CHAPTER 9 Indigenous health
At the completion of this chapter and with further reading, students should be able to
• Explore the concepts of colonisation in relation to Indigenous health
• Outline the impact of historical, social and political processes on the health of Indigenous people in Australia
• Discuss traditional and contemporary Indigenous healthcare knowledges and practices
• Discuss contemporary issues associated with Indigenous health and health service delivery
This chapter provides students with the knowledge and understanding to support successful health service delivery for Indigenous Australians. Key concepts that underpin the historical, social and political impacts on the health of Indigenous Australians are explored. The significance of Indigenous knowledges (see Ch 8) and practices on their own health and wellbeing is also presented alongside western knowledges and practices that inform healthcare in Australia and beyond. In this chapter students are presented with the opportunity to enhance their self-reflection knowledge and skills, particularly as they relate to working with identity and difference and diversity.
This chapter provides useful information and discussion points about factors influencing health status, related policy developments and a comparison of Indigenous and non-Indigenous health in Australia.
Mr D was an Indigenous man of 68 years from a remote Arnhem Land community in the Northern Territory. He was suffering from end stage chronic obstructive pulmonary disease (COPD) and non-metastatic prostate cancer. Mr D’s access to healthcare services was through the local Indigenous health service. He had accessed their services over a number of years since moving to the regional centre 15 years earlier. He lived only a few streets from the health service. Mr D was also under the care of the regional hospital for appointments with various specialist teams. Until he passed away he was under the care of surgical, respiratory and oncology services as well as palliative care services. He accessed the hospital regularly via ambulance for episodes of pain, shortness of breath and urinary retention or catheter blockages. In the final 12 months of his life he attended the emergency department from 2–17 times per month via ambulance; in 30% of cases he declined to wait for review before leaving the hospital. He declined admission on every occasion offered in those final 12 months. Mr D attended 9 out of 22 outpatient appointments to specialty clinics but didn’t always wait to be seen.
Mr D’s appearance was ‘unkempt’. His body and clothes were often unwashed, he was frail and towards the end he was skeletal in appearance. He had an in-dwelling catheter (IDC) in situ for urinary retention secondary to prostate cancer. His mobility was compromised due to becoming short-winded on any exertion and he was reliant on a wheelchair for mobility though independent with transfers. Mr D was referred to palliative care services from the emergency department, primarily in an attempt to better control his symptoms and reduce his presentations and requests for ambulance transfers in non-emergency situations.
Community health services first became involved at the request of the palliative care team to monitor symptoms and provide support weekly while changing his catheter bag. For unknown reasons a request to the Indigenous health service for the mobile outreach health workers to attend to this was declined. At each weekly visit it was noted that the client became irritated with health staff presence and was disengaged and eager for us to leave. At one stage his wife made a comment about the bag leaking overnight; this led to an outburst in language by the client to his wife as he became furious with her but he declined to say what was wrong to the visiting nursing staff. At this stage it was suggested that a male case manager would visit Mr D and discuss his health and what his wishes were. It was acknowledged that Mr D was obviously uncomfortable with having the catheter bag changed by the female nursing staff, but there were no males available on a regular basis to attend to this. The health staff offered to teach a more appropriate person if there was someone who was willing to do the simple procedure. After this conversation Mr D seemed easier with health staff presence on a weekly basis, though they always attended to this procedure as quickly and discreetly as possible. When the male case manager attended the house, Mr D was able to discuss his prostate cancer in simple terms. He was aware of the need and reason for the catheter and declined the recommended change to a supra-pubic catheter. The health staff were then able to document this in his notes, thus decreasing the number of interventions by the surgical team and the need for review on each presentation to emergency for problems associated with his IDC. Though the visiting case manager did not document a comprehensive cultural assessment, he did mention that Mr D found his decreased mobility and shortness of breath to be of little concern to him, but he was distressed (though not in pain) by the presence of the IDC, though he declined to say why.
Mr D’s wife was an Indigenous woman who had previously relied on him for help because of her heavy alcohol intake. She was an engaging woman who was open to assistance and suggestions by healthcare providers but would often leave Mr D alone for a few hours or a few days. She required help to access her entitlements for carer’s payment from the social worker and was thankful for help to organise regular transport to appointments. She was mostly a good support for Mr D but she was unwilling to physically assist him with his activities of daily living. Unfortunately, there was no reliable family member willing to assist in this area and all home care services had refused because of issues with safety in the house at various times.
Housing was also an issue for Mr D because while he had a ground-level two-bedroom flat in a public housing block in the city, kinship obligations (particularly for his wife) meant that there were always many people at the house. Mobility aids put in place for Mr D such as a shower chair would end up in another flat, the wheelchair was damaged and supplement drinks were consumed by others. Palliative care instigated a family meeting at Mr D’s request; however it was poorly attended by family members. The Housing Department was then contacted to move on non-residents but further family members arrived within a matter of weeks. Mr D acknowledged that his house and family had always been like this but that it was hard now that he was unwell. His situation with housing also decreased his access to services as it was considered unsafe to visit the public housing units in this complex after hours or on weekends. This meant that he was unable to have after hours nurses visit him if required.
