The evidence base for interventions into Indigenous public health
National Centre For Epidemiology & Population Health, Australian National University, Canberra
Indigenous Health Forum
Master Of Applied Epidemiology Program
Tom Calma
Aboriginal and Torres Strait Islander
Social Justice Commissioner
Human Rights and Equal Opportunity Commission
September 12, 2007
Slide 1
Good afternoon - i would like to begin by acknowledging the Ngunnawal peoples, the traditional owners of the land where we meet today and to pay my respects to their elders. I would also like to thank the National Centre for Epidemiology and Population Health and Dr Lorrae van Kerkhoff for inviting me to speak to you and for ensuring that Indigenous health – so often overlooked in the ongoing debates about health and health reform in Australia – receives the attention it deserves in this context.
Part 1: My role
In July 2004, I took up my appointment as the Aboriginal and Torres Strait Islander Social Justice Commissioner at the Human Rights and Equal Opportunity Commission or HREOC. This role was created in 1992 to provide an ongoing monitoring agency for the human rights of Indigenous Australians.
I undertake this role in a number of ways. In particular, I am required to report annually to the federal parliament on the status of enjoyment and exercise of human rights by Indigenous Australians. This is called the Social Justice Report. the 2006 report was tabled in parliament in June. It is also available on the HREOC website. I also produce a community guide that outlines the salient points in the Social Justice Report and a second annual report I produce called the Native Title Report.
My 2005 Social Justice Report included a chapter titled ‘Achieving Aboriginal and Torres Strait Islander health equality within a generation: a human rights approach’. In this I recommended that governments of Australia commit to achieving equality of health status and life expectation between Aboriginal and Torres Strait Islander Australians, and non-indigenous Australians, within 25 years. In order to achieve this goal, governments need to commit to achieving equal access to primary health care and health infrastructure within 10 years; and to fund programs based on need. This has since been published as a stand alone publication and I have copies available today. I will be discussing the campaign at various points in my presentation today.
Slide 2
Now, as a memory refresher I am going to begin by providing a snapshot of Indigenous health and health inequality in Australia: data available in the excellent Australian Bureau of Statistics and Australian Institute of Health and Welfare’s publication “The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples 2005”. (Can I make a note here that if I do not reference statistical data specifically from now on, it can be sourced to this publication.)
The headline indicator – one that is well known – is life expectation. Over 1996–2001, there was an estimated difference of approximately 17 years between Indigenous and non-indigenous life expectation. What this means in practice is that 75% of indigenous males and 65% of females will have died before the age of 65 years compared to 26% of males and 16% of females in the non-indigenous population.
If only it was simply a matter of producing a vaccine to reduce that burden of ill-health! In fact, there are a number of disturbing indicators and trends that reveal an entrenched health crisis in the Indigenous population – one that indicates a comprehensive, long term address is needed.
I highlight:
- high rates of chronic diseases such as renal failure, cardio-vascular diseases and diabetes. In 1999–2003, two of the three leading causes of death for Indigenous people were chronic diseases of the circulatory system and cancer. Hospitalisation for heart disease for Indigenous males was double the rate, and for females four times the rate, than for the general population;
- high rates of poor health among indigenous infants do not bode well for the future adult population. Apart from high rates of infant mortality, in 2000-02, babies with an Indigenous mother were twice aslikely to be low birth weight babies as babies with a non-indigenous mother. Those that survive are likely to be of poorer health for the rest of their lives, and
- high rates of unhealthy and risky behaviour, including an increased prevalence of substance abuse and alcohol and tobacco use in the Indigenous population.
With a significant proportion of Indigenous peoples in younger age groups, there is an additional challenge to programs and services being able to keep up with the future demands of a burgeoning population. Unless substantial steps are taken now, there is a very real prospect that the health status of indigenous peoples could worsen.
So how do we understand what is going on with indigenous health? Why is there such an inequality gap? And why is it so entrenched?
Slide 3
The first reason is not mysterious. It is that indigenous people’s health suffers because we suffer an inequality of opportunity to be as healthy as other Australians. We have significantly less access to primary health care and the health infrastructure in Indigenous communities is of a poorer standard than that in other Australian communities. A solution boils down to Australian governments planning effectively and committing the needed resources.
