Portal de Periódicos da CAPES

TOWARDS A CULTURE OF IMPROVING INDIGENOUS HEALTH IN AUSTRALIA

1999; Wiley; Volume: 7; Issue: 1 Linguagem: Inglês

10.1046/j.1440-1584.1999.00218.x

1440-1584

Lowitja O’Donoghue,

Indigenous Health, Education, and Rights

Thank you very much for inviting me to deliver the keynote address at this Conference. I am always very pleased to talk about Indigenous health and I am especially pleased to be able to hear what is being done in the area of remote and rural health. The title I was given, Towards a Culture of Improving Indigenous Health in Australia, has been carefully chosen. My thanks to the person who framed it because it has given me an opportunity to reflect on the word culture. My task is not to come up with a catalogue of cures. I'm not going to suggest a checklist of 'Twenty do-it-yourself tips for Indigenous health workers'. If only I could! If only it were that simple! Besides, you're the experts — you're the ones at the coalface! You're the ones with the intimate knowledge of what's happening out there every day. I'm going to use a broader brush and then try to take a few steps back to look at the bigger picture. The word culture implies that we are dealing with a whole array of public processes involved in shaping and implementing Indigenous health strategies. We are not just talking about individual behaviours here. We are talking about social structures. We are talking about institutional practices. We are talking about professional priorities. We are talking about politics and policies. We are talking about money. We are talking about people's lifestyles. And we are talking about the philosophies that underpin all of these. These are all a part of the culture that shapes Indigenous health and health care, and to change a culture requires changing all of these. To work towards a culture of improving Indigenous health in Australia means real head shifts and real power shifts, not just knee-jerk reactions to particular problems. So this all sounds pretty simple! I'm sure we can sort all that out in the next 48 hours or so! I do not need to remind you, of all people, how immense is the task before us. I am not going to go through the depressing list of health problems that beset our people, suffice to say that Indigenous health is a national disgrace. With the eyes of the world on us as we approach the 2000 Olympics it is likely to become an international disgrace. Nonetheless, there are many initiatives in the area of remote and rural health that we can celebrate. I was pleased to see how many papers at this conference are taking into account broader social and environmental health determinants. I was also pleased to see that so many of the presenters are thinking about communication and education, and working on ways to match their professional cultures with consumer needs — and how much emphasis there was on cross-cultural awareness. There is obviously much good work being done and I look forward to hearing more about it, but back to my big picture. We live in worrying times. In this so called 'one nation' of ours, two nations coexist. We are a nation of the 'haves' and 'have-nots'. Largely invisible in the shadows of the first world that we all inhabit, there is a Third World struggling to survive. An underclass is developing in Australia, and there is a real danger that this underclass will become permanent, with their misery and poverty perpetuated by neglect and myths generated about them. No where is this more evident than in the area of Indigenous health. Our health profile compared to that of the white population is appalling. It has been described as Third World health within a First World nation. There have been significant improvements in the health of the white urban mainstream population in Australia. Many infections that caused death and infirmity have been eliminated. Others such as HIV infection have been significantly controlled. The life expectancy of non-Indigenous Australians continues to rise but there has been little improvement amongst Indigenous Australians. In fact, it's estimated that Aboriginal mortality statistics in the Northern Territory today are comparable to those of poor people in the slums of Australian cities during the 1920s. Yet the health of Indigenous people in many South Pacific countries, such as New Zealand, has been improving. I'm sure you are familiar with the depressing array of diseases that affect our people in disproportionate numbers and far too early in their lives. And I'm sure you are familiar with the mortality statistics. For example: • Aboriginal people live 18–20 years less than their white counterparts. • Only 2 out of 5 Aboriginal men can expect to live beyond their 65th birthday. • At any age, Aboriginal people are much more likely to die than are non-Aboriginals of the same age. Sometimes these statistics are quoted like a grim mantra; as if reciting them will ward off the reality of the human suffering which underlie them. But behind these statistics are real human beings; real babies who are born and who die in infancy; real adults who live diminished lives and whose aspirations are never achieved. In talking about Indigenous health we need to be very clear about where the problems originate and how they are perpetuated before we can begin