Indigenous people have experienced miserable health outcomes compared with other Australians for decades. Efforts going back to the 1960s brought some improvements but these were not enough to remove the inequalities. The federal government was prompted to try to resolve this impasse by establishing the so-called ‘Close the Gap’ Strategy in 2008. This brought fresh hope that this international embarrassment would be removed from Australia’s report card. Indigenous people welcomed the initiative but medical experts questioned whether the massive changes the Strategy set as targets could be achieved, as planned, within a single generation. It seems that the reservations about the feasibility of the Strategy were well founded. When the seventh annual Close the Gap report appeared in 2015 the then Prime Minister Abbott admitted that progress was “far too slow” and that the findings were “profoundly disappointing”. When the 2016 report was published the situation was still unsatisfactory and Prime Minister Turnbull limply commented that the results were “mixed”. There was no statement of determination from him that his government would do all in its power to put things right. Surely that wasn’t too much to expect.
Why didn’t the government, then or since, admit that the Strategy was failing and start again, using more realistic targets? As next month’s federal election nears it must be questioned why there is such profound silence from aspiring politicians about this pressing national issue. Why don’t the so-called advocates of fairness and equality for all, especially for people who are marginalised or oppressed, make themselves heard? After all, this is an issue of fairness and equity within our own society.
There are multiple impediments which hold back the much needed improvements in Aboriginal health and wellbeing. While many of the problems are considered to be ‘medical’ their root causes are diverse and complex and their solutions aren’t in the arena of clinical medicine. But these problems are not insoluble. Focusing on medical approaches alone cannot resolve this issue unless and until their wider determinants are addressed comprehensively. These social determinants include poverty, living in unhygienic conditions, lower educational standards, high rates of unemployment or under-employment, racial prejudice, exclusion and social stigmatisation, limited access to and use of clinical services particularly those directed at health promotion and disease prevention, under-nutrition, and high levels of risky attitudes to healthy daily living.
There are also many structural impediments to better Indigenous health. The way health services are delivered, particularly in rural and remote areas can be inefficient and ineffectual. This may be due to the poorly coordinated way that preventive and curative services are provided by multiple government and non-government agencies. In many places there is expensive and confusing duplication or triplication of clinical care provision. Sometimes territorial rivalries between health services and their personnel lessen the effectiveness of the services which should be available. This could be overcome if different services cooperated rather than competed to achieve what should be their common goal – better health for Indigenous people. Recruitment of clinical staff is often difficult, especially in more isolated areas, for long-term appointments of suitably qualified people who can understand and respect the cultural and inter-personal dynamics of Indigenous communities. This is sometimes complicated in dysfunctional communities, as occurred recently when an experienced remote area nurse was murdered in a very isolated community in the far north of South Australia. Emergency evacuations of staff occur from time to time as happened in Cape York recently. These violent incidents are not rare and are potent deterrents against recruiting staff, often single women, to work in such places.
A major reason that enhancement of the lives of Indigenous Australians is being held back is the widespread low standard of management and governance of Indigenous enterprises. This involves all aspects of management of communities and their essential services, including those dealing with health and wellbeing. My personal experience over more than forty years indicates that such poor standards of collective or corporate management are widespread. They are motivated by greed and opportunism when inadequately qualified people find themselves appointed to positions of power without being scrutinised by adequate external checks and balances before and during their tenure.
There have been numerous instances reported over recent years when Indigenous enterprises, including those dealing with health, have run into serious financial difficulties which led to legal intervention and severe penalties. Some of these have been linked to dubious financial activities undertaken by community advisers or administrators and some have resulted in enquiries by the Registrar of Indigenous Corporations resulting in heavy fines. Those instances have mostly been when vast sums of public funds, amounting to millions of dollars, have been misappropriated for personal gain by unscrupulous swindlers. These episodes of misuse of taxpayers’ funds have occurred in widely dispersed parts of Australia, from its biggest cities to remote areas of the outback. When such events directly affect health services the link to impaired delivery of clinical care is clear; but even when misuse or mismanagement of funds affects Indigenous communities or corporations in a general sense the negative impacts are widespread; health care and community wellness and functionality are seriously impaired.