Let’s look at primary health care
The importance of primary health to better population health has long been recognised: at least since the W.H.O. Declaration of Alma Ata in the 1970s, and I am assuming that I do not need to spell this out to such an expert audience.
Given that Indigenous peoples’ poorer health status would indicate a greater need for primary health care services, it is disturbing that in the 2004 'bettering the evaluation and care of health' or beach survey, it was estimated that indigenous peoples enjoyed 40% of the per capita access of the non-indigenous population to primary health care provided by mainstream general practitioners. Of course there are Aboriginal community controlled health services, and while their impact is hard to quantify, the gaps that are still evident indicate an outstanding “need” shortfall. I highlight:
- In terms of availability: in 2002, there were twice as many medical practitioners per person in major cities than in remote areas and ten times the number of specialists. Because a higher proportion of the Indigenous population live in rural and remote areas, this has a greater impact on Indigenous peoples when compared to the non-indigenous population.
- In terms of physical accessibility: the Australian Bureau of Statistics Community Infrastructure and Housing Needs Survey 2001 -- a survey of all ‘discrete’ Indigenous (i.e. predominantly indigenous) communities in Australia reported small but significant numbers of remote communities living over 100 kilometres from any kind of health service. The barrier of distance is compounded by a relative lack of access to transport among Indigenous peoples: the 2002 ABS National Aboriginal and Torres Strait Islander Social Survey reported that 23% of households with Indigenous persons did not have access to a motor vehicle (compared to 10% in the non-indigenous population).
- In terms of economic accessibility: fees charged for health services (including top-ups charged by general practitioners) will act as a greater barrier to Indigenous peoples’ access to the services than for the non-indigenous population as Indigenous peoples’ average income is significantly lower than that of the non-indigenous population.
- In terms of acceptability: Indigenous peoples do not tend to use mainstream primary health care even where it is otherwise available and physically accessible, for example in urban areas. This can be for many reasons including a lack of cultural ‘fit’, language barriers, or the perception that mainstream services are not welcoming to Indigenous peoples.
Per capita Medicare under spend estimates have been used to assess the quantum of the Indigenous primary health care shortfall. Estimates of the shortfall range from $250 million per annum by Professor John Deeble, ‘the architect of Medicare’, in 2003 to $570 million per annum depending on the quality of service offered in a report prepared for the Australian government in 2005.
Health promotion and education is an absolutely vital aspect of primary health care. How are people to make informed decisions about their health – diet and the like - without it? How are they to know when to visit a doctor? Yet indicators suggest that this vital information is not reaching Indigenous communities.
Professor Deeble quantified the health promotion shortfall in Indigenous communities at $50 million in 2003. But I think we need go no further than the rates of STIs in some communities to understand something of the information void in which many Indigenous people are making decisions about their health. I highlight that in 2003, in certain communities, rates of chlamydia, gonococcal infection and syphilis infection among indigenous people were up to 93 times the rates among other Australians.
Importantly, studies such as the 1996 Bowden –Fairley study do not attribute this imbalance to increased promiscuity. On one hand, the lack of primary health care meant that infections were simply not being detected and so spread. The point I want to highlight, however, is that fundamental health promotion messages, namely in this case the ‘safe sex’ message, was simply not getting through.
So what about health infrastructure?
Slide 4
‘Health infrastructure’ is a term I am using to describe all the things that support good health, but that are not health services. Examples include: potable water supplies, healthy food, healthy housing, sewerage and sanitation, and so on.
The dominant feature of health infrastructure inequality in Australia relates to Indigenous peoples’ housing. Nationally, 5.5% of Indigenous households live in overcrowded conditions. The proportion of overcrowded households was highest for those renting from Indigenous or community organisations (25.7%). Among the jurisdictions, the proportion of overcrowded households was highest in the Northern Territory (23.7%). More broadly, in relation to roads, sanitation, water supplies and electricity, a century of neglect of health infrastructure in Indigenous communities has left what could be (according to ATSIC in 2001) a 3 - 4 billion dollar project for this generation.
