MICHAEL GRACEY. Aboriginal health: An embarrassing decades-long saga

It’s been widely known for fifty years that the health of Aboriginal people lags far behind that of other Australians. Despite that and the expenditure of billions of taxpayers’ dollars, serious gaps persist between Indigenous versus non-Indigenous health and wellbeing.

Recognition of an Aboriginal Health Problem

When these inequities were recognised in the 1960s the very high rates of Aboriginal childhood malnutrition and infections and high death rates of infants and young children brought home the unpalatable fact that Australia had a so-called ‘Third World’ health problem. This is a feature of poverty-stricken nations. This was clearly unacceptable in our otherwise affluent and healthy country. There was a public outcry which stirred the federal government into attempts to remedy this embarrassing state of affairs.

In 1979 the Commonwealth Parliamentary Committee on Aboriginal Affairs found that . . .

‘the appalling state of Aboriginal health’ . . . ‘can be largely attributed to the unsatisfactory environmental conditions in which Aboriginals live, to their low socio-economic status in the Australian community, and to the failure of health authorities to give sufficient attention to the special needs of Aboriginals and to take proper account of their social and cultural beliefs and practices’ . . .

The Committee criticised governments for their lack of recognition of these factors and commented on the need for Aboriginal people to be much more closely involved in all stages of planning and delivering their own health care. Notwithstanding some improvements in Indigenous health which occurred over the almost forty years that followed, many of that Committee’s findings and criticisms are still valid.

Efforts to Improve Indigenous Health

In 1981 a $50 million Aboriginal Health Improvement Program was launched with the aim of upgrading environmental health standards, such as better housing and community and family hygiene conditions. Government funds were allocated and State and Territory health departments implemented strategies and programs and deployed clinical and allied staff in order to achieve better Indigenous health. An important objective was to provide more accessible services for Indigenous people. Some positive health gains followed; for example, better pregnancy outcomes, fewer maternal deaths, fewer infant and young child infections, suppression of vaccine-preventable illnesses through immunisation, and lower infant death rates. This should have helped Indigenous youngsters to negotiate the rough ride through early life that would otherwise have been their lot. However, health and disease statistics for Indigenous Australians generally stayed well behind those of other citizens in the years that followed.

Strategies to ‘Close the Gap’

The persisting poor standards of Indigenous health prompted the Federal Government in 2008 to ‘Close the Gap’ for Indigenous Australians in a range of health outcomes and other facets of life and wellbeing so that they and other Australians would have ‘equal life chances’. The then Prime Minister Rudd anticipated within a decade halving the widening gap in literacy, numeracy and employment opportunities for Indigenous people. The Statement of Intent also anticipated better opportunities for Indigenous children so that within a decade . . . “the appalling gap in infant mortality rates between Indigenous and non-Indigenous children would be halved and, within a generation, the equally appalling 17-year life gap between Indigenous and non-Indigenous when it comes to overall life expectancy” . . .  would be gone.

These aspirations seemed commendable and were well received by the public. However, their feasibility was questioned soon after they were announced. The target of closing the gap in life expectancy was said to be “probably unattainable” and the capacity to extinguish the risk of chronic diseases (like heart disease, diabetes and kidney disease) and related deaths was considered publicly by a renowned medical expert to be “implausible” in the 22-year timetable set out by the government. This is pertinent because those chronic diseases are the main contributor to the discrepancy in Indigenous versus non-Indigenous deaths. Those reservations were well founded.

Obstructions to Closing the Gap

Indigenous Australians now have very high rates of chronic diseases, as already mentioned. These are aggravated by smoking- and drug-related disorders. These conditions are long-term and have permanent complications, such as visual loss or blindness, or severe limitations on mobility. These cannot be reversed and, therefore, restrict prospects for longevity. In many Aboriginal communities a third or half of adults 35 years or over have one or more of these problems. Nationally, these diseases and accidental or intentional injuries, including suicide and homicide, are several times more prevalent in Indigenous Australians than in the total Australian population. This well-documented and widespread heavy burden of illnesses, disabilities and related excess premature deaths among Indigenous Australians makes it virtually impossible to remove, within a generation, the inequalities between this pattern and the better outcomes which prevail in the rest of the population. This is made more difficult because some of these problems are trans-generational and can have their origins during intra-uterine development.

