Culture and health.

CHAPTER 3
CULTURE
AND HEALTH
Robyn Williams | Janie Dade Smith | Regan Jane Sharp
A people without the knowledge of their past history, origin
and culture is like a tree without roots.
( M A R C U S G A R V E Y )
Imagine the perfect world where our children play in the sunshine with their multicultural friends, where everyone is treated equally, where we all understand and
respect each other for our strengths and our diﬀerences. To live in such a peaceful
multicultural society it is important to understand why we ‘think what we think’ and
why diﬀerent cultural groups ‘think what they think’. Tis understanding is particularly important for health professionals who will all at various times work in crosscultural contexts. Working as a ‘culturally safe’ practitioner is just as important as
being a ‘clinically safe’ practitioner. A crucial part of being culturally safe is being able
to defne our own culture, to know how our own cultural identity inﬂuences and
shapes our work practice and being able to negotiate shared meaning and relationships of trust with all people receiving our care.
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46 AU ST R A L I A’ S R U R A L , R E M OT E A N D I N D I G E N O U S H E A LT H
Learning about our own cultural identity, particularly for those from the dominant or largest cultural group, is an interesting process that can be confronting and
extremely challenging. Tis is because we commonly think that our way of doing or
seeing things is the most obvious and logical way. Tis chapter aims to challenge those
beliefs so that you, as a health professional, can provide the most appropriate services
to all who make up our very culturally diverse population.
Tis chapter also examines the issue of culture from international, national and
rural perspectives. It explores how to turn one’s gaze from ‘the other’ and how to look
at one’s self, that is, what goes into making up our professional and personal identity
and how this impacts on work practice. It then explores in detail three key concepts,
racism, social justice and cultural safety, and applies these principles through the use
of a case study.
WHAT IS CULTURE?
Culture describes the particular way of life of a group of people, as they are living
today. It is like a group’s own particular pattern or template for living. It includes what
they think – their beliefs, values and philosophies; what they say – their stories, myths,
languages, symbols and traditions; what they do – their lifestyles, customs and behaviours; what they believe – their ambitions, traditions and expectations; and what they
make – their buildings, technology and food.
Culture is learned. It evolves, adapts and is passed down from generation to generation. It is based on shared perceptions about the cultural group’s beliefs, values,
Reproduced with permission from: iStockphoto/Christopher Futcher.
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C H A PT E R 3 C U LT U R E A N D H E A LT H 47
philosophies and norms (Tidwell, 2003). It is these shared perceptions that defne the
culture and bind the group together. It tells them what is ‘pretty’ and what is ‘ugly’;
what is ‘right’ and what is ‘wrong’. It inﬂuences their preferred way of thinking, of
behaving and of making decisions (Eckermann et al., 2012).
Culture is constantly changing; it has to in order to survive. Our culture changes
slowly and constantly as we fnd new ways of doing things and through our exposure
to other cultures. Discoveries and innovations, such as television and the internet,
and social and political movements, such as the women’s movement, help bring about
these changes. We borrow and discard from other cultures, such as worldwide fast
food chains like McDonald’s where we now fnd Australians asking for fries instead
of chips. Our long-term contact with other cultures also brings about change in how
we view the world (Tidwell, 2003). Tese subtle inﬂuences aﬀect our culture and
slowly and constantly change our own template for living as a group as we accept,
respect and take on these beliefs and practices as our own. Tis means that we always
have a culture. It is not something we can lose; it is what we are living now (CadetJames, 2003).
Diﬀerent cultures ofen have difculty in understanding one another. Tis is not
just due to diﬀerences in language and lifestyle, but also to the diﬀerent processes
they use to interpret the world and consequently make their decisions. Tese decisions are based on their own set of principles, values and philosophies and their
diﬀerent ways of knowing and doing (Eckermann et al., 2012). It is ofen easier to see
‘diﬀerences’ in other people than in ourselves; ofen we cannot recognise our own
culture because it is so much a part of us. Tis can then raise a ‘fear of diﬀerence’
between two groups, which is based on the insecurity that arises from unfamiliarity.
Consequently, most of us think that what we see and believe is the ‘right or only’ way.
Tis ofen leads us to make judgements or disapprove of others who think or behave
diﬀerently from ourselves. Tis is particularly prevalent for those who belong to the
largest and dominant group, largely because this is the section of society that has the
most inﬂuence on how people behave.
Tere are a variety of diﬀerent subcultures within every culture (Dreachslin,
Gilbert, & Malone, 2012). Tese include the practices of a school group – ‘school
culture’; or the values of a workforce – ‘corporate culture’; or the perceptions of a
gendered group – ‘male culture’; or the actions of a particular group – ‘the culture of
violence’. Te women’s movement of the 1970s created one such subgroup and substantially changed the way in which women are now viewed by, and socially integrated into, society. Tere may also be subcultures between mainstream groups,
such as gays, lesbians, bisexuals, transgenders, queer and intersex people, the elderly,
single parents, intravenous drug users, teenagers, football players and diﬀerent professional groups. One culture that dominates all health professionals is ‘medical
culture’, which is based on the scientifc rationalist and biomedical model of health
care. For centuries it has provided the lens through which we understand the scientifc basis of illness; it has provided society with one ‘worldview’ of health and
illness.
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What is worldview?
Te concept of worldview provides a lens for understanding culture. It refers to how
diﬀerent people or groups of people perceive and relate to the world in diﬀerent ways.
Worldviews inﬂuence how we ‘understand the world’ and all aspects of life. It aﬀects
how we experience health and illness, what it means to be well, what we do when we
are sick, who we talk to and how we understand the causes and treatments of our
conditions.
Worldview is also tied to the concept of diﬀerent ‘knowledge’… how we ‘know’
the world, which will inﬂuence understandings of all aspects of life, including health.
If we only know one way of seeing the world, or one way of understanding it, we will
take this to be the ‘true’ way of seeing the world – it becomes our ‘reality’. However,
we then may be more likely to disregard others’ worldviews, or to not see them as
legitimate ways of knowing about the world.
We all make assumptions about what is true and these assumptions are embedded
within our knowledge systems. All knowledge is also political, in that it is constructed
by relationships of power based on domination and subordination. Te objectivist,
scientifc view of knowledge is dominant in Western society and particularly in areas
such as health.
Tese concepts of knowledge and worldview are very important to understand,
as they are fundamental to what we understand about culture. It is important to
remember that it is not just other cultures whose worldviews we need to recognise.
MacLachlan (1997, p. 59) said that we need to ‘think through’ our own culture, which
means being aware of our own worldviews and understandings to help us explain
Reproduced with permission from: Shutterstock/ARENA Creative.
Everyone has a worldview
whether they realise it or not.
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C H A PT E R 3 C U LT U R E A N D H E A LT H 49
why we think and act the way we do. In doing so, we can understand that our way
of experiencing the world is just one way, rather than the only or the right way.
To be an eﬀective health professional, it is important to be aware that not
all groups think like you do, particularly if you are part of the dominant group.
When one culture tries to convert another culture to its way of thinking or doing, it
ofen results in ‘culture conﬂict’. Tis can occur when one cultural group has power
over another, and where it tries to impose its systems and organisations, beliefs and
values on the less powerful – usually by violence or legislative sanctions (Eckermann
et al., 2012).
