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Indigenous health: A comparison of indigenous and Departmental perspectives (A Review of Government Policy on Aboriginal Health in New South Wales) AEJNE Volume 3 - No.2 March,1998. Lynne Macer
Abstract While Government policies attempt to address Indigenous health issues, to date all incentives have provided no significant improvement in the health of Australia's Indigenous People. While self-management is endorsed, the Indigenous voice, when proposing appropriate solutions to Indigenous problems is frequently ignored or given lip-service. Unfortunately, this attitude permeates the whole of society, and is frequently enacted within the public health care facilities, by the often, well-meaning, health professionals, such as nurses. Nurses, are in a unique position to facilitate the reconciliation process within their sphere of professional prowess. As this process is embraced, the Indigenous People in this country may begin the long journey of regaining a favourable health status, currently enjoyed by the rest of Australian society, and by themselves, prior to invasion.
Introduction Policy is not an unambiguous blueprint for practice. The
policies enunciated by governments are as often statements
of ideals, or statements to placate and/or silence
particular interest groups within society, as they are the
basis of action (Saggers & Gray, 1991:132-3). This
report is divided into two sections. Part One, aims to give
an overview of the state of Indigenous health, on a national
and local level. A brief coverage is given, of the
Australian Health Care System and how health policy is
formed, along with an overview of the history of government
policy relating to Australian Aboriginal People. Addressed
also, is how Indigenous health relates to this health care
system. Part Two, presents relevant issues within Indigenous
health, the different perspectives that exist between the
Indigenous view and the non-Indigenous view, and how it
relates to existing policies. How these issues affect the
role of nurses is discussed, and how nurses can effectively,
improve health care for Indigenous clients, and contribute
to the reconciliation process. State of indigenous health in Australia The health of Australia's indigenous people is deplorable. According to the 1986 census data there were, 227,645 Aborigines and Torres Strait Islanders living throughout the continent. This represents only a small percentage of the overall population. The North Coast region, has a slightly higher ratio than the whole of NSW, 2% as compared to 1.1% for the state (NSW Dept. Of Health North Coast Region, 1990:167). There health status has been equated with that of developing countries (Franklin, & White, in Reid, & Trompf, 1991:1). This is difficult to imagine in a country boasting one of the healthiest populations in the world, particularly where life expectancy and infant mortality are concerned (AIHW, 1992:173). Statistical evidence leaves no doubt that Indigenous people represent the least healthy of any sub-population in Australia. Life expectancy for Aboriginal males at birth is 55.2 years, overall, and for females it was 63.6 years. This represents approximately 20 years less than non-Indigenous Australians (AIHW, 1992:212-3; see Appendix A). The leading causes of death are circulatory disease, respiratory disease, infective/parasitic disease, injuries/poisoning and neoplasms (NSW Task force, 1983; Thomson, 1986; National Aboriginal Health Strategy, 1989; cited in Eckermann, Dowd, Martin, Nixon, Gray & Chong, 1995:72). The National Aboriginal Health Strategy (1989), stated that Aboriginal people were admitted to hospital 1.6 and 3.2 times more frequently than non-Aboriginals. The leading causes of admissions being respiratory diseases and injuries (Eckermann, et al., 1995:72). Leprosy, although practically non-existent in other Australians, continues to grow at 0.15 new cases per 1000 in NT and at 0.51 new cases per 1000 in north west WA. Tuberculosis was almost 7 times more common in 1984 and Aboriginal hospitalisation of diabetes mellitus has been documented to be 7 and 15 times that of non-Aborigines in rural NSW. Hepatitis B is also spreading at an alarming rate (Thomson, 1985; cited in Eckermann, et al., 1995:73). 