Michael Gracey

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. (more…)

By most recognised markers of socio-economic status, Indigenous Australians fare badly compared with their non-Indigenous counterparts. This is certainly the case where health standards are concerned. For example, rates of infections and hospitalisation for these and many other illnesses are much higher; chronic diseases like heart disease, stroke and diabetes are more prevalent; and hearing loss and blindness rates are increased as are a multitude of other disabilities. Illnesses and deaths linked to alcohol and drug abuse, and accidents and violence are more frequent, as are disorders associated with psychosocial stress. Death rates are increased across the life span and Indigenous people tend to die younger and have a life expectancy which is somewhere between 10 and 17 years shorter than that of other Australians. The statistics are stark and this situation represents one of Australia’s worst embarrassments internationally.

But we need to understand how this situation evolved, what has and is being done about it, and whether these inequities in health and wellbeing are being corrected. It may come as a surprise to readers aged below 50 to realise that the divide between health standards among Indigenous and other Australians became generally recognised and acknowledged only within their lifetimes. The earliest reliable reports about poor Aboriginal health appeared in the mid-1960s after it was recognised that Aboriginal infants had very high rates of gastroenteritis, malnutrition and high death rates and that the life expectancy of Aboriginal people was much shorter than for other Australians. When the media reported these findings there was a public outcry and a quick but poorly organised political response was provoked to try to fix the problem. By then this was labelled the “Aboriginal Health Problem”.

The late 1960s and early 70s brought many rapid changes into the lives of Indigenous Australians. These included: the 1967 Referendum which allowed the federal parliament to enact laws relating to Indigenous people and to include them, for the first time, in the national census; the federal court decision to grant “equal pay for equal work” for Indigenous workers; the establishment in Sydney of Australia’s first Aboriginal Medical Service in 1971; the gradual relaxation of restrictions on access to alcohol by Indigenous adults; and a rapid shift of Aboriginal people in rural and remote areas into towns and their fringes. In 1979 a federal parliamentary committee acknowledged the poor standards of Indigenous health and identified their root causes as being in deprived socio-economic circumstances and sub-standard living conditions. By that stage almost two centuries of marginalised living and social exclusion had reduced the original inhabitants to being an under-class in Australian society; the late Professor Rowley called them “Outcasts in White Australia”. This group of people by then had an entrenched core of ill-health, chronic disease and premature deaths which would be extremely difficult to correct.

The social determinants underlying the patterns of ill health that affect Indigenous Australians must be addressed before significant and sustained improvements in health and wellbeing will occur. These contributing factors include poverty, overcrowding, unhygienic living conditions, low education standards, under-employment, social stigmatisation and marginalisation, disengagement from mainstream society, and their inadequate participation in decision-making processes which affect health and wellbeing. It must be appreciated, also, that some of the factors which have strong negative impacts on Indigenous health are trans-generational. For example, prenatal under-nutrition and impaired growth can adversely affect pregnancy outcomes over multiple generations; this means that those negative effects may take 50 years or more to be eliminated.

In 2005 Tom Calma, then Aboriginal and Torres Strait Islander Social Justice Commissioner, released a report which called on Australian governments to commit to achieving equality for Indigenous Australians in health and life expectancy within 25 years. The Federal Government then made a formal Statement of Intent in 2008 to ensure that Indigenous people would have ”equal life choices”. The target date of 2030 was set for the various goals to be reached. This ambitious strategy and program was warmly received but within a year it was being questioned whether the targets were achievable in the time allotted; in particular, the goal of removing the life expectancy gap between Indigenous and non-Indigenous people was considered to be “probably unattainable” (https://www.mja.com.au/system/files/issues/190_10_180509/hoy11300_fm.pdf . These reservations were soundly based. By then there were many thousands of Indigenous people with long-standing chronic diseases like diabetes, chronic respiratory and cardiovascular diseases, late-stage kidney failure, irreversible visual and hearing loss and a range of other permanent disabilities. Added to that formidable burden was the increasingly heavy load of illnesses, social and stress-related disorders, and premature deaths associated with cigarette smoking, alcohol and drug abuse, in Indigenous people as well as those linked to accidents and violence. Quite clearly this wide-ranging and massive range of illnesses, disabilities and premature deaths would have no simple, single solution as, for example, could be applied to successfully control or prevent an infectious disease outbreak by a community-wide immunisation program.

Yet, despite the timely and nationally published cautionary advice cited above, the Close the Gap Strategy and program continued. Each year a formal report has been released in parliament outlining progress towards the stated targets. There have been some improvements in Indigenous health over the past decade or so but it is difficult to attribute them to this strategy alone. For example, improved pregnancy outcomes such as heavier birth weights, suppression of childhood infections by immunisation, and lowered infant and maternal mortality, were achieved largely by other programs based on sound public health principles; that work began well before the Close the Gap initiative began. Annual report cards have mostly shown what is often officially called “mixed outcomes” – this usually means that the reporting agencies and their bureaucrats could find little that would attract a favourable headline in the press. This is disappointing because most Australians, black and white, want to see Indigenous people share the high levels of health which most of us take for granted. These mixed results in health, wellbeing, living standards, education, employment and productivity among Indigenous people have left them feeling let down. When the seventh annual Close the Gap report was presented by Prime Minister Abbott in February 2015 he acknowledged that the results were “bitterly disappointing”. Why didn’t he grab the nettle then, acknowledge that the strategy was failing, indicate that it had been introduced by former Prime Minister Rudd, and then ditch the policy and start again? That opportunity was lost and yet another year passed until the next Prime Minister, Turnbull, reported this month that the results of the eighth annual report were “mixed”.

