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Dear Editor
The extreme health disadvantage of Aboriginal and Torres Strait Islander people has been recognized and documented for some time1,2. Unfortunately, comparatively little has been written regarding potential lasting solutions3,4. When discussing Indigenous health issues it seems easier to document health disadvantage or to describe the great need that exists for improved services, than to define potential solutions. Indeed, it is an area for which there is precious little evidence to help guide policy makers in their quest for answers.
When examining the evidence for the greatest public health gains in the past two centuries, one cannot ignore the great contribution of housing, sanitation and clean water5. That these basic human rights are denied to many Indigenous Australians is inexcusable. Other determinants such as poverty, social exclusion and education are now widely recognized to have a major impact on health6, and these issues also need urgent attention if the poor state of Indigenous health is to be improved.
The Howard government provided an impetus by declaring a 'national emergency' in Aboriginal health7; the outcome of this approach is now in the hands of a new (Rudd) government. The activities that have commenced to establish law and order need to be closely followed by long-term initiatives to address the underlying issues within these communities. Thus, the Rudd government has a great opportunity to set in place a holistic, well developed plan, and provide the lasting solutions that Indigenous people deserve. A comprehensive plan could be drafted within 12 months, if there was sufficient government will.
A plan for improving Indigenous health
A plan aimed at improving Indigenous health, needs to provide a broad outline that can be adapted to different communities, reflecting the heterogeneity among Indigenous people. Just as there cannot be a 'one size fits all' plan, the details of such a plan cannot be proposed by one person alone. To do so, would deny the wealth of experience and knowledge that exists in Indigenous communities and the wider community. Creation of a plan could be formulated by a group of people in a series of well-coordinated and conducted workshops. It would be prudent to utilize relevant experts in specific fields, such as education, health, employment and economics. In addition, there are numerous resources in the form of government reports suggesting solutions to specific issues; many of these are still relevant and should be addressed. Importantly, any plan needs to be closely followed by an injection of resources, both financial and human.
Guiding principles
Tackling Indigenous health requires strong partnership among Indigenous people, the Federal and State governments and other service providers. Consultation is a key to empowerment and should not be seen as a barrier to timely action. Good consultation is, in fact, necessary time spent, without which there may be many barriers to action. Such dialogue would not need to be too onerous, as much of it has already occurred. The existing strengths of a wide variety of Indigenous leaders and communities should be valued and applied to this important mandate.
Making real and sustained improvement in Indigenous health will require a massive government commitment and this must be a Federal government initiative. Although progress has been made in certain isolated areas, little information flows across Australia to benefit communities in other settings with quite similar problems. For this reason, the Federal government must provide leadership and overall coordination.
To achieve the types of gains that need to be made in Indigenous Health, a generational commitment will need to be made. Financial resources will need to be dedicated and quarantined to ensure ongoing action for the long term (>20-30 years). These will need to be carefully monitored, to ensure the best use of government and philanthropic spending. Money needs to be directed at specific projects, which have a strong foundation in consultation and evidence. There needs to be great caution applied to spending, as so much money has been historically wasted on ineffective, tokenistic and ill-conceived programs and projects, which have not been properly evaluated. Of equal shame is the wasteful 'rolling out' of very good programs that are destined to fail because basic human rights (access to adequate shelter, food and education) are not being addressed. Great caution also needs to be applied in the selection of appropriate human resources.
It is important, particularly where historical issues constrain progress for Indigenous people, that a solution be found that allows wronged parties to move forward8. This cannot be overlooked or ignored, as it may present an enormous barrier to improvements in health and wellbeing. Historical issues that require resolution include such issues as: the Stolen Generation, land rights and Aboriginal deaths in custody. These issues may have different significance for different people and communities but nevertheless require appropriate resolution. It is encouraging to note that our new government is taking steps to start this process with a very long overdue apology.
Dealing with the detail
Certainly, there are immediate and urgent problems in some communities that need to be addressed, such as law and order issues, child sexual abuse and alcohol problems. However, focusing only on these symptoms will further marginalize Aboriginal communities and compromise long-term sustainable solutions. A plan to address Indigenous health needs to focus on the social determinants of health. These include infrastructure, housing, government services, economic development, education and primary health care. Other key factors that, if nurtured, will lead to improvements in health, include social capital and Indigenous culture.
