The persisting poor health of Aboriginal people over decades is an embarrassing stain on our national reputation and one that seems obstinately difficult to erase. How can this situation be effectively managed?
In 2008 the Federal government formally pledged to provide Indigenous Australians with “equal life chances” including in health. This became known as the Close the Gap (CTG) initiative; it was expected to halve the wide gaps in literacy, numeracy and employment within a decade. The commitment anticipated halving the very high Indigenous infant mortality rate within that decade and eliminating the 17-year life expectancy gap within a generation. Medical opinion seriously questioned the feasibility of reaching the health-related targets within the 22 years specified by the government. Despite that, the program went ahead. The decade which followed has seen some stuttering progress, but this has been overwhelmed by a sorry series of disappointments with no clear end in sight to the elusive and much needed goals towards equity in health for Indigenous people.
The prestigious international medical journal, The Lancet, commented on the 2019 annual CTG report ( https://doi.org/10.1016/S0140-6736(19)30405-2) by stating that only two of seven CTG targets were on track and the life expectancy for Indigenous men and women was 8.6 and 7.8 years shorter, respectively, than for other Australians. The Editorial described these results as “utterly disappointing” and went on to accuse successive Australian governments of “hypocrisy” and paying “lip service” to Aboriginal health. Pertinently, the Lancet commentary pointed to the need for more attention to be given to social changes and to tackling the widespread and potent social determinants of health and disease.
A response to that Editorial (https://doi.org/10.1016/S0140-6736(19)31247-4)
indicated that the manifest failures of the government’s CTG Strategy are more complex than they seem from afar. Underlying and inter-related factors include entrenched socioeconomic disadvantage, high-risk health-related behaviours, inept health services planning, unrealistic health targets, cumbersome top-down bureaucratic processes, and poor governance of health-related services. There is also a lack of understanding of the cultural needs of Indigenous people and communities and insufficient Indigenous involvement in organising and running health services and programs at the local level. Over-riding all of these factors is the challenge of overcoming the entrenched social disadvantages of Indigenous people.
It is tempting, but misleading, to think of Aboriginal Health as a ‘medical’ problem. Sick people must receive adequate clinical care, but the reality is that clinical services alone, therapeutic and preventive, can play only a limited role in overcoming ill-health at the population level. The poor health of Aboriginal and Torres Strait Islander people in this country will persist as long as their root causes remain in such areas as inadequate housing, overcrowding, poor education standards, under-employment, poor nutrition, and limited access to and usage of appropriate medical and health services. This cannot be achieved by one section of government in isolation; all relevant agencies must share their responsibilities if the gaps are to be closed. This will occur only if there is a commitment and determination from the highest levels of government for the promises made so many years ago to be met.
Achieving equality in health between Indigenous and other Australians is not only sorely needed, it would help improve understanding and trust between them. As such, this could prove to become an important step towards reconciliation which is currently so high on the national priority list.
Michael Gracey AO is a paediatrician who has worked with Aboriginal families and communities for more than forty years. He was Principal Medical Adviser on Aboriginal Health for the Health Department of WA and became Australia’s first Professor of Aboriginal Health. He is a previous President of the International Paediatric Association.