The spectrum of ‘new racism’ and discrimination in hospital contexts: A reappraisal

Article Outline

• Summary
• Introduction
• The illusion of non-racism in health care
• Scenario #1
• Scenario #2
• Scenario #3
• Racism or just ‘poor care’?
• Racism
• ‘New racism’
• Xenophobia
• ‘Seeing race’ and racism in nursing and health care
• Unmasking racism in nursing and health care
• Conclusion
• References
• Copyright

Summary 

In keeping with the United Nations Declaration of Human Rights, all people have the right to the highest attainable standard of health. Despite the universal right to health, people of minority racial and ethnic backgrounds experience commonplace and significant unjust inequalities in their health and health care. A key reason for this rests on what might be described as ‘the illusion of non-racism in health care’ – an illusion that rests on the frequently articulated belief that ‘racism is not an issue any more’. Although there has been increasing recognition in recent years that race and racism have a particular, consistent and complex independent negative effect on the health and health care of racial and ethnic minority groups, racism per se still tends to be under-recognised and poorly addressed in health and nursing care domains. In this paper, it is suggested that a key reason racism in health care has been largely ignored is because of its ‘changing face’, making new and different forms of it difficult to recognise and manage. A key premise on which this paper rests – and also its ultimate conclusion – is that the problem of racism (to be distinguished from ‘culturally insensitive’ and ‘culturally incongruent’ care) needs to be unmasked and managed so that those most at risk of being discriminated against on racialised grounds can rest assured that when in need, they will receive the equitable, safe and quality care they are entitled to receive.

Keywords: Cultural racism, Racialised care, Ethnicity, Nursing, Health care

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Introduction 

Hospitals are supposed to be safe havens where people who are ill and injured can go for care and treatment without prejudice. In keeping with the humanitarian ethos of the health care professions, patients and their loved ones rightly expect that when requiring and receiving hospital care they will be treated in a non-discriminatory manner, that is, they will receive the care and treatment they need and will not be discriminated against on the basis of their personal characteristics such as race, ethnicity, culture, religion, spiritual orientation, disability, age, gender, sexual orienation, economic, social or health status. There is emerging evidence, however, that people are often discriminated against on the basis of their personal characteristics, and that those of minority cultural and language backgrounds are particularly at risk of experiencing what has been termed elsewhere as ‘every day racism’ (Essed, 1991) in health care domains.

Racism and racialised health care practices are being increasingly linked to disparities in the health and quality care of people from minority cultural and language backgrounds (Bhopal, 1998, Johnstone and Kanitsaki, 2006, Johnstone and Kanitsaki, 2008a, Johnstone and Kanitsaki, 2008b, Johnstone and Kanitsaki, 2008c, Karlsen and Nazroo, 2002, Larson et al., 2007, Smedley et al., 2003, Stone and Dula, 2002). Despite this, racism per se and its harmful consequences to and in health care domains have been largely ignored, and for the most part remains poorly addressed at an individual and institutional health service level. In the interests of patient safety and quality care it is imperative that stakeholders redress this oversight.

In the discussion to follow, a brief examination will be made of the problem of unacknowledged racism in health care. It will be suggested that one of the key reasons racism in health care has been largely ignored is because of its ‘changing face’, making it difficult both to recognise and manage its expression in every day practice. A key premise on which this paper rests—and also its ultimate conclusion—is that in order for every day expressions of racism in health care to be managed, the new and subtle ways in which it now tends to be manifest must first be recognised. To this end, attention will be given to exploring conceptualisations of the highly contested notions of ‘racism’, ‘new racism’ and ‘xenophobia’ as commonly used in discourses on race and racialised practice. With reference to three real life case scenarios, attention will also be given to showing how an understanding of the changing face of racism could be applied in nursing and health care contexts to help identify and challenge racialised practices that might otherwise have been overlooked, or treated simply as ‘poor care’.

