37 Colonisation and healthcare

The second potent area of sociology to draw on critical theory after the 1960s was racialised and Indigenous scholarship. Like feminism and disability activism, these drew heavily on the effects of injustice and oppression on people, their bodies, their land and culture, so it is perhaps surprising that so little of this has influenced the physiotherapy literature ^[1]. Over the last decade, there have been smatterings of work done looking at physiotherapy’s relationship with colonisation, race and ethnicity, including discussions of racism and ethnic diversity in physiotherapy ^[2][3][4][5] and physiotherapy training ^{[6][7][8][9][10][11][12][13][14]}, trans-cultural meaning making ^[15][16], experiences of racism ^[17], professional attitudes towards culture ^{[18][19][20][21][22]}, the impact of ethnicity on employment equality ^[23][24], work on cultural humility, competence, allyship, responsiveness and safety ^[25][26][27]Oosman S, Durocher L, Roy TJ et al. Essential elements for advancing cultural humility through a community-based physical therapy practicum in a Métis community. Physiother Canada. 2019;71:146-157.[/footnote]^{[28][29][30][31][32]}, culturally-informed care ^[33][34][35], and the influence of ethnicity on treatment efficacy ^[36][37][38], but these are very marginal subjects in the profession as a whole.

For many racialised and Indigenous scholars, this is not that surprising, and only reinforces how deeply socialised white, middle-class cultures are in most Western health professions ^[39][40]. Because biomedicine places great stall on its supposed objectivity and value neutrality, it assumes its position is ‘colour-blind’ when it comes to issues of ethnicity, race, and culture. But, as is true with gender blindness, Western medicine has largely ignored the fact that it is deeply embedded in dominant ‘Northern’ culture. As Zadie Smith wrote recently; ‘White people belong in the world. It’s theirs, they own it, and they don’t even appreciate it. But they do get defensive when you point it out’ ^[41].

What Smith points to here is the taken-for-granted, uncritical ‘givenness’ that comes with being part of a dominant white culture ^[42][43]. Part of this givenness relies on the idea of White European culture as the stable referent (read, ‘norm’) against which myriad others are judged ^[44]. Critical race and postcolonial theorists argued that dominant cultures actively suppress and marginalise the ‘other’, even while claiming not to do so ^[45][46][47]. Edward Said’s Orientalism ^[48], Guyatri Spivak’s Can the subaltern speak ^[49], Frantz Fanon’s The wretched of the earth ^[50], Nancy Chodorow’s The reproduction of mothering ^[51], and Paulo Freire’s Pedagogy of the oppressed ^[52], are perhaps the seminal examples of this.

Racialised and Indigenous critical theorists have been drawing on these works since the 1980s, arguing that the evidence for this can be seen throughout society, including within the healthcare system. Racialised people ‘have endured (and continue to endure) a long history of trauma and loss as a result of colonisation, racism, and discrimination, all of which have fragmented their family and kinship structures’ ^[53]. This has resulted in generations of people working in lower-paid jobs; being more likely to be employed in low-skilled, manual work; and being more likely to occupy the lower ranks in every professional scope and work in the less favoured specialities ^[54]. Their labour is often used to ‘prop up’ the healthcare systems of past colonial countries, particularly during times of workforce shortage or rapid expansion, effectively creating labour shortages in their own home countries, with some of the brightest minds leaving their home to pursue work overseas. The British welfare state has drawn heavily on migrant doctors to overcome shortages in the NHS, as have healthcare systems in Australia, Canada, and many of the advanced European economies. Unfortunately, many of the migrant workers are still seen as inferior to their colonial counterparts ^{[55][56][57][58]}. Christopher Kyriakides and Satnam Virdee have suggested that this functions to perpetuate the dominance of empire, long after colonised countries have reclaimed their independence ^[59].

