MICHAEL GRACEY. ‘THE GAP’. A rhetorical thought bubble with good intentions

Mar 11, 2020

In February 2008 then Prime Minister Rudd stated that “our challenge . . . is to embrace a new partnership between Indigenous and non-Indigenous Australians”.

The core of this partnership was to close the gap on “life expectancy, educational achievement and employment opportunities”. To date those expectations have not been met. Why?

A Statement of Intent was made in 2008 for Indigenous and other Australians and their organisations to achieve equality in health status and life expectancy between Indigenous and other Australians by the year 2030. This was the genesis of the Close the Gap (CTG) Strategy.

Given the disparities that had existed in these and other aspects of life between Indigenous and other Australians, these sentiments seemed fair and the goals seemed desirable. But were they achievable?

About that time the life expectancy for Indigenous males was more than 11 years shorter than for non-Indigenous males while for females the gap was almost 10 years. Life expectancy in population groups changes slowly. For example, from the first decade of the twentieth century to the same decade of that following, Australians were expected to live roughly 2.5 years longer each decade Yet, the government commitment in 2008 expected Indigenous people to improve their expectation of life at more than three times that rate. The infant mortality rate (i.e. up to 12 months of age) was more than double in Aboriginal and Torres Strait Islanders than in other infants. Why were the gaps in vital statistics so wide? Was it, for example, because Indigenous Australians differed genetically from other peoples? Or was it because Indigenous people had higher levels of ill-health for biological and environmental reasons that might respond to rational interventions?

Surely it was important to have answers to these questions before embarking on an ambitious and inevitably expensive nation-wide program that, somehow, would be expected to solve these important problems no matter what their root causes.

There was a much heavier “burden of disease” among Indigenous adults than in their non-Indigenous counterparts. Much of this was due to chronic or life-long diseases such as circulatory and respiratory diseases, chronic kidney disease, diabetes and its long-term complications, and malignancies. Apart from making those people less healthy in the long-term, these were major reasons for the excess premature deaths in the Indigenous population. Similarly, the Indigenous population had much higher rates of death from so-called “external causes” such as intentional self-harm, transport accidents, assaults, and accidental poisonings.

A substantial proportion of these statistics was related to use and/or abuse of alcohol and other drugs as well as to cigarette smoking. Added to that, Indigenous pregnancies had higher rates of unfavourable outcomes for their infants. These included the intra-uterine impacts of maternal undernutrition and infections on the developing infant. One example is the foetal alcohol syndrome which is prevalent and has serious life-long effects on Indigenous children. Maternal cigarette smoking can also negatively affect intra-uterine development. Some of these maternal-to-infant impacts are trans-generational meaning that later generations can also be affected. This burden of chronic disease among Indigenous Australians was not likely to respond positively in the short- to medium-term.

The targets set by the government to “close the gap” were considered to be “probably unattainable” in a paper published in the Medical Journal of Australia months after the government’s program was launched. Was this important caveat missed, ignored or considered not of sufficient import to warrant a re-consideration of the Rudd government’s CTG Strategy and Program?

The national program went ahead regardless. And the results fell well short of the government’s stated targets. The Prime Minister (PM) reports annually to parliament on results of the CTG Strategy. Successive PMs have noted patchy improvements in some aspects of the Strategy but have recorded their continuing disappointment at the findings overall. The 2020 report noted that only two of the seven government targets were “on track”. They were to (a) have 95% of Indigenous 5-year-olds enrolled in early childhood education by 2025 and (b) halve the gap in year 12 attainment by 2031. Regrettably, targets set to be achieved by 2018 including: halving child mortality; halving child literacy and numeracy gaps; closing the gap in school attendance; and halving the gap in employment rates were not being met. Notably, the important goal of closing the gap in life expectancy by 2031 was not on track.

This was deeply disappointing to all stakeholders, particularly Indigenous people who expected that the CTG program would bring new hope to their lives, individually and collectively. After working in Aboriginal health for more than forty years this top-down, “we know best” attitude seems to me to be typical of health bureaucracies

Why did the CTG Strategy fail so badly to meet its stated targets? As mentioned, the very choice of ‘closing a gap’ was questionable. Why select vital statistics that, by their nature, are intrinsically slow to change either because of their biological determinants or associated environmental modifiers? Why not choose more modest goals which were more likely to be achievable, particularly if they were selected by those people most closely identified with the outcomes, that is Indigenous people or their chosen representatives? A basic flaw throughout the CTG process was a lack of active involvement or participation of Indigenous people. Acceptance of responsibility for decision-making must be a part of the process in such programs and will be vital if the government goes ahead, as has been suggested, with a fundamental review of the future of Indigenous wellbeing.

Successive federal governments have acknowledged the repeated failures of the CTG program, but can they correct the mistakes of the past?

Michael Gracey AO. is a paediatrician who has worked with Aboriginal children, their families, communities and organisations for more than forty years. He was Principal Medical Adviser on Aboriginal Health in the West Australian Health Department and Foundation Professor of Aboriginal Health at Curtin University.

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