There are practical impediments in bringing better health to the Indigenous population. Inadequate access and maldistribution of facilities, personnel and services can be serious drawbacks, particularly in rural and remote areas. Of course, improving access to services does not necessarily lead to their appropriate utilisation. And compliance with treatments and follow-up supervision and medications can be problematic. Similarly, altering health knowledge and modifying risky personal lifestyles are difficult among many people whether they are Indigenous or not. There have also been serious problems with management and governance of clinical services for Indigenous people whether they are Indigenous-specific or mainstream services. This has tended to weaken their impact on health service delivery and waste limited financial and other resources. Collectively, all of these factors have diluted the much-needed positive outcomes of efforts to close the gaps in Aboriginal health standards and statistics.

Indigenous Health: the current situation

Some indicators of the current situation are revealing: death rates of Indigenous children under five years are more than double the national rates; their low birth weight rate is about double the overall national rate; hospitalisation rates are almost three times the national rates; hospital admission rates for potentially preventable conditions are almost four times higher; deaths from complications of diabetes at 35 to 55 years are approximately twenty times higher; and dementia rates are about five time higher than in non-Indigenous Australians and the  condition starts earlier in life. The Australian Institute of Health and Welfare estimated that among Indigenous Australians born from 2010 to 2012 life expectancy would be about nine to ten years shorter than for other Australians. These indicators of health status, illness patterns and life expectancy are disgraceful and require urgent attention.

Where to from here?

The targets set to be met by the Close the Gap Strategy are reported publicly each year. Regrettably, the goals are falling short in many of the government’s nominated areas. These include several of the health-related areas which have been mentioned. Tellingly, the targets are not being met in many other facets of Indigenous life which have significant impacts on physical, emotional and mental health and wellbeing. These include, for example, early childhood schooling rates, closing the gaps in literacy and numeracy for older Indigenous schoolchildren, achieving equity in employment rates and the economic benefits which should follow, having Indigenous people housed in adequate and hygienic living conditions, and being more engaged with the wider Australian community in various day-to-day activities. These failures have been publicly acknowledged by successive Prime Ministers including Abbott and Turnbull.

In the health arena itself there is a need for closer cooperation and collaboration between the three main sectors which provide curative and health promotion activities for Indigenous people. These sectors are: (a) mainstream services provided by governments; (b) Indigenous-specific services from Aboriginal or Indigenous Health or Medical Services; and (c) privately funded clinical and allied services. There is often overlapping of these sectors and, sometimes, issues of territoriality which detract from their effectiveness and, potentially, add to the financial costs involved. As mentioned by that Parliamentary Committee as far back as 1979, there is a pressing need for more Indigenous involvement and responsibility for decision-making and delivery of their own health services. Although this is improving slowly, there is a long way to go before those people who need the services have the power to help control their own future health. This is particularly so in remote areas where local communities and their committees are often sidelined from this important function.

Social Dimensions which affect Health

There is compelling evidence that social factors are potent determinants of the health of populations. In the simplest of terms these are (a) social disadvantage, and (b) the relationship of Indigenous Australians to mainstream society. Associated with these are basic issues already mentioned; these include education, housing standards, employment and socio-economic status. These must be addressed if health disadvantages are to be overcome. Until this happens the poor health outcomes of Indigenous Australians will persist.

