Racism and Indigenous Health
Summary and Keywords
There are an estimated 300 million indigenous peoples worldwide. Although there is ample evidence of worse health and social outcomes for the majority of indigenous peoples, compared to their non-indigenous counterparts, there has yet to be a review of racism as a determinant of indigenous health using global literature. Racism constitutes unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious, or cultural differences that can occur at three levels: internalized, interpersonal, or systemic. For indigenous peoples this is closely related to ongoing processes of colonization. Available research suggests that at least a third of indigenous adults experience racism at least once during their lives and that about a fifth of indigenous children experience racism. For indigenous peoples, racism has been associated with a considerable range of health outcomes, including psychological distress, anxiety, depression, suicide, posttraumatic stress disorder, asthma, physical illness, obesity, cardiovascular disease, increased blood pressure, excess body fat, poor sleep, reduced general physical and mental health, and poor oral health, as well as increased alcohol, tobacco, and marijuana use and underutilization of medical and mental healthcare services. Disparities in medical care experienced by indigenous patients compared to non-indigenous patients have also been found. Existing studies indicate that avoidant and passive coping tends to exacerbate the detrimental health impacts of racism for indigenous peoples, whereas active coping ameliorates the ill-health effects of racism. Reducing individual and interpersonal racism can be achieved by (a) providing accurate information and improving awareness of the nature of racism and racial bias; (b) activating values of fairness, reconciling incompatible beliefs, and developing antiracist motivation; (c) fostering empathy and perspective-taking and confidence in regulating emotional responses; (d) improving comfort with other groups and reducing anxiety; and (e) reinforcing antiracist social norms and highlighting personal accountability. There are five key areas for combating systemic racism in organizations and institutions: (a) institutional accountability; (b) diversity in human resources; (c) community partnership; (d) antiracism and cultural competence training; and (e) research and evaluation.
There are an estimated 300 million indigenous peoples worldwide (Hall & Patrinos, 2012), across more than 90 countries (Department of Economic and Social Affairs, 2009). The United Nations Permanent Forum on Indigenous Issues (n.d.) notes that the following aspects tend to characterize indigenous peoples: self-identification as indigenous peoples at the individual level and acceptance as a member by the community; historical continuity with pre-colonial or pre-settler societies; strong link to territories and surrounding natural resources; distinct social, economic, or political systems; distinct language, culture, and beliefs; being from non-dominant groups in their society; resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities.
In the studies cited here, self-identification as indigenous (including related or local terms) is considered sufficient when reporting on the available evidence that examines racism as a driver of health for indigenous peoples. A recent review of data from 23 countries details ongoing evidence of worse health and social outcomes for the clear majority of indigenous peoples compared to their non-indigenous counterparts in relation to life expectancy, mortality, birthweight, malnutrition, obesity, educational attainment, and economic status. However, this review did not focus on factors such as exposure to racism (Anderson et al., 2016).
Racism can be conceptualized as unfair and avoidable disparities in power, resources, capacities, or opportunities centered on ethnic, racial, religious or cultural differences (Berman & Paradies, 2010). Racism can manifest through cognitive beliefs (e.g., stereotypes), feelings (e.g., prejudice) or practices and behaviors that are discriminatory. Although they are not mutually exclusive, racism can occur at three levels: internalized, interpersonal, or systemic racism.
Internalized racism relates to a sense of inferiority about one’s own ethnic or racial group or viewing other ethnic or racial groups as superior (Paradies et al., 2009). Addressing internalized racism involves considering how “one’s values, knowledge and life experience are heavily influenced by racism,” often at an unconscious level (Ife, 2013).
Interpersonal racism can happen between people from within the same racial group (i.e., intraracial racism between two indigenous people) or between people of different racial groups (i.e., interracial racism involving an indigenous person and a non-indigenous person). In indigenous communities, intraracial racism is also known as “lateral violence” (Dudgeon, Garvey, & Pickett, 2000).
Systemic racism (also called “institutional” or “organizational” racism) encompasses a range of processes, practices, and policies (Berman & Paradies, 2010). Efforts to “help” indigenous people participate in mainstream culture (e.g., the economy, education, etc.) often fail to grapple with the ways in which indigenous people are “prevented from enjoying the full benefits of the dominant culture through racist exclusion” (Ife, 2013).
In relation to indigenous peoples, colonial practices are closely intertwined with racism. These include ecological damage; displacement; (un)intentional transmission of disease; slavery; forced labor; removal of children; violence; massacres; the banning of indigenous languages; the regulation of movement and marriage; assimilation; and the suppression of social, cultural, and spiritual practices (Paradies, 2016a).