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The illusion of non-racism in health care 

There is a genuine belief among nurses and allied health professionals that ‘racism no longer exists’ in health care and that if racialised practices do exist, they cause little or no harm (Stone & Dula, 2002). We have termed this stance elsewhere as ‘the health care illusion of non-racism’, which is defined as ‘an illusion’ that rests on the frequently articulated belief that “there is no racism here” and “racism is not an issue anymore” (Johnstone & Kanitsaki, 2008c). The basis of this illusion and the reasons for its durability are complex, and regrettably beyond the scope of this present paper to discuss. What is plain, however, is that maintaining the illusion of non-racism in health care is no longer tenable (if it ever was), and that if the ideals of safe, egalitarian and evidence-based health care are to be upheld, racialised health care practices—whether expressed by individuals or institutions—need to be unmasked. In order to unmask racialised health care practices, however, health service providers need first to have some idea of what expressions of racism in health care might look like. To help facilitate this insight, consideration will be given to three case scenarios that were described in the context of an Australian research study investigating cultural competency and cultural safety in health care (Johnstone & Kanitsaki, 2005).

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Scenario #1 

In the aftermath of the September 11, 2001, terrorist attack on the World Trade Centre Towers in New York City, an Arabic woman living in Australia, whose son required hospitalisation every month for the treatment of a serious medical condition, noticed a significant and soul-destroying change in attitude and behaviour toward her by hospital staff. Whereas staff had previously been attentive, engaged and supportive in their encounters with this woman and her child, after the events of September 11, they rejected, shunned and avoided her, and ultimately became inattentive and indifferent to her plight. The experience of this mother and her family is recounted by her sister in the following words:

My sister has a son with a condition that she has to spend a week in hospital every month and she said her experience before September 11 is much more different. She is still the same person. She wears a hair cover and she dresses very nicely and neatly. Her experience is really different and she describes it in a very big way. She said, ‘Sometimes I want to say, “We’re not terrorists, we’re not liars.” I said, ‘No you don’t have to explain yourself. They can see you are a mother caring for your own son, you don’t have to say that.’

You’re put in a position of having to declare who you are and distance yourself from what happened internationally. It's not just the stress of having a very sick son that you have to deal with, but you have to deal with acceptance […]

A welcoming gesture, an open statement that says “We know people here have nothing to do with what happened over there. We have no control over what people decide to do internationally and that you are part of our community”—that would relax you that statement. It is acknowledging that there might be that fear (Case 4.4).

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Scenario #2 

A health interpreter of many years experience had hospital staff over the years repeatedly treating patients of minority cultural and language backgrounds in a rude and dismissive manner. In the context of being interviewed about her experiences, she recounted:

Sometimes the attitude of the reception staff is so cool—they are extremely abrasive, they are extremely rude. They yell at the patients if they don’t understand … they speak louder, so the patient gets intimidated. Sometimes they will make comments like, “You’re getting free service, you should be grateful”, which puts the patients in their place straight away… And you will not believe it, the reception staff in the hospitals where you have the largest numbers of non-English speaking background patients are the worst (Case 4.16).

The interpreter further revealed that nurses had been observed directly both by her and other health interpreters placing the files of non-English speaking patients ‘at the bottom of the pile’ because of concerns they had that the patients would get ‘preferential treatment’ on account of an interpreter being booked for a specific time. In one case an interpreter, who had been kept waiting for an hour and a half as a direct result of staff placing his patient's file last, could not wait any longer as he had to attend an appointment with another patient. When he explained to the receptionist that he had to go to another appointment, she responded, ‘But the patient hasn’t been seen.’ After apologising and reiterating that unfortunately he had to go because his ‘time has expired’, the receptionist retorted, ‘Well, that's on your conscience then’ (Case 4.17).