It’s easy to identify medical problems, perhaps because they can be classified and measured. It is tempting then to decide that these problems are ‘medical’ and, therefore, should respond to ‘medical’ interventions or approaches in isolation. This is dangerously misleading. It’s time for clinicians to realise and publicly acknowledge that most of the important issues which determine the health status of Indigenous people have ‘non-medical’ roots and need vigorous ‘non-medical’ approaches in order to be corrected. This means, of course, that non-medical sectors of governments must accept more responsibility and become more actively involved in issues which ultimately determine the health of populations which they are expected to serve. This will require a major shift in thinking within Federal and State governments and bureaucracies and wider acceptance among the Australian community.

The challenges are daunting but the need is urgent. Surely it is within our collective capabilities to turn around this sad and long-standing saga into a success story.

Michael Gracey AO is a paediatrician who has worked with Indigenous children, their families and communities for more than forty years. He was Australia’s first Professor of Aboriginal Health and for many years was Principal Medical Adviser on Aboriginal Health to the Western Australian Department of Health. He is a former President of the International Paediatric Association.


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3 Responses to MICHAEL GRACEY. Aboriginal health: An embarrassing decades-long saga

  1. Geoff Edwards says:

    Thanks Prof Michael

    Without a clear understanding of causation – in other words, a theory to explain Indigenous disadvantage – the best efforts of numerous well-meaning people and governments are likely to be directed to futile actions and policies. Unless some fundamental causative preconditions are identified, we are left with a situation where something has to be done about everything, which becomes highly problematic for governments that are inevitably segmented along portfolio lines.

    I don’t see a clear theory in your article, although there are hints here and there, such as the reference to “intra-uterine development”.

    Of course, any complex field of policy resembles a can of spaghetti, but an application of scientific method ought to be capable of establishing some causative factors as more fundamental than others. “‘Non-medical’ approaches” is a very large tangle of issues to unscramble. Can we simplify?

    If we start from a first principle that humans are fundamentally mammalian biological creatures, upon which sociological factors such as upbringing are superimposed, then this leads to a conclusion that proper attention to malnutrition and drug status during pregnancy is an essential condition for human health and well-being, even though it is far from sufficient.

    So a policy that ensured that every Indigenous child has an adequate diet and every mother is quarantined from alcohol during pregnancy would surely be a first start. As a clinician, you don’t need me to observe that a child who has a can of caffeinated cola drink for breakfast is programming their body for a lifetime of obesity, is unlikely to learn anything in the classroom, and is not receiving the vitamins and zinc essential for disease immunity.

    Once this variable is managed satisfactorily, then other psychological and sociological conditions can be seen for what they are. So long as the biological foundation is malfunctioning, no other remedy will work.

  2. Meg Perkins says:

    There is one thing that has not been mentioned and that is the massive overrepresentation of Indigenous people in the prison system and especially in the juvenile justice system. Indigenous boys are suspended from school at a much higher rate than non-Indigenous boys or girls from both communities. 75% of the children appearing in NSW Childrens Courts are Indigenous boys aged 10 to 12. These statistics tell us that Indigenous people. especially men, are being pushed out of school along the school to prison pipeline. We know that prison perpetuates the economic disadvantage and the health disadvantage, the unemployment, the homelessness, the anxiety and depression, the substance abuse, the suicides, and creates communities of poverty and absent parents. It may well be that mass incarceration is driving disadvantage for Indigenous people and that it could be stopped in the first years at school if appropriate support was offered to children and families. Exclusion from school means exclusion from mainstream society and creates far more problems than it solves.

  3. Rosemary Lynch says:

    The public health approach to Indigenous Health will certainly identify inadequate housing + high population density + high cost healthy foods – low cost unhealthy foods + inadequate economic infrastructure + low employment + inadequate infrastructure, poor waste disposal, periodically unsafe water supply, inadequate and expensive power supply. Really, even without racism, which marks indigenous access to any government or health service, why would the slow response to closing the gap be in the least surprising? Should government, local or regional, not address these fundamental building blocks, to which most citizens have access, then, perhaps the gap can be addressed.

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