Mr D unfortunately had developed a reputation of being non-compliant in his dealings with the healthcare services. However, on discussion there was always a reason why an appointment was not attended. The reasons included: an hour wait, the temperature of the air-conditioning and the refusal of a staff member to loan a blanket to a client. Issues such as these make it difficult for clients to feel comfortable and accepted as important within the healthcare system. For Indigenous clients they can often reinforce feelings of inferiority, disempowerment and prejudice. These feelings, together with a failure of healthcare staff to provide safe and culturally appropriate services, and the difference between the client’s world view and health beliefs and the traditional biomedical model used by healthcare providers, exacerbate an already complex and difficult communication process (Humphery et al 2001).
Mr D died after another admission via ambulance to the hospital. He declined an admission to the hospice and died in the emergency department due to respiratory failure.
Much of Mr D’s care was influenced by cultural beliefs and values of the clients and the healthcare providers involved. The non-Indigenous health staff will never fully know or understand the specific health beliefs held by Mr D or what his understanding was of his condition as he navigated the healthcare system. Much of his care was offered in a culturally inappropriate way. New catheters were inserted by female registrars; the same was true of the involvement of community health staff in the bag changes. Nowhere in his notes was there any acknowledgement of his cultural differences. This is despite knowledge in the health system of the Northern Territory that the clear gender separation in Indigenous cultures between men and women’s business is an issue that requires sensitivity (Maher 1999; Humphery et al 2001). There was an issue with an Aboriginal health worker at community health who declined repeated requests to become involved in his care though it was impossible to get a reason for this. It can be incredibly frustrating attempting to coordinate care in a system that isn’t designed to acknowledge cultural differences as a priority.
Another major issue that made best practice for Mr D almost impossible was the lack of safe and suitable accommodation where the safety of staff could be ensured while they carried out their duties. The client repeatedly commented with frustration about his accommodation but cultural obligations to kin meant it was very difficult to change his situation. The pressure on the accommodation of the increased number of residents and insufficient facilities for washing and food preparation added to the rundown nature of the property (Carson et al 2007) and to the fact that he and his family were unable to care for him according to western standards. This negatively impacted on his ability to get home care services to assist in his care.
The encounters with Mr D were not professionally or personally satisfying for the nurse primarily responsible for his care. He was consistently on the nurse’s mind as a client for whom she felt she had failed to make a difference. The attitude of other health staff who had become jaded by the healthcare system also had an effect on the care the nurse was able to offer, since workplace policy stated that she was not able to visit alone. The most problematic issue and the source of her frustration was the failure of the healthcare providers and the nurse herself to be able to connect with Mr D on any real level, or to develop a therapeutic relationship which made it possible to make any improvements to his care. Without this basis of trust, the client declined offers of support which may have succeeded in making a difference to his end-of-life quality of life, and for his wife.
This lived experience looked briefly at a client from a cultural background different to that of the mainstream health system. The client had a world view plus a lifetime of experiences that the health professionals needed to take into account when attempting to build a relationship with him. While this client is just one example, his story highlights some of the differences that arise when providing services for Indigenous clients.
The statistics of Indigenous ill health in Australia are well documented. These include rates of death three to six times of that of the general population, a life expectancy around 17 years less than that of other Australians, ubiquitous infections (particularly ear and eye diseases), and rising rates of chronic conditions. This situation has been widely criticised by many people over the years and places the Australian Federal Government in breach of a number of international conventions to which it is a signatory.
Australian governments and the public have been informed of the rates and reality of early death and widespread disability and ill health among Indigenous peoples many times. Most people are shocked by these facts and figures and governments typically promise to give the issue a high priority—although not necessarily in relation to funding allocations and meaningful strategies. These responses appear to have almost no positive impact on the situation. At best, the statistics remain the same or get worse—one of the few national Indigenous health figures that has shown significant improvement in recent decades is infant mortality. For those jurisdictions with reasonable information about Indigenous deaths in 2006–08, the highest Indigenous infant mortality rate was in the Northern Territory (13.6 per 1000 births) and the lowest in South Australia (6.4). These rates are considerably higher than those for the total population in these jurisdictions, which range from the Northern Territory (7.8) to Western Australia and South Australia (both 3.5) (Australian Indigenous Health Infonet 2011).
Morbidity and mortality figures provide information about the levels of people’s ill health and what diseases they suffer from. However, to focus on diseases or on their immediate associate risk factors only will, at best, have a marginal effect on health status and will not address the complexities. To get a better picture, it is necessary to consider not only the links between various health problems, direct causative factors and underlying factors, but also to view the whole situation as a social justice issue.