Colonialism is an ongoing process (Wolfe, 1999) that has “often swung (and still does) between the poles of elimination and coercive exploitation” Glenn (2015, p. 62). Racism has also been characterized as oscillating between extermination and exploitation (Hage, 2015). It is, therefore, not surprising that societal systems of racism continue to maintain colonial structures of material and political privilege to the present day.
Indigenous People’s Experiences of Racism
There is relatively little research on the frequency, extent, and nature of the racism experiences of indigenous peoples around the world. What research has been done varies by country, the measurement instruments used, and the nature of sampling involved.
A 2014–2015 survey conducted in Australia with probability-based sampling that was designed to be representative of the national population, and that utilized a long-form measure of racism that assessed exposure across multiple domains (e.g., home, work, education, recreation, etc.), indicated that 34% of indigenous adults had reported experiences of racism in the past year (Australian Bureau of Statistics, 2016). A representative survey from Norway conducted in 2012 found that 34% of respondents reported being discriminated against at some point in their lives because of their Sami ethnicity (Hansen, Minton, Friborg, & Sørlie, 2016). In New Zealand, 28% of Maori reported experiencing racism in a 2011–2012 survey (Ministry of Health, 2015). Despite the variety of questions that were asked in these studies and the fact that the participants lived in various corners of the globe, the findings are surprisingly consistent, and suggest that at least a third of indigenous adults experience racism at least once during their lives.
Even less information is available on indigenous children’s experiences of racism. Representative national longitudinal data from 2008 to 2013 indicates that 14% of indigenous Australian children aged 5–10 years have experienced racism (Shepherd, Li, Cooper, Hopkins, & Farrant, 2017); a 2012 nationally representative survey found that 23% of Indigenous Australian children (aged 12–13) had experienced racism in past 6 months (Priest, King, Bécares, & Kavanagh, 2016). Carers in a nationally representative U.S. survey reported that 10% of Native American children aged 0–17 years had experienced racism at some point in their lives (Kenney & Singh, 2016). Vicarious (e.g., parental) reporting tends to underestimate the experiences of the targets themselves (Holt, Kaufman, & Finkelhor, 2008), which may explain the lower prevalence compared to the Australian study.
A range of studies have indicated that racism is experienced by indigenous people in common life settings, such as employment and education, and in public places such as transportation, shopping centers, and on the internet. Evidence from Australia indicates that the most prevalent forms of racism are teasing, jokes, exclusion or stereotyping, in addition to physical assault and property damage (Ferdinand, Paradies, & Kelaher, 2012). Findings from Norway suggest that the perpetrators can be indigenous or non-indigenous, and can include colleagues, peers, and people in authority such as teachers and public officials (Hansen et al., 2016).
In addition, internalized racism has been examined in qualitative studies (Bennett, 2014; Clark, Augoustinos, & Malin, 2016; Doyle et al., 2017; Hickey, 2016; Poupart, 2003). In an indigenous context, internalized racism is also sometimes known as lateral violence, and often centers on indigenous authenticity (e.g., skin color or cultural knowledge), manifesting as innuendo, exclusion, insults, sabotage, undermining, scapegoating, backstabbing or failure to respect privacy (Bennett, 2014). For example, a 2011 survey of 172 Indigenous university staff in Australia found that 60% had experienced lateral violence in the workplace from other indigenous colleagues (National Indigenous Unit of the National Tertiary Education Union, 2011).
The widespread presence systemic racism for indigenous people has been documented in areas such as employment (Arceo-Gomez & Campos-Vazquez, 2013; Booth, Leigh, & Varganova, 2012; Hughes & Davidson, 2010), housing (Houkamau & Sibley, 2015), education (Bodkin-Andrews, Denson, & Bansel, 2013), healthcare (Came, 2014; Came, Doole, McKenna, & McCreanor (2018), public transport (Mujcic & Frijters, 2013), media (Proudfoot & Habibis, 2015), and criminal sentencing (Jeffries & Bond, 2012). For example, in one study, 4,000 fictional resumes were sent out in response to job advertisements. Despite these resumes detailing equally qualified and experienced applicants, those with “indigenous” names attracted 35% fewer interviews than resumes with “White” names (Booth, Leigh, & Varganova, 2012).
