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The Indigenous health curriculum in Australian medical schools

Tom Calma

Aboriginal and Torres Strait Islander Social Justice Commissioner

Human Rights and Equal Opportunity Commission

Leaders in Indigenous Medical Education Conference

University of New South Wales

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September 23, 2007

Slide 1

Part 1: Opening remarks

I begin by acknowledging the Gadigal people of the Eora nation, the traditional owners of the land where we meet today, and pay my respects to their elders. I would also like to thank the LIME conference organisers -- and Gregory Phillips and Lisa Jackson-Pulver in particular -- for inviting me to speak tonight and for organising this event and for ensuring that Indigenous health – so often overlooked in the ongoing debates about health and health reform in Australia – receives the attention it deserves in this context. I also acknowledge our Maori, New Zealand and Pacific brothers and sisters here with us today. Kia ora.    Cross-national collaborations of this regard are exciting and we have much to share and to learn from each other.

Part 2: My role

In July 2004, I took up my appointment as the Aboriginal and Torres Strait Islander Social Justice Commissioner at the Human Rights and Equal Opportunity Commission or HREOC. This role was created in 1992 to provide an ongoing monitoring agency for the human rights of Indigenous Australians.

I undertake this role in a number of ways. In particular, 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.   The 2006 report was tabled in parliament in June. It is also available on the HREOC website. I also produce a community guide that outlines the salient points in the social justice report and a second annual report I produce called the Native Title Report.

My 2005 Social Justice Report included a chapter titled ‘Achieving Aboriginal and Torres Strait Islander Health equality within a generation: a human rights approach’. In this chapter I recommended that governments of Australia commit to achieving equality of health status and life expectation between Aboriginal and Torres Strait Islander Australians, and non-indigenous Australians, within 25 years. In order to achieve this goal, governments need to commit to achieving equal access to primary health care and health infrastructure within 10 years and to fund programs based on need. This has since been published as a stand alone publication and I have copies available today.   

Slide 2

I am pleased to report that over 40 Indigenous and non-indigenous organisations are currently working in partnership to lobby Australian governments to commit to the campaign for achieving indigenous health equality within 25 years and this includes the Close the Gap campaign that,  no doubt,  many of you are aware of.         

Slide 3

I have fairly limited time with you today, and the focus of my speech will be on primary health care and health services, but before I start can I note that the campaign addresses, many issues that relate to Indigenous health and the right to health (for example,  health infrastructure and the need for a holistic address to indigenous health)  as well as primary health care and I would urge you to look at the published versions of the campaign to get an overall picture of it as I will be skimming over these vital elements of it here today to make sure the points relating to primary health care and training a health  workforce  come through.      

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Part 3:   A snapshot of Indigenous health inequality

Now, as a memory refresher I am going to begin by providing a brief snapshot of Indigenous health and health inequality in Australia. 

The headline indicator is, of course, life expectation. I am sure that most of you will know that there is an estimated 17 years difference between indigenous and non-indigenous life expectation -- it’s like comparing Australia with Bangladesh.     For Indigenous peoples this means that 75% of indigenous males and 65% of females will (statistically speaking) be dead before the age of 65 years compared to 26% of males and 16% of females in the non-indigenous population.   Yes 75% – 26% for males and 65% – 16% for females

Much of this is due to the high rates of chronic diseases affecting Indigenous peoples -- diseases that take years to develop. As I am sure many of you are aware, two of the three leading causes of death for Indigenous people are chronic diseases of the circulatory system and cancer.    

Related to this, there are also high rates of unhealthy and risky behaviour, including an increased prevalence of substance abuse and alcohol and tobacco use in the indigenous population.

The importance of primary health care in any address to these two factors, as well as to better population health more generally, has long been recognised: at least since the W.H.O. Declaration of Alma Ata in the 1970s,  and I am assuming that I do not need to spell this out to such an expert audience.

Of course, health promotion and education is an absolutely vital aspect of primary health care. How are people to makes informed decisions about their health – diet and the like - without it? How are they to know when to visit a doctor? Yet indicators suggest that this vital information is not reaching Indigenous communities.       

Slide 5

Part 4:   So why is this happening you might ask?           

There are many reasons, most of which I will mention only in passing here due to time restraints and because I am assuming that you will be familiar with most of them. 

The main ones being:

• Poor housing,  water supplies and hygiene in Indigenous communities (or health infrastructure as I refer to it); 
• The quality of food in communities; 
• Poverty; 
• Psychosocial stress – the impact of racism, for example and – a factor that touches on many aspects of Indigenous peoples’ community’s lives – the perception of not being in control.  

But what I want to highlight today is the need for indigenous peoples to have greater access to primary health care. One might expect that given Indigenous peoples’ poorer health status, they would have much greater access to GPs.   However, it was estimated in a national representative survey of general practitioners in 2004 that Indigenous peoples enjoyed 40% of the per capita access of the non-indigenous population to primary health care provided by mainstream general practitioners. Of course there are Aboriginal community controlled health services, and while their impact is hard to quantify, the gaps that are still evident indicate an outstanding “need” shortfall.