Improved infrastructure, housing and access to government services: Urgent infrastructure investment will be required in some communities to allow service access and improve immediate safety. Such infrastructure includes roads, streetlights, airstrips and communication systems. Adequate and appropriate housing for all Indigenous people is needed, with timely maintenance cycles. The dearth of government services available to Indigenous people, particularly in remote settings, including police, welfare, crisis and judicial/legal services, needs to be addressed.
Economic development: Indigenous communities, particularly in remote settings, require comprehensive plans for economic viability, with a goal of poverty alleviation. Expert, innovative economic guidance will be required to create industry and meaningful jobs. Communities that are not currently economically viable will need special, in-depth consultation.
Investment in education: It is universally accepted that education and literacy are inextricably linked to health outcomes9. There needs to be a great investment made in the education of Indigenous children. Improving education in Indigenous communities will require expanded resources, increased numbers of experienced teachers, smaller class sizes, and better resources for children with 'special needs'.
Primary health care and specialist health services
Accessible primary health care for all Australians should be explicitly recognized as a basic human right. Health services in many rural and remote Indigenous settings are grossly inadequate. Adequate acute care, comprehensive primary health care and selected specialist health services should be a priority. How these services can be offered and improved is already known by many of the doctors, nurses, Aboriginal health workers and allied health professionals who have worked in this field for an extended period.
Build social capital: Social capital is the 'invisible net' within communities that binds people together and should not be underestimated. It is strengthened by activities that build community spirit and pride, and it is weakened by high crime, violence, excessive alcohol use, mistrust and boredom. The building of social capital may require the provision and maintenance of a few 'luxuries' (for example a swimming pool or youth centre), especially for remote communities. In general, these do not exist in remote Indigenous communities and may not be truly accessible for Indigenous people living in larger communities.
Centrality of Indigenous culture: Australia needs to invest in Indigenous culture, on Indigenous people's terms. It is important for all Australians to respect Indigenous culture and strive to safeguard this for the benefit of future generations. For all Australians, Indigenous culture is a national treasure. For Indigenous people, it is integral to their health and wellbeing.
Conclusion
Finding solutions to the poor state of Indigenous Health is a daunting task. Real gains will only follow a comprehensive plan that is shaped on a long term commitment. The plan needs to be a well-coordinated, cross-disciplinary effort that is formulated with Indigenous leaders, Indigenous communities and experts with knowledge and experience from a broad range of fields. It should adhere to key guiding principles. Broad outlines of key issues should be agreed; however, the details will need to be consolidated within individual communities. The solutions are there to be implemented; great improvements in Indigenous health can be achieved. With government will, cooperation and the right plan, the gross inequity that currently exists in Indigenous health can be overcome.
Clare Huppatz, BMBS, MPH, FRACGP
General practitioner
References
1. Trewin D, Madden R. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Belconnen, ACT: Australian Bureau of Statistics and Australian Institute of Health and Welfare, 2005.
2. Couzos S, Murray R. Aboriginal primary health care: an evidence based approach 2nd edn. South Melbourne: Oxford University Press; 2003.
3. Ring I. A 'whole of government' approach needed on Indigenous health. Australian and New Zealand Journal of Public Health 1998; 22: 639.
4. Ring IT, Wenitong, M. Interventions to halt child abuse in Aboriginal communities. eMJA Rapid Online Publication. (Online) 2007. Available: http://www.mja.com.au/public/issues/187_04_200807/rin10803_fm.html (Accessed 11 January 2007).
5. Hamlin C, Sheard S. Revolutions in public health: 1848, and 1998? BMJ 1998; 317(7158): 587-591.
6. World Health Organization. Social determinants of health: the solid facts. Denmark: WHO Regional Office for Europe; 2003.
7. Prime Minister of Australia. Joint press conference with the Hon Mal Brough, Minister for Families, Community Services and Indigenous Affairs. (Online) 2007. Available: http://www.pm.gov.au/media/Interview/2007/Interview24380.cfm (Accessed 11 January 2007).
8. Jackson LR, Ward JE. Aboriginal health: why is reconciliation necessary? Medical Journal of Australia 1999; 170(9): 37-40.
9. Green LW, Potvin L. Education, health promotion, and social and lifestyle determinants of health and disease. In: R Detels, J McEwen, R Beaglehole, H Tanaka (eds). Oxford Textbook of Public Health 4th edn. New York: Oxford University Press; 2002, 124-125.