Racism is a "basic, underlying" reason for poor health suffered by Māori and Pacific New Zealanders, a major DHB has concluded.
Auckland DHB will put managers through training modules as part of a new plan to stamp out institutional racism - a term that describes how procedures or practices result in some groups being disadvantaged.
Māori health leaders have hailed the DHB's position as courageous and groundbreaking.
"It's a first for DHBs, and it's a great move," said Dr David Tipene-Leach, chair of Te Ora, the Māori Medical Practitioners Association. "The first step is to recognise the problem. And then start working on it."
Auckland DHB executives were recently briefed on an internal "equity deep dive" report by the HR department. Racism was a "basic, underlying" reason for poorer health suffered by Māori and Pacific New Zealanders, concluded the report.
"We must be intentional in addressing institutional racism and eliminating systemic barriers," it stated.
"With the increasing recognition of racism as a basic underlying determinant of ethnic inequities in health, eliminating institutional racism within both workforce development and service delivery is integral to achieving health equity."
The report mapped out responses that included putting managers through "institutional racism modules", mentoring programmes for Māori and Pacific workers, and ongoing Te Reo classes.
The DHB has already started a hiring policy that automatically fast-tracks all eligible Māori and Pacific job candidates straight to the interview stage.
It refused to detail what institutional racism training would involve.
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"Our people want to learn and understand how to play their role in health outcomes for Māori but they would like tools and guidance to help them do so," a spokeswoman said. "We are also rolling out programmes to improve equity and health outcomes for people from the Pacific nations."
Racism can be both explicit (intentional) and implicit or unconscious (automatic and outside awareness). Institutional racism means the procedures or practices of particular organisations result in some groups being advantaged.
In the health context, this could mean Māori health organisations being made to jump through more hoops for less funding, for example, or medical advice being delivered in a culturally insensitive way, making the patient feel talked down to.
Tipene-Leach said institutional racism was "one of the basic tenets of inequity", and a focus for Te Ora and, recently, the Waitangi Tribunal.
"The system was set-up purposefully to serve a different group of people. Why, therefore, should we be at all surprised that Māori and Pacific people are having poor outcomes?"
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Te Ora was working with the Medical Council of New Zealand and the Council of Medical Colleges, who train medical specialists, on cultural competency. Addressing equity had to be a stated objective of every different policy and procedure, Tipene-Leach said.
"It often isn't. And even when it is, it gets pushed to the side because it isn't the priority, it continually gets put off when you have constrained resource."
Dr Owen Sinclair, a Māori paediatrician at Waitakere Hospital who researches health inequalities, said institutional racism included some groups not being able to access services as easily, for reasons like the cost of transport or a clinic only being open during work hours. However, other aspects were less tangible.
"Māori are twice as likely to die from cancer, and have much higher rates of things like type 2 diabetes. But when they do actually access care, they get less of it. When Māori go to primary care they are much less likely to be referred, for example."
Sinclair is currently in Sydney to talk to Australasian anaesthetists about systemic racism, a presentation he's made to other medical conferences. The response from some attendees is always, "Why don't Māori help themselves?" he said.
"These are people who are in charge of caring for New Zealanders. And instead of saying, 'Oh my god, what are we doing and how can we improve?' They immediately push it away. It's seeing Māori as an 'other' type of person."
However, Sinclair said "complete ambivalence" about the problem was changing. The next step needed to be targeted initiatives and services.
"There's been this blind spot since colonisation to helping Māori. But it's starting to come into the light...there is momentum and people are recognising it's a real problem."
Last year the Perinatal and Maternal Mortality Review Committee called for compulsory cultural competency training for everyone working in maternity and neonatal care, after finding very premature babies were less likely to receive a resuscitation attempt if Māori, Pacific or Indian.
New Zealand research has found final-year medical students reacting to hypothetical patients differentiated only by surnames — Wiremu/Williams or Tipene/Stephens — had, on average, implicit bias, including thinking "Māori" patients were less likely to take prescribed antidepressants.
In March, a special edition of the New Zealand Medical Journal highlighted the fact half of Māori and Pacific deaths in New Zealand are potentially avoidable, compared to 23 per cent for non-Māori and non-Pacific people.
While there were multiple factors in the avoidable death statistics, the journal said racism was the "ethnic health inequities elephant in the room": "It is a term that causes quiet discomfort - or at times not quiet. Yet, if we do not talk about racism and call it by name, its ubiquitous hold on health cannot be challenged."
NOTE: An earlier version of this story used a photo depicting a baby sleeping on its side near a soft toy. For safe sleep, babies should be placed on their back in a clear sleeping environment free of toys, pillows, loose bedding or bumper pads.