An excerpt from the essay titled “Public health issues regarding chronic diseases faced by the Indigenous population of remote Northern Territory of Australia” by Shaun Gerschwitz.
The Indigenous Health Gap
1% of the total Australian population lives in the Northern Territory (NT) (1), of which 29.8% is Indigenous, (2) and a majority of whom live in remote locations. In 2004 Aboriginal life expectancy was “20 years less than other Australians”, and this health disparity remains today, widely referred to as “The Gap” (3). Non-communicable diseases (NCDs) account for 70% of this health inequality (3) (4). 60% of the Indigenous population in the Northern Territory have diabetes (5), with similarly high rates of hypertension, chronic heart, stroke and other vascular diseases. The incidence of high-risk behavior within the Indigenous population of the NT is as follows: 41.6% smoke tobacco and 66% are overweight, whilst only 4.8% meet daily vegetable intake guidelines (6). 52.5% of the Indigenous population is unemployed, whilst only 45.7% of the population completed year 12. Furthermore, in many remote communities a large proportion of the population is living in unsuitable housing, with little access to affordable fresh fruit and vegetables, comparably cheap and easy access to unhealthy foods, and poor living conditions overall. Each of these statistics are significantly worse than those of the non-indigenous population. The NCD burden is multifactorial, however largely due to the social determinants of health (7), and wider public health policy and systems. Root cause analysis also suggests that “dispossession, forcible relocation, removing children from their families, and heavy handed paternalism” (8) are potent underlying factors.
The government has implemented several measures to “close the gap”. This included the topical Basics Card system, an element of the Intervention aimed at reducing the health disparity. The Basics Card system was introduced in 2007 by the Australian government as a form of income management, whereby a proportion of specific populations’ welfare payments are available only on this card and can only be used to purchase certain items at approved stores. Excluded products include alcohol, tobacco, gambling, and other ‘harmful’ consumer goods and services. The Basics Card system paternally addresses many of the social determinants of health that contribute to the development of NCDs in the Indigenous population. Many Indigenous people in the NT have been automatically included in this program (9) in “a blanket basis” (10) disproportionately to Non-Indigenous. Only 6.8% of Indigenous people are exempt from the system in some categories, compared to 93.2% Non-Indigenous (10). The Government states that the “approach attempts to control peoples’ patterns of
behavior in what are perceived to be their own interests” (11). However determining the Indigenous population’s best interests is unlikely to occur as the Indigenous lack adequate political representation and positive media portrayal (12). The government claims the Indigenous “disadvantage is primarily a result of a deficit of necessary social values and norms” (11), whilst the program’s introduction required suspending elements of the Commonwealth Racial Discrimination Act (10) as it “treated people differently on the grounds of race” (11), and therefore has been labeled as a discriminatory approach to health and welfare promotion. The Australian media has likened it to apartheid, and many prominent Indigenous people have voiced disapproval of the scheme. Overall, it perpetuates discrimination towards Indigenous Australians, and does not empower them to take control of their health. It causes distrust of the government, and thus resentment towards government run community health centers. This has negative consequences on the management of NCDs in the population. Research has shown that there are far more effective less discriminatory programs that would greater benefit NCD management (11).
The government has also ensured that there are primary health care facilities in many remote Indigenous communities. However, there are some issues due to large the difference that exists between Indigenous and non-Indigenous cultures. Most health practitioners are non-Indigenous, and were trained in ‘Western biomedical medicine’. High quality Indigenous education is not taught in medical schools, with “significant gaps and areas for improvement identified in all [Australian] medical schools” (13). Health professionals’ “training, orientation, and support programs are often limited or non-existent, [failing] to adequately prepare the healthcare professional” for their role in the Indigenous community (14). This creates an environment of cultural miscommunication and misunderstanding, culture shock, and decreases the quality of care, providing access barriers. “Culture shock experienced by healthcare workers in these communities can have a potentially detrimental effect on the delivery of quality healthcare services” (14). It causes healthcare workers to leave, taking expertise, and causing Indigenous loss of faith in the healthcare system, negatively influencing quality of care, and therefore NCD outcomes.
Community clinics struggle with “poor rates of staff retention [and] high turnover rates of remote healthcare workers” (14), whilst any regular doctors rotate between several clinics in either monthly or longer intervals. This interrupts continuity of care, vital for NCD management. Staff struggle to build rapport with patients, decreasing the compliance of patients with NCD management, and trust of the health system. The Indigenous population of Australia is incredibly diverse, and cultural and social differences exist between each community. Therefore, without spending extended periods of time in a community, a health worker does not sufficiently understand the population they are treating, and may misinterpret the community’s needs. Furthermore, staff unavailability in some clinics results in a sole health worker. This provides a cultural barrier to access as it is inappropriate for a female to attend to a male, and vice versa. If the consult occurs regardless, the patient may not feel comfortable or be culturally permitted to divulge full information about their illness. Overall, it leads “to distrust of the system and hostility towards future non-Indigenous employees” (14) which is diabolical for adequate management of NCDs.