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Scenario #3 

Aboriginal people have been identified as being especially vulnerable to being treated ‘badly’ in health care contexts. The following case, described by a hospital Ethnic Liaison Officer, is a sobering example of this:

One guy, who was admitted to hospital with tuberculosis, was avoided completely by all the staff. I came in after he had been admitted for four days, and the way they spoke of him was really degrading as a person, and as an Aboriginal person. They considered him as a ‘dirty person’ and that he was aggressive—which was because he was in a restricted area …He was being ‘barrier nursed’ and he couldn’t handle it and they made no provisions for his family to actually be with him. Once the family hours were finished they were asked to leave. There are a lot of things that weren’t appropriate—they’d never contacted the Aboriginal Centre to find out if there were requirements that they could make his hospital stay easier, and there are a lot of issues around that. And just the way the staff talked about him, it was awful. Things like that, ‘he was dirty’; that ‘he was a poor person and had an aggressive nature’, that ‘he needed to be handled a bit differently because he was very confrontive [sic]’…and that ‘we need to get him into the shower twice a day because he's got a smell about him’. Just things like that, where, if it was a non-Aboriginal person, I don’t think it would have been said (Case 4.7).

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Racism or just ‘poor care’? 

Few nurses would disagree that the attitudes and behaviours of the staff depicted in these scenarios were inappropriate, unprofessional and even unethical. Whether they would agree that the staff's attitudes and behaviours in these scenarios were also racist, however, is another matter entirely. Moreover, if it was suggested to the actual staff involved that they had behaved in a racist way to the patients concerned, not only would they probably reject such a suggestion but would also likely be deeply offended by it. Here the question arises: Are the cases given above truly examples of racism in health care, or were they just instances of ‘poor care’?

In attempting to answer this question, it is necessary to note and understand the extremely subtle and sophisticated ways in which expressions of racism have changed over time. Compared with the more publicly focussed traditional forms of racism, what Dovidio and Gaertner (2000, p. 318) call ‘old fashion racism’, manifestations of ‘new racism’ (also called ‘aversion racism’) occurs in such subtle and indirect ways that recognising it is extremely difficult. This means that even those who subscribe to the highest ideals of ethical, unbiased and non-prejudicial professional practice, who support egalitarian values, and who regard themselves as being non-racists, may nonetheless ‘otherise’ people and unconsciously discriminate against them in subtle and rationalised ways (Dovidio & Gaertner, 2000).

To help further clarify the various and sophisticated ways in which racism and its expression has changed over time, a brief examination of the core notions racism, new racism, and xenophobia as commonly used in discourses on race and racism is warranted.

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Racism 

The term racism is typically defined as a ‘dislike, hatred and fear of people belonging to races other than one's own, often wedded to the conviction that some races are fundamentally superior to others’ (Bullock & Trombley, 1999, p. 719). In reality, however, racism refers to a highly complex and hotly contested notion that is often misused and misunderstood (Bhopal, 2004, Corlett, 2003, Fredrickson, 2002, Miles and Brown, 2003, Miles and Torres, 1999, Wolf, 2006). Premised on (the now) debunked scientific theories of ‘race’, racism is principally a classificatory term that has been (mis)used to imply, establish, and sustain a hierarchical racial order in human society (Goldberg, 1993).

Historically, racial ordering has been used to collectively produce and fallaciously justify the structured subordination, exclusion, and disadvantage of those deemed racially inferior (‘other’), and the structured hegemony, inclusion and advantage of those deemed racially superior (‘the dominant’) (Apple, 1999, Corlett, 2003, Goldberg, 1993, Miles, 1989, Miles and Brown, 2003). Thus, although ostensibly a principle of gradation, as Goldberg posits, racism is also at once ‘a principle of degradation’ (Goldberg, 1993, p. 51).

Despite being utterly discredited and shown to have no genetic or scientific basis, race as a concept and its implied inferior/superior racial gradation of people continues to have considerable currency and practical influence in contemporary life and thought. Many people continue to believe and act ‘as if’ race is a scientifically warranted category, and continue to differentiate and discriminate against people on racialised grounds (Miles & Torres, 1999, p. 20; see also Fredrickson, 2002, Hage, 2003, Kalantzis and Cope, 2001, Miles and Brown, 2003, Wolf, 2006). This is most evident in recent debates on the proper use of racial categories in contemporary genomic, biomedical and biotechnical research, leading some to suggest that claims about the demise of the biology of race have perhaps been ‘premature’ (Roberts, 2006). Even those who are at the forefront of actively working to subvert racism and its insidious power in everyday life are at risk, paradoxically, of inadvertently reinforcing it through the continued use of the terms ‘race’ and ‘racism’ (and hence their embedded commonsense meanings) in public discourse (Ashcraft and Allen, 2003, Miles and Brown, 2003, Miles and Torres, 1999).

