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Contents

Aims of this Session

  • Who are Indigenous Peoples? How do Indigenous Australians view health?
  • Overview of Indigenous Australian health status
  • Looking broadly into the causes of poor health, including housing and environmental health
  • Improvements in Indigenous health
  • Throughout the week – discussing and reflecting on the role of doctors in Indigenous health

Who are Indigenous Peoples Globally?

  • An estimated 370 million Indigenous Peoples live in about 90 countries worldwide.
  • Indigenous Peoples live in very different contexts and have many distinctive aspects, for example about 4,000 languages, there are many generally shared broad features of Indigenous People’s values, culture and worldview.
  • “It is this all-encompassing nature of indigenous cultures that makes them unique and so different from the cultures of those groups that hold the political, economic and social power in the nation-states in which they live.”

Widely shared experience and consequences of loss of land and disempowerment of culture

  • Poverty
    • “Indigenous peoples continue to be over-represented among the poor, the illiterate, and the unemployed. .. while they constitute approximately 5 per cent of the world’s population, Indigenous Peoples make up 15 per cent of the world’s poor. They also make up about one-third of the world’s 900 million extremely poor rural people.”
  • Poor Health Status
    • “Indigenous peoples suffer from poorer health, are more likely to experience disability and reduced quality of life and ultimately die younger than their non-indigenous counterparts. “

Recent Australian History in a Nutshell

  • Historical and Current Legacy
  • SERIES OF POLICIES AND PHASES
    • Precontact (>70,000 years in Australia, estimated 500k to >1m pop)
    • Frontier conflict / trauma, displacement from land, new infectious diseases, massive number of deaths
      • Terra nullius – empty land
      • Killing, as well as keeping people away from water supplies; fencing reduced food supply
    • Institutionalisation / loss of control, confinement
      • Soothing the “dying pillow” (it was accepted that Aborigines were going to die out), Stolen Generation (put Aborigines into white families to hope that Aborigines would convert into white culture)
    • Deregulation / Referendum 1967 (began to be counted in the census as people) with sudden access to alcohol, loss of work + welfare dependency (particularly in isolated areas that had no economic base)
    • Self Determination : Overnight transition from mission to state control, community councils (poor planning; poor training; councils weren't trained how to lead - makes people disempowered, disorganised)
    • Contemporary times / Apology/ Long road toward recovery / Close the Gap

Definition of Indigenous: Who is an Indigenous Australian?

  • “An Aboriginal or Torres Strait Islander is a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which he (she) lives”.
    • This can not be determined from appearance!
  • Q’s:
    • How do we determine this? This cannot be determined by appearance. Can only tell by asking.
    • Why is it so important for Drs and health care workers to correctly identify Indigenous Australians?
      • It's important for identification of risk factors
      • Data sets - measure the effectiveness of different campaigns
  • Cannot dilute identity - there aren't fractions of Aboriginality

Definition of Health: What is health to an Indigenous person?

  • ...not just the physical wellbeing of an individual, but the social, emotional and cultural wellbeing of the whole community in which each individual is able to achieve their full potential as a human being thereby bringing about the total wellbeing of their community.
  • It is a whole of life view and includes the cyclical concept of life-death-life (NACCHO 1997).
  • Q: Why is it so important for Drs and health care workers to understand this perspective?
    • Healthcare systems in Australia don't focus on social, emotional and cultural wellbeing. Doctors focus on the physical.
    • When there's stress, people neglect their health
    • So address stressors

Huge Diversity: Aboriginal & Torres Strait Islander Homelands

  • Even within the Torres Strait Islands there is a great diversity in language and culture
  • Importance of the diversity - just ask about their ways of living + culture
  • One size never fits all - so programmes we roll out to the Aboriginal people do not act uniformly - need to ask, listen etc

Indigenous Australian Population: total numbers by State & Territory and (%) of total State population.

