“I'd been walking and went running across the road and slipped and fell arse-over-head. When I went in there to have the x-rays and I told her what happened…She turned around and said to me, you weren't charged up were you? I just thought, well that's the last thing I expected to come out of your mouth. Next time I see her, I'm going to sit her down and say, hey, just because I'm an Aboriginal person, doesn't mean I'm charged up. You're making them assumptions and generalisations you know. I thought it was disgusting coming from a health professional” (Respondent to the Member Survey).

The prevalence of racism and its adverse impact on health and wellbeing is well documented (eg. Larson et al, 2007; Priest et al, 2012). The ‘Experiences of Racism Survey’ in Victoria , funded by the Lowitja Institute, showed a relationship between mental health and reported episodes of racism (Ferdinand et al, 2013). Critical race theory (eg. Moreton-Robinson) and critical discourse analysis (eg. Hardy, 1999; Phillips and Hardy, 2002) provide theoretical bases for understanding the perpetuation of racism through institutional practices.

Conducted as part of broad based consultations for the development of the National Aboriginal and Torres Strait Islander Health Plan during

“I had my second child at another hospital... He was above birth weight, a healthy baby. The baby had no problems attaching, breast feeding, weight, everything. I've got no issues whatsoever, I'm in a stable marriage, got a previous healthy child. I know how to look after my child I'm ready to go home - as I'm leaving with my bag she said, “what nationality are you?” I said, “I'm Aboriginal” and she went, oh. She goes, “oh, we're allowed to keep you in here”. I said, “for what reason?” She goes, “because you're at risk”. How am I at risk? How's my child at risk; please do tell me. Without knowing my race, everything's fine, and all of a sudden..." (Respondent to Member Health Survey)

Siggins Miller were commissioned to conduct a 47 question telephone- based survey over a three week period October-November Part quantitative, part qualitative, covering topics including: - Self reported perceptions of health and wellbeing; - Barriers and motivators for health behaviour change; - Access to services and health information; - Racism and other forms of discrimination and its impacts; and - Culture and traditional healing. 169 respondents drawn from a sample of 559 Members which was a stratified random sample by states/territories, age and gender (response rate 30.2%).

Semi-structured interview: - Have you experienced discrimination? - If so what type? - Where did this happen? - Explain in your own words what happened? - Did you complain about it? If so, how was this resolved? - What impact has your experience had on the likelihood of you using health or wellbeing services in the future? - What needs to change for you to use healthcare or wellbeing services more regularly?

Approximately half (n=81, 49%) of surveyed Members indicated experiencing discrimination when accessing a health service Racism was the most commonly cited form of discrimination

“ She asked what nationality [my children] were and I said Aboriginal…I said their father's from Northern Territory and I'm from Tasmania. She said - she made reference to them not being what she determined a real Aboriginal person. So to me she was saying well they're not black enough to be real Aboriginal kids.” (Respondent to Member Health Survey)

Racially based stereo-typing. Prejudicial assumptions of health risk and status based on race, rather than the presenting clinical factors. Challenging a person’s Aboriginality on the basis of skin-colour:

1.There is still a high and unacceptable prevalence of racism in Aboriginal and Torres Strait Islander peoples’ interactions with the health system. 2.Institutional forms of racism (including well-intentioned or paternalistic clinical pathways) compromises the quality of care provided to the individual, undermining their trust in the health system and acting as a barrier to people seeking health care at the time when they need it. 3.Inappropriate and unnecessary care undermines the performance of the health system as a whole, diverting resources away from clinical need.

Narrative evidence on the experiences of racism by Aboriginal and Torres Strait Islander people provided an important educative role on its impact at the national health policy level. This shifted discourse from defensive and avoidance (“non-discrimination”) to constructive and direct (“free from racism”). Vision for the National Aboriginal Torres Strait Islander Health Plan: “ The Australian health system is free of racism and inequity and all Aboriginal and Torres Strait Islander peoples have access to health services that are effective, high quality and affordable…: (p.7)

Shift the focus to de -instutionalising racism: - This is more than just talking about cultural competency – its about system competency. - Gaps in the governance frameworks of health systems (ie. how decisions are made) - The curricula of health and medical training institutions (ie. what health care providers are taught). The voices of Aboriginal and Torres Strait Islander people are the means to address the semiotic void between their experiences of health care and an under-performing health system.