I note that Indigenous peoples do not tend to use mainstream primary health care even where it is otherwise available and physically accessible, for example in urban areas. This can be for many reasons including a lack of cultural ‘fit’, language barriers, or the perception that mainstream services are not welcoming to Indigenous peoples.  

Per capita Medicare under-spend estimates have been used to assess the quantum of the Indigenous primary health care shortfall. Estimates of the shortfall range from $250 million per annum to $570 million per annum depending on the quality of service offered.  

And yet while spending has increased on primary health care (as well as things like health infrastructure),  there is no ambitious plan to meet this primary health care need as soon as possiblein the current national indigenous health policy:   that is, the National Strategic Framework for Aboriginal and Torres Strait Islander Health. For a government that recorded a 17.3 billion dollar surplus this year, on top of record surpluses for the past decade, I believe this is unacceptable. The time has come to act.

There is sufficient evidence to demonstrate that real improvements in Indigenous peoples’ health status are achievable in a short time-frame. International figures demonstrate that optimally and consistently resourced primary health care systems can make a significant difference to the health status of populations, as measured by life expectancy, within a decade. For example, in the 1940s to the 1950s in the United States, Native American life expectancy improved by about 9 years; an increase in life expectancy of about twelve years took place in New Zealand over two decades from the 1940s to the 1960s.

Slide 6

Part 5:   So let me turn to the Indigenous health equality campaign

The main thrust of the Indigenous health equality campaign currently underway in Australia is to set a timeframe for achieving Indigenous health equality, building on the National Strategic Framework for Aboriginal and Torres Strait Islander Health as well as on the commitments of the Council of Australian governments to overcome Indigenous disadvantage.

It is not about reinventing the wheel.

The basis of the campaign are recommendations I made that, Australian governments commit to achieving equality of health status and life expectation between indigenous and non-indigenous people within 25 years. 

A vital secondary target proposed is that Australian governments should also commit to achieving equal access to primary health care (as well as health infrastructure) within 10 years for Indigenous peoples.

In relation to primary health care, the campaign involves continued support for Aboriginal community controlled health services and an expansion in their number. This must take place alongside efforts to improve the accessibility of mainstream services.

Part 6:  The curriculum and the campaign

It is in relation to the ten year target for securing equality of opportunity for primary health care that I am focusing my speech to you tonight.

Can I spell it out? Without the implementation of the Indigenous health curriculum -- and without the training of a workforce suited to meet the health needs of Indigenous Australians – the campaign target cannot be met. So I hope you can see why I place such importance on the implementation of the curriculum.

It is vital that the medical workforce, doctors in particular, are trained:

• to be aware of the health issues facing Indigenous Australians;

• to be comfortable working with Indigenous Australians and able to provide a service that respects Indigenous cultures;

• to be understanding of the barriers to accessing primary health care that may be faced by Indigenous Australians and most importantly;

• to know how to be skilled change agents to ensure their patient’s needs get met by the care they provide and the health system around them.

Armed with this kind of education, doctors can make a real difference to the health of Indigenous Australians.

I highlight the well known work of Dr Noel Hayman at the Inala Health Centre General Practice in urban Brisbane who, by focusing on making the practice more friendly to Indigenous peoples, increased its indigenous patient list from 12 to 1,200 over five years.

I believe any doctor working in a mainstream practice with a low Indigenous patient list should be educated to ask why, and not simply accept that this is how things are, or should be. Ensuring the local Indigenous population use the practice isn’t necessarily rocket science. Following Noel Hayman’s example, putting up posters that signal ‘Indigenous people welcome here’, conducting staff cultural training and placing an Indigenous face on reception, made all the difference.      But without doctors being educated to think along these lines, simple steps like this will not occur.

It is vital that all doctors are able to make a positive impact in reducing the burden of disease in Aboriginal health.

Part 7:  The curriculum framework

I want to acknowledge and commend the Deans of Medical Schools Australia and New Zealand, Dr Ian Anderson and Gregory Phillips for their work in medical education and Indigenous health, particularly in developing the Indigenous health curriculum framework for implementation by all Australian medical schools.

This work addresses a great omission. To me it is almost inconceivable that an Australian medical student or health professional could spend the best part of a decade in training, yet during that time may not have any significant exposure to what is undoubtedly the greatest public health crisis in Australia today – Aboriginal and Torres Strait Islander ill-health.

The development of the curriculum framework is the first step. The second step is the linking of the accreditation of Australian medical schools to their implementation of the curriculum by the Medical Council of Australia and can I commend the Council for this move too.

What impresses me about the development of the Indigenous curriculum framework is that Indigenous people have worked with the Deans to further a common goal. In fact, the Indigenous staff at the Onemda VicHealth Koori Health Unit at the University of Melbourne, as well as within the Australian Indigenous Doctors Association (or AIDA), have lead this project from its inception, and this is a significant contributing factor to its success. 

