Prof. Anna Ranta

Current models of care for Indigenous people including Aboriginal Australians and New Zealand Māori cannot deliver equitable health outcomes while ignoring underlying cultural differences, historical oppression and persistent institutionalised racism, neurologists have heard.

Delivering the ANZAN 2024 meeting Mervyn Eadie Lecture recognising career achievement in neuroscience research, stroke neurologist Professor Anna Ranta told delegates that the evidence for inequities was apparent locally and globally.

Professor Ranta, from the University of Otago in Wellington, said New Zealand data published last year [link here] demonstrated that Māori were more likely to have unfavourable stroke outcomes and increased odds of death at 3-, 6- and 12-months compared to NZ Europeans.

“In New Zealand, Māori are the most disadvantaged in essentially all health settings, not just stroke, so there is definitely something going on,” she said.

She also shared 2018 data showing that stroke deaths were higher in US counties where historical slavery had occurred [link here].

“Globally, Indigenous and post-slavery people are especially disadvantaged which begs the question [why] … because these are very disparate groups of people with no common ancestors.”

She said there were cultural factors at play and often distrust in mainstream Western medicine.

“Maybe patients are not as interested in seeking my healthcare or coming to hospital because there have been bad experiences in the past. There’s a general discomfort with being in our hospitals and even active avoidance of them.”

“I’ve heard more than one Māori person say, ‘Go to hospital for stroke? But you go to hospital to die.’ I’m not making this up.”

She said we needed to move on from discussion around environmental risk factors, especially diet and smoking, which increasingly tended to involve victim blaming.

“A lot of it isn’t within people’s control and overall it is probably too simplistic from a world view.”

“Instead, our evidence as well as evidence from others, increasingly shows these pattern are attributable to the negative transgenerational and persistent impact of colonisation and systemic oppression.”

Professor Ranta said everyone agreed that there should be the same access to healthcare and equal health outcomes.

“But some people require a different or more intervention . …to achieve equal outcomes. So doing the same for all is simply not enough.”

“I think the important thing is we recognise we are operating in a place that is post colonial, post oppression, and so we have created unfair systems and we need to pivot and compensate for that. Eventually we won’t need to do this but currently we do.”

She said developing cultural competence was time consuming but potentially very worthwhile.

“If you really want to do it properly you embark on cultural safety which does not only consider the culture of the patients or research subjects but it also starts with you or me.”

“What is my cultural background? What biases do I bring to the encounter? What’s the power difference? There’s usually a power difference – let’s be aware of that. Let’s be aware of our own situation and self reflect and address our own biases, attitudes, assumptions and emotions.”

Seeking feedback

Professor Ranta also encouraged clinicians and researchers to seek feedback from patients or research participants on the degree of cultural competence they had achieved.

“They actually decide what is culturally safe. To go around saying you’re culturally safe judged on your own assessment, isn’t quite the right approach.”

She also encouraged clinicians and researchers to think outside the Western box to create more culturally supportive environments.

“The concept of health can be very different in different cultures and this is something shared by Indigenous cultures globally. It’s very much a strength based model that is health promoting rather than a deficit model which is looking at a sick patient and fixing a problem.”

She said Māori health systems for example were more holistic involving not just physical health but also family, spiritual and mental health as well as connection with ancestral lands.

“We can’t go around saying we have RCTs and the rest is fluffy stuff. It’s very disrespectful to see it that way of course and even more importantly, it hasn’t worked. We’ve been imposing our colonial Western model on Indigenous people and there are still all these health inequities…and in fact some of the gaps are widening.”

“So maybe it’s time to think a little bit differently and integrate things like wellbeing and mind/spirit and family into our practice… maybe there is something we can learn from other cultures,” she said.

Professor Ranta said that Indigenous-focussed research had to use methodologies which respect these issues and use culturally appropriate outcomes.

“A physical outcome may be meaningless if it doesn’t come with family, mental and spiritual health and so maybe some of our studies don’t apply as well as we thought.”

She said the goal was co-design, supporting self determination and capacity building, and eventually “by Indigenous for Indigenous”.

“And then there is the issue of diversifying the workforce because how are we going to do “by Indigenous for Indigenous” if we don’t have Indigenous researchers or clinicians?”

“It’s a controversial topic because of course how do you achieve that? You achieve it best through affirmative action which some people feel is unfair but if you think about it, it’s really only unfair if you forget about the 200 years of unfairness that have come before.”

She said there was robust evidence that measures that improve diversity, increase patient trust, adherence and reduce health inequities.

“More diverse teams perform better because you get more perspectives and you are asking more culturally-relevant research questions.”

“But there are challenges with a diverse workforce because often the people we are recruiting come from a disadvantaged background themselves so there is active mentoring required. There aren’t a lot of Indigenous mentors so these are gaps we need to somehow fill.”

Professor Ranta provided some tips for improving every day practice:

• Be aware of and avoid the detrimental effects of deficit framing/critiquing affirmative action
• Learn about local native communities, minority groups, language, etc
• Be familiar with cultural support services and offer them
• Make diversity in your clinical/research team a strategic goal
• Lead by example in promoting cultural competence/safety training
• Take a little bit of extra time to make a connection & build trust
• Consider an observed ward round/clinical interaction
• Reflect on your own experience after each consultation
• Engage with local minority health leaders; visit remote sites
• Involve and recruit minority colleagues & consumers in research & improvement work