Warning signs were emerging many decades before, but by the early part of this century it was obvious that the health of indigenous Australians was much worse than that of other citizens. Indicators such as high infant mortality, widespread malnutrition and infections in children, much shortened life expectancy, high rates of chronic diseases and disabilities, mental illnesses, Alzheimer’s disease, drug- and alcohol-related disorders, suicide and homicide, were all very unfavourable when indigenous and other Australians were compared.
This situation was clearly unacceptable and governments tried to address the inequities by putting more efforts and resources towards ‘Aboriginal health improvement’. Those responses to this widespread and serious problem were reactive, patchy and uncoordinated and their outcomes were not rigorously assessed. Not surprisingly, improvements which were documented over the decades from the 1960s were often disappointing, although maternal and child health and nutrition showed encouraging advances.
Momentum developed over the past two decades to remove these inequities. The best recognised initiative came in 2008 when the federal government committed to ‘close the gap’ in several key areas including health, life expectancy, education and employment. Federal, state and territory governments and their agencies agreed to implement strategies and programs to meet the targets by the year 2030 and the national government would report annually on progress towards these objectives. The sentiments behind this national strategy seemed commendable and were widely accepted around the nation. Indigenous people thought this plan would bring fresh hope to improvements in their health and social wellbeing. However, medical experts long-experienced in indigenous health had serious misgivings about the feasibility of achieving the targets within the 22-year schedule that had been set. Despite this caveat, the strategy went ahead.
By 2015 Prime Minister Abbott said that the annual report showed disappointingly slow progress and that some targets were not being met; the following year Prime Minister Turnbull gave a similarly downbeat assessment of the results. Several nationally prominent and respected Indigenous leaders were highly critical of the Close the Gap Strategy, suggesting that it needed a ‘radical overhaul’.
The Australian Human Rights Commission reviewed the situation in 2018 ‘to critically reflect on why Australian governments have not yet succeeded in closing the health gap to date, and why they will not succeed by 2030 if the current course continues’ (https://www.humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/publications/close-gap-10-year-review). The review found that: the original 2008 Close the Gap Statement of Intent had been only partially and incoherently implemented; preventive health activities had been under-utilised; programs needed to be focused more closely on outcomes; a ‘refreshed’ Closing the Gap Strategy is required; and governments need to recognise and appropriately fund the disproportionately higher costs of providing health care to indigenous people because of their much heavier burden of ill-health. That review was accompanied by a series of recommendations aimed at responding to the criticisms which have been summarised above.
The 2018 Close the Gap Report was released by the Prime Minister in the same week; again, most of the targets were not met, including that of life expectancy. Although the national indigenous infant mortality rate had improved, that rate for non-indigenous youngsters had also fallen. That means the indigenous rate was still relatively very unfavourable against that of their peers. Despite expenditure of billions of dollars, the overall results of closing the gap programs continues to be disappointing and frustrating for all Australians. The Aboriginal and Torres Strait Islander Social Justice Commissioner, June Oscar, called on premiers, chief ministers, health and indigenous affairs ministers in every jurisdiction to provide regular accountability of their efforts and to stop finger-pointing between governments.
The Opposition Leader, Bill Shorten, used his response in parliament to this year’s Close the Gap Report to pledge his party to create an indigenous ‘advisory’ voice to parliament ahead of planning a constitutional referendum if elected to office. More specific responses to closing the continuing inequities in health have not yet been announced. If these changes and the proposed ‘refresh’ of the Close the Gap strategy go ahead, it is important that their possible consequences are anticipated well before their implementation. ‘Good intentions don’t necessarily produce good results.’
Whatever governments, politicians, health administrators and planners, other bureaucrats and clinical professionals provide towards improving health standards and lessening the burden of illness among indigenous Australians, their task is seriously challenging. It is clear, however, that those organisations and individuals cannot succeed in isolation. In fact, it is misleading to consider closing the health gap to be a ‘medical’ challenge. The complexities and interactions between so many determining factors produce poor health and unfavourable health, disease and death statistics as end results. Those contributing factors include education, employment, income levels, housing standards, self-esteem, engagement at all levels with the wider community, and much closer involvement in decision-making and responsibility for their own future wellbeing. These are all prerequisites to meaningful and sustained long-term improvements in indigenous health. Until these multiple and potent causative factors are fixed, poor health outcomes will persist.
The burden must be shared between all sections of society, indigenous and non-indigenous, before the much-needed improvements occur. Governments and their agencies must accept that the indigenous population is tired of the long-endured but often resented ‘top-down’ approach of bureaucracies to their multiple disadvantages. Indigenous people, communities and organisations must be encouraged to play their part in meeting this national challenge. After all, they are the people who have most to gain from solving this dilemma which so far has embarrassed us all.
Michael Gracey is a paediatrician who has worked with Aboriginal children, their families, communities and organisations for more than forty years. He was Principal Medical Advisor on Aboriginal Health to the Health Department of Western Australia for many years and was Australia’s first Professor of Aboriginal Health.