I’d also like to commend and encourage the LIME network, AIDA, and the Deans to continue to work towards truly multi-disciplinary Indigenous health education.     For reasons of geographical location, cultural needs, burden of disease and workforce shortages, nowhere is it more important to encourage multi-disciplinary collaboration than in Indigenous health. I commend those in the medical education system who are broadening the way they train students in multi-disciplinary settings and encourage the LIME network to continue to reach out to and include nurses, pharmacists, dentist and other allied health professionals.  The sheer amount of the work that needs to be done means we will need truly collaborative teams to hope to make a positive impact on Indigenous health outcomes.

Part 8:  The implementation of the framework curriculum

This pattern goes through to the implementation of the framework by individual medical schools. The mantra developed by the Medical Deans’ Indigenous Health Project to describe the process of implementing the curriculum reform is ‘indigenous leadership, faculty responsibility’. This is a critical component of its continued success in my view. 

It means that on the one hand Indigenous staff must contribute meaningfully to key decisions around Indigenous health within faculties. On the other hand, it should mean the Dean’s and senior management staff shares the responsibility for the workload (that is, reforming the way curriculum and indigenous student support measures are delivered and resourced).

This way of working in partnership will ultimately ensure Indigenous health is not left as a side issue for the medical fraternity of the future, but rather, is front and central in the way Australia delivers its mainstream health services.

Australian medical schools have to varying degrees implemented the framework.    However, there is still enormous variance at the amount of information provided about Indigenous health in medical schools,  and the very slow progress of some in implementing the curriculum is one of the more disappointing features of this reform process.

Slide 7

In relation to this, reflecting on the use of time bound targets in the broader Indigenous health equality campaign, can I propose that realistic yet ambitious targets are put in place for the implementation of the curriculum by all Australian medical schools, as a priority task?  

This is a theme I have picked up in my work in Indigenous health and the Closing the Gap campaign - that while aspirational goals and targets are important,  they must be backed up with credible performance measure frameworks, such as targets and benchmarks,  if results are to be seen.

The LIME network will play an important role in this regard. Targets can not be set by one group for another (for example, by Aboriginal groups for the Deans) to implement. Rather, the hard work of setting goals and developing credible performance measurement frameworks must be a collaborative, joint effort, where Indigenous stakeholders share equally in both decision-making and responsibility functions. Reflecting on achievements and priorities for reform regularly at meetings like the lime connection will be important in this regard.

Part 9:  Recruitment and retention of Indigenous medical students

Another vital aspect of the reforms underway in Australian medical schools relates to the recruitment and retention of Australian medical students. 

I acknowledge and commend again the Australian Indigenous Doctors Association for their partnership with the Dean’s of Medical Schools to improve Indigenous medical student recruitment and support and for their leadership in advocating for increased numbers of Indigenous students entering, being supported and graduating from medical school.

The experience from Ao Tea Roa shows that having Indigenous doctors in the system as professionals in their own right, as advocates and as role models, is a critical part of generational change.  Medical schools in Australia and New Zealand will make a critical contribution to their respective nations if they can work with others to deliver on this promise. 

Related to this point, another critical area I would like to encourage the Deans’ further in is the development of culturally safe medical school organisational arrangements. History and international experience show that individual awareness of other cultures does not necessarily produce better health outcomes unless it is accompanied by genuine and broad institutional reform. That is, it is one thing to make a curriculum inclusive, but it is another to ensure the knowledge, skills and attitudes of all staff (beyond limited individual champions) are also aligned with any area of new endeavour. Further, unless power-sharing, decision-making and resource arrangements are restructured to include Indigenous people and their health needs meaningfully, then we may not reach our overall goal if improving health outcomes as effectively or efficiently as we might like.

Slide 8

Part 10:  Closing remarks

So in closing can I observe that I look forward to AIDA and the Deans’ developing their relationship even further than the agreement for collaboration already signed.    While new relationships like these across cultural and organisational divides may not always be easy, they ultimately provide a solid platform for our endeavours today to bear fruit in the years to come in terms of increased Indigenous entry and graduation, better trained doctors overall, and hopefully better Indigenous health outcomes.

Finally, I would like to commend the Deans’ for your remarks in the media recently in regards to the Federal Government’s intervention in the Northern Territory.  While the announcement by the Government took us all by surprise, I took note and was encouraged by the Deans’ press release saying a well trained Indigenous health workforce will be necessary in the years to come, I encourage and commend you for stepping up to the plate to undertake this work.

What has been achieved by the development of the Indigenous health curriculum is an example of the type of ‘intervention’ that I like to see. There are too few mainstream organisations willing to do the hard yards in working in truly collaborative relationships with Indigenous health organisations to actually change the health situation of Indigenous peoples in this country.

In reforming medical curricula and accreditation standards and in undertaking to recruit, support, mentor and graduate more Indigenous medical students, you all should be proud. Those of you who choose to lag behind may well miss out on an important moment in the social and medical development of this land. Those of you who excel and stretch yourselves may well be recognised and celebrated as health and medical system reformers and change agents.

I look forward to celebrating your collective successes at tomorrow night’s inaugural LIMElight awards and look forward to hearing more about the admirable work being undertaken in the years to come. 

Thank you