Although the scientific theories of race have been debunked and the notion of race itself shown to be ‘conceptually empty’ (Corlett, 2003, p. 2), the realities of racism and the demonstrable harms that they cause are ever present (Corlett, 2003, Fredrickson, 2002, Hage, 2003, Horne, 2003, Miles and Torres, 1999). It is for this reason, that, paradoxically, in order to redress the problem of racism, the term needs to be retained. When being used, however, the term must also be meaningfully defined since, as Miles and Brown explain:

…In the absence of any definition, the concept becomes meaningless, and opposition to racism is hindered. If racism is defined too broadly—‘all white people are racist’, for example, or even ‘everyone is racist’—the concept again becomes meaningless and racism escapes censure…If racism is defined too narrowly—as an explicit belief in ‘racial’ hierarchy, for example, then discourses that would otherwise be regarded as racist may attain a degree of legitimacy (Miles & Brown, 2003, pp. 3–4).

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‘New racism’ 

As scientific theories and related concepts of race have been attacked, debunked and rejected ‘as a package of irrational beliefs; prejudices’ (Barker, 1981, p. 1), a new conceptualisation of race has emerged, notably, race as culture. Whereas the ‘old’ concept of race was used almost exclusively to refer to skin colour (Barker, 1981, Miles, 1989), the ‘new’ concept of race is strongly identified with ‘language groups, religion, group habits, norms and customs: including typical style of dress, behaviour, cuisine, music and literature, etc’ (Goldberg, 1993, p. 70). As in the case of ‘old racism’, however, this new conceptualisation of race continues to use ‘racial otherness’ to service the rhetoric of racial ordering (Goldberg, 1993). An important example of this can be found in what Clyne (2005a) describes as a potent rise in ‘us/them’ racialised discourse over the past 30 years and its associated language of envy, resentment, scapegoating and exclusion that has been used to frame and justify ‘an increasing global intolerance of accepting immigrants, refugees and asylum seekers’ by democratic nations (Clyne, 2005a, pp. 174 and 175; Clyne, 2005b).

Termed ‘new racism’ (after Martin Barker's classic 1981 work: The new racism: conservatives and the ideology of the tribe), racial ordering along cultural lines is portrayed in a manner ‘that at once rationalise(s) and recreate(s) racialised exclusions, that are expressed in (terms of) and through the claims and chains of rationality’ (Goldberg, 1993, p. 208). Moreover, as research over the past decade has shown, by presenting their views as ‘unprejudiced and factual’ and by appealing to emotive arguments spuriously presented as morally principled arguments, proponents of the new racism are able to advance their negative views in a manner that enables them to avoid any threat to their status as ‘normal’ and ‘respectable persons’, or of being accused of ‘racism’ and hence as being ‘unethical’ people (Dovidio and Gaertner, 2000, Verkuyten, 1998). As Verkuyten (1998) explains, the persuasiveness of new-racist thinking largely lies in its contentions that

Principled considerations can always be countered by practical ones, and vice versa. Things may be desirable in principle, but one also has to be realistic. Hence applying moral principles stereotypically and rigidly to reality can lead to accusations of being unrealistic and moralistic. […] There is a natural limit to one's tolerance and responsibilities [in regard to foreigners]. People should control their emotions and behaviors, but when they are driven to the limit, a temporary outburst is inevitable and understandable (Verkuyten, 1998, pp. 155 and 159).