In addition, health professionals need to recognise and understand the influence of culture and world views on the value systems and decision-making processes of Indigenous peoples.
Key issues to address in relation to Indigenous health include power, governance and control of decision-making processes in general and, more specifically, appropriate strategies for facilitating social change which result in improved health outcomes.
Unfortunately, lack of progress has all too often been the norm, with sickness perceived as a way of life for Indigenous peoples. The notion that nothing can be done, that the problem is insoluble, becomes entrenched in the minds of both Indigenous and non-Indigenous Australians. The everyday human cost is not felt or understood in any meaningful way by the wider public, and lack of hope for a healthier future for Indigenous peoples becomes pervasive. This demoralising powerlessness and cumulative stress are two of the major contributors to the health problems Indigenous peoples suffer.
Yet among the numerous reports and analyses of the issues there are many common conclusions and suggestions for positive ways forward. These include:
• The importance of a primary healthcare approach
• The need for preventative rather than solely curative measures
• Stepping back and genuinely supporting Indigenous people as they determine how to identify and implement and evaluate their own solutions
• That it is as much a social and political issue as it is a biomedical one, and that this dictates a holistic approach involving all aspects of community development and self-determination for Indigenous people.
Of course, the obvious question is—if there is indeed widespread agreement about all these things, why then does so little seem to change, and what will it take to move the rhetoric into reality?
If progress in Indigenous health was measured by the number of press releases, special projects, glossy posters or by the number of pamphlets (in English) exhorting Indigenous people to eat more fruit or clean their houses or brush their teeth, there would be little to worry about.
Health to Indigenous people determines all aspects of their life, including control over their physical environment, their dignity and community self-esteem and access to justice. It is not merely the provision of doctors, hospitals and medicines, or the absence of disease and incapacity. Health is a multidimensional concept that embraces all aspects of living and stresses the importance of survival in harmony with the environment.
According to Indigenous world views, when factors that influence social wellbeing and harmony with groups are maintained, people are healthy. However, when social, emotional and cultural wellbeing is disrupted, ill health results. Indigenous spirituality was, and still is, essentially land centred. While this broad definition of health is emphasised by Indigenous peoples in different ways, they generally know and believe that health cannot be disassociated from self-determination, land rights and cultural vitality; and it cannot be neatly divided into wellness and illness or mental and physical aspects.
Indigenous health and the factors affecting it are complex and most Indigenous peoples are disadvantaged, or vulnerable in some way. They often share many of the negative characteristics of other disadvantaged or vulnerable groups, including poverty, poor education and training, low paid jobs, high rates of unemployment, substandard housing and ill health. However, they have also had to endure the history of Indigenous and non-Indigenous contact and deal with the pain of racial prejudice and the reality of discrimination, evident in marginalisation and social dysfunction.
The legacies of past policies live on in the present day, in people’s experiences, attitudes, values and perceptions. It is not possible to understand Indigenous health without setting it in a historical perspective. This topic is also explored more broadly in Chapter 8 in the section on world views and health.
Although little information exists about Indigenous health before colonisation, there are indicators that their health was good. The social organisation based on kinship through ties with the land provided an effective psychological network which was conducive to human health and wellbeing. In relation to physical wellbeing, the predominantly hunter–gatherer lifestyle dictated frequent exercise, which minimised the risk of obesity and associated health problems. In addition, the environment provided a wide range of naturally occurring plants and a great diversity of animal life. This allowed for a well-balanced, nutritious diet of protein and plant foods, high in fibre and low in salt, sugars and fats. The actual composition of the diet was dictated by regional and seasonal variations in the availability of food.
Groups were also spread out over the continent and this mitigated against the spread of disease. Hygiene was not a problem and diseases specific to Indigenous peoples appear to have been few. Dental disease was relatively rare. The common cold, yaws and some skin diseases were probably endemic. Trachoma may also have been present. Indigenous peoples developed a very extensive and effective pharmacopoeia, commonly known as bush medicine.
While the context for this chapter is Indigenous Australia, it is worth noting that many other colonised countries have similar histories and numerous Indigenous peoples suffer similar effects as a result of colonial settlement patterns and policies. Most, if not all, contemporary health problems in Indigenous Australian and in Māori communities are the direct result of the huge and often catastrophic changes resulting from invasion, dispossession and colonisation.
The effects of colonisation include:
• Loss of traditional food sources and lifestyles
• Separation of children from their families
• Inadequate and inappropriate health, welfare and education services
• Enforced establishment of dislocated, socially dysfunctional, under-resourced communities based on dominant paradigms of settlement and planning.
The above-mentioned points about the effect of colonisation are supported by the Public Health Association of Australia’s 2010 policy statement on Indigenous health:
• The legacy of dispossession of country has a continuing impact on the economic, spiritual and cultural life of Indigenous people.