Diet too is a major issue. The recent Western Australian Aboriginal Child Health Survey or (WAACHS) reported that the diet of only one in five Aboriginal children met all four of its indicators of dietary quality. What studies exist have found the consumption of sugar, white flour and sweetened carbonated beverages at much higher levels than in the non-indigenous population in remote communities. Despite the poverty reported in Indigenous communities, food has been reported by the Fred Hollows Foundation as up to 150% - 180% more expensive there than that in major centres.
Beyond health infrastructure, Indigenous peoples in Australia experience a number of collective stressors and social determinants that impact on the health of individuals. As first noted by the National Aboriginal Health Strategy in 1989 the health of Indigenous individuals cannot be discretely treated as discrete from the health of their families, communities and cultures.
The most obvious example is the socio-economic disadvantage suffered by Indigenous peoples on all major indicators, (and I am assuming that you are aware of the demonstrated correlation between poverty and poor health):
- At the 2001 national census: the average gross household income for Indigenous peoples in Australia was 62% of the rate for non-indigenous peoples; the unemployment rate for Indigenous peoples was 20%; or roughly three times higher than the rate for non-indigenous Australians.
- Nationally in 2004, Indigenous students were also half as likely to continue to year 12 as non-indigenous students. This impacts on health education and promotion in Indigenous communities, much of which has traditionally come though schools.
Slide 5
However, equally important is collectively experienced psycho-social stress and its reflection sometimes in emotional and social stress in indigenous individuals. I am sure that you are aware of the studies that link such unhealthy stress to poor health, notably hypertension and heart disease that (as I have highlighted) are so prevalent among Indigenous peoples.
Psycho-social stress is usually understood as arising when an individual perceives that they have little or no control over their environment: their life, their family’s life; or their community’s life. However, it obviously has a collective dimension when a population group are exposed to similar stressors or collective disempowerment as a result of political or social forces:
- The unfinished business of colonisation and ongoing second class status afforded Indigenous peoples in Australian society will have a distinct and collective impact on Indigenous peoples not felt by the non-indigenous population. This includes the ongoing difficulty with reconciliation, and the ongoing uncertainty surrounding the issues of land, control of resources, cultural security, and the rights of self-determination and sovereignty.
- The stressor of collective trauma – notably, the impacts of the stolen generations practices on many Indigenous Australians. The 2002 ABS National Aboriginal and Torres Strait Islander Social Survey found that 38% of respondents had either been removed themselves and / or had relatives who had been removed from their families. This has created inter-generational health impacts and trauma; the WACCHS, for example, found that 12% of Indigenous young people and children surveyed were looked after by a carer who had been forcibly removed. These children were more than twice as likely to be at high risk of clinically significant emotional or behavioural difficulties and twice as likely to abuse alcohol and drugs.
Racism too is likely to affect the social and emotional (as well as mental and physical) health of indigenous Australians in a way not experienced by most other Australians. A review of 53 studies in the United States by Williams, Neighbours and Jackson in 2003 found a decline in mental health status as racism increased. Eight out of 11 studies found links between the elevated prevalence of high blood pressure in Afro-Americans and racism. Building on this overseas work in Australia, researchers such as Yin Paradies are working to identify the specific health impacts of racism on Indigenous Australians.
- It may also be that the lack of collective control acts as a determinant of poor social and emotional health. This might manifest at a community level, providing another reason for effective indigenous community governance and community control of services, including health services as I will discuss later. Certainly, in the National Aboriginal Health Strategy (1989) Indigenous peoples stated that their health status is linked to ‘control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity’. While hard to quantify, it is interesting that the WAACHS found that the environmental safety and the emotional and social health of indigenous children improved with isolation (that is, those in remote communities had better mental health). Children living in Perth had significantly poorer (in fact, five times worse) emotional and social health than those living in very remote, isolated communities. The report concludes that traditional cultures and ways are protective against poor environmental safety and emotional and social health.
