Inequity is not a bug in the system—it’s a feature

Racism expresses itself in many different ways. Sometimes it’s right in your face, like when a policeman kneels on a black man’s throat, or when a white supremacist murders Muslim people.

Other times it’s more subtle and difficult to recognise. It can even be expressed through acts of omission. In other words, not doing something. Indeed, inaction in the face of need is one of the ways in which institutional racism works.

A recent example is the decision by the Ministry of Health and Te Aho o Te Kahu (the Cancer Control Agency) not to follow expert advice around extending the bowel cancer screening age range for Māori and Pacific people.

Okay, you might say, that’s potentially problematic, but can we really say it’s racist? They’ve provided a rationale which, on the surface — when viewed in isolation and allowing a healthy benefit of the doubt — could appear to be justifiable.

But looking at the bigger picture of New Zealand health policy, a more disturbing pattern emerges. A pattern of persistent rejection of pro-equity interventions. To understand how this plays out, let’s look in a bit more depth at what happened in this case.

The National Bowel Screening Programme story goes a long way back. The Ministry of Health had been advised from day one that, without remedial action, the screening programme would be inequitable.

One of the key issues was that bowel cancer, on average, affects Māori and Pacific people at younger ages. If the screening programme were to adopt a one-size-fits-all age cut-off, based on the population average, it would be weighted heavily towards New Zealand European patterns of disease — and it would miss a substantial proportion of cancers in Māori and Pacific populations.

In spite of this advice, the national screening programme went ahead with a universal age range of 60–74 years. From the outset, it was racist by design.

Since that time, there have been repeated calls for the eligibility to be extended to include Māori and Pacific people from age 50, including from Hei Āhuru Mōwai (Māori Cancer Leadership Aotearoa), the Cancer Society, and Bowel Cancer NZ.

In response to ongoing pressure, the ministry’s National Screening Unit, in February last year, held a hui that focused on achieving equity for Māori in bowel screening.

I had the privilege of facilitating the hui, which drew representatives of all the key national organisations and a host of experts from across the cancer care sector.

At the hui, we were presented with the latest evidence and heard from experts in bowel cancer, screening and equity. Robust discussion ensued, and that led to a series of recommendations to address equity in the national screening programme.

The highest priority recommendation was that screening eligibility should be extended down to 50 years of age for Māori.

Despite being advised by Ministry of Health representatives that no changes would be considered until after the rollout to all DHBs was complete, there was a strong consensus at the hui that it would be unethical to wait until that time to correct the baked-in inequity.

Immediate action was required to ensure that Māori would no longer be denied equitable access to bowel screening. It was recommended that the age range extension should be introduced as soon as possible.

Later in the year, a fono of Pacific health advocates and clinicians agreed that this recommendation should be extended to include Pacific peoples.

The Ministry of Health and the Cancer Control Agency recently announced a decision on this issue. Their report recommended deferring any consideration of adjusting the age parameters until the programme is fully implemented, which was expected to be by December 2021.

By which time, the landscape will no doubt have changed and we’ll be back to square one — needing to review the evidence again and relitigate the case. And, if the same people are making the decisions based on the same values, criteria and institutional norms, who would bet against a similar outcome?

This fits a well-established pattern. Every time decision-makers are given an opportunity to take action that is pro-equity, they find reasons not to. The advice of Māori and Pasifika experts is devalued and marginalised while other considerations are elevated.

We’ve heard numerous justifications in this case, from problems with IT systems, to concerns about DHB buy-in, to lack of colonoscopy capacity. In other situations, it has been cost-effectiveness, or concerns about safety or health care quality.

There’s always a reason.

In the case of bowel screening, the policy settings could have been adjusted at any point to extend eligibility for Māori and Pacific people. If resource constraints were an issue then a corresponding reduction in eligibility for non-Māori, non-Pacific people could have addressed that. But that would have required an acknowledgment that certain groups were benefiting disproportionately from the existing arrangements. It would have meant confronting white privilege.

And so we see continuing inaction in the face of need — one of the key manifestations of institutional racism. (Perhaps “inaction” is the wrong word here. Behind the scenes you can guarantee there is a lot of action directed at finding ways to justify the inaction.)

That might seem critical, but it’s simply a description of what is going on rather than any kind of judgment. It’s important that we name racism wherever we see it — only then can we work to dismantle it.

If we don’t foster a critical understanding of how racism operates in these settings, we’ll keep trying to solve the wrong problem. We’ll keep looking for more or better evidence, or different arguments to persuade the powers-that-be. We’ll keep trying to work within processes that are designed to exclude and silence us. We’ll keep trying to iron out the bugs in the system.

Instead, we have to recognise that, within the machinery of government, inequity is not a bug, it’s a feature. The system is doing exactly what it was designed to do. And that calls for a whole different set of solutions.