefs are seen as acceptable and others are not in the way in which cultural safety is recognised. So that's the thing, understanding how people are deemed different and changing not the person, not forcing the person to shed themselves of their culture, their language, their dress, everything that makes them different, which often is impossible to do and is such a hollowing-out process for that person. Instead, change the system to be more transparent, responsive, and accountable to everyone.

Cheri: Yes. Because when we come from overseas, we can assimilate, but that doesn't mean to say that we have to completely lose our culture, the culture that we came from. That's important to overseas nurses and midwives.

Giridharan: Yeah. And I don't like the term assimilate because assimilate, for me, is about shedding everything that makes you different and it is also a form of racism to me. And I think, actually, part of that is based on a sense of what this country is, which is not a true one. So firstly, we have the longest continuous culture in the world. Secondly, we have a very rich history of migration. There were at least 8 Jews and 15 Africans on the first fleet. We had migration from Asia from the early 1830s, from all over Asia, migration from other parts of the world. So we had the Afghan what are known as the Afghan camaleers from the 1850s.

Islam was on our shores well before Christianity through the Makassam traders. But whilst we have this really rich history of migration, we have a really rich history of racism towards migrants that has constantly shut them out from the national identity, national conversation, culminating in the white Australia policy. So people might say, "Oh, well, you need to come here and be like what Australia is." We go, "Well, Australia is kind of the way it is because it deliberately kept excluded the stories of migrants and excluded the richer history. And we'd be better if we were to recognise and embrace our true history and identity."

Cheri: Yes. Because the way you've described that really is multicultural, isn't it? And differences can be celebrated, and that's better for everyone when we do that.

Giridharan: Yeah, because I often think there's a huge benefit to being curious and humble, to just think about what you can learn from others rather than assuming that you always know best. And I think in health, in particular, that's really important because health privileges certain types of knowledge, hierarchy, and that can really shut out alternative ways of thinking or communicating or systemic change and why not be curious and open to learning all the time.

Cheri: Yes. Indeed, why not be? That's a really great question, isn't it? I don't know if we're going to answer that in this podcast, Giri. But one of the things that we hear about racism is that it's not always obvious. And I'm always curious about how racism manifests and why we don't always see it for what it is. Can you talk a bit about what are the things that stop people from reporting racism?

Giridharan: Yeah. I think there's a few reasons why. Firstly, people often have very little faith in complaints mechanisms because they see little change and often, the person that calls out racism gets attacked or victimised far more than the alleged or penalised, I should say, far more than the alleged perpetrator. Secondly, I think people look at leaders, and if they don't see much diversity, they kind of think, "Well, what's the point? Am I going to get anywhere if I raise an issue? My career will be curtailed." A patient is already in such a power imbalance with the health service, they're unlikely to talk about racism because they're worried that the healthcare they get will be compromised in some way. They rock the boat. So putting the obligation on individuals, particularly the targets of racism, to bring about the change is almost a guaranteed way to stop that change from happening because you're not giving them the tools and the capacity to participate in decision-making to actually bring about the change. So you need leaders who are often white to step up and to but not to dictate or to prescribe, but to listen, learn, and then lead. Listen and learn from people who've suffered racism or been targeted by racism. Don't gaslight. Actually believe that it might be an issue and then be prepared to change.

Cheri: So listening to those who may be experiencing racism, it's really quite a significant thing and maybe an easy thing that can be done. So overall, then, who is responsible for addressing racism in the workplace? Is it me if I'm experiencing it to take it to my manager or someone else?

Giridharan: Well, everyone has a role to play. That's for sure. But I also think everyone should be identifying their power or privilege within an organisation and see what change they can make. Usually, you may not have much if you're the target of the racism. You might have a little, and you should use it. But leaders have a lot. Leaders really have to step up. Leaders of organisations, people in executive positions, they're the ones that have to genuinely and honestly name the problem and commit to change and see it through.

Cheri: You make it sound easy. Easy for those people to do that.