To the degree recognising Indigenous peoples’ right to self-determination supports communities to regain control of their lives, including through the maintenance of traditional cultures, it can be understood as having positive health impacts. It is also a stepping-stone to the goal of social and economic equality. Experience from overseas – notably from the so-called Harvard project, a study into North American Indigenous communities to ascertain what made communities ‘work’ -- confirms that Indigenous communities’ control over their own affairs can be crucial to their social and economic regeneration.
There are also the individual life stressors that manifest in significant personal events like the deaths of family and friends, poor health or disability, unemployment, imprisonment and so on. In many cases, these will reflect the operation of collective stressors on indigenous individuals and families.
- The findings of the National Aboriginal and Torres Strait Islander Health Survey (2006) suggest a strong association between the experience of stressors and physical health problems in the Indigenous population. The WAACHS reported a clear association with the experience of ‘major life stress events’ in a family in the 12 months prior to the survey and a high risk of clinically significant emotional or behavioural difficulties in the children of that family. Of children aged 4 to 11 years, 42% were at high risk of clinically significant emotional of behavioural difficulties in families that had experienced 7 or more life stress events compared with 25% of children in families experiencing 3 to 6 life stress events and 15% in families experiencing 0 to 2 life stress events.
- The National Aboriginal and Torres Strait Islander Social Survey (2002) reported that 82% of respondents had experienced at least one stressor in the last 12 months. The most frequently reported stressors were the death of a family member or close friend (46%), serious illness or disability (31%) and inability to get a job (27%).
I highlight that the two top stressors are related to physical health. This suggests that in a vicious circle, the low life expectation and commensurate high death rates and illness among Indigenous people is also profoundly undermining Indigenous peoples’ social and emotional health, and – in that way – compounding and causing physical health problems. But then the third most prevalent factor – unemployment – suggests that a comprehensive address to collective Indigenous disadvantage will help improve the health of indigenous individuals.
So what is the solution?
Slide 6
Improving Indigenous health rests on ensuring Indigenous Australians have the same access to primary health care as non-indigenous Australians. Given the size of the shortfall, this won’t happen overnight. Training the doctors and nurses and establishing more clinics will take time. It requires long-term planning and investment. But ultimately, it is a question of political will -- the will to do the planning, and to make the extra investment of $250- $500 million a year in the health and quality of life of our Indigenous peoples.
Best practice indicates that where possible these new services should be Indigenous community controlled services -- namely because these are optimally culturally and economically accessible as well as often being the only option in remote areas. Such services empower Indigenous communities and people to look after their own health. They literally speak the language of the community, know the communities problems and are best placed to work out solutions – for example, choosing to invest more of its funds into integrating drug and alcohol counselling or mental health programs into its practice.
Significant investment in health infrastructure is also needed in communities. This is quantified at up to $4 billion as I have mentioned earlier. But spread over ten years that amounts to $400 million a year, declining as capital works costs gives way to the lesser cost involved in maintenance. Again, this is a question of political will.
Addressing these fundamental social justice issues – and remember, we are talking about ensuring equality of opportunity here, not special treatment -- should make a huge difference.
There is sufficient evidence to demonstrate that significant improvements in Indigenous peoples’ health status is achievable in a short time-frame.
International figures demonstrate that optimally and consistently resourced primary health care systems can make a significant difference to the health status of populations, as measured by life expectancy, within a decade. For example, in the 1940s to the 1950s in the United States, native American life expectancy improved by about 9 years; an increase in life expectancy of about twelve years took place in New Zealand over two decades from the 1940s to the 1960s.
And yet while spending has increased on primary health care (as well as things like health infrastructure), there is no ambitious plan to meet this primary health care need, as soon as possible,in the current national indigenous health policy: the National Strategic Framework for Aboriginal and Torres Strait Islander Health. And for a government that recorded a 17.3 billion dollar surplus this year on top of record surpluses for the past decade I believe this is unacceptable. Devoting a small fraction of these accumulated surpluses would have addressed this issue a long time ago. We have wasted enough time, and indigenous lives, already.
In fact, there have been a number of developments in Indigenous policy over recent years where governments have made commitments to addressing Indigenous health inequality a major priority.