  • There are more Indigenous people in the cities than remotely (but proportion is higher for Indigenous people in remote areas)
  • NSW has the most Aborigines
  • NT has a high proportion of Aborigines (30.3%) while it's 1-3% elsewhere

Geographical distribution across remoteness

Age profile of Australia’s population

Why is it important for Drs and Health care workers to be awar

  • Low life expectancy
  • High birthrate
  • So they have a younger population; child focus, and concentrate on adolescence moving to parenthood
    • While our population is ageing


Higher Fertility Rate, Younger Population, Higher Death Rate

  • Median age about 21 yrs versus 37 years – so a higher proportion of Aboriginal and Torres Strait Islander women are within the reproductive years.
  • “In 2010, the total fertility rates were 2,575 births per 1,000 for Indigenous women and 1,886 births per 1,000 for all women.
  • In 2008, the average birthweight of babies born to Indigenous mothers was 3,196 grams, 189 grams less than the average for babies born to non- Indigenous mothers.
  • In 2008, the proportion of babies of low birthweight born to Indigenous women was twice that of babies born to non-*Indigenous women (12.3% compared with 5.9%).”

Life Expectancy Gap

  • In 2008, Life expectancy for Indigenous Australians was 59 yrs for males and 65 years for females, compared with

77 yrs for all males and 82 yrs for all females, a difference of around 17 years. (ABS, 2008)

  • New method “reduced” this estimated gap to 11 years (ABS, 2009)
  • The median age at death for both Indigenous men and women in 2010 is about 20 years lower than that of their

non-Indigenous Australian counterparts. (AIHW 2011)

Proportion of deaths(a)(b), Indigenous status(c), age group(d) and sex - 2007- 2009 (ABS 2010).

  • Aborigines die earlier
  • High infant mortality in ATSI
    • Also in childhood, teens, and middle years
  • Every death impacts on a lot of people - their culture is very tight

Wilcannia football team

Rate ratios of death between non indigenous and indigenous

Types of cancers most common among Aboriginal and Torres Strait Islander people and rate ratios compared with non-Indigenous Australians: Lower incidence rates overall but higher death rates

  • “FROM THE AVAILABLE INFORMATION, INDIGENOUS PEOPLE ARE: SIGNIFICANTLY MORE LIKELY TO HAVE CANCERS THAT HAVE A POOR PROGNOSIS; USUALLY DIAGNOSED WITH CANCER AT A LATER STAGE; LESS LIKELY TO RECEIVE OPTIMAL TREATMENT; AND ARE MORE LIKELY TO DIE FROM CANCERS THAN OTHER AUSTRALIANS [60].”

Dimensions of Risk

  • Indigenous risk factors & illnesses often:
    • Occur earlier in life
    • Multiple and mutually reinforcing
    • Recurrent/persistent
    • Are widely experienced in community/cohort (a lot of people have the same disease at once)
    • Less likely to be offset by protective factors
    • Less likely to be recognised as a need that health services can help with
    • More likely to be seen as unmodifiable

Ecological model of health

  • Historical and current legacy still has an impact on peoples' health

Higher proportion in the lowest SES Quintile re Household income

Many Aboriginal and Torres Strait Islander people, especially children, live in overcrowded and/or poor housing, often lacking basic facilities

  • Low SES --> poor housing

MANY CONTINUOUSLY EXPERIENCE HIGH/VERY HIGH LEVELS OF PSYCHOLOGICAL DISTRESS(a), by Indigenous status—2008

  • Poor housing --> high psychological distress
  • They probably don't have control over the behaviours we're suggesting they take up
    • Need healthy hardware in your house

Environmental conditions essential to maintain health (Healthy Hardware)

  1. Safety
    • Reduce Immediate life threatening dangers - electrical, gas, fire, sewage and structural safety issues are addressed as the highest priority.
  2. Healthy Living Practices
    • After safety issues have been addressed, target Healthy Living Practices

Nine priorities for healthy living practices

  1. Wash people
  2. Wash clothes and bedding
  3. Remove waste safely
  4. Improve nutrition
  5. Reduce overcrowding
  6. Reduce impact of vermin and pests
  7. Control dust
  8. Control temperature
  9. Reduce risk of trauma

Indigenous environmental health priorities

  1. Environmental health workforce development
  2. Housing issues and planning
  3. Local regional and national initiatives
  4. Community capacity building/partnerships
  5. Community food supply and nutrition
  6. Environmental health services in communities

Social justice report 2005

Many major activities and reports have focused on attained health equality between Indigenous and non-Indigenous Australians, including the social justice reports, the signing and adoption of the UN Declaration, the National Welcome to Country and Formal Apology to the Stolen Generations. Many recent milestones have opened new doors to reconciliation, commitment and the achievement of health equality.