50% of children in various communities had been ill during the month prior to interviewing for the National Strategy (1989) (Eckermann, et al., 1995:74). In children there are high levels of malnutrition and infant mortality, and the leading causes of death are cited as diseases of poverty, such as gastroenteritis, pneumonia and malnutrition (Moodie, 1973:72; cited in Saggers & Gray, 1991:6). A recent report published by the Australian Bureau of Statistics (ABS), and the Australian Institute of Health & Welfare (AIHW), confirms the alarming health deficits of Indigenous people. Aboriginal men between the ages of 15 and 24 are almost three times more likely to die than non-Aboriginals. Young aboriginal women in this age group are three and a half times more likely to die. This disparity worsens between 25-34 and 35-44 year age brackets, and worse again when isolating a particular area of illness such as diabetes related diseases. Here Aboriginal women are 17 times more likely to die than those of non-Aboriginal descent. Overall life expectancy remains 20 years less and infants are four times more likely to die (Stramandinoli, G, 1997:9-11). These figures clearly indicate the poor physical health existing within Indigenous communities. Physical disease, represents only a limited view of the situation, however, as it is well documented how stress, tension, anxiety and feelings of powerlessness also contribute to the development of disease. These emotional states frequently contribute to high levels of substance use and abuse, which proves to be a huge problem among Indigenous communities. Substance abuse, such as the over use of alcohol, is frequently utilised as a means of escape from hopeless circumstances. The reality, however, only serves to exacerbate the problem, leading to violence and increased depression. A recent example of this was a front-page article in Brisbane's Courier Mail newspaper, relating the dilemma of Brenda Diamond. As a recent victim of domestic violence associated with alcohol abuse, Brenda states, a lot of sad things happen to black women. Grog is the main problem, as the men get so angry and violent (Koch, 1997:1). Brenda is from Doomadgee community, north of Mt Isa in Qld., and at 25 has a ten year old son, and only recently had her three year old son die, as a result of heart problems. Alcohol is only one form of substance abuse. The overeating of highly refined foods, also leads to shocking health ramifications. Statistics show that 35% of men and 58% of women were found to be overweight or obese, 37% of men and 47% of women were using more than 1000mgs of caffeine a day, 62% of men and 65% of women smoked, 60% of men and 72% of women were abusing alcohol (Eckermann, et al., 1995:75). Looking at these figures, the high mortality and morbidity rates are not surprising, when considering the association between these negative lifestyle behaviours and the development of chronic disease. Local statistics support this National perspective. The poor health of Indigenous people in The North Coast Region, have been identified by the Department of Health (1991), as resulting from poor housing, unemployment, lack of land ownership, inadequate education, dependence on social security, cultural identity and low self-esteem (NSW Dept. Health NCR,1990:167). The causes of these statistics are complex and varied, but have been summed up by Saggers and Gray (1991), when they stated: the ill-health of Aborigines is a consequence of the past policies and actions of colonial and Australian governments and their non-aboriginal citizens. The high levels of ill health among Aborigines are directly attributable to their dispossession, their marginalisation and the creation of their dependence on various government and welfare services (Saggers &Gray, 1991; cited in Eckermann et al., 1995:75). Saggers and Gray (1991), also state elsewhere, that the invasion by militarily superior society was the direct cause of this poor health status (Reid & Trompf, 1991:382). This appalling condition of Indigenous health, has developed over the 200 year period since British colonisation .Aboriginal policy within Australia has gone through a variety of attitudinal changes, from European Invasion and Settlement (1788-1890s), Segregation (1890-1950s), Assimilation 1950s-1960s), Integration (1967-1972), Self-Determination (1972-1975), to Self-Management, Stage I (1975-1989), and Stage II (1989-present) (see appendix B). These different policy approaches elicited a variety of reactions from Indigenous and non-Indigenous members of society most of which has tended to be negative from the point of view of achieving reconciliation and good health for the Indigenous population (Eckermann, et al., 1995:76-7). It is no doubt that, conditions identified by the NSW Department of Health, as the cause of poor health (poor housing, unemployment, lack of land ownership etc), are the direct consequence of these governmental policies. These issues underpin the concepts of Reconciliation and Social Justice Policy. Reconciliation, embraces the idea of national healing and Social Justice addresses the restoration of balance between disadvantaged sub-groups and the rest of society (Eckermann, et al, 1995:177; Ramsay, & Kermode, 1997:33). It is not surprising that Aboriginal people in the main