The Impacts of Racism on Indigenous Health
Overall, racism can result in negative health impacts through several key pathways (Paradies et al., 2013):
• Cognitive, emotional, and physical strain, stress, or damage impacting upon mental, physical, spiritual, or social well-being;
• Reduced engagement in adaptive behaviors (e.g., physical activity);
• Maladaptive behaviors (e.g., alcohol and drug use);
• Compromised access to key health-promoting settings (e.g., education);
• Attenuated benefit from everyday routine activities (e.g., sleep); and
• Heightened contact with health-damaging exposures (e.g., toxic substances).
In Australia, racism has been associated with poor self-assessed health status (Paradies & Cunningham, 2012a), mental ill health (Ziersch et al., 2011), psychological distress (Kelaher et al., 2014), depression (Paradies & Cunningham, 2012b), reduced general physical and mental health (Larson, Gilles, Howard, & Coffin, 2007), and poor oral health outcomes among indigenous adults (Ben et al., 2014a, 2014b). Kelaher et al. (2014) found that those experiencing racism in healthcare settings were almost twice as likely to have high or very high levels of psychological distress compared to indigenous people who experienced racism in other settings. This is one of the few studies to date to compare the setting-specific impacts of racism among any population worldwide.
Among Indigenous Australian youth, racism has also been associated with emotional and behavioral difficulties and suicidal thoughts (Zubrick et al., 2005), anxiety, depression, suicide risk, mental ill-health, physical illness (Priest, Paradies, Gunthorpe, Cairney, & Sayers, 2011; Priest, Paradies, Stewart, & Luke, 2011; Priest, Paradies, Stevens, & Bailie, 2012), poor oral health (Jamieson, Paradies, Gunthorpe, Cairney, & Sayers, 2011; Jamieson, Steffens, & Paradies, 2013), as well as increased alcohol, tobacco and marijuana use (Zubrick et al., 2005). In a recent Australian national longitudinal study, racism was associated with child mental ill-health, asthma, obesity and poor sleep outcomes (Shepherd et al., 2017), while data from the same survey indicate that racism was associated with poor general health and increased anger, worry, and depression for adult primary carers (Bodkin-Andrews et al., 2017).
Evidence from nationally representative cross-sectional surveys in New Zealand indicate that racism was associated with mental ill health, psychological distress, poor physical health, cardiovascular disease, excess body fat, smoking, and hazardous drinking (Harris et al., 2012), as well as depression and smoking specifically among Māori youth (Crengle, Robinson, Ameratunga, Clark, & Raphael, 2012).
In Europe, research has focused on the health impacts of racism for the Sami people. A study of 13,703 Sami adults found that racism was strongly related to increased psychological distress (Hansen & Sørlie, 2012). Racism was also associated with worries, sadness, depressed feelings, and less feeling of calm among Sami youth (Omma, Jacobsson, & Petersen, 2012).
In the United States, racism has been associated with physical pain and impairment; general ill health (Chae & Walters, 2009); hospitalization, a history of heart attacks and depressive symptoms (Wall et al., 2015); fewer screenings for breast cancer incidence (Gonzales et al., 2013), dental visits, and blood pressure, creatinine, and cholesterol levels; and general underutilization of medical and mental healthcare services (Burgess et al., 2008), as well as reduced vaccinations (Gonzales et al., 2014) among Native Americans. Similarly, racism has been linked to discontinued diabetes care among indigenous people in Chile (Ortiz et al., 2016). Racism has also been associated with poor self-esteem (Galliher, Jones, & Dahl, 2011), increased blood pressure, depression, anxiety, posttraumatic stress disorder, suicidal ideation, and alcohol and substance abuse (Antonio et al., 2016; Galliher et al., 2011; Brockie, Dana-Sacco, Wallen, Wilcox, & Campbell, 2015; Thayer, Blair, Buchwald, & Manson, 2017; Walls, Whitbeck, & Armenta, 2016; Whitbeck, Hoyt, Chen, & Stubben, 2001; Young, Hanson, Craig, Clapham, & Williamson, 2017) among Native American youth (Freedenthal & Stiffman, 2004; Yoder, Whitbeck, Hoyt, & LaFromboise, 2006).
In Canada, racism has been associated with depression (Bombay, Matheson, & Anisman, 2010); stress (Spence, Wells, Graham, & George, 2016); gambling and posttraumatic stress disorder (Currie et al., 2013); and a perceived need for preventive care, fear of going to dentist, never having received orthodontic treatment, and a perceived impact of oral conditions on quality of life (Lawrence et al., 2016). In Australia, doctoral research has noted links between historical loss and trauma symptoms and between racism and trauma (Gee, 2015).