It has been claimed publicly over recent weeks that unscrupulous business advisers and a lack of business literacy in indigenous corporations have combined to bring high levels of fraud into the running of remote communities, with dozens of organisations and programs around Australia being investigated. (Fitzpatrick S. ‘Fraud suspected in 44 remote programs’ The Australian: 7 June 2016 : visit www.theaustralian.com.au ). Two instances involve large Aboriginal corporations in the Kimberley region of WA. Dubious multi-million-dollar management fees were apparently paid to outside managers or advisers through schemes which have been labelled “unconscionable”. Warren Mundine, chairman of the Prime Minister’s Indigenous Advisory Council, has said this would not be tolerated in the wider Australian community (Fitzpatrick – AGAIN). The horrible reality of exploitation of the poorest and most vulnerable Indigenous communities has been exposed graphically in an ABC television ‘4 Corners’ program (6 June 2016) entitled “Ripped Off”. One of those people interviewed was an Indigenous community CEO who complained . . . “there are weasels out there that just know what to look for and can infiltrate”.( www.abc.net.au/4corners ). That program shows how serial swindlers and conmen managed to defraud the communities, and expropriate millions of dollars of taxpayers’ money in the process.
Surely the time has come for such devious practices to be treated severely in accordance with expected business and management standards in order that this type of corporate abuse is stamped out.
The bureaucratic processes that control many aspects of planning, financing and overseeing how Indigenous programs operate, including those responsible for health care, have also been roundly criticised. In particular, the Indigenous Advancement Strategy (IAS), which is charged with allocating hundreds of millions of dollars to programs to assist the advancement of Indigenous Australians, has drawn public rebuke. The respected Aboriginal leader, Noel Pearson, has said that the IAS failed to deliver reform, but left an entrenched system of “parasitic” organisations and passive service delivery unchanged. Pearson is critical of “overbearing” ministerial direction and “inexperienced bureaucrats” for unsatisfactory results because of ill-directed and ineffective use of funds. Apparently, more than half of $4 billion of recently allocated IAS grants went to organisations with charitable or tax-exempt status and only about two-thirds of $1 billion worth of IAS grants supposed to benefit very remote areas was, instead, going to organisations located mainly in cities and towns. Pearson claimed the IAS was flawed because it lacked “a funnel and a sieve” to direct funds to where the real needs exist. The Australian. Two out of 10: Noel Pearson berates indigenous spending overhaul. 7 September; 2015.
The low level of Indigenous involvement and engagement of Indigenous people in decision-making, and in formulating and delivering health services and taking responsibility for the health of their own people is another area of concern. There have been real advances in this area over recent years with increasing numbers of indigenous doctors, nurses, and other health professionals now in the workforce. Some Indigenous people now have positions of influence and leadership in such fields as health administration, policy development, research, and in academic and political life. Yet, at the community level, much of the decision-making and day to day provision of services remains the domain of non-Indigenous people. When this imbalance is corrected it is likely that increased ownership of these responsibilities will lead to improved health outcomes.
Overriding these challenges is the reality that health outcomes are largely due to factors which are outside the control of clinicians and related health professionals. Clinicians should make it clear to others that there limits to what they alone can achieve. There is a need for other sectors to accept responsibility for much of the burden of multiple negative impacts of social disadvantages which cause ill-health. As mentioned earlier, these include poverty, sub-standard housing, inadequate infrastructure services, low levels of education, high unemployment, unsatisfactory nutrition, and social marginalisation. There is a real need for governments and their agencies to accept their shared roles in overcoming these serious obstacles to better health for Indigenous Australians. Unless and until this happens and the workload is distributed between different areas of government services, Indigenous people are likely to have to endure unsatisfactory health for years to come.
Is this acceptable? And importantly — do our politicians care?
Michael Gracey AO is a paediatrician who has worked with Aboriginal people and communities for more than forty years. He was Australia’s first Professor of Aboriginal Health.