are very distrustful of the non-Aboriginal population. While
health care is considered to be available to all Australians
on a equal basis, it would appear as one takes a closer look
that some are more equal than others, (to quote George
Orwell's, Animal Farm). With factors such as, power
relations clearly against Indigenous people and the practise
in recent history of Integration (separating children from
their families), it is not surprising that Aboriginal people
are reluctant to use white-fella institutions, such as
hospitals (Saggers & Gray, in Reid & Trompf,
1991:382). There was a considerable turn around in
Government policy after 1972, when Self Determination and
Self Management Strategies were introduced. The formation of
The National Aboriginal Conference (NAC), and later The
Aboriginal and Torres Strait Islander Commission (ATSIC), in
1989, which took over all consultative and decision-making
functions at a federal level, saw some positive moves
(Eckermann et al., 1995:40). The effectiveness of these
measures is yet to be proven, however, with any significant
changes to conditions experienced at the community level,
still to become evident. The health care system in Australia According to the Australian Institute of Health and
Welfare (AIHW), (1972), the health of Australians continues
to improve, and the Nation, enjoys the position of one of
the healthiest countries in the World (Australian Institute
of Health and Welfare, 1992:3). This only serves to
highlight the plight of our Indigenous people. Australia's
health care system reflects the type of Government policy,
that has largely resulted from the British
colonisation/invasion of this country. Policy formation has
also been strongly influenced by the Canadian example, which
led to the short-lived, introduction of Medibank in 1975,
and also with itís reintroduction in 1984 as Medicare
(Palmer, & Short, 1994:6). This was influenced by a
Canadian report that Lalonde (1974), published, linking
causes of disease to a number of factors such as biological,
lifestyle, environmental and health care factors (A I H W,
1992:16). This North American influence continues to the
present time, and has affected, not only the direction our
health policies are taking, but also the legislation process
by which they are formed The term policy, is a rather
general term, and varies in its interpretation from a
general statement of intentions and objectives to a specific
set of rules intended for action. In short, government
policy includes what governments say they will do, what they
do, and what they do not do (Palmer, & Short, 1994:23).
While health care is affected primarily by government policy
making, non-governmental organisations such as the
Australian Medical Association (AMA), heavily influences
policy making decisions. There are four categories of Public
Policies. Distributive policies, which cover the provision
of benefits or services for specific groups such as pension
health benefit cards. Regulatory policies, which outline
limitations and restrictions on individuals or groups and
Self-regulatory policies, which are those sought by
organisations such as the Australian council on Health care
Standards. Redistributive policies, are those which consist
of efforts by governments to alter the distribution of
income, wealth, property or rights between groups within
society (Palmer, & Short, 1994:23). How these policies
are implemented, at a regional level, and how they relate to
Indigenous people and their specific problems, requires
further discussion. Current health policy and its effect on indigenous health The policies of Segregation and Assimilation did not officially get laid to rest, until the practice of removing Aboriginal children from their families finally stopped during the early 70s. Some movement toward Self-Determination and Self-Management began as certain Aboriginal people became more politically active in the mid-sixties. In 1967 Indigenous people were given the right to vote, following the passing of the national referendum giving the Federal government power to legislate on Indigenous issues. Approaching 1970, it became evident, particularly with the influx of Aboriginals into the cities, that accessible health services were a problem (Palmer, & Short, 1996:265-6). The racist treatment that Aboriginals received at public hospitals was traumatic and degrading. This discouraged them attending unless a case of emergency, and for many not even then would they take the risk. This fear of white institutions continues to the present time. It was out of this situation that the first Aboriginal Medical Service was established at the inner