Numerous Australian studies have found disparities in medical care experienced by Indigenous patients compared to non-indigenous patients after adjusting for a range of confounders (age, sex, marital status, socio-economic status, place of residence, hospital type, comorbidities etc.). These include Indigenous Australian patients being less likely to receive early diagnosis and treatment across all conditions (Cunningham, 2002); lung cancer (Gibberd, Supramaniam, Dillon, Armstrong, & O’Connell, 2016; Hall et al., 2004), cancer survival (Condon et al., 2014; Moore et al., 2014); cervical cancer diagnosis, screening, (Whop et al., 2016), and treatment (Diaz et al., 2015); breast cancer (Dasgupta et al., 2017; Moore et al., 2016); head and neck cancer diagnosis (Gibberd, Supramaniam, Dillon, Armstrong, & O’Connell, 2015); general cancer diagnosis (Banham et al., 2017; Tervonen et al., 2016); death from cancer (Tervonen et al., 2017); and coronary procedures (Coory & Walsh, 2005; Lopez et al., 2014), and, in addition, being about three times less likely to be given a kidney transplant (Cass et al., 2004), compared to their non-Indigenous counterparts. Similar findings have been detailed in relation to reduced access to kidney transplants in Canada (Tonelli et al., 2006) and cancer outcomes (Decker et al., 2016) among First Nations people.
Racism has also been associated with decreased cortisol levels among Native Hawaiians (Kaholokula et al., 2012) and blunted cortisol response to stress among Indigenous Australians (Berger et al., 2017). This may be the result of stress-induced hormonal dysregulation which could, in turn, contribute to various mental and physical disorders (Sarnyai et al., 2016). As well as further investigation of the physiological impacts of racism on indigenous peoples, another possible avenue for future research is to examine the health impacts of colonization, operationalized as historical loss, trauma, consciousness or as collective, intergenerational or multigenerational trauma (Paradies, 2016a). For example, a recent study found that a higher level of historical trauma among Native Hawaiian students was directly associated with reduced substance use but also indirectly associated with increased substance use through experiences of racisms (Pokhrel & Herzog, 2014). Historical trauma may strengthen ethnic/cultural identity (Pokhrel & Herzog, 2014), which, itself, has been associated with both greater self-reported racism and attenuation of its detrimental health impacts (Brondolo et al., 2009).
Indigenous Responses to Racism
There are a number of possible affective, cognitive, physical, and behavioral responses and reactions to racism that can be self-protective, self-controlled, or confrontational (Mellor, Merino, Saiz, & Quilaqueo, 2009). These can include seeking social support, ignoring or avoiding situations in which racism could occur, minimizing the experience, reacting with humor or acceptance, making a complaint, reporting the incident to police or taking legal action. Physical reactions can include headaches, nausea, muscle tension, or a rapid heart rate (Ferdinand et al., 2012; Paradies et al., 2012a, Paradies et al., 2012b). Deciding to not “allow” racism to affect health has also been reported as a response among Indigenous Australians (Ziersch, Gallaher, Baum, & Bentley, 2011). An Australian study showed that about a third of indigenous people choose to ignore racism; another third confronted the perpetrator; and while two thirds reported that they “sometimes,” “often,” or “very often” avoided situations because of racism (Ferdinand et al., 2012).
The limited extant research with indigenous peoples generally indicate avoidant/passive coping tends to exacerbate the detrimental health impacts of racism, while active coping ameliorates the ill-health effects of racism (Ferdinand et al., 2012; Paradies et al., 2012a, 2012b). For example, a study among Native Hawaiians found that racism was associated with psychological distress through the passive coping strategies of venting and behavioral disengagement (Kaholokula et al., 2017). The beneficial impacts of resilience to trauma on health outcomes have also been demonstrated in Australia and Canada (Gee, 2015; Spence et al., 2016), while another study highlighted the importance of parents engaging in cultural and racial socialization, especially in relation to coping with racism (Yasui et al., 2015).
Addressing Interpersonal Racism Against Indigenous Peoples
Reducing individual and interpersonal racism can be achieved by: (1) providing accurate information and improving awareness of the nature of racism and racial bias; (2) activating values of fairness, reconciling incompatible beliefs and developing anti-racist motivation; (3) fostering empathy/perspective-taking and confidence in regulating emotional responses (4) improving comfort with other groups and reducing anxiety; (5) reinforcing anti-racist social norms and highlighting personal accountability (Paradies et al., 2009; Chapman et al., 2013). One of the earliest studies on this topic demonstrated the success of a social marketing campaign in Australia in diminishing negative stereotypes about Aboriginal people in employment and improving beliefs about Aboriginal rates of employment and how long Aboriginal people remained in paid employment (Donovan & Leivers, 1993). More recent evaluated anti-racist social marking campaigns in Australia have showed mixed findings in terms of combating racist beliefs and stereotypes about Indigenous people (Paradies, 2016b).