Understanding health culture
Te concept of health diﬀers between individuals, both within and across diﬀerent
cultures, and this diﬀerence has important implications for health systems and services. Te word ‘health’ carries considerable cultural, social and professional baggage
and it is a key to our culture. It is a word that involves important ideas and strongly
held values (Baum, 2008). Using it in diﬀerent ways gives rise to particular ways of
seeing the world and behaving.
In many Western countries such as Australia, the dominant health systems operate
using a biomedical model of health (Baum, Bégin, Houweling, & Taylor, 2009).
When a biomedical approach is used, the body is essentially viewed as a machine
with a set of interrelated parts. Te malfunctioning or ‘sick’ part is isolated, causes
are sought and treatment is instigated. From this description, it can be seen that this
biomedical model is derived from a typically Western scientifc framework of knowledge and understanding, based on objectivity and scientifc rationalism. Tis means
breaking something down into its smallest components for analysis, rather than
seeing something as a whole (Crotty, 1998).
As with many other cultures, Indigenous Australians tend to see health from a
holistic perspective, where it is not just the physical wellbeing of the individual but
includes the social, environmental, cultural and spiritual wellbeing of the whole community (NAHS Working Party, 1989).
Terefore, as health professionals it is important to question one’s own understandings of health, to begin to understand how health can diﬀer across cultures. Differing and ofen competing worldviews, language barriers and misunderstandings can
inhibit eﬀective service delivery. A major factor that inﬂuences access to and equity in
a service is the appropriateness of the service to all of its users and the previous experiences of the client, both within wider society and within the service industry.
P A U S E A N D T H I N K
Think about your own worldview of health. How do you defne it?
What factors have you brought to this worldview from your own family?
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Recognising difference
People who look physically diﬀerent from the mainstream group cannot hide
their identity or choose not to disclose it. Every day they come in contact with mainstream groups or belief systems where they are aware of their diﬀerences. Tese
experiences, many of which begin in childhood, will strongly contribute to the identity and sense of self held by marginalised individuals and groups. Tese experiences
will interact and be simultaneously inﬂuenced by cultural diﬀerences, family and
worldview.
In some cases individuals can choose when to declare their ‘diﬀerentness’. For
example, they can decide not to tell the GP that they use recreational drugs or have
hepatitis C – for fear of being labelled a drug user; they might not tell their next door
neighbour that they are gay or lesbian – for fear of being judged or subjected to
homophobia; they might not tell their workmates that they are a devout Christian
– for fear of being discriminated against for their religious beliefs; or a teenager might
not tell their midwife that they have had an abortion – for fear of being judged as
promiscuous or stupid. Tese people still suﬀer marginalisation and discrimination
from mainstream (or other minority) groups, but it is less constant because physically
they can ‘blend in with the crowd’.
INTERNATIONAL PERSPECTIVES
A number of new Australians, in particular health professionals, are being moved to
rural and remote areas as they come through our borders from war-torn countries,
where many have been victims of terror, displacement and violence. We no longer
live in an insular world where we can choose to ignore the activities of other countries. As our nation becomes more multicultural, it is important that we have some
insight into some of the rites and rituals that other cultures practise so that we can
understand the thinking behind what they do, and their beliefs and value systems.
Once we can see the thinking behind the action, it becomes easier to tolerate or
respect these cultural groups for thinking what they think, and to suspend judgement
about those things that we do not understand (Eckermann et al., 2012). Tis may
then provide us with some insight into why they think that. It is really a matter of
tolerance and respect.
Rites and rituals
First, let us look at the number of ways in which we all learn our value systems
throughout our lives. Tis occurs through traditions that are passed on from parent
to child, and family to family; through rituals that we hold dear such as christenings,
marriages and funerals; through those rites of passage that acknowledge a new phase
of development, such as bar mitzvahs and school graduation ceremonies; and through
our religious, cultural and political beliefs.
Tere are key rituals that we accept in all cultures at the most important times in
our lives, such as at birth, when we become adults, on marriage and at death. Tese
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C H A PT E R 3 C U LT U R E A N D H E A LT H 51
are the occasions when we take time to acknowledge, recognise, respect and honour
the new, the maturing process and the dear departed. In Australia we honour our
fallen soldiers – ‘lest we forget’; our ‘lovable larrikins’ such as Ned Kelly; and of course
our sporting, music and activist heroes, on whom we bestow awards such as ‘Australian of the Year’. Each culture does these things diﬀerently, and the traditions are
passed down from generation to generation, from cultural group to cultural group
and from religion to religion. Honour, therefore, forms part of the value system upon
which cultures base their philosophies.
Not all countries have the freedoms, guaranteed human rights and value systems
that Western cultures take for granted. In other cultures, what Australians proudly
consider their cultural norms could be seen as crimes of the state or acts that would
bring great dishonour and disrespect on the family. Some cultures can have overtly
defned roles for men and women. For example, women may not be considered equal
to men; the institution of marriage and the concept of ‘marriageability’ may be held
in the highest regard; women may be ‘protected’ by men; and there may be strong
traditional family or caste* systems. Examples of acts that might be considered disrespectful or a social crime could include females wearing revealing clothes or travelling without a male companion in many Muslim countries or females marrying into
another caste system in India.
Likewise, there are numerous cultural practices that many Australians may consider wrong, ridiculous or even barbaric in the context of their own cultural template
for living. Tese include: praying three times a day; requiring women to wear veils;
paying dowries so that daughters can marry; arranging marriages; and circumcising
or killing daughters. For example, in Pakistan the United Nations estimates that there
are over 5000 honour killings every year (cited: Chesler, 2010). Tese women are
killed at the hands of their fathers, brothers and husbands in the name of honour and
tradition. Te value and belief system behind these killings is based on strong patriarchal and tribal traditions that regard the male as the sole protector and controller
of the female, and her ‘right to life’ as conditional on her obeying social norms
and traditions (Morgan, 2003). If the male’s protection is violated he is viewed as
losing his honour, which in turn brings dishonour to his family. Te thinking
behind this is that he either failed to protect her, or failed to bring her up correctly
(Jones, 2008).
In our Western cultural value system we treat honour killings as murder and as
a violation of our most basic human right: our right to life. In Western cultural value
systems our right to life and the rights of women to be equal to men, to be protected
from violence and abuse and to marry whom they want are taken for granted. Tey
are assumed to be basic human rights; but of course not everyone adheres to these
*Caste system is a system of social hierarchy particularly used in Hindu society, where
members have no social contact with other classes but are socially equal to one another and
ofen follow the same occupations (Australian Concise Oxford Dictionary, 2000).
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52 AU ST R A L I A’ S R U R A L , R E M OT E A N D I N D I G E N O U S H E A LT H
beliefs, which is evident in our high rates of domestic violence across all levels of
society.
Te cultural conﬂict here lies in the ways in which these two value systems
see the role, value and ‘humanness’ of women compared with men. Te value systems are supported by learned traditions that are passed down from one century to
the next.
Now let us examine our own Australian culture and the values, beliefs and philosophies that characterise our template, and the way in which we live as a group.
AUSTRALIAN CULTURE
Australian culture consists of a diverse combination of cultural groups. Walking down
some of the city streets in metropolitan Melbourne or Sydney, you could be forgiven
for thinking you were in Tokyo, Saigon, Rome or Athens.
