Diabetes in Indigenous Communities

Diabetes in Indigenous Communities

A symptom of society International Diabetes Forum

Melbourne Australia

13 November 2006

Tom Calma

Aboriginal and Torres Strait Islander

Social Justice Commissioner

Human Rights and Equal Opportunity Commission, Australia

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I would like to begin by acknowledging the traditional owners of the land where we meet today and to pay my respects to their elders.

I would also like to thank the International Diabetes Foundation and the organising committee for the invitation to speak here today.

May I also congratulate the organisers for convening this important Forum. We know that rates of diabetes among indigenous peoples across the globe, and in Australia, are extremely high and require specific, focused attention. And we also know that we need action urgently.

So I hope that this Forum is able to make a substantial contribution to raising awareness of the specific issues relating to diabetes that are being faced by Indigenous peoples and to clearly articulate what can be done to address this situation.

I intend to talk to you about the challenges that are raised in addressing diabetes among Indigenous communities in Australia within a human rights based framework.

When I read through the draft position statements on diabetes and Indigenous peoples that have been prepared for consideration and ultimately adoption at this Forum, I was struck by the similarity between the calls for action in these statements and a human rights based approach to addressing Indigenous health inequality.

If we truly believe in equality then we should see addressing the extremely high rates of diabetes among Indigenous peoples, and the causative factors that lead to this, as a key human rights challenge. As one of the draft position statements puts it: “We have enough knowledge to put… programmes into place..… It is time for action.”1

For the benefit of our international guests, let me start by explaining my role as Aboriginal and Torres Strait Islander Social Justice Commissioner.

This role was created in 1992 to provide an ongoing monitoring agency for the human rights of Indigenous Australians. It is one of five Commissioner Positions within the Australian Human Rights Commission – our independent national human rights institution.

I undertake this role in a number of ways. I am required to report annually to the federal Parliament on the status of enjoyment and exercise of human rights by Indigenous Australians. This is called the Social Justice Report. I also report to the federal Attorney-General annually on the impact of native title legislation on Indigenous peoples’ human rights – this is the Native Title Report.

I supplement these reports with activities to raise awareness about Indigenous peoples’ human rights; the development of educational materials; and also commenting on draft legislation and proposed reforms at the federal, state and territory level.

My latest Social Justice Report was tabled in federal Parliament in February this year. A chapter was dedicated to the evaluation of current approaches to Indigenous health against the right to health and sought to establish whether current policy making and service delivery processes are capable of overcoming the health inequality experienced by Indigenous Australians.

What I argue in the report, and what I want to talk about today, is that human rights, and specifically the right to health, have very detailed content that ought to be guiding the development of policy and the delivery of programmes to Indigenous peoples.

The right to health ought to form the cornerstone of policy development and programme design for Indigenous health generally and in addressing particular chronic diseases, such as diabetes.

And a specific focus on diabetes is warranted in relation to Indigenous Australians. The statistics tell us that Indigenous peoples experience diabetes at far greater rates than non-Indigenous Australians. The statistics vary but the age-standardised prevalence of self-reported diabetes among Indigenous Australians was between three and four times the rate among non-Indigenous Australians.2 Figures derived from hospitalisation rates for Type II diabetes for Indigenous males and females were eight and ten times those for other Australian males and females.3

So let us look at the challenges of addressing the prevalence of diabetes among Indigenous communities in Australia from a human rights based approach.

Fundamental to a rights-based approach is ensuring the effective participation of those people affected. So when we talk about diabetes prevention and treatment among Indigenous peoples, it must take place on a basis of full engagement and participation of Indigenous peoples.

This is being increasingly recognised in the international human rights and development context, and should be fundamental to any international statement on diabetes screening and management. The Declaration on the Rights of Indigenous Peoples – an international instrument that is currently under debate in the General Assembly of the United Nations - sets this bar for participation very high. Articles 3 and 4 of the Declaration recognise the right of Indigenous peoples to exercise autonomy or self-government in matters relating to their internal and local affairs, including the provision of health services, as well as affirming their right to self-determination.

So this is fundamental to any approach – it requires full participation of Indigenous peoples, which I interpret as also requiring efforts to build the capacity of Indigenous communities to be self-determining. This has implications for how diabetes prevention and treatment is undertaken.

But let me focus predominately on the right to health. This does not mean a ‘right to be healthy’. No Government can guarantee the health of its citizens in an absolute sense against the forces of old age, natural disasters and personal choice, for example.

What the right to health does say, however, is that the state has an obligation to provide opportunities for its citizens to be as healthy as possible.What this means in practice is that the state provides two things:

• The first might be characterised as a foundation for good health – safe drinking water, hygienic conditions (with sewerage and garbage safely disposed of), healthy housing, and a supply of healthy food for a start. I refer to this as ‘health infrastructure’ in shorthand.

• The second is access to health care. That is, hospitals and medicines for when people are ill and primary health care services that aim to prevent ill health in the first place or detect it at an early stage. Health education and promotion is also vital. Access means:
  1. Physically accessible or reachable services,
  2. Affordable services, and
  3. Non-discriminatory services, meaning – among other things – culturally tailored services for individual communities.