• One of the manifestations of the dispossession and alienation of Indigenous people has been the over-representation of Indigenous people in police apprehensions, court appearances, incarceration and deaths in custody. This over-representation in the legal system, coupled with other racially discriminatory practices (both covert and overt), is part of a negative feedback dynamic which continues to reproduce the conditions for poor health among Indigenous communities.
• The emotional trauma and grief stemming from the systematic abductions of Indigenous children has a continuing impact on the family, community and spiritual resources of Indigenous people.
• The denial of family and culture implicit in the practice of removing children is a contributing factor in the excessively high rates of incarceration of Indigenous juveniles and the continuing court-sanctioned removal of children from their families. This cycle contributes to the conditions for continuing poor health at the community level as well as creating a new generation of stolen children.
• The causes of the persisting poor state of Indigenous health are complicated but the continuing consequences of the colonial experience constitute an important dynamic in reproducing this poor health status.
• Improving the health status of Indigenous people, especially high young adult mortality, cannot be achieved simply through technical interventions but also requires a strengthening of family, community action, economic development and spiritual healing. Poor educational outcomes among Indigenous people, with illiteracy rates increasing in some jurisdictions, are a major barrier to better health.
• Community controlled health services and other community controlled organisations are the main community development vehicles through which Indigenous communities are working together for better health and from which they can build effective partnerships with mainstream institutions and practitioners (PHAA 2010).
From the beginning of European occupation, Indigenous peoples were subjected to pressures that had disastrous consequences for their health and severely decimated the population. This drastic reduction in numbers resulted, in part, from the devastating effect of introduced disease to which Indigenous peoples had no immunity. These diseases include smallpox, measles, tuberculosis and influenza. Violence was another major factor responsible for population reduction.
The ramifications of the historical events highlight the fact that the enforced change from the ‘hunter–gatherer’ way of life to an impoverished way of life has had disastrous consequences for both the physical and the psychological health and wellbeing of Indigenous peoples. In particular, the dramatic change in diet and nutrition cannot be stressed too strongly. With inadequate nutrition and living in appallingly unhygienic and overcrowded conditions, Indigenous peoples became susceptible to all manner of illness to which they had not previously been vulnerable.
In addition, since colonisation Indigenous peoples have been subject to non-Indigenous medicine and services. The services have largely failed to recognise the cultural basis of Indigenous traditional healthcare and that the problems they faced are largely of public health origin, a result of unsatisfactory living conditions.
The health status of Indigenous populations is worse than that of the general population on all criteria. Children’s health continues to reflect a Third World or developing country’s pattern of disease, while the health of adults demonstrates the influence of western culture on diet and lifestyle (Australian Medical Association 2008:3).
In response to this situation, the PHAA 2010 Aboriginal and Torres Strait Islander Health Policy included the following key points:
• The causes of the persisting poor state of Indigenous health are complicated but the continuing consequences of the colonial experience constitute an important dynamic in reproducing this poor health status.
• Improving the health status of Indigenous people, especially high young adult mortality, cannot be achieved simply through technical interventions but also requires a strengthening of family, community action, economic development and spiritual healing.
• Poor educational outcomes among Indigenous people, with illiteracy rates increasing in some jurisdictions, are a major barrier to better health.
Community controlled health services and other community controlled organisations are the main community development vehicles through which Indigenous communities are working together for better health and from which they can build effective partnerships with mainstream institutions and practitioners.
Here we cover briefly aspects of the role of the social determinants of health, with particular regard to the premises that land and culture are integral to Indigenous health and that colonisation was detrimental to health. There is a growing recognition of the social determinants of health, particularly at an international level. The debate places emphasis on human rights and the need to build an evidence base for the social determinants of health through research. In 2004 the World Health Organization (WHO) established a Commission on the Social Determinants of Health and, as the late Dr Lee Jong-Wook (then Director General of WHO) noted:
The goal is not an academic exercise, but to marshal scientific evidence as a lever for policy change—aiming towards practical uptake among policy makers and stakeholders in our countries (cited in Anderson et al 2007).
This type of action is not just about developing an understanding of the social determinants of Indigenous health, but is also about identification of which policies and interventions are likely to have a positive and sustainable impact on Indigenous health.
The living environment shapes behaviour for everyone and colonial settlement has created a number of infrastructure problems which have become a major cause of social discord and ill health. These problems include:
• Infrastructure is historically inappropriate, inadequate and inadequately maintained
• Layout of roads and housing reflects European service delivery norms rather than Indigenous sociocultural perspectives
• Housing is designed for European nuclear family rather than Indigenous kinship groups
• Houses are overcrowded, not because more housing is needed but because the whole concept of housing needs to be revised.
In Indigenous society an individual may move between different houses for various reasons, including:
The nuclear family and urban-style housing are western concepts that do not fit the reality of most Indigenous social organisation. Some of the ramifications of this difference are:
• Social patterns result in alternately empty and overcrowded houses
In this situation, houses and people’s living environments obviously become health hazards.