Most Australians see Australia as a relatively young country because they calculate
its age in terms of European settlement. However, there were ancient Indigenous
cultures and traditions in existence for at least 45 000 years before the arrival
of Europeans (Human Rights and Equal Opportunity Commission, 1997). Yet
Australia’s now dominant cultural group has taken on few of these traditions, apart
from a growing appreciation of Indigenous art, dance and bush tucker. Due to colonisation, the very essence of Australian culture has become that of the dominant
English and Europeans, and more recently the United States. It includes those characteristics and icons that we now hold dear as a nation such as our obsession with
‘football, meat pies and Holden cars’.
In Australia today there are more Italians, South Africans and Greeks than there
are Indigenous Australians, and there are many sixth and seventh generation Australians who think of nowhere else as home. It is our borrowing from diﬀerent cultures
that has given this great country of ours its diversity and richness and makes us one
of the more successful multicultural societies in the world.
Typical Aussies
What underpins the worldview, values, philosophies, belief systems and ways of doing
that make Australian culture diﬀerent from other cultures? On what have we forged
our national identity?
First, we have the values that we as a nation hold dear, and upon which Australian
culture is based. As Australians we take great pride in what we see as uniquely Australian values, such as ‘our sense of fairness, that is, giving and getting “a fair go”; our
camaraderie – “mateship”; our sense of optimism – “she’ll be right”; and our sense of
equality and egalitarianism’ (Sidoti, 1996, p. 1).
Second, there is our philosophy for living, which is based on a sense of our basic
human rights supported by our values of equity – fairness, equality and sameness. As
Australians we now take for granted our right to work, vote, travel and speak freely;
our freedom of religion and from arbitrary arrest; and the right of ethnic and racial
minorities and those with disabilities to protection (Human Rights and Equal
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C H A PT E R 3 C U LT U R E A N D H E A LT H 53
Opportunity Commission, 2015b). Generally, we believe that women should be
treated as equal to men, able to work for the same pay as men and to wear whatever
clothing they choose. We believe all adult people should be free to marry, or not to
marry, have their own sexual preferences and choose their own partners. Most Australians see these beliefs as their right, without question. In fact these human rights,
which we take for granted, provide us with a strong core national value system that
is based on justice, equality and a ‘fair go’ for all. Tey form our national identity and
they are the reason why so many people want to live in our wonderful country. Tis
philosophy is right for us as a group of people. Today, if we did not hold these values
and philosophies, we would probably be labelled ‘un-Australian’.
Te third factor, our belief system, is based on our concept of human rights plus
our value system. Generally speaking, we have a value system that tells us what is
‘beautiful’ – being thin and young; what is ‘ugly’ – being fat and old; what is ‘right’
– getting ahead and having a nice house, a good job and lots of money; and what is
‘wrong’ – breaking the law or abusing children. As Australians generally, we make
our decisions accordingly.
Tis has not always been the case in Australian life. Australian culture, like all
other cultures, is forever changing. For example, the discovery of the contraceptive
pill in the 1960s and the 1970s push by the women’s movement for equal rights produced many innovations, including a change in government policy that brought
about supporting parents’ benefts and abortion legislation. Tis enabled women, for
the frst time, to choose whether or not to keep their babies rather than have them
adopted out, and to escape from violent and unhappy relationships. Tese changes
brought with them new freedoms, belief systems, lifestyles, expectations and values,
new ways of behaving and making decisions, new government policies and new
perceptions of male and female roles. Tis has consequently changed our cultural
template for living as a group.
In 2015 the push for ‘marriage equality’ will have another long-term impact on
our belief systems, values and expectations, and will change not only our policies but
our template for living as a group – one that is inclusive of those with sexual preferences diﬀerent from the dominant group.
RURAL CULTURE
Tere are many subcultures within the overall Australian culture. Rural culture is
one, which is important for health professionals to understand. As we have already
noted, rural people see themselves as diﬀerent from city-dwelling Australians, and
they have diﬀerent perceptions of health. Tis worldview is probably due to the different experiences of rural people that resulted from historical perceptions of the
‘strong, rugged, male’ foundations laid in rural history. Hence, the values and beliefs
illustrated in such expressions as ‘a hard day’s work for an honest day’s pay’, ‘sticking
by your mates through thick or thin’ and ‘not big-noting yourself ’ continue to be
held strongly by rural people. Although this ethos is also held by other Australians,
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it is far more pronounced among the people of the bush, who believe in the superiority of their way of life (Dempsey, 1990) and who are renowned for their independence, resourcefulness, capacity for hard work and stoicism in the face of adversity
(Rolley & Humphreys, 1993).
Tese distinctive sets of values, beliefs and priorities form Australia’s rural
culture – its template for living as a group. Tese values and beliefs were perpetuated in the 1920s by political attitudes that fostered a sense of ‘country-mindedness’
and the ideology or ‘truth’ of being rural people. Farming was seen as an ennobling
experience that commanded respect because it involved hard work, perseverance
and strong family structures (Gray & Lawrence, 2001). Te image of a ‘real’ Australian that was promoted to the world was one of a countryman, able to tame his environment and make it productive through hard work (Aiken, 1985). City life was
decried as competitive and nasty, and city people as being much the same the world
over (Aiken, 1985). In more recent times, movies like Crocodile Dundee and television series like McLeod’s Daughters have perpetuated this rural belief system. While
many of the values of the time were both sexist and racist, the values behind them
were largely based on the concept of a ‘fair go’, a belief in the productivity of hard
work and the optimism and stoicism expressed in ‘she’ll be right, mate’. Tis is
where rural people’s characteristic perceptions about their own health may have
originated.
Rural communities are made up of long-term residents: tradespeople, general
workers, farmers, teachers and professional people. While it is generally understood
that rural people tend to be very friendly, hospitable and loyal, Ken Dempsey (1990)
in his study Smalltown found that there are also some other unique characteristics
that diﬀerentiate the archetypal rural person from the city-dwelling Australian.
He found that there are ofen very clear divisions between certain groups in small
towns, and he places them into four categories: the ‘no-hopers’ – long-term residents
who are usually the drinkers, unemployed and unkempt; the ‘blockies’ – hippie types
who build a shelter on a block to get away from the city but end up on the dole and
are not welcome in the community; ‘deviant women’ – women without local kinship
who visit bars and are ofen judged on their performance as mothers; and ‘transients’
– ‘two-bob blow ins’ who owe no loyalty to the town, such as professionals and especially teachers (Dempsey, 1990, p. 48). It is from these kinds of perceptions that
worldviews of rural culture have been formed.
Rural communities also possess systems of social status that can be distinguished
by wealth, longevity in the community, perceived gender roles, religion, class, social
standing and reputation for service (Stehlik, 2001). Rural people can also marginalise ‘newcomers’: those who may have diﬀerent politics, religion, class or cultural
background (Dempsey, 1990). Tere is ofen distrust and suspicion of newcomers,
who can be defned as those who were not born in the town, or who do not have
their family name on a plot at the cemetery. Tere is a potential for marginalising
particular people who may be labelled ‘ﬂy-by-nighters’ and ‘no-hopers’ by the locals
(Dempsey, 1990). Tese can include short-term professionals on rotation or miners
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C H A PT E R 3 C U LT U R E A N D H E A LT H 55
who ﬂy in and ﬂy out. Many newcomers have been sanctioned and sometimes
driven from the community if they have failed to conform to the community’s
standards.
Tis process is called stereotyping and is about attributing certain characteristics
to a group based on some common factor the group has – such as being from a rural
town and therefore not being as bright as someone from the city.
As health professionals it is important to understand how these values and belief
systems aﬀect how people from diﬀerent cultures and diﬀerent cultural groups form
their worldview, as well as their concept of health and illness.