The right to health also obliges a state to ensure that everyone – regardless of their sex, race, or other status – has an equal opportunity to be healthy.

What my latest Social Justice Report to federal Parliament shows, is that Indigenous Australians do not currently have the same opportunities to be as healthy as the non-Indigenous population. This is in relation to both access to health care, particularly primary health care, and health infrastructure.

• For example - based on a national survey of general practitioners - it was estimated that in 2004, Indigenous peoples enjoyed only 40% of the per capita access of the non-Indigenous population to primary health care provided by general practitioners. Further research – based on Indigenous peoples’ use of Medicare - indicates that the primary health care shortfall in communities can be quantified at between $250 - $570 million per year. There are also identified gaps in relation to health promotion and education.

• In relation to health infrastructure, many Indigenous communities, particularly in remote areas, do not have the same foundation for good health as in the rest of the country. Historically, contaminated drinking water supplies – situations where sewerage, garbage and water supplies were mixing - was a big cause of disease in communities. While there have been real improvements in this situation over the past 15 years, there are still some areas of concern. For example, where hard water from bores is impacting badly on the kidneys of people suffering diabetes. However, perhaps the most pressing areas in this regard remain food supplies and housing.

What this tells us is that:

• the physical conditions in which some Indigenous peoples in Australia live contributes to an environment where there is a greater likelihood that Indigenous peoples will suffer diabetes or diabetes related illnesses; and that
• the absence of access, that is equal access, to primary health care also means that there is a reduced chance of early intervention and prevention of diabetes for Indigenous Australians.

We know that the provision of primary health interventions specifically designed to address the over-prevalence of diabetes can achieve results within a short timeframe.

As an example, in 1999 a trial to improve diabetes care in the Torres Strait Islands resulted in an 18% fall in hospital admission rates and a reduction of 41% in the number of people admitted to hospital for diabetes-related conditions. On follow-up in 2002 there was a continuing reduction in hospital admissions for diabetes complications (from 25% in 1999 to 20% in 2002). The proportion of people with good glycaemic control increased from 18% to 25%, and the proportion of people with well-controlled hypertension increased from 40% to 64%.

Wendy Hoy’s research on trials relating to kidney failure in the Tiwi Islands in northern Australia show that similarly startling improvements can be achieved within a short timeframe through focused primary health care interventions.

The existing inequality, in outcomes and in access, has been acknowledged and identified as a problem by successive governments in Australia.

The National Strategic Framework for Aboriginal and Torres Strait Islander Health – that is the overarching framework for addressing Indigenous health nationally, with endorsement from all governments in Australia - notes the importance of providing access to primary health care for Indigenous Australians.

The main focus of the National Strategic Framework is to increase Indigenous peoples access to both mainstream and Indigenous-specific primary health care services. It recognises that a focus on primary health care interventions can be expected to have a significant impact on Indigenous peoples’ life expectation and health.4 And it has a subsidiary aim of addressing rates of diabetes among Indigenous peoples.

But these commitments and objectives and agreements among government of what needs to be done, have not been matched by the necessary action.

My latest Social Justice Report to Parliament noted the following failings of the current approach to Indigenous health in Australia from a rights perspective.

First, the goals of the National Strategic Framework have not been set within an achievable time frame. In fact it explicitly avoids imposing health targets or benchmarks on progress. As a result, there is no projected timeframe for when health equality will have been achieved. In the shorter term, there is also no timeframe or targets for when the over-prevalence of particular chronic diseases among Indigenous communities will be reduced to levels comparable to the rest of Australian society.

This is the first challenge in relation to diabetes. At what point do you acknowledge that diabetes and related illnesses are so predominant in Indigenous communities that an urgent response is required? How about when a third of the population over the age of 55 years has diabetes? That is the rate of diabetes for Indigenous Australians according to recent data.5

Second, there are no incentives within our federalised health system for Australian governments to commit resources commensurate with the need to improve Indigenous health.

This is despite the fact that it is possible to provide incentives. For example: in the Australian Health Care Agreements, additional federal funding to the States and Territories’ hospitals could be made contingent on the States and Territories increasing their funding of Indigenous primary health care on the basis that investment in the latter will lead to savings in the former.

In the Northern Territory, for example, an absence of primary health care access can be compared with the prohibitive cost of providing dialysis support to Indigenous peoples in droves. I am not suggesting dialysis should not be provided, but there needs to be a longer term view taken that is rebalanced and focused on preventative measures rather than the other end of the treatment scale.

The third main problem with the current approach to Indigenous health is that there is a lack of integration of health perspectives and goals in broader policy processes. In other words, there is insufficient attention devoted to the social determinants of health and consequently, insufficient recognition of the inter-connections between improvements across a range of socio-economic factors and health status.

Frameworks for Indigenous health acknowledge the requirement to address Indigenous health status from a holistic perspective, yet governments have failed to coordinate their other programs and services with identified health planning needs.

