Michael Gracey . What’s needed to fix aboriginal health?Jun 16, 2015
By most of the usually accepted markers the health of Australia’s indigenous people compares unfavourably with that of other Australians. This has been known for decades and numerous strategies and programs have been developed to correct this inequity. Despite the best of intentions and expenditure of billions of taxpayers’ dollars over the past half-century, a yawning chasm remains in this so-called “gap”. The Prime Minister, no less, admitted in February 2015 that the findings of the seventh annual Close the Gap Report were “profoundly disappointing”.
Two important questions flow from this:
- What’s to be done about it?
Why have past and current programs failed?
The reasons for this being such a difficult problem are complex. They are historic, entrenched, cultural and deeply divisive, as are many of the issues that bedevil the relationships between indigenous and other Australians. The alienation felt by indigenous people which was caused by colonising powers, such as loss of traditional lands and waters, food and water sources, destruction of long-held beliefs, customs and behavioural norms, is almost incomprehensible to non-Aboriginal people. But these issues are real, resented and sour the relationships between fellow Australian citizens.
We must ask ourselves what is health? And does the concept of “health” mean the same to all peoples? To most Westerners “health” means the absence of illness, disease or disability, or not needing to go to a doctor or other therapist for treatment or hospitalisation. But this concept is not shared by all cultures; in some societies health can mean the equivalent of “happiness” or living in harmony with one’s environment. For Australian Aboriginal people health has been described in the National Aboriginal Health Strategy as “not just the physical well-being of the individual, but the social, emotional, and cultural well-being of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life”. How often do health professionals consider such different attitudes from what they consider to be the norm? And how often do conventional clinical carers think that others might take a different view of health and, perhaps, even put it low on their list of the necessities for survival? How, also, could such concepts be considered when assessing the health of individuals or groups of people?
Any consideration of what affects health must include physical and environmental factors such as: living standards; overcrowding; personal and community hygiene; food availability and quality; and knowledge, attitudes and behavioural patterns towards maintaining health and wellness. In all of these categories many indigenous Australians are disadvantaged when compared to their average non-indigenous counterparts. Added to this background must be possible genetic and cultural influences as well as the context of what importance is put on staying healthy among any individual’s essentials in their day-to-day needs. In all human societies seemingly mundane requirements such as food, shelter, and the means to sustain those can override all others. Just as importantly, attitudes to a person’s or a family’s or a community’s aspirations and attitudes to well-being can influence their physical and emotional health. The stage is therefore set for many indigenous Australians to fare poorly in the health stakes. These are at least some of the ways that the why can be explained.
What should be done?
The first thing that should occur is an admission by government that the approaches used over the past 30 to 40 years have failed. Unless this happens the failures will persist. A fresh approach is the only way to overcome past mistakes. Some will say “but there have been past successes”. True; let’s look at some of them.
Rates of infections and parasite infestations have dropped; infant and maternal mortality have declined; infants’ birth weights have improved; childhood malnutrition is not as severe as it was, say, 40 years ago, and; life expectancy has improved although, in relative terms, the gap is still unacceptably wide. Many of those welcome improvements can be explained rationally and objectively. For example: widespread immunisation coverage against many infections has assisted with the drop in infections; better hygiene has also helped with this decline; earlier referral and improved treatments have lowered the disease burden from infections such as gastroenteritis, and; improved therapies have brought better outcomes for people with conditions that need long-term clinical care. Overwhelmingly these improvements are due to responses to classical public health prevention measures or to better clinical care and follow-up.
But – there are areas where Aboriginal health has deteriorated. We’ll examine them, at least briefly. They include: a rapid upsurge in so-called chronic ”lifestyle” diseases such as obesity, diabetes, cardiovascular disease and hypertension; chronic kidney disease and renal failure; smoking-related disorders; drug and alcohol abuse, and; accidents and violence. Most of these disorders have a common theme; they are linked to inadequate knowledge and attitudes about health and about potentially hazardous behaviours that can undermine an individual’s health. This is crucial because it introduces the elements of knowledge or education regarding health and how people can use that information to sustain their own health. This, in turn, brings into the equation a component of individual and collective responsibility for one’s own health.
The “balance sheet” or ledger of improvements, on one hand, and deterioration on the other, has probably tipped unfavourably against overall improvement in Aboriginal health statistics over the past 30 years. This imbalance is where the task of improving Indigenous health in future becomes really difficult.
Viewed objectively, at least two challenges must be met. First, government alone cannot solve all of the problems that characterise Aboriginal health. Second, individual and collective responsibility for one’s own health must become a principal issue to be addressed by the nation’s Aboriginal community. These two challenges provide opportunities which should be met enthusiastically by complementary responses through working in partnership.
Past failures can be sheeted home to three main sectors which provide health and medical services to the Aboriginal population. They are: (a) federal and state government services; (b) the specially developed and independently-run Aboriginal Health or Medical services, and; (c) private or other non-government operators of clinical and related services for Aboriginal people. These three sectors must work together to correct the currently unacceptable state of play. In order for this to succeed a fourth sector must become involved; that is individual Aboriginal communities and their local administrative structures. This is the fourth dimension which has been lacking in the past and which, I believe, can help to break the current impasse.