Medical culture
Our medical system is derived from Western worldviews, our understandings of
health, the body and our scientifc rationalist thinking. On this basis it is not surprising that signifcant issues can arise when a person of a diﬀerent worldview or cultural
background interacts with such a system. Tis can impact on how a patient or client
accesses a system, how they are diagnosed and how they are treated, as well as how
compliant they are with the treatment recommended. As has also been seen, culture
can be viewed from a number of perspectives when talking about interactions with
the medical system. One of the most powerful examples comes from Indigenous
experiences with a non-Indigenous medical system. Many Indigenous people report
difculties with mainstream medical services and many cases result in avoidance.
Some culturally related examples include the physical environment for healing,
family, communication and compliance. Tese issues can cause harm for clients who
may not be receiving care in a culturally safe way.
CULTURAL SAFETY
Te concept of cultural safety frst came to prominence in New Zealand in the late
1980s from work spearheaded by Māori nurses including Papps and Ramsden (1996)
and some of their Pakeha (white) colleagues. Tey identifed issues relating to the
interactions between Māori, the New Zealand health system and the institutions who
educate health professionals for their roles. Tese issues included students’ ongoing
experiences of institutional racism, especially in the education system, and lack of
appropriate tertiary education opportunities for Māori.
According to Woods (2010), the construct of cultural safety was originally inspired
by the principles of protection, participation and partnership that were derived from
the 1840 Treaty of Waitangi in New Zealand. Tis treaty, although not always fully
honoured, was the foundational agreement between the Māori, the Indigenous people
of the land, and the Pakeha, or British colonists. Cultural safety has subsequently been
perceived as a guide for responding to the health problems of many of the world’s
most vulnerable or marginalised ethnic groups, that is, where similar experiences of
colonisation have frequently led to signifcant health disparities between the Indigenous peoples and more recently arrived colonists in New Zealand, Australia and
Canada.
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So what does cultural safety mean? Cultural safety has its antecedents as a philosophy of health care that aimed to improve the health of all Indigenous peoples in
First World colonised countries by providing culturally appropriate health care services. It is framed as a social justice approach to health care, aiming to address the
health status of Indigenous peoples through continuous improvement in their health
communication and interactions with health service providers (Kowal & Paradies,
2005; Ramsden, 2002). It needs to be said, though, that the concept of cultural safety
has grown much more in recent years and has been broadened to include working
cross-culturally in diverse contexts – not only in Indigenous health.
Cultural safety requires health professionals to undertake a process of personal
reﬂection of their own cultural identity to be able to recognise the impact that their
own culture has upon their health care practice. An acceptance and respect of cultural
and individual diﬀerence is a critical factor in culturally safe practice.
Williams (1999, p. 1) tells us that cultural safety is about having a ‘shared respect,
shared meaning, shared knowledge and experience, of learning, living and working
together with dignity, and truly listening’. Cultural safety can therefore be ‘as simple
as “having manners” and treating others with dignity and respect’, and it can be ‘as
complex as having a discussion on culture and power’ (Williams, 1999). ‘Unsafe
cultural practice would therefore comprise any action that diminishes, demeans or
disempowers the cultural identity and well-being’ of the person whose health is being
acted upon (Nursing Council of New Zealand, 2011, p. 9). Cultural safety also extends
beyond ethnic groups and includes ‘age or generation; gender, sexual orientation,
occupation, socioeconomic status, ethnic origin or migrant experience, religious or
spiritual beliefs and disability’(Nursing Council of New Zealand, 2011, p. 6).
Principles of cultural safety
Ramsden (2002) describes three key principles that underlie the concept of cultural
safety:
1 partnership
2 participation
3 protection.
Tese ‘three Ps’ provided the building blocks for developing culturally safe professional health practice. When put into action these principles require:
• commitment from all involved to embrace cultural safety in a meaningful and
transformative way
• developing all resources in partnership and using participatory models of appropriate health care
• protection against individual, structural and institutional racism
• acknowledgement that feelings of isolation and culture shock are common
• acknowledgement of language and cultural barriers that prevent meaningful
exchanges
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C H A PT E R 3 C U LT U R E A N D H E A LT H 57
• recognition that concepts of health and wellness vary between cultures
• recognition of a client’s past negative experiences with the system, both direct and
observed (Ramsden, 2002).
How do you achieve cultural safety?
Te following model has been adapted from Ramsden’s work (cited Eckermann et al.,
2012, p. 187) and is used to describe the three interrelated domains of culturally safe
practice (see Figure 3.1). Tese three domains can be concurrent, and will vary with
individual experience depending on the context and over time. Te domains can
begin initially by being aware that there is ‘diﬀerence’, such as diﬀerences in language,
culture, appearance, gender, upbringing and socioeconomic status. Tey can then
ﬂow onto being sensitive and fnally move to safe practice – as experienced by both
the practitioner and the person whose health is being acted upon.
Cultural awareness domain – cultural awareness is a beginning step toward understanding that there is diﬀerence. It acknowledges the diﬀerent social, economic and
political contexts in which people exist. It is much more than information about
formal cultural rituals and practices. For example, it could include sitting down with
someone from another culture and talking about being parents of teenagers, thereby
building relationships through establishing common ground and celebrating
diﬀerences.
FIGURE 3.1 Culturally safe practice.
Cultural sensitivity
Cultural
safety
Cultural
awareness
Partnership
Participation
Protection
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Cultural sensitivity domain – this is more than cultural awareness; it is about acting
upon and legitimising diﬀerence through understanding, accepting, respecting and
validating cultural diﬀerence. Tis domain involves a process of self-reﬂection and
introspection where a person can begin to understand the formation of their beliefs
and values (Bird-Rose, 2005; Ramsden, 2002). For example:
I returned to Bali for the ffth time and was greeted by our Balinese driver
whom we knew quite well. I was very pleased to see him and I went to kiss
his cheek and suddenly realised that perhaps it was culturally inappropriate. He looked relieved and shook my hand enthusiastically to convey his
pleasure.
( W I L L I A M S , 2 0 1 5 )
Tis quote demonstrates a process of self-reﬂection when two diﬀerent sets of beliefs
and traditions were in play.
Cultural safety domain – cultural safety means an environment that is spiritually,
socially and emotionally safe, as well as physically safe for people; where there is no
assault, challenge or denial of their identity, of who they are and what they need. It
is about shared respect, shared meaning, shared knowledge and experience, of learning together with dignity and truly listening. Unsafe cultural practice is any action
that diminishes, demeans or disempowers the cultural identity and wellbeing of an
individual or group (Williams, 1999).
Culturally safe practice requires openness, honesty, acceptance, reﬂection, commitment and respect. It is important to recognise that actions ofen speak louder than
words – the way we move, our approach, the expressions on our face and the look in
our eyes are all signs that make any words, actions or reactions truthful. It is also
crucial to recognise people can only speak with authority about their own experiences. As such, cultural safety enables individuals to retain their right to determine
if the process or outcome of experience (past and present) is culturally appropriate
(Ramsden, 2002). For example:
We developed a cultural immersion program for medical students. We
were a diverse and international cross-cultural team of nine with different
beliefs, values and practices. Everything we did was in partnership with all
team members; we negotiated all aspects – the program, the resources,
the implementation and the evaluation of the program. It was a very
respectful team where our differences, similarities and what each person
brought to the team were acknowledged. We all learnt more than we
taught by being open, respectful and standing back when required. We
won two awards for this work.