Sydney suburb of Redfern, in 1971. This has expanded to over 60 Federally funded, community-controlled and independent, Aboriginal Medical Services around the country. They run a range of services including medical, dental and nutritional programs (Palmer, & Short, 1996:266-7). Out of these health programs, the Central Australian Aboriginal Congress in Alice Springs developed the idea of a borning centre. This service emerged from the desire of Indigenous women to live by their grandmothers Law (Palmer & Short, 1996:267-8). The concept of borning, is a broader concept than obstetric practise, it incorporates symbolic processes, closely linked to Aboriginal Dreamtime, the land and its people (Duncan, 1986; cited in Palmer, & Short, 1996:268). This is women's business, attended only by women according to Alukura Law. The process of establishing the Congress Alukura, provided a prototype, which could be imitated and applied in other areas of policy-making and Aboriginal Health (Palmer, & Short, 1996:268-9). It also highlights the different perspectives Indigenous people place on managing their own health. The fact is, that Indigenous people see their priorities as being different from those designated by non-Indigenous, government officials. This was made evident in a meeting held in 1994 in Darwin between Commonwealth health officers and members of the National Aboriginal Community Controlled Health Organisation (NACCHO). Priorities were clearly different, as the Commonwealth officers listed Cardiovascular disease, Cancer, Mental health then Injury as the primary areas of concern. NACCHO members, in contrast, proposed a different set of priorities. They saw first, Land, Stress, Grief and Trauma, Dispossession, Lifestyle, Alcohol and Drugs and finally Nutrition as the areas needing to be addressed, in that order (cited in Ramsay, 1997). This identifies the different concept Aboriginals have surrounding health. Theirs is an holistic concept embracing land, spirit, family and the body intertwined with well-being (Eckermann, et al., 1996:174). Some of the most positive developments in Self-Management
of Aboriginal Affairs, included the formation of ATSIC,
mentioned earlier, and the Royal Commission in to
Aboriginals Death in Custody in 1991, which compiled a
comprehensive list of recommendations (Palmer, & Short,
1996:270). This drew a lot of attention to Indigenous
suffering and social injustice, but unfortunately, is yet to
be embraced and acted upon by government (Freckmann, &
Stramandinoli, 1997:14). Significantly, the High Courts Mabo
Decision in 1992, regarding Aboriginal land rights and the
subsequent successful native title claim by Dunghutti people
of Kempsey in NSW (ATSIC News, 1997:11), have proved to have
some of the most positive impact on the Aboriginal
communities, and their outlook for the future.
Unfortunately, this bright light on the horizon, has been
dimmed somewhat by the present government. Prime Minister,
John Howard, has proposed a seven-point plan regarding
changes to the Wik judgement. These changes are seen as
detrimental to the progress made by the Mabo Decision and as
removing some of the rights gained for Aboriginal people,
after so long and difficult a struggle (Stramandinoli, &
AAP, 1997:4). These Indigenous perspectives on health and
how policies should be implemented challenge the Medical
Model whereby our hospitals function. This brings into
question as to how Nurses can best work within the system
and the paradigm of the Medical Model, while still gaining
an improved understanding of Indigenous people and how to
relate to them. The role of nurses: understanding indigenous health and promoting reconciliation The Medical Model functions around a power based hierarchy. Medical Dominance remains a strong construct within Australian Society. Nurses, although lower down on the power pyramid than physicians, many times still uphold these ideologies, by taking control and exercising power over clients as they enter their care. This powerful institution has been brought into question by sociologists, concerning the negative implications it has on society as a whole. This is surely, more relevant for those less powerful within our society, such as Aboriginal people, immigrants, women and the like (Sargent, Nilan, & Winter, 1997:144-5). How nurses perceive these sub-groups, reflects the views of society as a whole, which in turn, hold some very racist attitudes. Sargent, et al (1997), explain that this behaviour occurs in group relationships of dominance-submission which are based on a difference in political power (Sargent, et al., 1997:228). Hospitals certainly exercise power over individuals, which therefore, place nurses in a prime position to exercise such ideology, particularly