to think about how they can be prevented. Health and illness do not exist in some kind of vacuum. Medical mysteries are relatively rare. The current patterns of Aboriginal morbidity and mortality can be explained. They are mostly related to lifestyle. And the lifestyle of Aboriginal people is the product of a constellation of forces — historical, social, economic and political. Since white settlement — or invasion, as our people experienced it — we have been dispossessed of land and the life that was lived on it. Dispossessed of land, of children and of traditional ways, Aboriginal people faced a life on the sidelines of white culture. We were exposed to the most destructive aspects of this culture: its introduced disease, its high fat and sugar diet, its alcohol and, perhaps worst of all, its violence, hostility and complete disrespect towards cultural difference. In reminding us today of this history I am not trying to be a prophet of doom and gloom. On the contrary, I have some optimism about what can be achieved with hard work and a genuine will to collaborate. And, particularly in contexts like this, when I speak with dedicated people such as you, I come away with renewed optimism. Any individual's health status can be profiled against key indicators such as diet, level of education, financial comfort, adequate housing, unpolluted environment, and access to a range of goods and services. In Western societies this means that the richer you are, the more educated you are, the healthier you are likely to be. This stark reality is not good news for Aboriginal people whose education participation is low and for whom wealth is not a likely possibility. It isn't surprising then that a group of people who have consistently been treated as outsiders and aliens in their own country will not enjoy the state of good health that comes with belonging, with having aspirations that can be achieved, and with access to key resources. So, when considering health, we need a model that acknowledges the cultural, social and emotional dimensions that impact on sickness and health. When we talk about health for any society, we must adopt the broadest possible definition. The limitations of a clinical, curative approach have been widely recognised. We need a holistic definition, one that encompasses caring as well as curing. One that considers communities as well as individuals. We need to consider environmental health issues like sanitation, adequate sewerage systems, a clean water supply and adequate housing. We need to understand that there is a whole complex interconnection between death and disease and nutrition and environmental health and education. And, of course, geography, the tyranny of distance, is something you would all know about. Members of remote Aboriginal communities who are ill experience triple jeopardy. They are Aboriginal with all the socioeconomic disadvantages that go with that, they are ill, and many of them live far from medical help. The Australian Bureau of Statistics (ABS) surveyed Aboriginal communities a few years ago and found that over 15% did not have a doctor available to them within 25 km of their home; only one in three people had a permanent doctor within 25 km; 17% did not have access to a nurse within 25 km; 22% had no access to an Aboriginal health worker within 25 km; and almost 60% had no access to a dentist within 25 km. The statistics get even grimmer when you look at specialist services like mental health services, where 78% had no access within 25 km. Overall, over 12% of Indigenous people have to travel more than 100 km to get to a hospital. For more than 23% an Aboriginal medical service was more than 100 km away, and for over 37% a detoxification centre was more than 100 km away. Over half of all Indigenous people living in rural areas had to travel more than 50 km to a hospital. In the Northern Territory, the figures are the worst. Over half of the Indigenous people in the Northern Territory had to travel over 100 km to get to a hospital. When you consider that many of these people do not own or have access to vehicles, it is clear that the difficulties are extreme. With conditions such as kidney disease, which require regular specialist treatment, compliance with medical regimens is extremely unlikely. The ABS also found that there was another factor of great significance for Indigenous people in remote and rural areas: the extent of Indigenous health involvement in the medical services they can access. Over three-quarters of their respondents said they felt that it was important for Aboriginal and Torres Strait Islander people to be involved in the provision of their health services. This view was most strongly held in the Northern Territory. Over 80% of those living in rural areas regarded it as important. This was true across all age groups. None of these factors — be they geographical, environmental, or socioeconomic — can be treated in isolation from each other. Nor can they be seen as problems of the here and now and divorced from their history. For example, we know from the report of the National Inquiry into the separation of Aboriginal and Torres Strait Islander children from their families, that the policies of forcible removal had a devastating effect on these children and their families. The entire fabric