( S M I T H e t a l . , 2 0 1 5 )
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C H A PT E R 3 C U LT U R E A N D H E A LT H 59
Cultural safety in Australia
A few years ago, I ran a remote health workshop on working cross-culturally with
two Aboriginal facilitators. There was a mixed bunch of participants – ranging
from ‘newbies’ to ‘cynical old hands’ with varying degrees of clinical as well as
cultural competence. Mr R was a young man fresh off the plane from Tasmania
who was heading out to a remote community in Arnhem Land with his family.
During the introduction, he stated that he had (not knowingly) ‘met an Aboriginal
person, but he was feeling fairly confdent clinically and wasn’t afraid of asking
questions’. About a third of the way into the frst session on engaging in effective
and respectful communication with Indigenous peoples in the delivery of health
services, Mr R said: ‘No offence, but this cultural safety stuff is bullshit and I can’t
see what it has to do with my job’. I commended him on feeling comfortable
enough to speak his mind and then the group proceeded to have quite a robust
discussion.
Eighteen months later, Mr R turned up at another workshop I was facilitating. He
sought me out at the frst break, thanked me and told me that he had been
thinking about what I said in the previous workshop and that now it was making
sense. This got me thinking and wondering how to create opportunities for
people to get the importance of this concept and take on board that working in
a culturally safe way is equally as important as being clinically safe.
My story as an educator
What does a culturally safe health care environment look like?
A culturally safe environment is one that accepts the legitimacy of diﬀerence and
diversity in human values, beliefs, behaviours and social structures. It exists in an
environment where people feel spiritually, socially, emotionally and physically safe.
In essence, its practice is based upon trust and genuine partnerships.
Critically, it does not require the examination of any culture other than our own
– so as to be open-minded and ﬂexible in attitudes towards people from cultures
other than our own. Identifying what makes others diﬀerent is simple – understanding our own culture and its inﬂuence on how we think, feel and behave is much more
complex and a lifetime journey.
Te occurrence or success of cultural safety is determined by the experience of
the person whose health is being acted upon – the recipient – as well as the staﬀ
involved.
Culturally safe care is met when:
• one’s actions include recognising, respecting and nurturing the unique cultural
identity of an individual
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• one’s actions support the positive health, wellbeing and empowerment of those
with whom you live, work and interact
• it involves revealing, understanding and responding to the power relationships
between a service provider and the people who use the service
• it challenges service providers to examine their own practices (encompassing
their own culture, history, attitudes and life experiences).
To provide a culturally safe and quality service, providers must engage in selfreﬂection so that any service is provided knowing that the clients or users of the
service have cultural values and norms that are diﬀerent from their own. (Tis means
looking at preconceived ideas and stereotypes.)
In a relationship where one has institutional power, it is the ‘moment of trust’
where the client or patient does not feel the need to hide or protect their
diﬀerence.
There are many words that are used interchangeably with cultural safety, including cultural competence, cultural security, cultural respect and cultural responsiveness. Many of these terms have been adapted from other countries with a
similar history of colonisation of Indigenous populations, such as New Zealand
and Canada (Sherwood & Edwards, 2006). Let us brieﬂy unpack these terms and
what they are taken to mean.
Cultural security is built from the acknowledgement that ‘awareness’ of culturally
appropriate service provision is not enough. It shifts the emphasis from attitudes
to behaviour, focusing directly on practice, skills and effcacy. This includes workforce development, workforce reform, purchasing of health services, monitoring
and accountability, and public engagement (Human Rights and Equal Opportunity Commission, 2010). This means ensuring all voices are heard and respected,
in relation to our community challenges, aspirations and identities, and that this
is done in such a way that the community have ownership over themselves
(Human Rights and Equal Opportunity Commission, 2010).
Cultural competence is a term that has risen to prominence in nursing education
over the last 10 years and, more recently, in medical education (Australian Medical
Council, 2013; Committee of Deans of Australian Medical Schools, 2004). It has
been defned as a ‘set of congruent behaviours, attitudes, and policies that come
together in a system, agency, or amongst professionals that enables them to
work effectively in cross-cultural situations’ (Cross, Bazron, Dennis, & Isaacs, 1989,
p. 4).
Cultural responsiveness is defned as an extension of patient centred-care. It
includes paying particular attention to social and cultural factors in managing
Terminology
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C H A PT E R 3 C U LT U R E A N D H E A LT H 61
POWER, AUTHORITY AND HEALTH CARE OUTCOMES
It is important to discuss the issue of power when we discuss culture and health care
as they are intrinsically related. Te medical profession is a useful area to begin to
explore the notion of power and authority. Te general public can easily recognise the
authority that doctors, who reputedly hold the highest level of specialist medical skills
and knowledge, have in the health system. So does power automatically come with
authority and status? And how are this power and authority maintained?
Tere are many symbols in the health system linked to power and authority.
Traditionally, the white jacket, complete with the stethoscope, was part of the ‘image
of the doctor’ perpetuated by the media.
Uniforms are another powerful symbol in health. Nurses and midwives have
longstanding traditions of wearing uniforms that have transformed over the years
from the white starched uniform and cap to coloured corporate style dress and more
recently ‘scrubs’. Te argument for the continued use of uniforms includes easy identifcation, professionalism and infection control. But how does the presence of the
uniform inﬂuence the relationship between professional and client?
therapeutic encounters with patients who are from different cultural and social
backgrounds. This is viewed as a cyclical and ongoing process, requiring health
professionals to continuously self-reﬂect and proactively respond to the person,
family or community with whom they interact (Indigenous Allied Health Australia,
2013).
Cultural respect aims to uphold the rights of Indigenous peoples to maintain,
protect and develop their culture and achieve equitable outcomes (Australian
Health Ministers’ Advisory Council, 2004). It includes a commitment that health
services will not compromise the legitimate cultural rights, practices, values and
expectations of Indigenous peoples.
Cultural diversity is not only focused on ethnicity but also on gender, age, disability and sexual orientation.
Culture conﬂict occurs when one culture tries to convert another culture to its
way of thinking or doing. This can occur when one cultural group has power over
another, and where it tries to impose its systems and organisations, beliefs and
values on the less powerful, usually by violence or legislative sanctions (Eckermann et al., 2012).
Culture shock is that feeling of uneasiness or disorientation that a person experiences when in unfamiliar surroundings or with a dominant culture that is different
from their own. This often happens when visiting another country or when cultural
practices and language are different from their own.
Terminology—cont’d
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P A U S E A N D T H I N K
Why is it that doctors, acute care nurses and midwives have always worn uniforms but social workers,
mental health nurses and other allied health workers do not?
Is it because of the need to protect and be protected for those professions involved in ‘hands on’ care?
Nurse managers, community nurses and midwives are rarely exposed to bodily ﬂuids, other than in labour
and birth settings. So why do they continue to wear uniforms?
Health professionals’ source of knowledge and power confers authority over
clients. It is important to be aware that power can be understood in many ways and
takes many forms. Some are obvious; others are very subtle but no less powerful.
Some of the types of power commonly encountered include: authority – a soldier
obeying an order; force – a court order removing a child from its carer, coercion – the
threat of physical violence with actual violence being used, or inducement or manipulation (Chenoweth & McAuliﬀe, 2005, p. 36).