Indigenous peoples’ living environments often reflect and reinforce their disempowerment. Self-determination or Indigenous governance should be a major factor when addressing these issues. Indigenous communities should be designing their own physical environments—rather than the standard top-down consultation models of housing design and settlement planning that have created and perpetuate these problems.
Indigenous communities are also constantly dealing with the tension between creating sustainable and appropriate economic opportunities and conflicts about depletion of their resources and the environmental consequences. Mining, tourism, fishing and wildlife harvesting are some of the activities that can create such tensions.
Many of these issues threaten not only Indigenous peoples’ physical environment but also spiritual frameworks. The homeland movement or outstation communities is one way that Indigenous people are trying to cope with these problems and regain control of their own spaces. Outstations have been well established across the Northern Territory since the late 1960s, reinforced by the Aboriginal Land Rights (Northern Territory) Act in 1976.
Outstations have had the potential, and provide one option, to resolve many of the problems of ill health associated with European-style settlement communities. They are ideally based on the integration of useful non-Indigenous technology with Indigenous cultural values and lifestyles. A common myth is that outstations are about turning the clock back 200 years but Indigenous cultures, like all cultures, are dynamic, constantly transforming and adapting. Items such as cars, rifles, aeroplanes, hospitals, telephones, computers and mobile phones are part of contemporary Indigenous cultures. These are useful technologies, often essential in terms of survival.
However, there is a lack of government understanding of their role in and responsibility for outstations. A lack of real support for outstations results in service, access, transport and communication disadvantages becoming an inherent part of outstation life.
Responsibility for outstations is usually delegated to a resource centre in the nearest community. There are associated problems with funding allocations to these centres—a result of bureaucratic, top-down structures. These issues limit real self-determination, even in outstation communities. Regional agreements may resolve some of these problems by decentralising power structures and allowing for funding flexibility.
Indigenous peoples in urban areas often have problems associated with urban settlement and planning. A study by the University of Tasmania found that nearly one-third of the country’s Indigenous population lives in major cities, while 75% are based in regional or urban areas (Atkinson 2008).
There is an increasing body of literature that relates to urban Indigenous communities. Prominent Indigenous lawyer Professor Larissa Behrendt states:
There are some tenacious stereotypes about Aboriginal people in urban areas like Sydney. I often get asked, ‘How often to you visit Aboriginal communities?’ And I reply, ‘Every day, when I go home.’ The question reveals the popular misconceptions that ‘real’ Aboriginal communities only exist in rural and remote areas. And it is a reminder of how invisible our communities are to the people who live and work side-by-side with us … [These urban communities] are just as strong here as they are in more discrete rural and remote areas. And it is an aspect of contemporary Indigenous culture that kinship and family ties bind our communities in a way that reinforces our more traditional obligations but interweave more widely than they once did (Behrendt 2010).
Poorer levels of health and distinct health issues, lower life expectancy and higher mortality rates, lower levels of education, higher levels of unemployment and large and increasing levels of over-representation of Indigenous peoples in the criminal justice system are all dimensions of the unique needs and circumstances of Aboriginal people in urban areas (Australian Productivity Commission 2006, cited in Behrendt 2010).
State and Federal governments have put a lot of emphasis over the years on improving health and life expectancy in remote Indigenous communities. However, research shows that the standard of health in Australia’s largest urban Indigenous communities is generally no better than in rural and remote communities, and life expectancy is about the same. The National Aboriginal Community Controlled Health Organisation (NACCHO) (2001) stated in their submission to the Commonwealth Parliamentary Inquiry into the Needs of Urban Dwelling Aboriginal and Torres Strait Islander Peoples that there is often a misconception among policymakers and indeed, the general public, that efforts should be directed at Indigenous peoples in remote areas only, as Indigenous peoples in urban areas are not seen as having the same level of health challenges and unmet need.
Indigenous peoples in all areas experience similarly poor health status. The morbidity and mortality rates experienced by Indigenous peoples living in urban areas are far closer to those for Indigenous people living in remote areas than they are to those for non-Indigenous peoples in any area. This is not surprising, given the key underlying factors of this poor health status, as discussed earlier. Many Indigenous peoples in urban areas experience ongoing effects of colonisation, dispossession, racism and isolation, just as their counterparts in remote areas often do.
It is also thought by some that a lack of services or access to services in remote areas is the major issue impacting on Indigenous health, and that because there are more doctors, pharmacies, hospitals and so on in urban areas, urban Indigenous people do not experience barriers to access to healthcare. Again, this is a grave misconception. The fact that mainstream services exist in urban areas does not mean that they are appropriate or accessible to Indigenous peoples. Indeed the evidence shows that there is a range of financial, cultural and other barriers to Indigenous peoples in all areas accessing mainstream services.