if they also, happen to hold these views. This type of behaviour can demonstrate a type of ethnocentricity, which attributes superior qualities to one's own cultural group (Eckermann, et al., 1995:12). Nurses, as people, are subject to the same socialisation processes that affect society as a whole, and unfortunately most often only the negative side of Indigenous people are observed. This is particularly pertinent to hospitals. It is through programs such as the course unit, health and Australian Indigenous People, which has been incorporated into the Nursing degree at Southern Cross University at Lismore, NSW, that changes in attitudes might eventually be brought about (Ramsay, & Kermode, 1997:38-9). It was shown in a study conducted by Ramsay and Kermode (1997), that students underwent changes in their perspectives, as their knowledge and understanding of Indigenous people was facilitated (Ramsay, & Kermode, 1997:36-7). As more programs such as these emerge, change will become evident, and such concepts as primary health care can take on renewed meaning. In caring for Aboriginal clients, as nurses, it is essential to understand the process of hospitalisation from an Indigenous perspective. It represents Isolation, characterised by withdrawal, fear/stigma of depression/segregation. Customs are affected by hospital routines, technology, movement and restraint. This promotes a loss of identity and autonomy, and creates alienation. A change in Attitudes/Beliefs, where the doctor/nurse knows best, and professional authority abounds. There may be a fear of dying, dependency/powerlessness Communication can become a problem with different language/jargon, pattern of speech or understanding. Mechanical Differences can cause shame/embarrassment and restriction. These factors represent a cycle of stress compounded by the legacies of segregation, regimentation, institutional racism and systemic bias (Eckermann, et al., 1995:159). One way to overcome these problems is through primary
health care, facilities, such as an Aboriginal Medical
Service, where Indigenous Health Workers can be employed.
This has been shown to be successful in many instances
including Redfern in Sydney and through research projects
such as conducted by Handorf, et al. (1996), in the Peel
region of Western Australia. This showed that Indigenous
people were more likely to express satisfaction with the
Aboriginal health worker and the local doctor services than
with the local hospital (Handorf, Wallace, Gillam &
Stevenson, 1996:S83-4). It may be advantageous for hospitals
to employ Aboriginal health workers to act as intermediaries
between clients and staff, where appropriate. It is through
community based health services that primary health care, is
most likely to be practised. This concept is an holistic
one, embracing education, nutrition, family care and
generally promoting preventive measures (Eckermann, et al.,
1995:176). While this is not always possible in an hospital
emergency, it is an aspect of care which nurses cannot
afford to overlook if they seek to provide holistic care for
their clients. Conclusion The indisputable, appalling state and complexity of Indigenous health, becomes difficult to imagine, for those of us who have not experienced it. It is therefore, imperative that greater awareness of Indigenous health status, be achieved, and an understanding of their individual cultural perspectiveís and relationship to current health services, be improved. Hospitals might employ Aboriginal Health Workers to expedite communication, and undertake staff training programs, for nurses, as they represent the face to face, facilitators of public health policy. These measures, along with improved education programs for nurses training, could prove to be some of the main instigators of change. Within society, nurses have a unique position that would enable them to do an enormous amount of good for the reconciliation process.
References Editorial, 1997 Dunghutti make history, ATSIC News 6(2):11-12. Australian Institute of Health and Welfare 1992 Australia's health 1992: the third biennial report of the Australian Institute of Health and Welfare, Canberra: Australian Government Publishing Service. Eckermann, A., Dowd, T., Martin, M., Nixon, L., Gray, R.,
& Chong E. 1995, Binanj Goonj: Bridging cultures in
Aboriginal Health, Armidale: University of New England
Press. Freckmann, M., & Stramandinoli, G. 1997 Massive
opportunity lost, says new report on deaths in custody,
ATSIC News, 6(3):14. Ramsay, L., & Kermode, S. 1997, Nurses facilitating
reconciliation through education, Australian Journal of
Advanced Nursing, 15(1):32-39.
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© 1997 Peter Cleasby | pcleasby@csu.edu.au | ISSN 1322-8676 |