Communication has an important inﬂuence on the dynamics of power between
groups and individuals in the health care environment. Te ability to communicate
clearly and assertively has been recognised as an essential skill in the management of
workplace demands and stress for health professionals. Assertive communication
helps to reduce conﬂict with others and therefore serves as a useful skill to maintain
long-term wellbeing for everyone.
When dealing with people from other cultural groups, it is crucial to ask who
provides care and who is responsible for making decisions within the client and
family context. For many cultural groups, this means taking into consideration the
kinship and family structure and what determines acceptable social behaviour. For
example, an Aunty may have the authority to speak on a child’s behalf.
When any health professional is working in a cross-cultural context it is critical
to work in a culturally safe and eﬀective way that includes:
• respect for each other’s culture, knowledge, experience and obligations
• not assaulting a person’s identity
• treating each person with dignity.
When people interact in a health setting, the symbols and language used directly
inﬂuence each person, for example by using medical terminology instead of plain
English. Outcomes are dependent on these communications, and so are trust and
respect.
Symbols such as uniforms, stethoscopes and even the system of appointments
(show up and wait) can result in confusion, fear, intimidation and disorientation,
even before the professional encounter begins. When these factors combine with
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C H A PT E R 3 C U LT U R E A N D H E A LT H 63
P A U S E A N D T H I N K
It is now time to think about power and privilege in the context of culture. Consider:
1 What do you think it means to have control over your own health?
2 Have you ever been to the doctor and felt put down, not listened to or not taken seriously?
3 When someone asks you for advice about their health, how do you go about answering their
questions?
cultural diﬀerences the outcomes and processes of health care can be haphazard and
less than ideal. It is almost like a triple whammy when you combine these three factors
together – the client, the health professional and the cross-cultural interaction.
For example, when a health professional talks about someone going to the doctor
or the hospital, they usually say that the client ‘presents’, as in ‘the patient presented
with the following symptoms’. Some argue that the use of this kind of language takes
something away from an individual’s identity whereby they are regarded as an object
to be operated upon. Perhaps this is one of the central points of cultural safety: each
person is a member of a group and is also an individual with their own priorities and
identity. To assume otherwise is disempowering as it fails treat the person with
respect, dignity or validate their identity as a human being.
Lupton (2012) describes the health encounter as a voluntary agreement between
the patient and the provider, where they agree to participate on the grounds that they
think it will be of beneft, but not necessarily because they agree that the provider is
intrinsically more worthy (Lupton, 2012). Terefore, the practitioner needs to
acknowledge an unequal power relationship exists in the health encounter and there
is a potential impact on the client and their health outcomes.
Power, inﬂuence and a reputation for ‘getting it right’ or ‘being the expert’ can
change the way people respond to health advice, and that response is ofen critical to
health outcomes. If a client tries to access a health service but feels disrespected, they
are less likely to trust it or follow advice given. Similarly, if the health professional is
only interested in the presenting disease rather than the person it may result in
non-compliance.
Tese skills applied well can make signifcant diﬀerences to your practice and
eﬀectiveness, and will increase the chance that your professional performance
improves your clients’ lives.
Willis and Elmer (2011, p. 257) argue that ‘the medical encounter must be understood as a social interaction and not simply as a clinical encounter’. It is also important
to remember that power imbalances and their eﬀects in these situations may not
always be intentional. Tey can arise from patterns of work such as time management,
from appearance and a sense of ‘otherness’ developed over time or from assumptions
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P A U S E A N D T H I N K
What are the likely outcomes when a health professional:
• does not make assumptions about who you are
• speaks with respect and understanding
• shows interest in your priorities (e.g. family and work obligations)?
Ask yourself:
• Are you paying attention to the person in front of you? Or are you operating from assumptions that
do not apply to them?
• What did you learn from them?
• How did you become better at your job as a result of meeting that person?
• How can you build your knowledge of culture and people from this interaction?
about which behaviours are acceptable and which ones are derided within the dominant group.
Control over health information also plays a disempowering role in health care.
Tis is even more unhelpful for people who are already disenfranchised or marginalised, for example refugees or people with disabilities. Te eﬀect ofen can be so great
that health care and its benefts are systematically denied to some people.
CASE STUDY
The following case study provides an opportunity for you to explore your own values and
cultural understandings by applying them to health professional practice. Using the principles and the three domains for achieving cultural safety, reﬂect on the practice of this allied
health professional working in a remote Indigenous setting. Discuss how recognition of differences and power imbalances between patients and health professionals helps to improve
the safe delivery of health services.
Note: This case study can be used as a teaching and learning resource in tutorials or to
generate discussion in a small group setting.
Case study 1: Cultural safety – Kelly White
Kelly White is a 32-year-old clinical psychologist. She has worked as part of the assessment
team at Metropolis Hospital’s Secure Mental Health Unit for the past nine years. She also
spends time at Metropolis University marking papers and occasionally guest lecturing.
Having succumbed to her desire for a sea change, Kelly accepts a position in the small
remote community of Littleton. She works for the local Aboriginal Community Development
Corporation (ACDC) at their primary health care centre. Her role is to participate in the
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C H A PT E R 3 C U LT U R E A N D H E A LT H 65
development of their Youth Suicide Strategy as part of the ACDC Taskforce. Kelly is very
enthusiastic about this new position, and she hopes this will be an opportunity for her to
apply her years of experience in a different cultural setting.
Kelly’s frst week in Littleton is a very eye-opening experience and she encounters many
issues that she has never faced before. Most of her clients are Aboriginal. Though they are
there by choice, many of her clients will not look her in the eye and seem very reluctant to
talk. While many of the women appear introverted and say very little in Kelly’s presence, she
later sees them talking, laughing and behaving in extroverted ways outside the clinic. Many
of the men talk to Kelly as though she is a child, and they seem determined to talk only
about their physical health and their family members – not about themselves personally.
Kelly is also confronted by a subtle sense of segregation within the community between the
Aboriginal people and the non-Aboriginal people who live there. She is unsure about how
she fts into this environment.
After six weeks of consulting on the Youth Suicide Strategy, Kelly feels out of her depth.
She has found her work with ACDC to be more challenging than she expected. Kelly is
confused about the apparent gender hierarchy in the taskforce – many of her contributions
are ignored and she is frequently told suicide is different for ‘Blackfellas’. She feels that,
although she is very skilled as a professional, her skills do not seem relevant to many of her
clients’ problems. Kelly begins to question her own professional competence and how she
applies her knowledge and skills when treating her new clients.
In the past week Kelly has become quite angry on occasions and is feeling very isolated.
She decides to discuss her concerns with Daisy, one of her colleagues. Daisy is an Aboriginal
Health Practitioner at the health centre and sits in on many of the Youth Suicide Strategy
development meetings. She seems to be very close to many of the locals. Daisy agrees to
mentor Kelly and begins by discussing cultural safety.
Case study questions
1 Discuss which domain of cultural safety you believe Kelly is in. Is she working in a
culturally safe manner?
2 Discuss the signs and symptoms of culture shock. Is Kelly suffering from culture shock?
Explain your answer.
3 Using the three Ps of cultural safety (partnership, participation and protection), discuss
the issues that you think Kelly has accepted and those that she needs to understand
and work on.
4 What should Kelly do to get the women to engage in a partnership with her?
5 Why do the men wish to only discuss their health problems?
6 Why do the men dismiss Kelly’s contributions?
7 What issues within the community does Kelly have to address in order for her to be
suffciently informed and able to work in a participatory way?
8 What would be the most suitable way for Kelly to discuss her concerns with Daisy?
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RACISM
What is racism?