The overwhelming conclusion to be drawn from the evidence is that Indigenous peoples in urban, rural and remote areas are in need of positive measures to address the disadvantage they face. Access to appropriate healthcare services is but one of these measures (NACCHO 2001).
The policy timeline from the Australian Indigenous Health Infonet illustrates some of the major developments in Indigenous affairs as well as the numerous Indigenous health policies, strategies, reports and inquiries that have occurred over the last 40 or so years (Australian Indigenous Health InfoNet 2010). It is not enough to simply quote the appalling Indigenous health statistics, as that does not appear to make an impact. The problem lies mainly in bureaucratic inertia and the lack of political will to make positive change happen.
As is the case with policies and programs in Australia generally, those specific to Indigenous health at any given point in history have very much been influenced by the dominant political ideology of the government of the time. At the same time, government practice has been influenced by the struggles of Indigenous people for rights and for control of their lives and decision-making processes.
Most of the improvements in health services for Indigenous Australians are the result of political pressure and actions taken by Indigenous organisations and related groups working to change the dominant political ideology and practice. Government policies on Indigenous issues have, to a greater or lesser extent, supported and often exacerbated the process of colonisation.
Australian government policies aimed at Indigenous affairs have always been focused on changing Indigenous society rather than on structural changes within the dominant non-Indigenous society.
Non-Indigenous perspectives of ‘the Indigenous problem’ have shaped political attitudes towards Indigenous health, whereas from an Indigenous community perspective, health problems are mostly a direct result of colonisation. The mismatch or juxtaposition of these differing and conflicting viewpoints is reflected in the high levels of frustration and prejudice in both groups.
At this point, it is worth examining or reviewing the connections between health and politics in order to understand the present state of Indigenous health in Australia. As Bennett (1989) states so pertinently:
Aborigines have been at the mercy of officials since arrival of the First Fleet. For many years various ‘Protection’ Boards organised them, settlement managers bullied them, the police took away their children if they were deemed to be at risk, or less than ‘full blood’ (itself a bureaucratic means of classification)—all in the period when Aboriginal rights received little notice from governments. In the years since World War II, and particularly since the 1960s, Commonwealth and State governments have shown much more awareness of indigenous needs, many programmes of help and support have been established, and there are many more public servants with a sound knowledge of their Aboriginal clients and their needs. Despite this change in attitude and approach, however, Aborigines still have to cope with the bureaucratic restrictions.
The impact of politics and policymakers on Indigenous health can be seen in specific areas including health service delivery. An examination of the development of Indigenous health policy highlights an entrenched problem, the complexities of which include the nature of modern bureaucracies, politicians’ actions and agendas, the attitudes of the general non-Indigenous public, and the perceptions and expectations of the Indigenous clients themselves.
Fesler (cited in Bennett 1999:131–2), has identified six possible barriers to successful policy implementation. These are:
The framework of health policy in Australia has been broadly shaped by certain cultural assumptions in society, by the power of groups such as the medical profession and by the policy goals of successive governments.
The result is a structure, which is more egalitarian than that in the USA and one that offers more choice than that of the UK, but which continues to be a contested site for political struggles and social inequality. According to Sargeant et al (1997), sociologists and anthropologists have typically viewed social, economic and cultural factors as producing vulnerability in certain groups. This vulnerability stems from the positioning of these groups in relation to dominant groups, thus reducing both their access to the benefits of and their opportunities for full participation in the society. This perspective points to the need for structural and societal change, rather than an approach that ‘blames the victim’ or the individual. Prevention or alleviation of problems comes through community development and health promotion rather than relying solely on clinical intervention—that is, on treatment of diseases only.
Governments typically seem to be more interested in restraining public expenditure than in improving public health in any sustainable way. Therefore, certain groups such as Indigenous peoples can all too often experience considerable difficulty in negotiating the health system.
As mentioned, since 1788 Indigenous peoples have had control of their health and wellbeing progressively eroded. Colonisation caused significant destruction of traditional means to achieve good nutrition, healthcare and a functional lifestyle. Politicians, administrators and, historically, missions largely determined the place of living, hygiene measures, water supply, diet, education and housing for Indigenous peoples (see Clinical Interest Box 9.1).
CLINICAL INTEREST BOX 9.1 The impact of the protection and segregation policy era
In the early part of the twentieth century, it was assumed by many colonists that the Indigenous peoples were a ‘dying race’. It was commonly believed that Indigenous peoples as a ‘lesser race’ would succumb to the ‘superior strength’ of the non-Indigenous population. The first missions were mainly established to ‘smooth the pillow’ of the dying race, and ensure their salvation in heaven. The first mission in north Australia was established by the Christian Missionary Society on the Roper River (now Ngukurr community) in 1908. Many others followed this mission and the experiences of Indigenous peoples in the missions varied widely, depending on the religion of the missionaries and the beliefs that they held about the Indigenous people. Broome (1994) provides a history of the missions, and the influences (both positive and negative) that the missions had on Indigenous life. It provides a useful introduction to the ambiguity that is inherent in Indigenous peoples’ relationship with the missions.