of communities was often destroyed. The effects reported were multiple, ongoing and likely to set up a vicious cycle of damage from which these children and their children have had difficulty escaping. Cycles such as this desperately need to be broken. Changes will inevitably be slow — and this slowness is demoralising both for those directly affected, their families and communities; and people such as you, who are committed to working in these areas. It is also demoralising for the professional health workers, like many of you here, who have dedicated their lives to this work. It is not surprising that there is a high level of 'burnout' amongst people working in remote areas. However, we must not be defeated by the enormity, or the long-standing nature of the problem. Much Indigenous disease and death is preventable. This is particularly true of cardiovascular disease, diabetes and injuries. Infectious and parasitic diseases can also be greatly reduced. So what are some of the things that can contribute to turning around this appalling situation? Or that can break the cycle? First, we need the will to do something about it, and the determination to put an end to this sorry state of affairs. As for specific strategies, there is a range of them and they all connect. First, I would suggest education. This needs a multipronged approach. Most fundamentally, it means raising the general educational attainment of Indigenous people — finding ways to keep Aboriginal students at school longer, encouraging vocational training after school, and devising strategies for redressing drop-out rates at TAFE colleges and universities. This means making schools and colleges and universities more culturally aware, and more sensitive to the needs of the diverse populations they serve. Better education will have spin-offs in higher levels of employment, better housing, and better nutrition. In other words, all those things we understand are essential to primary health. It is absolutely vital that health promotion campaigns; for example, about smoking, nutrition or sexually transmitted disease, be culturally sensitive and appropriate. And that means getting Indigenous people in on the act: seeking their advice about appropriate language, appropriate imagery and utilising, where possible, Indigenous media outlets. Then, we need to educate health workers about Indigenous health. This means providing regular in-service training and development opportunities so that those working in the field can update their knowledge and establish networks for dialogue and support. It means building a cross-cultural perspective in to undergraduate and postgraduate nursing and medical training Australian medical students are overwhelmingly from middle and upper-middle class backgrounds. Their medical education is strong on the physical pathology of illness but weak on the sociology and psychology of people whose lifestyle differs from their own. It's encouraging to note that the Committee of Deans of Australian Medical Schools has seen fit to commission a cultural awareness package on Indigenous health, designed for use with medical students. I am also pleased to say that the Yunggorendi First Nations Centre for Higher Education and Research at Flinders University, with whom I work as a Visiting Fellow, has managed this project. It recently released a package of a video and a study guide, which was officially launched by the Federal Health Minister in July this year. The package is designed to promote Indigenous perspectives on appropriate and effective health care. It's an interactive program that assists students in the health professions to develop a coherent personal and professional approach to Indigenous health. It encourages them to use medical knowledge integrated with understandings about cultural difference, Indigenous history and racism. It's a very good example of the kind of holistic approach that we know to be absolutely necessary. If health workers do not have in their curricula education about the broader issues of culture, racism and social justice and their relationship to health, their work can't genuinely serve Aboriginal people in a holistic way. Judgements will continue to be superficial and often stereotypical. This is not only ethically wrong, it is medically unsound. I notice that one of the postconference workshops is on 'Cultural Awareness for Health Professionals Working with Indigenous People in Rural and Remote Areas'. I also note that one of the presentations today is promoting careers in rural health as being 'cool'. The whole area of Indigenous health is not a glamorous one, and crosscultural training may not appeal as an exciting, cutting-edge aspect of medicine. But there is nothing attractive or glamorous or ethical about the contradictions that allow Third World ghettos in a First World country. I believe that all those employed in the medical professions must undertake the difficult task of recognising, in all its implications, that, by definition, health work is political work. If the health professions ignore the shocking state of Indigenous health in this country then they exacerbate the problems of history. On the other hand, if they take the initiative to act, to advocate and to work for significant change, they assist in the crucial work of