Racism, like sexism and classism, is about power. Te Oxford Dictionary (2015)
defnes racism as the ‘belief that all members of each race possess characteristics,
abilities, or qualities specifc to that race, especially so as to distinguish it as inferior
or superior to another race or races’ and the expression of such prejudice.
It is the approach by which one dominant racial group has, and maintains, power
over another racial group and subordinates it. Tis subordination is ofen based upon
a belief that some races are genetically superior and that races diﬀer decisively from
one another. Racism is then ofen coupled with ethnocentrism – the notion that one
race is absolutely superior to other racial groups. Racism then becomes an institutionalised system of power and subordination, created and perpetuated by the dominant racial group.
Tis system of power is openly entrenched within our institutions. It includes the
way in which the institution is organised in all aspects of its workings – economically,
politically, socially and culturally. It ensures that the dominant racial group has, and
maintains, power and privilege over all others in all aspects of life (Derman-Sparks
& Brunson, 1997). It is something we learn as we grow up, just as we learn about our
own cultural norms, values and beliefs. We are socialised into it from probably two
years of age, and most certainly by three to four years (Derman-Sparks & Brunson,
1997). One could therefore argue that, essentially, we are all racist; it is something we
need to unlearn throughout our lives.
However, Derman-Sparks and Brunson (1997) argue that it is the outcome of
individual, cultural and institutional policies and actions, rather than the intent
behind them, that determines the presence of racism. As a result, it is more about
‘what you do’ than about ‘what you think’ – it is about your actions. One may therefore act in a racist manner without knowing it, and without thinking of oneself as
racist. One of the challenges in discussing racism is that few people would label
themselves as racist. Yet ofen in the media we hear reports about racist acts in sports,
on public transport and by individual members of the public. Te truth is that hatred
and intolerance underlie all societies. Tey simmer closely below the surface of all
our dealings in this country (Hall, 1998).
Ofen the terms ethnicity and race are used interchangeably; while they are
related, they are not the same. Te concept of ethnicity is based on the idea of a social
grouping marked especially by shared nationality, tribal afliation, shared genealogy
or kinship and descent, religious identifcation, language use or specifc cultural
and traditional origins. However, the concept of race is premised on biological classifcation – genetic similarities, familial traits and heredity (e.g. blue eyes, a big nose
or brown hair).
Racism can present itself in several ways through stereotyping, prejudice and
discrimination. It is important for all health professionals to understand and take
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C H A PT E R 3 C U LT U R E A N D H E A LT H 67
responsibility for how racism manifests itself because it can aﬀect both health care
delivery and health outcomes.
Stereotyping is about placing all people with certain characteristics in a group based
on some commonalities that the group has – such as ‘all blondes are dumb’, ‘all
Muslims are terrorists’. Making assumptions to predict behaviours in individuals or
groups who are diﬀerent from ourselves can lead us to stereotype. Stereotyping does
not tend to allow for individual diﬀerences within cultures and commonly victimises
groups by blaming their cultures for perceived and negatively valued practices.
Prejudice is the process of making a judgement about an individual or group on the
basis of their social, physical or cultural characteristics. It is usually based on a stereotype rather than on actual evidence. Prejudice is usually negative but it can also be
positive such as ‘one can be prejudiced favourably towards Tai cooking or the Wilderness Society’ (Hollinsworth, 1998, p. 48). All of us carry around erroneous or
unsubstantiated beliefs about the world, or at least others in it. In most cases, however,
when confronted with new information or experiences that contradict or question
such errors, we can change our mind without too much difculty or trauma. Just like
over-generalisations, prejudices are usually highly resistant to change.
Discrimination is the unjust or prejudicial treatment of diﬀerent categories of people,
based especially on the grounds of race, age or sex (Oxford Dictionary, 2015). Te
Human Rights and Equal Opportunity Commission (2015a, p. 1) states that: ‘Racism,
racial discrimination, xenophobia and all kinds of related intolerance have not gone
away’ in Australia. Teir ‘persistence is rooted in fear: fear of what is diﬀerent, fear
of the other, fear of the loss of personal security. And while we recognize that human
fear is in itself ineradicable, we maintain that its consequences are not…’
Understanding one’s own prejudices, and taking responsibility for how these feelings can aﬀect health care, is one of the most signifcant things an individual can do
to improve health outcomes. Most people do not intend to be racist in their attitudes
but every time a negative feeling towards someone based on their culture, language,
behaviour or beliefs is assigned, this is a form of racism. Working with groups or
clients who are from a dissimilar culture does not require an overemphasis on the
diﬀerences that could impede relationships between the provider and the client. It is
more important to focus on similarities and what we have in common.
Types of racism
Tere are three key forms of racism. Tey all interact with one another:
Institutional racism ‘refers to the ways in which racist beliefs or values have been
built into the operations of social institutions in such a way as to discriminate against,
control and oppress various minority groups’ (Henry, Houston, & Mooney, 2004).
Tis includes all those structures, systems and services that are automatically built
into an organisation or institution, such as its mission, policies, organisational structures and economic system, as well as its corporate culture, which reﬂects and perpetuates its beliefs and behaviours (Derman-Sparks & Brunson, 1997). It is the
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68 AU ST R A L I A’ S R U R A L , R E M OT E A N D I N D I G E N O U S H E A LT H
thinking behind ‘this is how we do it here’ and ‘we have always done it like this’. In
Australia these institutional structures are essentially built upon Western ways of
doing and knowing; priorities are set according to this thinking. A good example is
found in the inequitable way in which Aboriginal Community Controlled Health
Organisations (ACCHO) receive ‘body part’ funding, when Indigenous people tend
to have a holistic view of health. Yet the funding is based on body parts and separate
funding streams for conditions such as diabetes and heart disease. Tis means that
one ACCHO had 26 diﬀerent sources of funding upon which they had to report
(Henry et al., 2004).
Cultural racism or ethnocentrism is the set of cultural beliefs, values, symbols and
underlying rules of behaviour that teach and endorse notions of the dominant culture’s superiority (Derman-Sparks & Brunson, 1997). It reﬂects the ideology of
the dominant group with identifable structures and practices and plays a critical
role in socialising people to participate in, and maintain, institutional racism (Derman-Sparks & Brunson, 1997). A good example can be found in the Australian
education system, which is based on non-Indigenous ways of teaching and learning.
Despite the fact that we now know Indigenous children ofen respond and engage in
diﬀerent ways from non-Indigenous children (Human Rights and Equal Opportunity
Commission, 2001), the system continues to be unresponsive to cultural diﬀerences
in learning and teaching contexts.
Individual racism constitutes more than mere prejudice, or stereotyping of specifc
groups of people. It also includes the attitudes and behaviours that enable, and maintain, the power relationships of racism (Derman-Sparks & Brunson, 1997). Although
acts of racism may appear to be specifc to the person carrying them out, they are
ofen fuelled by, and reﬂect, institutional and cultural dimensions of racism (DermanSparks & Brunson, 1997). Examples include name-calling during sporting activities
or in the schoolyard that is ignored by those whom the institution places in authority.
Racism is therefore a result of racial prejudice plus institutional power.
Overt and covert racism
Racism can operate overtly; that is, through policies and practices that openly maintain the right of the dominant group to the exclusion of others. Australian examples
are the White Australia Policy, which persisted for more than 100 years in Australia,
and the Queensland Aboriginal Preservation and Protection Act from 1939–1966,
which excluded Indigenous children from attending school or from enjoying the
usual liberties of other Australians (Kidd, 2007).