Australian Govt Efforts for “Closing the Gap” have focused on

  • Broad Changes in Policy and National Strategies in some areas (Commonwealth), guiding frameworks about what ‘should’ be done
  • Better Government Systems and Services (States)
  • Aboriginal Community-controlled Health Services (Local upwards)

What services do Aboriginal and Torres Strait Islander Australians use?

In comparison with service access of other Australians, Aboriginal and Torres Strait Islander people are:

  • High users of public in-patient and out-patient hospital services, transport and public health;
  • Low users of medical, pharmaceutical and dental services; and
  • Very high users of community health services.

Telltale sign of service access and environmental health issues

Better government services

  • More culturally safe environments for Aboriginal and Torres Strait Islander people (example = Inala Health Service in Brisbane, Torres Strait Island PHC championed by Aboriginal and TSI leaders)
  • key issue has been the Aboriginal and Torres Strait Islander health workforce development
  • Some strive to include family in the delivery of their care
  • adopting health promotion programs into the health service setting
  • Fully Implementing Enhanced Models of Primary Health Care

Aspects of Enhanced PHC include

  • Team approaches and Indigenous and non-Indigenous service providers working together to address clinical needs
  • Regular Health Checks and Screening
  • Information systems with recall functions
  • Clinical guidelines for Acute and Chronic disease, as well as mental health and social and emotional wellbeing
  • Clear and appropriate Pathways of Care
  • Checking for change, Continuous Quality Improvement

Aboriginal Community-Controlled Organisations (ACCHO’s, AMS’s)

  • Peak Body
    • NACCHO: National Aboriginal Community Controlled Health Organisation
    • http://www.naccho.org.au/Files/Documents/Achievements %20book%202nd%20edition%20completed.pdf
    • NACCHO’s Vision is “for Aboriginal Peoples to achieve a state of well being, consistent with our holistic concept of health”
  • WHAT’S SO SPECIAL ABOUT ABORIGINAL COMMUNITY-CONTROLLED HEALTH SERVICES?
  • “They are the best manifestation of Aboriginal peoples taking control and responsibility for solving their own problems. The services have been initiated, planned and managed by Boards elected from the local Aboriginal community.”
  • http://www.naccho.org.au/Files/Documents/Achievements%20book%202nd%20edition%20complet ed.pdf
  • They can pick and choose from the best available from non-Indigenous settings and make it work.

Improvements have occurred, but long way to go

  • “Reductions in the impact of infectious diseases including lowering of:
    • respiratory infections in childhood
    • declines in death rates from invasive pneumococcal pneumonia (mostly due to vaccination)
    • incidence and severity of trachoma (though inflammatory trachoma remains endemic in some remote communities of central and northern Australia)
    • prevalence of HBV infection (since the introduction of vaccination programs)
    • incidence of invasive Hib disease in Indigenous children (after introduction of vaccination)
    • new cases of TB, from 79 in 1984 to an average of around 30 in the mid 2000s
  • Routine immunisation coverage of Indigenous and other children up to five yrs of age are similar
  • Participation of Indigenous people in sporting and recreational events increased between 2002 and 2008 and the level of smoking among Indigenous people has decreased slightly in recent years
  • Some [educational] improvements in the performance of Indigenous primary and secondary schoolchildren in recent years, and the proportion of Indigenous young people receiving a year 12 certificate increased between 2001 and 2008.”

Recommendations for further improvements

  1. Improved access to healthcare that is culturally appropriate and commensurate with need.
  2. Increased number of health practitioners working in Indigenous health care settings, and further development of the Indigenous health workforce.
  3. Improved responsiveness of mainstream healthcare services to Indigenous health needs.
  4. More effective targeting of maternal and child health and increased support for Indigenous targeted population health programs.
  5. Increased funding for access to the building blocks of health - nutrition, physical activity, fresh food, healthy lifestyles and adequate housing.
  6. National targets and benchmarks for achieving health equality, by which progress can be closely monitored.