Michael Gracey. Why is closing the aboriginal health gap failing so badly?19/02/2015
The disparity between the health of Aboriginal people and other Australians first drew wide public attention In the 1960s; it became known as “The Aboriginal Health Problem”. This awareness came from reports of widespread and severe malnutrition in Aboriginal infants and young children, high rates of infections and gut parasites, high infant mortality, and reduced life expectancy.
This wasn’t good enough for a wealthy nation like Australia, the “Lucky Country” if you like, where the luck seemed to not extend to the First Australians. There was a public outcry at the time, followed by almost predictable political reactions aimed at correcting the inequity.
Strategies were devised, programs planned, health professionals were employed, and huge sums of taxpayers’ dollars were allocated and spent over the next half century. So we are entitled to ask “what happened?”
There were some gains. Aboriginal infant mortality rates fell, their average birth weights increased, rates of malnutrition dropped, vaccine-preventable infections receded, rates of severe child infections declined and deaths from childhood gastroenteritis plummeted. These encouraging improvements were mostly due to conventional public health measures including childhood vaccination, better hygiene, and earlier referral for treatment of illnesses, greatly improved treatment for childhood diarrhoea and dehydration, and employment of skilled clinical personnel. But over the past thirty or so years many aspects of the health of Indigenous people have deteriorated. Why?
Since the 1970s there have been substantial changes in the living patterns of Aboriginal Australians, particularly in rural and remote areas. Political, legal and administrative changes occurred from the late 1960s that had profound effects on Aboriginal people and communities. Examples include the introduction of equal pay for equal work, the granting of drinking rights to Indigenous persons, various systems of welfare support and payments, increased reliance on the welfare system, and a rapid shift from traditional lifestyles to that of a typical Westernised contemporary society. This all occurred on an entrenched system where Indigenous people were disadvantaged in almost all aspects of their lives from the rest of the wider Australian society.
Indigenous people went through a swift lifestyle shift and became less physically active, more sedentary, and consumed modern foods and drinks that were more calorie-dense, contained much more fat and salt and less fibre than in previous times. The stage was being prepared for a tidal wave of chronic so-called “lifestyle” diseases which threatened their survival. The Tsunami of obesity, diabetes, high blood pressure, heart disease, stroke, chronic kidney disease and renal failure descended on them with a vengeance. Not only that, the stresses associated with maladjustment to these changes, socio-political disadvantage, under-education, unemployment and racial prejudice combined to make them a sub-group that was vulnerable to a heavy burden of disease, disability and excessively high mortality.
However, increasing numbers of Indigenous Australians are not trapped in this unfavourable vortex of negative factors. Many are being well-educated, achieving high levels of competence and success in their daily lives, in business, the professions, and academia, and are becoming leaders in Australian society. These people provide encouragement towards future successes and recognition of Indigenous people as exemplars.
But the negative impacts of various factors on the health statistics of Indigenous people over the past 30 years are a cause for serious concern.
The persisting, yawning divide between the health statistics of Aboriginal people and other Australians has become known as “The Aboriginal Health Gap” which is one of this country’s worst embarrassments. In 2008 the then Labor government committed to “close the gap”, a phrase which in my view has been overstated. That commitment was to make the health, disease and death statistics, as well as other markers of Aboriginal well-being, match those of other Australians by the year 2030. This is not achievable. Apart from the vast discrepancies that are so entrenched in the lives of most Indigenous Australians, such as poor educational standards, high unemployment, lower per capita incomes, and unsatisfactory housing and access to services, there are many biological factors that contribute to ill-health that have strong components that persist for more than one generation. This means that issues that affect future generations, such as the health and nutrition of pregnant Aboriginal women and breast-feeding mothers, must be corrected before improvements can occur for the following generation or more. This simply cannot be done within 20 or 30 years. Similarly, the heavy chronic disease burden of, for example, diabetes and its long-term complications, chronic kidney disease and kidney failure that are so prevalent in young Aboriginal people, cannot be fully eliminated within one generation.
Reviewing the official annual reports about progress over the past seven years is a disheartening exercise. Many of the stated targets have not been reached and, in some areas, things have deteriorated despite the immense amounts of public funds which have been used in “close the gap” programs. This was admitted in February 2015 by the Prime Minister when commenting on the seventh annual report; senior Indigenous spokespersons agreed that the findings were very disappointing. What’s gone wrong?
Looking objectively at the situation it must be admitted that the federal government commitment in 2008 was: (a) well-intentioned; (b) ill-informed; (c) not adequately thought through; (d) bureaucratically top-heavy and clumsy; (e) naïvely optimistic; (f) culturally insensitive; (g) rhetorical rather than realistic; and (h) ignored the biological restrictions imposed by previous generations on altering health outcomes in subsequent generations of children.
Why shouldn’t the government admit that the commitment made in 2008 was not feasible and start again? A serious problem with a failing program is that many people feel let down, disheartened and frustrated because the expectations are not being realised. This is particularly so for those who have the most to gain or lose – the Indigenous people. This won’t change until a more realistic strategy and timetable are devised, perhaps with a new name.
Government must accept that approaches used over the past 30 years or so have, with few exceptions, like those already mentioned, not worked. This applies to different levels of service delivery; government, the private sector, and Aboriginal-controlled medical services.
A fresh approach is needed. To date governments have given little encouragement to Indigenous people to become agents of change for their own health. Community engagement, commitment, and acceptance of responsibility must occur at the local level if real change is to be achieved. This will provide opportunities, previously denied to Indigenous communities and their members, to learn at first-hand: (1) the determinants of health; (2) what causes illness; (3) how diseases can be prevented; and (4) how health service systems operate and can be modified as required. Community involvement in these matters will provide, perhaps for the first time, a new deal with local people being real partners in programs to improve their own health. This will require collaborative teams with long experience in health and health services, community development, cross-cultural knowledge, empathy, patience, and inter-personal skills to work in small groups around Australia. This strategy uses a previously untapped resource, local Indigenous people and communities, to help “close the gap”. Governments will have to commit to radical changes in order to achieve this.
Meanwhile, all the other social, economic and environmental factors that affect health outcomes will need to be addressed vigorously. Without such changes, for example in education and employment opportunities, the failures of the past will continue.
Michael Gracey AO MD PhD FRACP FAAP
Professor Gracey is a paediatrician who has worked with Aboriginal people, families, communities and organisations for more than 40 years. He was Principal Medical Adviser on Aboriginal Health in the West Australian Department of Health and was Australia’s first Professor of Aboriginal Health. He has also served as President of the International Paediatric Association.