To date, racially conservative thinkers in all levels of society are being extremely effective in making their racist views seem understandable and more or less inevitable, and even logical and natural, and hence something that ‘all right minded people would agree with’ (Gray and Winter, 1997, Hage, 2003, Horne, 2003, Kalantzis and Cope, 2001, Lakoff, 2004, MacCallum, 2006, Sim, 2004, Verkuyten, 1998). An instructive example of this can be found in the extraordinary success of the political campaign run by the former Australian politician, Pauline Hanson, and her movement (‘Hansonism’) which gained notoriety in the mid-1990s in Australia. The success of Hanson's campaign largely rested on the emotive characterisation of Australia's migrant community as one that was ‘getting more than its fair share of the nation's resources’ (Ager, 1998, p. 72) and the Indigenous Australian community as being undeservedly ‘advantaged’ over the more deserving ‘Aussie battler’ (Kalantzis and Cope, 2001, MacCallum, 2006). Following the election of Pauline Hanson to the Australian Federal Parliament in 1996, the Australian Prime Minister, John Howard, not only refused to challenge Hanson's views, but encouraged them and, after making them seem respectable, ultimately adopted them (Kalantzis and Cope, 2001, MacCallum, 2006, Theophanous, 2001).

In the 21st Century, new racism (also called ‘symbolic racism’ and ‘cultural racism’) has come to symbolise a potent push for ‘cultural homogeneity’ (Miles, 1989, p. 62) and the defence of ‘our homogenous “way of life”’ (Barker, 1981, p. 16). At the heart of this stance is a theory of human nature, which holds that it is ‘natural’ to form bounded social units (e.g. a community; a nation aware of its differences from other nations) and to differentiate ourselves from outsiders (Barker, 1981, Goldberg, 1993, Miles and Brown, 2003, Verkuyten, 1998). By this view, national separatism is seen not only as being ‘natural’ and ‘inevitable’, but as something also to be defended—especially against immigrants, refugees, asylum seekers and even Indigenous peoples (Barker, 1981, Kalantzis and Cope, 2001).

By using carefully crafted linguistic framing devices (see Lakoff, 2004), proponents of new racism (disguised as national separatism) have been enormously successful in cultivating resentments and fears of ‘alien outsiders’ and fostering what Ghassan Hage calls ‘paranoid nationalism’ and a related ‘culture of worrying’ about losing ‘our way of life’, which we (the ‘ordinary folk’ constituting the homogenous insiders) have come to care deeply about (Hage, 2003, p. 3). Because of their perceived ‘alienness as outsiders’, those who ‘refuse’ to adopt the characteristic life style of the country in which they have chosen to live are characterised as being ‘moral failures’ and a serious threat to the ‘homogeneity of the insiders’ and their ‘carefully nurtured individuality’ (Barker, 1981, pp. 16 and 20).

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Xenophobia 

It may be tempting to characterise racism as ‘merely’ xenophobia, a notion used by the ancient Greeks to describe ‘a reflexive feeling of hostility to the stranger or Other’ (Goldberg, 1993, p. 6). As Goldberg correctly cautions, however, while ‘xenophobia may be a starting point upon which racism can be constructed, […] it is not the thing itself [emphasis added] (Goldberg, 1993, p. 6).

The main problem with equating xenophobia with racism is that it reinforces the view that: ‘it is simply human nature’ to be racist/xenophobic in that we all have ‘a natural tendency to stay apart from culturally alien beings; even if they are not inferior, they are culturally different’ (Barker, 1981, p. 155). In other words, it naturalises and normalises xenophobic racism by treating it ‘as an innate response, a necessary part of our make-up, formed over millions of years of evolution’ (Barker, 1981, p. 154). This naturalisation, in turn, begs the question of the moral justification and rightness of ‘treating differently’ and discriminating against members of a group or a community just because of their ‘race’, religion, ethnicity or nationality (Horne, 2003).

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‘Seeing race’ and racism in nursing and health care 

As the discussion thus far has suggested, racism is not a static phenomenon; moreover the various meanings and use of the term itself are highly contentious. The complexity of the notion and phenomenon is underscored by the reality that, although people may not see ‘race’ anymore (or at least believe that they do not), when observing real or imagined somatic and cultural characteristics, such as language, dress, music and so forth, they nonetheless attribute meaning to the idea of ‘race’ and hence keep the social construction of race/racism very much alive (Miles & Torres, 1999, p. 32). Thus, simply avoiding the term ‘racism’ or using more commonly accepted euphemisms such as ‘cultural barriers’, ‘language barriers’, ‘ethnic dissonance’, ‘cultural insensitivity’, ‘cultural misunderstanding’, ‘cultural incompetence’, ‘cultural incongruence’, and the like, will not prevent racialised discourse or practice (Johnstone & Kanitsaki, 2008b).