Giridharan: Well, I think in this sense, it is a challenge, I think, for a leader to name racism and to acknowledge it exists. People run a million miles from doing that. But what I would say is, what is anti-racism about? Anti-racism is about making systems or institutions more transparent, responsive, and accountable to everyone. That actually helps everyone. It means that irrespective of the school you went to or class or socioeconomic background or age or gender or gender identity, sexuality, irrespective of all of those things, a system isn't transparent, responsive, and accountable to you. Now, a system that does that is a system that's good for everyone and ultimately health systems are meant to help everyone, not just some people, but everyone. So if you want to achieve your mission as a leader of a health-based service, then I would say embrace anti-racism because that's going to help you achieve your mission. It might be tough at first, but the rewards will be worth it.

Cheri: That's interesting. So what are the first steps that an organisation might be able to take to get this work underway, Giri?

Giridharan: Yeah. So I think, one, acknowledge racism as a significant health issue. But name it on its own. Don't subsume it under the category of DEE and I or anti-discrimination. Just call it what it is. Second, the follow-up step is create a standalone anti-racism strategy for your organisation. But do that first by some deep listening to the stories and experiences of people, both staff and patients, and have a co-design process. But don't put all their work and effort on people of colour. Particularly, what often happens is they get told to do all the work, and they don't even get paid for it. So, it's just more cultural load. So, if you pay people to do the work, co-design with them. Three, emphasise cultural safety. That's the most important thing, particularly for Aboriginal and Torres Strait Islander people.

Cheri: What is that, Giri?

Giridharan: Yes. So cultural safety was actually a concept identified by Māori nurses in New Zealand in the '90s as a different means of providing healthcare, one that didn't see difference as a deficit but as a strength, as a benefit, as something to be learned from, and that organisations should shift and change so that their services are acknowledged and work with those strengths. And I think it's a way in which to make health services better, more responsive. And in Australia, primarily, it's a concept for Aboriginal and Torres Strait Islander people, cultural safety. And once it's established for them, it can then be extended out in some form to other communities affected by racism. That's what cultural safety is. It's a genuine anti-racism approach.

Cheri: And it sounds as if it's essential.

Giridharan: Absolutely. It's absolutely essential. Yeah.

Cheri: Yeah, and I guess in nursing and midwifery as well, cultural safety is important in terms of enhancing our nurse-patient relationships as well because we can't move forward as individuals if we don't feel safe.

Giridharan: Yeah. That's right. I mean, and it's the nurses too who are employees. They need to be culturally safe as well. But yes, absolutely, for those that are seeking your care, I think it's absolutely essential.

Cheri: Yeah. On an individual level, as nurses and midwives, we know that we can begin this work by reflecting on our own biases and how that might influence our practice. But what other everyday actions can individuals take in the workplace or whilst working with our patients?

Giridharan: Yeah. So I think that I mean, it depends on your position. So, I think the first thing is identify your own privilege and power and people get really, some people get really upset when I talk about privilege, and they go, "Oh, I don't have privilege." And I go, "Everybody has some privilege." There's nothing wrong with having some privilege. I've got privilege. I'm a man. Being male gives privilege, right? And I'm paid a good salary. That's all privilege. There's nothing wrong with having privilege. It's just whether you use it to help others or not. That's what matters.

Cheri: For sure. Yeah.

Giridharan: So, I think identify your privilege, your capacity to help, be curious, and be prepared to learn. Be prepared to believe. Often, the problem is some will talk about an experience of racism, and they're just not believed. First reaction is, "Oh, that can't be true," or, "Such and such is not such a bad guy." They wouldn't say that. They didn't mean it, or, "Oh, well, the system's a system. We can't change it," or "No, it's got to be the same for everyone. Otherwise, it's not fair." Be prepared to actually believe the system could be unfair and that someone's experience is real. That's really, really critical. You can't make a meaningful difference without acknowledging your own position in the system, believing the experiences of those that are negatively impacted, and then saying, "Yes, I will make a change. I will commit to listening, to learning, and to making a difference."