When it was clear that the Indigenous peoples were not dying out, the aims of the missionaries changed from ensuring salvation after death through converting people to Christianity, to changing their way of life. Reverend Long said of the Arnhem Land Missions that their aim was to ‘… take them away from their hunting stage of culture, where they can live happily in village communities and produce their own food supply’ (Revd RCM Long, 1939, cited in Cole, 1985:75).
The missionaries attempted to achieve this by controlling and regulating people’s daily lives as described by Bern (2000):
On Roper Mission this policy was pursued by controlling the greatest part of the inmates’ lives. Children were separated from their parents, placed in sex-segregated, missionary supervised dormitories, and educated in English by Missionary teachers. Infant betrothal, polygamy and ritual were discouraged and acceptance into the congregation dependent on the abandonment of these practices. Industriousness and cleanliness were two values on which the Mission placed great emphasis.
Mission staff tended to focus predominantly on monitoring the cleanliness of the children and the state of houses. They provided some sort of food. People could not easily make choices about healthy lifestyles; they generally did what they were told to do, under threat of punishment from mission staff. In her ethnography on health beliefs, Senior (2000) commented that the missions had two important long-term effects on peoples’ health behaviours. One response was resistance to all practices that were associated with the missionaries, such as keeping a house clean. The other was reluctance by the Indigenous peoples to take responsibility for their own health because, as with most other aspects of daily life, the missions had assumed this responsibility.
By the late 1960s, the mission’s direct control of communities diminished as the Commonwealth Government took over much of the administration. Missionary influence, however, remains strong in many areas. McDonald (2001) described the situation in Halls Creek, which historically was strongly influenced by two groups of missionaries, the United Aborigines Mission, a fundamentalist Christian organisation, and the Assemblies of God, an American Pentecostal organisation. A local man from Halls Creek, Paddy Jarra, told his version of history and the specific events of colonialism, seen through the lens of the teachings of these religions which at the time preached that Aboriginality was a degenerative state and the only way to overcome this is to become a Christian: ‘When you become a Christian, you become white on the inside’ (McDonald 2001:87).
However, the mission era was a complex story and was not a case of all ‘missionaries bad’ as many missions were genuinely set up to provide protection for Indigenous peoples from the settlers. Overall, the main impacts of the enforced segregation included loss of power and control over decision-making processes, forced removal of children from their families, meagre rations, poor living conditions and the banning of most cultural practices. These practices of course had catastrophic effects on Indigenous health and most of the policies now in place are attempting to deal with this legacy.
As a result, many Indigenous peoples are in a situation or cycle from which there appears to be no straightforward way out. They require a great deal of government assistance to (at least) survive the disadvantageous social position in which they exist. Yet as Bennett states: ‘the programmes established to help them often do little more than retain the constraints that have restricted them for so long’ (1999:153).
As Mitchell (2006:61) states ‘Indigenous poor health is historical, cultural and political in character: it both results from and serves to perpetuate two centuries of colonial inequality and justice’.
So, in Indigenous health we find the medicalisation and politicisation of social issues.
The bottom line is that, whatever happens, Indigenous peoples must be encouraged and supported to regain and retain control over their own health and lifestyle. This in turn means significant structural changes at all levels of policy and programming.
Smith (2007) provides a detailed policy timeline 1967–2007 that describes some of the major affairs affecting Indigenous peoples nationally, including numerous health policies, strategies, reports and inquiries that have occurred in the 40-year period since the 1967 referendum. The timeline clearly demonstrated that despite the huge amount of data, reports and government inquiries conducted, the resulting health outcomes show little improvement in the overall health status of Indigenous peoples during that time.
In the Aboriginal and Social Justice Commissioner’s Social Justice Report 2005, Tom Calma talked about the poor state of Indigenous health and health inequality (when compared to the non-Indigenous population) and the right to health. In the report he argued that human rights, and specifically the right to health, ought to be guiding the development of policy and the delivery of programs to Indigenous peoples. Then in the Menzies School of Health Research Oration of 2007, Mr Calma expanded on this: he stated that in the 18 months since that report was released, it had received extensive coverage and discussion nationally and internationally. It had, for example, been cited as world’s best practice in developing a scheme for implementing the right to health by the United Nations Special Rapporteur on Health, as well as being of considerable interest to WHO and other UN agencies. The reason for this response is because it is one of the first comprehensive attempts to apply the right to health to the situation of Indigenous peoples.
A human rights approach would recognise the link between health status and systemic discrimination, address the issue of how to ensure meaningful commitment from governments, address Indigenous health in a holistic manner that reflects the social determinants of health inequality and build upon the opportunities and challenges of applying the whole-of-government approach to Indigenous health in Australia (Smith 2007: 46).