However racism may be defined (and whether expressive or ‘new’ or ‘old’ racism), there is a notable common feature that binds them together, notably: the lived reality of racism involving harmful and/or offensive acts and omissions that are based on the perceived racialised characteristics of a person, and that are committed against that person just because he/she is a member, or perceived to be a member, of a certain ethnic group. It is important to clarify here that racism involves much more than merely harbouring a negative belief about or negative attitude toward someone because he/she is, or is perceived to be, a member of a certain ethnic group. Racism fundamentally involves also acting on that negative belief/attitude, that is, acting (or deliberately refraining from acting) in such a way that results in ‘real discriminatory treatment’ (e.g. exclusions and/or threats to and/or violations of genuine welfare interests) of targeted people, and where the target of the discrimination ‘is wronged in a way that amounts to a harm and/or an offence’ (Corlett, 2003, p. 66, after Feinberg, 1984).

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Unmasking racism in nursing and health care 

The case scenarios presented in the opening pages of this article are all obviously examples of ‘poor care’. However, albeit less obviously so, they are also examples of ‘racialised care’. Because racism is rarely expressed openly and can come in many guises, the racialised practices exemplified by these cases need to be unmasked.

The attitudes and behaviours that are commonly associated with racist and racialised practice—and which the patients in the above scenarios each experienced—include antipathy, avoidance, ignoring, disengagement, rejection, disgust, contempt, scorn, ridicule, and indifference (Essed, 1991, Goldberg, 1993, Hollinsworth, 2006, Johnstone and Kanitsaki, 2008b, Moody-Adams, 2007). As the working definitions of these terms readily demonstrate (Table 1), these attitudes and behaviours are the very antithesis of those required and expected in a therapeutically effective clinical relationship. By virtue of ‘prejudging without evidence’ (being prejudicial), they also contravene the principles and standards of competent (evidence-based) practice in health care.

Table 1. Antithetical therapeutic attitudes and behaviours of racism.

There is a deep sense in which characterising the above case scenarios as being merely instances of ‘poor care’, or even as ‘culturally insensitive’ or ‘culturally incongruent’ care, would be to seriously miss the mark. This is because the mistreatment of the patients in question was unequivocally based on their perceived race, ethnicity and cultural characteristics by others more powerful than them and who were in a position to disadvantage them. This is most evident by the extent to which the patients were respectively:

Had these patients not been vulnerable to being identified and socially marked as ‘other’ (i.e. spoke English proficiently and did not require the services of a qualified health interpreter; did not dress in a manner that marked them out as Muslim and, by virtue of this marking, falsely associated with Muslim extremists; was not an Aboriginal person), it is unlikely they would have experienced such targeted negativity. As the ethnic liaison officer describing the case of the Aboriginal man reflected: ‘If it was a non-Aboriginal person, I don’t think it would have been said’. A similar comment could be made of the Arabic mother, and the non-English speaking patients awaiting the services of a health interpreter. The outcome for these patients was not merely to be inconvenienced or offended, but to be seriously wronged in a morally culpable way.

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Conclusion 

Despite being the subject of official condemnation, it will not always be possible to prevent or reduce the incidence and impact of racism and its adverse consequences in nursing and health care contexts. Nonetheless, it can and must be managed, so that it will not ‘burst out’ in cruel and harmful ways (Horne, 2003). To be effectively managed, however, nurses and other health service providers must first know what it is and be able to recognise the many guises that it can take. Then, and only then, can the strategies that are so desperately needed to combat racism be devised and implemented to make health and nursing care processes inclusive and safe for people of minority cultural and language backgrounds. By making hospitals and related health care settings free of discriminating prejudices for those who are racially and ethnically different, ‘others’ who likewise stand at risk of being distinguished on the basis of their personal characteristics (age, socio-economic status, sexuality, etc) may also be spared the harms of being discriminated against and be rest assured that when in need, they will receive the safe and quality care they are entitled to receive.

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