As it relates to diabetes among Indigenous communities, we know that there are increased risk factors associated with poor diet, nutrition and lack of physical activity; increased prevalence of low birth weight babies associated with poor maternal health; and that these issues are linked to poverty and the level of marginalisation and disadvantage experienced by Indigenous Australians.

While I agree with the comments in the draft position statement on diabetes screening that increased screening among Indigenous peoples could lead to reduced morbidity and mortality due to this disease, ultimately a response limited to the health sector will not result in the level of improvement that we require.

A health response needs to be accompanied by a raft of other processes, including:

• a focus on financial literacy and nutrition – we are seeing some good successes with the work being done by organisations such as the Fred Hollows Foundation with the Nyirr-ang-gulung Nutrition Project and Money Story in the Katherine region; the Ian Thorpe Fountain for Youth program in the Northern Territory, and Caritas Australia in the Kimberley region of Western Australia on these issues.

• improved availability of fresh foods, especially fruit and vegetables among Indigenous communities – something that quite extraordinarily does not exist at present for many communities. There are some good developments here, including the outback Stores initiative; and

• the provision of infrastructure to support greater physical activity, such as sporting facilities: in this regard, the federal government has much publicised its program of supporting the building of swimming pools in remote Aboriginal communities as a successful health promotion measure, and one linked to improved school attendance. Also, their funding to increase the number of people participating in sport, in particular youth, Indgenous Australians, Women and people with disabilities.

Again, something that is frustrating to note is that we are not suffering here for a lack of knowing what solutions are required. In terms of physical activity, the National Public Health Partnership has recently released the Be Active Australia Strategy for 2005 – 2010.6 This identifies Indigenous peoples as a priority target group. It provides a considerable opportunity to form collaborative and empowering partnerships between key Aboriginal and Torres Strait Islander health groups and other sectors of society in the coordination, delivery and funding of physical activity and health programs.

The Strategy notes a number of barriers to physical activity faced by Aboriginal and Torres Strait Islanders, ranging from:

• a lack of funding for programs, services and infrastructure; poorly coordinated program development within health and across sectors; and, disparate approaches to strategic planning and research;
• physical conditions including hot, dry, dusty or wet conditions or humidity; unsafe communities; lack of facilities and infrastructure; services and programs; and, limited income.
• services which are culturally inappropriate or unwelcoming; limited role models; racism; and competing influences (such as television and gambling);
• Psycho-social issues such as high rates of depression; dis-empowerment; sense of hopelessness; lack of motivation and a lack of confidence.
• At the individual level: poor health, including sickness; excess weight; inadequate nutrition; or limiting physical conditions; and
• Limits within available Health Services: such as limited funding for health related physical activity programs and a consequent lack of referral to these.

The Be Active Australia Strategy provides a significant pathway for addressing these issues at an inter-governmental level. And yet, there is no additional funding provided to implement the strategy. It is merely intended to consolidate the existing level of investment and ensure that it is spent strategically.

I would argue that the significance of in-activity in Australia warrants significant additional funding to that currently being invested. This strategy clearly identifies the priorities for action that require investment and commitment, if physical activity is to be addressed in Australia.

The same problems of funding apply to Eat Well Australia 2000-2010 that is the national public health nutrition strategy, and to the National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000 -2010 that was formulated out of the Eat Well Strategy.

So to conclude:

• We have the necessary commitments and mechanisms in place to achieve a more holistic response to Indigenous health issues, and to address entrenched problem issues such as the prevalence of diabetes and related illnesses among our Indigenous peoples.
• We also have a historically large budget surplus, just a small fraction of which could lead to dramatic improvements in Aboriginal and Torres Strait Islander peoples’ health status; and
• We have programs in place already such as:
• the Primary Health Care Access Program;
• Healthy for Life;
• the Community Housing and Infrastructure Program; and
• the overall National Strategic Framework for Aboriginal and Torres Strait Islander Health

that provide a sound programmatic response to the situation IF they were resourced to the level of actual need and placed within a framework of targets and benchmarks.

I have called for all Australian governments to commit to a campaign to eradicate the inequality in Indigenous health status within a generation, and to ensure equal access to primary health care and health infrastructure within a maximum of ten years. These may seem to be long time periods, but they are realistic as well as ambitious. And we know that current policies and programs are not capable of achieving this result.However, in expressing these concerns I am encouraged to note that on 16 October the federal government launched “Implementation matters: the better practice guide to the implementation of programme and policy initiatives" - where it was acknowledged, along with other things, that Government leaders must “appreciate fully the increasing importance of dealing with problems from a whole of government perspective or, given the concurrent responsibilities of our federal system, across jurisdictions.”

Once more, I congratulate the International Diabetes Federation for the focus and attention you are giving to the impact of this disease on Indigenous peoples, and I hope that I have been able to stimulate some thoughts for you from a human rights perspective that can contribute to the challenge of overcoming this significant challenge to us all.

Thank you.

Endnotes

Last
updated 14 November, 2006