Despite the failures of the past, there remains an attitude of goodwill among the wider Australian community to see that the First Australians should share the health standards that most of us take for granted. Unless tangible progress is made in the near future it is likely that this support will wane.
To break the current nexus there must be a coming together to plan a new way forward. Initially, the federal government should objectively examine the options and then arrange a consultative process which involves all four sectors: (1) federal and state governments; (2) Aboriginal Health or Medical Services; (3) private or non-government clinical and related services, and: (4) community-based representatives to involve “grass roots” people in the cooperative venture. Arranging such a consultative process will be tricky and will require funding. Certain organisations may feel unfairly excluded such as medical and nursing organisations and specialist Colleges, universities, and technical and other higher education institutes. If all such organisations were to be involved the process would probably become cumbersome, too large to be manageable, excessively expensive, and could involve too many conflicting interests. It is likely that some of the current players will feel threatened by this proposed process. So be it. If they feel threatened or that their territory is about to be invaded, this will be their opportunity to demonstrate, objectively, that their services are indispensable. All four sectors will need to recognise that compromise will be needed to achieve the desired outcome – better health for indigenous Australians. Arranging for the new sector, the fourth on my list, may be the most difficult but it is essential if success is to be achieved. No such body exists and it will need exquisitely sensitive skills to be realised. This new dimension will at last recognise that local Aboriginal communities have a real contribution to make to the health improvement process. This cannot be satisfactorily achieved by regional indigenous health organisations even if they claim to be “community-controlled” because members of local indigenous communities play no part in the selection of such regional bodies and are kept voiceless. Using this fourth sector will also acknowledge the great diversity of Aboriginal communities around Australia and their own special needs and aspirations, which are often ignored in current policy and program development and implementation. This fourth sector must be driven locally because this is a situation where “one size fits all” will not work. It will also be essential to avoid building yet another nationwide “grand plan”. These often fail because they ignore the real desires of those who matter most — the people who lack yet desire to have the same standards of health and well-being as other Australians.
If such a four-pronged negotiating process can be arranged, the next step will be to devise a plan of action and mechanisms to regularly assess its successes, failures, strengths, and weaknesses. A new plan should merit a new name. To avoid the notion of closing a gap I suggest for consideration the name Aboriginal Health Improvement Program or AHIP. At least that lends itself to measurable, incremental health targets and outcomes instead of trying to completely repair, in a rigid time frame, this problem that has been so elusive for decades.
How likely is it that such a meeting of the four sectors will occur? Regrettably, my experience over many years makes me suspect that the chances of arranging such a gathering and seeing it through to a successful conclusion are low. At least in the past, issues of territoriality, institutional responsibilities, the open and free sharing of information, and personality clashes and jealousies have too often led to impasses, failures, and sometimes to acrimony. What is the alternative? It seems that the failure to proceed along these or similar lines to a fresh start for Aboriginal Health would mean that the overall failures of the past would continue into the foreseeable future. Is that acceptable to the Aboriginal people or to the Australian government? Only they can answer that question.
It must be remembered that any new Aboriginal Health Improvement Plan must meet the needs of hundreds of thousands of Aboriginal people, of all ages, in vastly different circumstances, and with very different socio-economic levels in all parts of Australia. Additionally, consideration must be given to training and retaining a clinical and other technical workforce to serve the needs of the health improvement strategy and implementation plan; without that support the best intentioned plans are bound to fail.
Details of where to go from there and how the new approach will be funded, operated, and continually monitored must rest with the operational strategies that are agreed by the four major participating parties. To the “number crunchers”, policy makers, administrators, politicians and guardians of the public purse, health must be measurable. Otherwise how can we be confident that public monies are being put to best use? So we should all be informed and the operators of the program should be guided by the effectiveness of health expenditure to improve such outcomes as: life expectancy; rates of diseases, disabilities and deaths; nutritional status; and immunisation coverage rates against vaccine-preventable diseases such as measles, TB, whooping cough, tetanus, certain types of pneumonia and hepatitis. Other outcome measures, such as those relating to emotional well-being and social functioning should also be included.
The managers, administrators and day-to-day operators of any such new approaches must avoid the prevalent temptation to be interested only in outputs instead of outcomes. It is too easy, for example, to simply measure the number of persons or patients who attend a clinic or some other facility or activity without estimating the essential measure that is needed to determine whether a health intervention program is effective or not. That is, what changes has the new program brought to the health of the target group, the Aboriginal population?
The success or otherwise of any new program should be measured in this way and reported publicly so that the entire Australian community can see if their aspirations and the needs of the Aboriginal people are being met as they would reasonably expect.
Finally, it must be recognised that health is determined by many factors out of the control of health planners, administrators and clinicians. Significant improvements in health outcomes rest with significant improvements in other areas. These include education, employment opportunities, housing and hygiene standards, self-esteem, and the availability of affordable supplies of fresh and nutritious foods. Without improvements on this wide front initiatives that focus on medical issues alone can have only limited success.
Michael Gracey is a paediatrician who has worked with Aboriginal patients, their families, communities and organisations for more than 40 years, particularly in remote parts of Western Australia. He was Principal Medical Adviser on Aboriginal Health to the WA Department of Health, Professor of Aboriginal Health at Curtin University in Perth, and is a previous President of the International Paediatric Association.