At a general level, through the processes of the Council of Australian Governments there is now a joint commitment from all governments in Australia to coordinated service delivery with the objective of addressing Indigenous disadvantage, including health inequality. Progress in addressing these commitments is able to be measured against the Overcoming Indigenous Disadvantage Framework on a biennial basis.
In addition to these general commitments, specific commitments have also been made at the inter-governmental level to address Indigenous health inequality and inequality of opportunity. Notably, thealready mentioned National Strategic Framework for Aboriginal and Torres Strait Islander Health establishes a ten year plan for Indigenous health, building on the principles of the National Aboriginal Health Strategy.
The National Strategic Framework has as its goal the achievement of health equality. However, although it acknowledges the urgency of addressing Indigenous health inequality, it does not set a timeframe, targets or benchmarks for achieving this. It also contains a commitment to (and I quote) ‘comprehensive’ primary health care encompassing ‘clinical / medical care, illness prevention services, specific population health programs for health gain, access to secondary and tertiary health services and client / community support and advocacy’; and it is now supported by a revised Aboriginal and Torres Strait Islander Health Performance Framework, which has been agreed at the inter-governmental level, to report progress on the National Strategic Framework.
A number of national strategies and commitments in relation to environmental health workers, housing and the supply of food have also been developed under the umbrella of the National Strategic Framework.
The combination of these commitments and defined policy approaches provides a substantial foundation from which to address Indigenous health inequality. However – and crucially -- they do not address the main failings in the approach of Australian governments to date in addressing Indigenous health inequality.
They include (a) governments of all persuasions have not activated their commitments by setting them within an achievable time frame. Governments have instead left the achievement of equality to an unspecified future time. By doing so, all Australian governments have been unaccountable for progress in achieving health equality and (b) they have not matched their commitments with the necessary funds and program support to realise them.
Accordingly, the key issue for Indigenous health – and the focus of the Indigenous health equality campaign that I will discuss shortly-- remains the need to implement the extensive commitments of governments and to ensure that the quantum and pace of activities is sufficient to achieve the goal of addressing Indigenous health inequality.
My final observation is that Indigenous health must be treated holistically – and I am saying nothing new here in asserting this. As I have noted, since 1989 -- almost 20-years ago now -- Indigenous peoples have consistently linked their health to the health of their communities, to respect for their rights, to the tackling of discrimination and racism and so on. And it is therefore not possible to neatly separate out issues like reconciliation, native title and the broader question of lands, community control and self-governance and so on from the broader questions of Indigenous health.
In that regard, particular attention must be paid to the engagement and empowerment of Indigenous peoples in any address to health inequality, and at the general policy level. In part, the failure of the existing commitments and strategies to address Indigenous health is because of the failure of Australian governments to engage appropriately with Indigenous peoples and develop strategies and programs with the full participation of Indigenous communities. Governments must ensure that Indigenous peoples have the opportunity to participate effectively in all aspects of policy development and service delivery that impact upon their communities.
It is common sense that governments risk failure if they develop and implement policies about Indigenous issues without engaging with the intended recipients of those services. Bureaucrats and governments can have the best intentions in the world, but if their ideas have not been subject to the ‘reality test’ of the life experience of the local Indigenous peoples who are intended to benefit from this, then government efforts will fail in the medium to long term.
And we have a policy framework that reflects this. If you look at the National Strategic Framework, sure enough it advocates treating Indigenous health in a holistic manner and it advocates Indigenous engagement and empowerment. However, in practice things are working out very differently: the policy documents talk of empowerment, yet programs and responses that are likely to erode the strength and culture of communities are being introduced. And I want to illustrate this by looking at the intervention underway in the Northern Territory.
First of all, can I say that the intervention is framed as an effort to improve the well being of our children in particular, and with that basic intent I have no disagreement. However, the way this is being developed and implemented may be counter-productive.
In particular, I am concerned that the lack of consultation with communities in rolling out child health checks, and that the stripping of power away from communities by appointing administrators, is counter-productive in terms of collective control.