For historical reasons, responsibility for policy affecting Indigenous Australians has been divided between Commonwealth and State governments. Even now, there is inadequate national data on Indigenous health, and policymakers must take account of the variations in culture and social position of Indigenous peoples in different states and in urban or rural areas.
Traditionally in Indigenous societies, health indicated harmony of body, spirit and the environment, with knowledges handed down through the generations primarily via ceremonial means. Since the early 1970s, Indigenous communities have actively demanded more appropriate health services. From 1972 on, Commonwealth Government policy has been to support the training of Aboriginal health workers and the involvement of communities in planning and controlling services in an effort to reintegrate the traditional and the modern. This has not always been successful, but Indigenous communities have generally seized whatever opportunities come their way and made the most of them.
As McLennan said in her doctoral thesis (2009):
The alarming rate of ill-health and social disadvantage amongst Australian Indigenous peoples has continued despite improved understanding of the determinants behind these conditions. There appears to be an urgent need to review and re-orientate health and social programs, from a deficit-focused to a strengths-based model, whereby a community’s capacity and resilience is enhanced utilising, and building on, existing strengths and resources.
McLennan wrote of the need for more research to investigate the meaning and role of resilience in the wellbeing of Indigenous Australians. The aim of her study was to examine resilience within an Indigenous context, its potential role in strengthening the Indigenous response to adversity and the prospective ways in which this might be used in initiatives aimed at boosting health and wellbeing in Indigenous communities.
Across the range of health professional disciplines there is a similarity in relation to workforce issues. These include shortages, difficulty in recruiting and lack of locum relief and professional development opportunities and overall ageing of the workforce; all of which are exacerbated with geographical remoteness. Needless to say, the diversity and inequities in the Australian health system are reflected in the health workforce, with the Aboriginal health workers being the most marginalised and the medical profession being the most favoured.
Therefore as Smith (2007) asserts ‘the education of the … health workforce offers unique challenges’.
What is required is a continuum of education programs from secondary school right through to postgraduate and professional development programs of integrated curriculum frameworks underpinned by key concepts including working cross-culturally and the provision of relevant practical experiences.
These programs should be supported by nationally coordinated policies and initiatives and should focus most particularly on the needs of Aboriginal health workers.
Not only does the health system need reorienting and resources need reallocating, but the health workforce needs to be similarly balanced in order to meet the needs of the population (see Clinical Interest Box 9.2).
CLINICAL INTEREST BOX 9.2 NT National Emergency Response legislation and intervention
One of the recent and most controversial in the long line of policies aimed directly at Indigenous peoples was the Federal Government’s National Emergency Response (the Intervention) into child abuse in Northern Territory Indigenous communities. The Intervention attempted to confront the (real and acute) problem of child abuse by using a legal and ‘tough love’ policy approach.
However, as well as the emergency response, sustainable solutions are needed to deal with the broader health and social issues that underpin child abuse, and these solutions need to match the longer term aspirations of Indigenous peoples. The abuse of children cannot be dealt with effectively without also addressing the related social determinants of health issues. And these cannot be dealt with effectively without the full engagement of Indigenous communities. If the Federal Government continues to largely ignore the ongoing impact of colonisation (poor self-esteem, widespread lack of cultural strength, paucity of meaningful activities in communities, to name but a few), then the record of effective government health initiatives will remain bleak (Ring & Wenitong 2007:204–5).
However, the reality for many Indigenous primary healthcare services is that they feel overwhelmed with acute care demand. And being able to access an appropriate and competent health professional is also a key, legitimate demand of Indigenous communities.
This chapter looked at the effects that colonisation has had, and continues to have, on the health of Indigenous communities. It is widely accepted that before the non-Indigenous colonisation of Australia, Indigenous populations lived an integrated and balanced lifestyle. Knowledge of good nutrition was embedded in Indigenous ways of life and with that was access to a range of appropriate seasonal foods. Small population groups provided considerable protection from infectious or communicable diseases as people lived in mobile family groups. Mobility meant moving within prescribed areas to different places on land or ‘country’. This was in keeping with the seasons and the associated spiritual significance of particular places.
Colonisation by a non-Indigenous population brought about widespread and irreversible changes to Indigenous ways of life. The links between the health of Indigenous Australians, colonisation, disempowerment and the significant historical events occurring during the colonisation of Australia are briefly explored in this chapter. In addition, there is also a brief overview of the impact of specific policy outcomes.
This chapter is by no means a definitive view of Indigenous health in Australia. It is a snapshot of some of the many complexities that frame the lives of Indigenous peoples and those who work with them in trying the ‘close the gap’.
1. Comment on why an understanding of the history of Indigenous health policy is necessary in order to improve efforts to address specific Indigenous health challenges.
2. Comment on the notion that Indigenous families are a significant source of strength in Indigenous communities despite the impact and negative effects of colonisation.
References and Recommended Reading
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