Cheri: That feels quite empowering to me as an individual to be able to think of privilege in those terms. I think it would be hard for any of us living in Australia, working in any profession, to deny that we have some sort of privilege because we acknowledge in our nursing and midwifery relationships with our patients that there is a power disparity. And I think by acknowledging that, as you said, raising that awareness, it enables us then to start doing things differently, which is really important. Giri, if a nurse or a midwife in the workplace is experiencing racism, race discrimination, and they feel that their problem, their issue, isn't being addressed through the organisation, which we quite often hear, I quite often hear this when we're talking to our participants in this program. What other avenues can they go through outside of the organisation to address that?

Giridharan: Yeah. I mean, it's tough. It's not an easy thing to do. Of course, if they're a member of the union, I would always encourage people to contact their union because collectively, you're far stronger than you are on your own. It might be that not that many do, but the organisation might have some sort of independent grievance process. Perhaps you've got an enterprise agreement which has a dispute resolution procedure that allows you to take matters to the Australian sorry, to the Fair Work Commission. There are always people's rights under the Race Discrimination Act to make complaints to the Australian Human Rights Commission or to state-based commissions. So there are some options that you can use that are external to your employer. I'm not saying that they work all the time, but there's certainly options that are there.

Cheri: Yeah. And it always feels good when you have options, I guess, rather than just feeling that there's no hope in that situation. So we're coming to the end now, Giri. But for you, as the Race Discrimination Commissioner, do you have any messages about hope for addressing racism?

Giridharan: Yeah. Yeah. I've always got hope. You've got to have hope. I mean, just the fact that you reached out and wanted to talk to me, Cheri, that gives me hope. That shows that people are interested and hopefully, those that are listening to your podcast are motivated to bring about a difference. I think that I'll give you one example that's given me a lot of hope within the health sector. So I'll frame it in this way. In November 2024, we released the National Anti-Racism Framework, first-ever roadmap for eliminating racism in Australia. As I'm talking to you right now, Cheri, no level of government has endorsed that framework, let alone funded the recommendations so, that's disheartening. What's heartening is that organisations, the government departments, others have said, "We're just going to get on with the work."  and a really good example of that is an anti-racism in health collaborative in New South Wales. So, this one has been supported, set up really by the New South Wales Nurses and Midwives Federation and the important thing is they're providing the secretariat support because resources are all important. We're limited in our resources at the commission and I have a fantastic team. We have the expertise, but we just don't have the people. So, they set it up. They provided the list of invitees with our input. We gathered in Parliament House in New South Wales, 40-odd people, employers, union, minister's rep, Aboriginal-run organisations, other community nursing groups like the Fiji Nurses Association, the Nepalese Nurses Association, the Philippine Nurses Association and together, we're working on, "Well, how do we make a difference? What measures can we take that can be implemented by employers structurally that can make a difference?" I'm really optimistic about that group. A lot of goodwill there, people giving up their time and I think that that's a really good example where we're not waiting for government I mean, there are government reps there, but we're not waiting for formal government approval to move on things. People are just moving on things and there's lots of things like that that are happening. So I think that although we've seen the rise of populist political parties, anti-migration rhetoric, there's a lot of good people who realise or aren't seduced by vacuous populist policies and go, "No, actually, I do want to make a difference, and I want a better country for my children and my children's children, and I'm going to work together with others to do that." And I think if we work together, we can achieve anything.

Cheri: Wow. What a wonderful note to end this on. What I'm hearing is if there's a will, there's a way. And if we all want to live in a more inclusive society, we can go down that route. Sounds as if the work that you've just described is fabulous, just fabulous. Giri, thank you. Thank you for bringing that glimmer of hope to what can seem for many people quite a depressing world to live in. That's fabulous. So just to end, thank you so much for sharing your time and insights with us today and your reflections, especially around shared responsibility, are incredibly important. So, we hope the conversation encourages nurses and midwives to reflect, speak up where they feel safe to do so, and keep advocating for respectful, inclusive, and discrimination-free workplaces. Thank you for joining us.

Giridharan: Thanks, Cheri

Cheri: Thank you. For any nurse or midwife who might need support after today's podcast, you can access our service on 03 9415 7551. Thank you for listening.

Podcast links:  2024-2029 Anti‑Racism Strategy and Framework referenced within this podcast - Victoria's anti-racism strategy 2024-2029