One of the key targets of the Close the Gap program all along has been to equalise the life expectancy of Indigenous and other Australians. However, the 2016 report acknowledged that the improvements that have occurred so far are not happening fast enough for that target to be reached within the next 20 years. Even in some instances where improvements seem to have been encouraging, closer scrutiny of the details exposes otherwise hidden obstructions. Take infant mortality rates for example. While the rates of Indigenous children dying in their first 12 months of life have dropped substantially over the past 15 years, the rates among non-Indigenous infants have also been dropping. When the relative rates, that is Indigenous compared with non-Indigenous rates, are examined it is evident that Indigenous infants are dying at about double the rate of other infants before their first birthday. Prime Minister Turnbull conceded that achieving the target to close the life expectancy gap by 2030 remains “a significant challenge” (ABC News item, 10 February 2016). Regrettably, other aspects of the 2016 Close the Gap report which have significant impacts on health were also disappointing; they include educational attainments, employment rates and housing standards.

Repeated and protracted disappointments like these leave people feeling angry and frustrated, particularly the Indigenous community who have so much at stake for themselves and their future generations. Nationally prominent Indigenous leaders like Patrick Dodson have said recently that the Closing the Gap initiative is doomed to failure unless it is radically reformed. He added that the Prime Minister has not yet put his stamp on Indigenous affairs and has not paid sufficient attention to these issues.

Resolving the inequities in health between Indigenous and other citizens must be done with an all-inclusive approach to all of the inter-related issues that are involved. Providing better and more accessible and appropriate health and disease care can only be part of the solution. Strategies and programs that are aimed at promoting and improving wellness as well as treating illness must be given more prominence in the clinical approaches towards better Indigenous health outcomes. A crushing disappointment for clinical carers of all types who work in this field has been to see the substantial improvements in health which have occurred over recent years, much of it in children, be undermined by high-risk attitudes and behaviours in later life which result in preventable premature deaths. Examples are the serious illnesses and deaths due to tobacco smoking, physical and mental damage and deaths from alcohol abuse and other addictive drugs, vehicle accidents and other forms of violence, and the long-term consequences of overweight and obesity including diabetes and cardiovascular disease. The gains that have been made in reducing infant and young child deaths should lead to improved life expectancy but this is being thwarted by the continuing wastage of lives in adolescence and early and mid-adult life. Much of this wastage is preventable. This is where responsibility for personal, family and community-based health must become part of the equation. Indigenous acceptance of responsibility and participation must become an essential element of this process in order for real progress to occur.

A recurring theme in the continuing debate about trying to achieve equity in health and wellbeing between Indigenous and other Australians is the need for increased participation of Indigenous people in the activities and social circumstances which affect them. Not only is there a place for enhanced Indigenous involvement in these issues, there is a real need for this to happen. Examining the way health and clinical services are currently provided to Indigenous people shows that three main sectors are involved:

• federal and state government services
• the specially developed and independently-run Indigenous Medical or Health Services, and
• private or other non-government providers of clinical and related services

If these three sectors had been working cooperatively and effectively over the past thirty or more years, Indigenous health should not be in its present sorry state. Despite past failures there is still goodwill among the wider Australian community to see that this situation is corrected. I have previously called for a fourth sector to be organised to help bring this about (Refer to earlier Gracey blog on ‘What is need to fix Aboriginal health?’ here). This new sector would be established as a community-based organisation representing ‘grass roots’ Indigenous people who are currently sidelined from the process of policy development and making decisions about running programs at the community level to suit their own needs and aspirations. Adding this new dimension would show at last that local Indigenous communities have a real contribution to make in the health improvement process. This is not being achieved by regional Indigenous Medical or Health services although they claim to be ‘community-controlled’. In fact, members of local Indigenous communities have very little or no say in the selection of such regional bodies; in effect they are voiceless. The emergence of this fourth dimension would demonstrate that local communities and their members are prepared to accept this responsibility to contribute to planning and delivering health care for their own people. Such a development should help answer the repeated calls by Indigenous leaders from different parts of Australia for their people to play a bigger role in improving health and wellbeing of the Indigenous population.

It is time for the issues surrounding Indigenous health to be thoroughly and objectively reviewed. This would help to ensure that the mistakes of the past are not repeated and perpetuated. Australia must be able to do better. The health needs of Indigenous people are, indeed, more demanding than for other Australians. But more funds, more doctors, nurses, clinics, hospitals, and related services cannot alone provide the solution. There must be a wide-ranging approach to all of the infrastructure services and other factors which influence the determinants of wellness and illness. Education, employment, housing, hygiene, access to affordable nutritious food as well as avoidance of unhealthy lifestyles must all be part of the equation towards better health. The media often sensationalise negative factors in society that contribute to the continuing poor state of Indigenous health. While many mistakes have occurred in the past and marginalisation of Indigenous people has had serious negative impacts on their wellbeing, it is time to look to the future and take a more positive outlook. Present problems should be seen as opportunities or challenges to put things right. To focus repeatedly on racism or negative stereotyping as the root cause of this continuing dilemma could be counter-productive and tend to separate Indigenous and other Australians even further. Instead, we should try to reach a situation where Indigenous people are given better chances to accept responsibility for their own health. Encouragement and cooperation will foster trust between them and the wider society and its representatives, namely governments and their agencies and bureaucrats. But all sides must accept this will be a “two-way street” where flexibility and patience will be keys to ultimate success.

Michael Gracey AO is a paediatrician who has worked with Indigenous children, their families and communities for more than forty years. He was Australia’s first Professor of Aboriginal Health and for many years was Principal Medical Adviser on Aboriginal Health in the Western Australian Department of Health. He is a former President of the International Paediatric Association.

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.