“The gap between the mortality rate of the Indigenous population and the rest of the Australian population is becoming wider” (8), a large portion of which is due to NCDs. The current programs are not adequately effective. New strategies must be implemented to address the issue. The approach must be multifactorial, spanning health clinic improvement, political involvement, better health worker training, and a focus on the social determinants of health. A focus on prevention, early detection and prompt treatment is ideal, as it prevents disease development and progression.
Some studies suggest that new solutions are not needed, rather existing strategies that have been ‘ignored’ have significant evidence for improvements (8). These strategies have not been introduced due to lack of government willpower. Therefore Indigenous voice and political representation needs to be improved. This would provide the drive and political will to impose strategies and improvements that are known to work. Political decisions are influenced by the wider public opinion, and thus lack of effective action and resources may be due to a lack of public will. This may be due to poor public knowledge of the Indigenous situation and subtle racism ingrained in Australian culture (15) (16). Other barriers include geographical location issues and financial costs, as well as the “broader issues of dignity, identity, and justice [and] the need for further progress on reconciliation” (16).
- Australian Bureau of Statistics.0 – Australian Demographic Statistics, Dec 2015. 23 June 2016. [Cited: 27 July 2016.]; Available from: URL: http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/3101.0.
- Australian Bureau of Statistics.0.55.001 – Estimates of Aboriginal and Torres Strait Islander Australians, June 2011. 30 8 2013. [Cited: 27 July 2016.]; Available from: URL: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001.
- Voss T, Barker B, Begg S, Stanley L, Lopez A. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. International Journal of Epidemiology, 21 October 2008, Vol. 38, pp. 470-477.
- Zhao Y, Dempsey K. Causes of inequality in life expectancy between Indigenous and non-Indigenous people in the Northern Territory, 1981–2000: a decomposition analysis. The Medical Journal of Australia 2006; 184: 490-494
- Gracey M, King M. Indigenous health part 1: determinants and disease patterns. The Lancet 2008; 274: 65-75
- Australian Bureau of Statistics. 4727.0.55.006 – Australian Aboriginal and Torres Strait Islander Health Survey: Updated Results, 2012–13. 2014 [Cited 27 July 2016]; Available from: URL: http://www.abs.gov.au/AUSSTATS/abs@.nsf/mf/4727.0.55.006
- Hoy W, Normal R, Hayhurst B, Pugsley D. A health profile of adults in a Northern Territory Aboriginal community, with an emphasis on preventable morbidities. Australian and New Zealand Journal of Public Health 1997; 21: 121-126
- Ring I, Brown N. Indigenous health: chronically inadequate responses to damning statistics. Medical Journal of Australia 2002; 177: 629-631
- Australian Government Department of Human Services. Income Management. 2016. [Cited 17 August 2016]; Available from: URL: https://www.humanservices.gov.au/customer/services/centrelink/income-management
- Centre for Aboriginal Economic Policy Research and Altman J. Income Management and the Rights of Indigenous Australians to Equity. 2010 [Cited 17 August 2016]; Available from: URL: http://caepr.anu.edu.au/sites/default/files/Publications/topical/Topical_Altman_Equity_0.pdf
- Parliament of Australia. Income management: an overview. 2012 [Cited 19 August 2016]; Available from: URL: http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BN/2011-2012/IncomeManagementOverview#_Toc328056498
- Brough, M. Representations of Aboriginal and Torres Strait Islander health in Australian newspapers. Australian Journal of Communication 1999; 26 :89-98
- The Australian Indigenous Doctors’ Association and Medical Deans Australia. Medical Deans – AIDA National Medical Education Review. 2012 [Cited 14 August 2016]; Available from: URL: https://www.aida.org.au/wp-content/uploads/2015/03/AIDA-Medical-Deans-National-Medical-Education-Review.pdf
- Muecke A, Lenthall S, Lindeman M. Culture shock and healthcare workers in remote Indigenous communities of Australia: what do we know and how can we measure it? The International Electronic Journal of Rural and Remote Health Research, Education, Practice and Policy 2011;1607. [Cited 16 August 2016]; Available from: URL: http://www.rrh.org.au/publishedarticles/article_print_1607.pdf
- Australian Government – Australian Institute of Family Studies. Working with Indigenous children, families, and communities: Lessons from practice. 2011 [Cited 20 August 2016]; Available from: URL: https://aifs.gov.au/cfca/publications/working-indigenous-children-families-and-communities
- Alford K, Onemda VicHealth Koori Health Unit. Comparing Australian with Canadian and New Zealand Primary Care Health Systems in Relation to Indigenous Populations: Literature Review and Analysis 2005 [Cited 1 August 2014]; Available from: URL: http://www.onemda.unimelb.edu.au/sites/default/files/docs/dp13.pdf