Other research has also shown that false beliefs about alcoholism and government benefits can be reduced (Pedersen & Barlow, 2008), while intentions to respond to prejudice and positivity towards Aboriginal people can be increased (Pedersen, Paradies, Hartley, & Dunn, 2011). Other research has found that confidence to respond to everyday racism against Indigenous people is associated with being well-informed and authoritative about Indigenous people (Mitchell et al., 2011).
Structural Changes to Combat Racism Against Indigenous Peoples
There are five key areas for combating systemic racism in organizations and institutions: (1) institutional accountability; (2) diversity in human resources; (3) community partnership; (4) antiracism/cultural competence training; and (5) research and evaluation. Accountability can be achieved by implementing non-discriminatory standards across strategic plans, policies and performance indicators as well as developing fair and equitable planning, policies, processes and practices. Such accountability requires visible and strong organizational leadership to combat racism and foster anti-racist social norms as well as approaches to enhancing positive intergroup contact in workplaces and symbolic activities, such as welcome to country protocols and Aboriginal and Torres Strait Islander flags (Paradies et al., 2009; Trenerry, Franklin, & Paradies, 2010).
Institutions should undertake audits, conduct employee/client satisfaction surveys, and run interviews and ongoing feedback sessions to respond to racist incidents and disparities. It is also important to develop resolution and grievance procedures, monitor and respond to feedback as well as regularly reviewing training, mentoring, promotion, hiring, performance, remuneration, absenteeism and turnover for indigenous people. Anti-racist efforts within organizations require clear communication strategy including considerable lead times for consultation and feedback both internally and externally indigenous communities (Paradies et al., 2009; Trenerry et al., 2010).
Antiracism training can involve courses as well as mentoring and on-the-job learning. Attitudes, beliefs and behaviors need to be considered in relation to intercultural awareness communication as well as examination of one’s own prejudices and ways to address racism in the workplace. Key aims include: (1) understanding stereotyping, prejudice and bias and how to respond to racism; (2) acknowledging and examining one’s own racial identity and biases/prejudices and a willingness to “make mistakes” from a stance of cultural humility; (3) developing a familiarity with diversity, inequality and affirmative action; (4) practicing empathy for diverse groups in society; (5) supporting others to practice egalitarian values while combating beliefs; and (6) fostering opportunities for positive contact between people from diverse backgrounds (Paradies et al., 2009; Trenerry et al., 2010).
A successful case study is the Localities Embracing and Accepting Diversity (LEAD) program undertaken over five years in partnership with local government, NGOs and various community groups in Australia with the aim of improving the mental health of Aboriginal Victorians by addressing racial discrimination and facilitating social and economic participation. The program involved a range of top-down and bottom up data-collection, audits and program planning through partnership-building and collaborative priority setting using iterative processes of monitoring, evaluation and adaptation. LEAD resulted in successful organizational changes and positive training outcomes across two local communities (Ferdinand, Paradies, Perry, & Kelaher, 2014; Ferdinand, Paradies, & Kelaher, 2017).
Another example in Australia is a comprehensive program to address racism against Indigenous people in healthcare that has been underway for more than a decade. The project involves a recruitment strategy, a health-performance improvement program, patient journey audits, cultural-respect training, a cultural redesign initiative, counterracism policies, Indigenous leadership committee, consultation with local communities, and collaborative staff groups and partnerships (Martin & DiRienzo, 2012).
These two case studies highlight the importance of a long-term, multifaceted, whole-of-the-organization approach to addressing racism that includes transparency, trust, and information exchange within and beyond the institution and clear goals, measurable outcomes, accountability, evaluation, and continuous quality improvement (Trenerry, Franklin, & Paradies, 2012).
Throughout the history of colonization, indigenous peoples have suffered the impacts of various forms of racism. Only since the 1990s have public health researchers begun to study racism as a determinant of health and a key contributor to ongoing indigenous health disparities. The evidence attests to the fact that indigenous people experience racism of various kinds on a regular basis and that such exposure is detrimental to their health and well-being. Active and dynamic responses to racism appear to be most effective at the individual, interpersonal, and institutional levels, and antiracism studies have delineated a range of methods, principles, and approaches that could be effectively applied in efforts to create societies in which indigenous peoples are able to enjoy lives free from racism, prejudice, and discrimination.
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