reconciliation between black and white Australians. This stance inevitably requires a commitment to radically reformist positions about health. We cannot talk in simple rosy terms about holistic health without facing the fact that it really means a re-allocation of resources, a change of priorities, and a willingness to redirect power to the community level. Hence my suggestion in my opening address this morning, that you consider some recommendations for policy makers and politicians. Get to them when they're most vulnerable, when they want your vote! This leads to my next point about self-determination. As a matter of priority there needs to be Aboriginal participation at all levels of health service policy, administration and practice. This, I believe, is what primary health care is all about. It's about empowering communities and individuals to be in a position to take responsibility for their own health. The issue must be seen in terms of rights, survival rights if you like. Rights to decent standards of health, housing, water and education are as important as civil and political rights. They should be based on entitlement and not on charity. Good health begins in the family and in the local community. It does not begin in Canberra. It cannot be delivered from on high. Good health means working with the local people. It means community control. A wonderful example of this kind of community control and involvement is the 'Strong Women, Strong Babies, Strong Culture Project' in the Northern Territory. This project was devised because many young Aboriginal pregnant mothers were malnourished during their pregnancies, often smoked, were prone to infections and anaemia, and often gave birth to premature or low-weight babies. In consultation with dieticians and women's health workers from Darwin and regional districts, a whole network of Strong Women workers has been set up in bush communities and camps. I would like to quote from a report written by their Project Manager, which will give you a feel for their approach. Strong Women workers explain their story to the women. They encourage women to come to antenatal care early in their pregnancy. They explain why the health checks are necessary and help women understand their need for good strong food, for complete treatment of infections, for regular check-ups. Some of the Strong Women workers have learnt how to do some of the health checks for the women. Strong Women workers talk with the non-Aboriginal nurses and doctors and explain what women's needs are for health services. They work together to make the health service more friendly, more private, more able to understand the cultural ways and what Aboriginal people believe. We also have Strong Women Committees in each camp so that if the woman needs certain bush tucker or bush medicine, the committee members and the old women go out and collect bush medicine or tucker for her. The program is so that the Department of Health and Community Services can learn to plan for services that really meet the needs of Aboriginal people. Our women must be strong to have strong babies to keep our culture strong.1 There is a great sense of pride and ownership in this account. It is obvious that the project is succeeding because it starts with the women's needs in the camps and communities. Good health is seen as fundamentally linked to culture. It illustrates very powerfully that self-determination is a necessary foundation for any genuine sustainable improvement in Indigenous health. It is time we had our say. As I once told Minister Michael Wooldridge (Federal Minister of Health and Aged Care), this might mean letting us make our own mistakes. It's not as if plenty of mistakes haven't been made on our behalf. Part of self-determination involves developing a national training strategy for Aboriginal and Islander health workers. This must be aimed at the recruitment and training and retention of Indigenous health professionals. Such a strategy must be national in scope but must take into account regional variations and community needs. It must not be ad hoc or piece-meal. And it must be long-term to be given the chance to prove itself. There have been too many 'stop–start''flash-in-the-pan' strategies in the past. This brings me to matters of funding. I believe that the Federal Government's allocation of money to primary health care is far too small, at only 3–4% of the total health budget. And, of course, only a tiny fraction of that goes to Aboriginal health. I would like to see a shift from an 'unfix-it' approach to one that prioritised primary health care, concentrating on preventative strategies for lifestyle illnesses. This requires a broad cross-sectoral approach. It's not something that can be solved by the Federal Health Minister and his budget alone. An anecdote may help to make my point here. In the 1930s a world-renowned eye specialist, Professor Dame Ida Mann, visited remote Aboriginal communities and witnessed first-hand the appalling levels of the eye disease, trachoma. When asked what drugs she would prescribe for this problem, she replied, 'Drugs … I'd prescribe water. If governments were to put the water on, no one would have trachoma'.2 So what is needed is a concerted collaborative approach going well beyond health policy to agriculture, housing, public