‘In their ruthless pursuit of wealth and profit around the world’, Colin Samson argues, Europeans wreaked havoc upon native societies, inflicting violence and spreading disease’ ^[60]. And the health effects of colonisation are now well known. First Nations researcher Raven Sinclair has argued that ‘almost every contemporary social pathology or health issue in Aboriginal communities’ is the direct result of colonisation ^[61]. The WHO supports this, showing that Indigenous populations experience significantly higher rates of illness, disability and premature death but are much less likely to receive adequate care, or to want to engage in services that they perceive to be, at times, judgemental, incomprehensible, and antagonistic to their core beliefs ^[62][63].

Psychiatrist, philosopher and activist, Frantz Fanon, argued that colonisation systematically robbed people of their humanity, but also the material resources people needed to thrive. Indigenous populations become overwhelmed and then forcibly dependent on handouts for survival ^[64]. Fanon suggested that being a colonial subject creates a sense of ‘estrangement’ — that the person does not know who they are (ibid), which leads, in time, to poor multi-factorial health, the criminality of desperation, internalised violence, and post-traumatic stress (ibid). This multiplies the alienating effects of rapid industrialisation and resource exploitation that are often brought into colonised countries in the name of economic ‘advancement’.

One of the most powerful critical arguments for the systematic nature of racism in Western societies has recently come from Isabel Wilkerson. In her book Caste ^[65], Wilkerson argues that socialised white European and American people have taken up positions at the pinnacle of a racial hierarchy, and used this power to define the metrics against which ideas of normality, truth, legitimacy, and people’s beliefs and values are judged (as with commodity control in medicine seen in Chapter 3). This normalising hierarchy, which puts white people above all others, is a proxy for what is essentially a caste system based on entirely socially constructed ideas, into which we all, and perhaps especially health professionals, become socialised. (It is perhaps worth echoing Lennard Davis’s reminder that the concept of normalisation is a social construct, particular to modern (Western) societies: ‘A common assumption would be that some concept of the norm must have always existed. After all, people seem to have an inherent desire to compare themselves to others. But the idea of a norm is less a condition of human nature than it is a feature of a certain kind of society’^[66].) Indeed, Mershen Pillay and Harsha Kathard suggest that orthodox (Western) health professionals are entirely dependent on such practices of what they call ‘dis-othering’, for their legitimacy ^[67].

Because European culture has historically been ‘presumed both to represent the highest stage of societal evolution and to have a duty to export its institutional framework to the rest of the world’ ^[68]. Western approaches to health ‘repeatedly dismiss traditional knowledges as evidence of ignorance, or valued only as an exotic addenda to ‘conventional’ therapies ^[69][70][71]. But even where efforts are made to make healthcare more inclusive, the underlying structures, language, ways of thinking and practicing perpetuate white Eurocentric interests ^{[72][73][74][75]}.

Saleem Razack has suggested that this stems from the West’s colonial past, when it was necessary for nations to create a myth of national coherence and solidarity, and to defend itself against threats from ‘outsiders’. Implicit in this logic is the belief that there is a ‘imagined homogeneous citizenry’ ^[76] that must be protected, by embedding (white) Western values throughout curricula and scopes of practice, and regulating the entry of ‘interlopers’ (ibid). As Timothy Mickleborough argued recently; ‘Race thinking is a system of power that maintains the homogeneity of white society through eviction and containment of the ‘Other’’ ^[77], often undertaken on the basis that ‘it is our moral obligation to correct, discipline, and keep (the other) in line and to defend ourselves against their irrational excesses’ ^[78].

Some scholars have argued that developing cultural competence, responsiveness, and humility within Western healthcare professionals, may help to improve inclusivity ^{[79][80][81][82]}. But a number of authors have found that these approaches are hard to embed in health curricula; they are often poorly resourced; and they are frequently undermined by intransigence or outright hostility from practitioners who perceive them as a threat to their own beliefs about health and healthcare ^[83][84]. Cultural competence training can too easily be seen as something that can be achieved once and ticked off, rather than instituting meaningful change. They can also place the emphasis on the individual rather than the systems that perpetuate racism within society. Cultural ‘competence’ has largely been replaced by terms like institutional racism and structural violence should be standardised, so that the systematic nature of this prejudice can be recognised and tackled ^{[85][86][87][88][89]}.