Racism also operates covertly through hidden practices that consistently perpetuate inequitable relationships (Derman-Sparks & Brunson, 1997). Tis occurs in many
of our systems, including in our prisons, where mainstream intelligence testing and
other research tools are used, even though a quarter of inmates are Indigenous, many
have literacy problems and English is ofen their second or third language. Sometimes
covert racism becomes overt. A good example is found in the furore of ‘Ban the Burqa’
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C H A PT E R 3 C U LT U R E A N D H E A LT H 69
in the Federal Parliament House in 2015, which was based on fear arising from the
diﬀerent values and beliefs systems and tensions that simmer below the surface in
the Australian population.
Dealing with racism – building resilience
Racism can be very confronting and damaging. Racism is more than just words or
actions. It includes invisible barriers, big and small, that can prevent people from
doing well in life and can aﬀect health outcomes. How do we deal with this? One
way of looking at this is that, in every act of racism, there are three actors – the
perpetrator, the victim and the bystander(s) – and each one plays a role and each
has a responsibility to do something about it. Beyond Blue (2015) oﬀer three main
actions:
1 Report it.
2 Stand up for it.
3 Stop it.
Te Human Rights and Equal Opportunity Commission (Human Rights
and Equal Opportunity Commission, 2015c) recommends the actions outlined in
Figure 3.2.
P A U S E A N D T H I N K
Think about an act of racism that you have witnessed, or that has happened to you. Identify the perpetrator,
the victim and the observer. How was it managed and how could that management have been improved?
How do you feel as a result of this incident?
SOCIAL JUSTICE
Australians generally have a strong sense of social justice and belief in the freedom
to live in a fair society. So what does social justice mean? ‘Justice’ means ‘fairness’ and
is based on a human right. ‘Social’ refers to ‘society’, which is made up of human
beings. Terefore, social justice refers to ‘a fair society’. It essentially means giving
people a fair chance, a share or a choice based on their human rights as determined
by the United Nations Universal Declaration of Human Rights (United Nations,
1948). Tese include our rights to life, free speech and a vote; our freedom to choose
our religion and to travel, to marry or not, to work; to protection from arbitrary arrest
and the right of ethnic and racial minorities, and those with disabilities, to protection.
Most importantly, these human rights include our right to health (Human Rights and
Equal Opportunity Commission, 2015b).
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70 AU ST R A L I A’ S R U R A L , R E M OT E A N D I N D I G E N O U S H E A LT H
FIGURE 3.2 What to do about racism.
Adapted with permission from: Play by the Rules. .
A way to describe social justice and how it applies to real life is best conveyed by
this story by Frank Brennan, a Jesuit priest and lawyer and well-known spokesperson
on Indigenous land rights (Brennan, 1989, cited in Smith, 1995). Brennan describes
how, as a young boy, he went to boarding school. While he was very bright academically, he was never very good at sport and was therefore a member of the D grade
football team. Te A grade team were always allowed to play on the level feld, which
was protected from the wind, but the D grade team had to play on the hill slope.
He tried to convince his teachers that, if they were allowed to play on the ﬂat oval,
the D grade team’s game would greatly improve and the A grade team would be challenged, as they would have to try to play better on the hill slope. However, this was
never allowed. Te A grade team were the fttest and best, so they should have the
best oval, and the D grade team were the worst, so they were given the worst oval.
Tey would never have the opportunity to access the resources of the best team
because they would never equal them, in skill or in status.
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C H A PT E R 3 C U LT U R E A N D H E A LT H 71
Hence, social justice is also about fair and equal access to services and resources
and to freedom and choice to decide how we as Australians want to live our lives,
irrespective of where we live or our culture (Human Rights and Equal Opportunity
Commission, 2015b).
CONCLUSION – IT’S A MATTER OF RESPECT
As Australians we largely defne our national character in terms of values such as
fairness, acceptance, equality, human rights and social justice.
However, if we looked a little more closely at ourselves we would see that
things could be fairer than they are. We could be more accepting than we
are, and our participation in the economic, social and cultural life this
country has to offer could be more equitable and inclusive than it is.
( S I D O T I , 1 9 9 9 , p . 1 )
Our current inequitable and non-inclusive attitudes and policies are going to be
exacerbated by an inﬂux of new Australians, who have come from unjust and
extremely inequitable societies – their very reason for coming to the ‘lucky country’
in the frst place. Many are moving to rural and remote Australia as they pass though
the immigration system. Tey are ofen survivors of trauma and torture. Tey will
hold diﬀerent values, beliefs and practices, which does not make them any less
human, just diﬀerent. To be able to be fair, we need to appreciate this diﬀerence and
treat all cases equally, and diﬀerent cases diﬀerently (Brennan, 1989). Tis may mean
that we need to unlearn what we think we know, question our own values and cultural
norms and be open to doing so in an environment of tolerance and respect, since
countries can no longer be insular in today’s global environment.
Tolerance is not just about understanding or accepting; it is more about tolerating
other cultures, and people as human beings, as a mark of respect for their values,
philosophies, belief systems and ways of doing. Wilson (1998), however, argues that,
while tolerance is essential for a peaceful and united community, it is not enough.
He states that to develop a multicultural community spirit we need to ‘express a rich
and lively interest in one another’, really celebrate our diversity and ‘have an instinct
for compassionate sharing and sensitivity to another’s needs’ (Wilson, 1998, p. xiv).
Tis does not mean that we necessarily agree with what other cultures do; in fact, we
can vehemently disagree, especially over issues that violate others’ basic human rights.
What is important is that we do not view people as being any less human than ourselves, and that we can respect their rights as human beings to participate in our
society as equals.
Hence, to be able to respect other cultures, it is vital to understand our own
culture. It is not so much to understand ‘what we do’, such as drinking beer, having
barbecues and ‘taking the mickey out of each other’ (teasing), but the ‘thinking
behind what we do’ – our belief systems and our philosophy about what is important
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72 AU ST R A L I A’ S R U R A L , R E M OT E A N D I N D I G E N O U S H E A LT H
in our lives. It is the lack of understanding that diﬀerent cultures have about ‘why we
do what we do’ that creates conﬂict.
Eckermann et al. (2012) tell us that an acceptance of diﬀerent cultures does not
mean that we have to abandon our own traditions and philosophies. Rather, we need
to suspend judgement about those things that we do not understand, make a conscious eﬀort not to determine what is ‘good’ and ‘bad’ for others and constantly
question our predisposition to seek security in those things that we feel we ‘know’
about other groups (Eckermann et al., 2012). For health professionals, acceptance
also means that we need to provide health services in a culturally safe manner.
1 Describe your own culture – what are your beliefs, values and traditions
that make up your own template for living as a group?
2 Review current newspapers that reﬂect the common beliefs found in
mainstream Australian culture. Discuss.
3 What social trends have changed during your lifetime that are affecting
Australian lives now?
4 What international practices have been borrowed by Australian culture?
5 Discuss three key ways of preventing culture conﬂict. How does it occur?
6 Think of three examples of covert and overt racism that you have observed.
Discuss.
7 Think of the government departments and institutional systems that you
have worked in, and examine whether their systems or policies could ft
into the defnition of institutional racism. Discuss some systems that do not.
How do they work?
8 Discuss how rural and remote health practitioners could work in a more
culturally safe way.
Discussion points
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