A related point is the damage that is being done to the reputation of Aboriginal communities that are functional and achieving very positive things despite the odds. We can’t risk labelling all communities as dysfunctional and undermining their sense of pride when we know that positive cultural and community identity is linked to social and emotional well being. But regrettably this is what is happening.
On the issue of connection and control over land, there is a real risk that the compulsory acquisition of townships and town camps will undermine indigenous peoples’ ability to make decisions about their land. Scrapping the permit system removes one of the fundamental rights of ownership - to decide who can or cannot enter your property. Especially given that there is no link between these measures and child abuse, I am very worried about the negative social and emotional health impacts.
The legacy of the stolen generation is still well and truly with us and one of the things that we have learnt is that trauma, grief and loss needs to be addressed holistically and in ways that get to the root cause of the issue. It is for this reason that I am worried that measures such as alcohol bans without appropriate rehabilitation services, let alone more mental health services, are yet again treating the symptom and not the cause of the problem. If we are serious about increasing social and emotional wellbeing through alcohol reduction, there must be rehabilitation, treatment and diversion services immediately put in place. At the moment the vast majority of remote communities do not have access to a substance abuse or diversion service.
Government has a responsibility to improve the health of our children, families and communities. But we need to draw on the evidence to ensure that the policies put in place are truly best practice and will work for the betterment of all aspects of the lives of Indigenous peoples and communities – in a holistic fashion -- and not be a trade off of short term gains against long term losses in terms of the broader determinants of health of Indigenous peoples.
Slide 7
Let me conclude by discussing the campaign for Indigenous health equality.
Perhaps the factor that is most striking, in its absence from the current framework, is the lack of a timeframe for achieving Indigenous health equality. In relation to the health equality campaign proposed in my Social Justice Report 2005, I recommended that Australian governments commit to achieving equality of health status and life expectation between Indigenous and non-indigenous people within 25 years.
This recommendation seeks to place a time dimension on the goals and aims of the National Strategic Framework for Aboriginal and Torres Strait Islander Health as well as on the commitments of the Council of Australian Governments to overcome Indigenous disadvantage. It provides a long term vision to focus government activity.
This target cannot stand in isolation. It must be supported with the establishment of other, more detailed targets and benchmarks on a number of discrete, smaller indicators relating to health status and which exist over the short and medium term. The Overcoming Indigenous Disadvantage Framework, as well as the Aboriginal and Torres Strait Islander Health performance framework provides an appropriate basis for establishing these.
A vital secondary target proposed is that Australian governments should also commit to achieving equal access to primary health care and health infrastructure within 10 years for Indigenous peoples. An equitable distribution of primary health care rests on a prior effort to increase the numbers of health professionals to provide the services. It was estimated in 2001 that 500 new general practitioners and over 3,000 new nurses and Aboriginal health workers were needed.
Aboriginal community controlled health organisations have a vital role to play in the provision of primary health care. However, the expansion of community controlled health services must take place alongside efforts to improve the accessibility of mainstream services. It should also be accompanied by health care programs focusing on specific diseases like what Lisa and Travern no doubt mentioned. If, through these, early stage symptoms are detected, not only can suffering be prevented, but cost savings made.
Finally, the campaign advocates a holistic approach to Indigenous health. What this means is that things like reconciliation, land and native title, policing in remote communities (or lack of) and the empowerment of Indigenous communities at the community, regional and national level can no longer be seen as discreet issues to the broader question of Indigenous health equality.
And in winding up, I am pleased to report that over 40 Indigenous and non-indigenous organisations are currently working in partnership to encourage Australian governments to commit to the campaign for achieving Indigenous health equality within 25 years. In December 2006, the coalition published an open letter calling for an end to Indigenous health inequality in The Australian. In April 2007, Olympians Catherine Freeman and Ian Thorpe helped launch the campaign at the Telstra Stadium, Sydney. The partners are currently working towards hosting a national Indigenous health summit in early 2008 (after the election), where we will formally call for Australian governments to adopt the campaign to mark the 40th anniversary of the 1967 referendum.
Thank you. Any questions?