works, education, employment, transport, and communications. Improvement in the quality of life is needed. Some lateral thinking is required, with some attention to fundamentals, like clean water. For example, 34% of Aboriginal communities are still reliant on water that is below the minimum standards set by the National Health and Medical Research Council. The solution might seem simple, but it typically gets bogged down in bureaucratic buck passing. From whose budget line will these vital funds come? A breadth of vision and imagination is needed from the government. A commitment which will straddle petty departmental divisions and their budget lines, and a radically reformist restructuring. There is a tendency for politicians to intermittently visit outback communities, especially at election times, and then go back to Canberra and recommend another review, another feasibility study, another flow chart, or another one-off pilot program. As an Aboriginal health worker in South Australia said to me recently, 'We've had so many pilots we could join up with Qantas!' (S. Wilson, pers. comm., 1998). The eventual result of the politicians' visits is that some money may be flung in the direction of a specific problem they have seen. But this piece-meal approach is drip-feeding. It does not address the ongoing needs of communities. It does not lead to long-term management. It does not lead to self-determination. It's relatively easy but it doesn't work. People with more expertise than me have been saying this for some years. Unfortunately we still await the level of government commitment and breadth of vision necessary to change the situation. Not only do Indigenous communities receive less than their fair share of Federal health funding on a pro capita calculation, but their much greater needs are not adequately recognised. In spite of this, there are still some political forces calling for cuts to the funding of Indigenous programs. I was pleased to read recently that the new chief of the Australian Medical Association, Dr David Brand, has spoken out strongly against the political party, One Nation, on this matter. He said: We are deeply disturbed by comments which suggest funding for Aboriginal health programs might be cut or vetoed by One Nation politicians. Given the level of need and deprivation facing many Indigenous Australians, it would be an utter tragedy to see this country spend less on improving health outcomes for the most disadvantaged in our society.3 I'm sure that many of you feel, as I do, frustrated by the slowness of improvement in Indigenous health. It seems very difficult to get politicians and bureaucrats to see the bigger picture. I can fully understand that those of you working with particular communities and involved in particular projects are probably so consumed with the daily realities and pressures that it seems a bit of a luxury to be stepping back to look at the bigger picture. There is a paradox here. While it is important to take a bird's-eye view, as I have been doing today, it is also absolutely critical that we do not overlook what is happening on the ground. We must not become so overwhelmed with the enormity of the task that we forget to celebrate the small victories, the breakthroughs in particular communities, and learn from them. There are hundreds of examples where you are making a difference, where small gains and sometimes big improvements are evident. You need to share these with us. You need to inspire each other with success stories; to offer models of best practice to emulate; to give examples of snatching small victories from the jaws of defeat; to describe instances of necessity being the mother of invention; and, don't forget, to put the hard word on any politicians or bureaucrats you can buttonhole. As we approach the next millennium the eyes of the world are on Australia. In the year 2001 we will be celebrating the Centenary of our Federation as a unified nation. Yet we are divided in bitter debates about republicanism, globalisation, economic rationalism, immigration and native title. We are about to host the 2000 Olympics. Australia will be proudly promoting its beauty and its flora and fauna. And you can bet that exotic Aboriginal artefacts and cultural performances will be wheeled out for the opening and closing ceremonies. Now I have nothing against this. I would be one of the first to argue that Aboriginal culture and heritage should be highlighted. Yet I cannot help seeing the contradictions. On the one hand, Aboriginal culture is displayed as a kind of exotic window-dressing for Australia, yet, behind the scenes, in the urban ghettos and in the bush, we all know the realities of chronic poverty and ill health. Cathy Freeman, Nova Peris-Kneebone and Kyle Vander-Kuyp, to name only a few, will be running for gold. These athletes are wonderful Aboriginal examples of youthful health and physical and mental stamina. And yet so many of their people lead lives which are impoverished, diseased and all too short. The paradox of these contrasts is profound. Australia has much to be proud of as a nation, but Indigenous health is nothing less than a national disgrace. It is time, surely, to demand that governments meet the challenge of revitalising Indigenous health. It is time to set things right.