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Creating Futures – Influencing Social Determinants of Mental Health and Well-Being in Rural, Indigenous and Island Peoples

Presentation by Tom Calma,

Aboriginal and Torres Strait Islander

Social Justice Commissioner

and National Race Discrimination Commissioner

5 September 2006

I would like to begin by acknowledging the traditional owners of Cairns, the land where we meet today, and to pay my respects to their elders. I would also like to thank the Royal Australian and New Zealand College of Psychiatrists and Professor Ernest Hunter for organising this event and inviting me to open this very important conference.

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. If you have not read a Social Justice Report then I would encourage you to do so as it is most informative on contemporary Indigenous affairs issues.

In opening the conference I will speak briefly to the social determinants of mental health and well-being impacting on Indigenous peoples. But before I start can I point out that the Human Rights and Equal Opportunity Commission has been actively involved in addressing the mental health of Indigenous peoples over the past decade. I highlight:

• In 1993, the landmark Report of the National Inquiry into the Human Rights of People with Mental Illness, known as the Burdekin Report. This helped to highlight the issues confronting Indigenous people with a mental illness including many of the issues I will raise today. Many of the findings are still current 12 years later.
• In 1997, the well known Bringing Them Home Report also highlighted mental health issues, particularly in relation to Aboriginal people forcibly and unnecessarily removed from their families as children.
• In September 2004 I took part in a mental health community forum held in Darwin hosted by the then Human Rights Commissioner and Acting Disability Discrimination Commissioner, Dr Sev Ozdowski, and the Mental Health Council of Australia. In this consultation I heard first hand of the experiences of Aboriginal mental health service consumers, providers and their families and carers. Developed from this forum and many more like it around Australia, the Not For Service Report reflected on the experience of Aboriginal and Torres Strait Islander Peoples and communities and mental illness.
• In early 2005, it was through my intervention that the Senate Select Committee on Mental Health expanded its proposed terms of reference to include Aboriginal and Torres Strait Islander mental health issues and services as a topic of consideration. Along with the Human Rights Commissioner and Acting Disability Discrimination Commissioner, I made a submission to the Committee raising many of the issues I will discuss today.

And finally, chapter 2 of the Social Justice Report 2005 spoke at length to the poor state of Indigenous health and health inequality (when compared to the non-Indigenous population) and the role the right to health could play in achieving Indigenous health equality in Australia. That included an address to the social determinants of physical and mental health. It contained recommendations that all governments of Australia commit to a campaign to achieve Indigenous health and life expectation equality within 25 years. And that in order to achieve this goal, governments commit to achieving equal access to primary health care and health infrastructure within 10 years.

Now since then, my office has began a process to influence the government and decision makers to adopt these recommendations by the 40th anniversary of the 1967 referendum, which will occur in May next year.

Probably the most important part of the process is the building of alliances with other influential NGOs who support the recommendations. To that end, a partnership has been formed with Indigenous and non Indigenous peak bodies and organisations including in part: the National Aboriginal Community Controlled Health Organisation (NACCHO); the Australian Indigenous Doctors Association; the Royal Australasian College of Physicians; the Australian Medical Association; the Australian Divisions of General Practice; the Royal College of Australian General Practitioners and the National Heart Foundation. It also integrates with similar campaigns being mounted by other partners namely Reconciliation Australia, Oxfam Australia and ANTAR – the Australians for Native Title and Reconciliation.

Now an important part of what is being proposed in my campaign is an address to social determinants of health such as income, education, housing, mental health and functional communities, and a broader address to the position of Aboriginal and Torres Strait Islander peoples in Australian society. As my report notes, the Royal Australian College of Physicians report that Aboriginal and Torres Strait Islander communities are the prime exampleofnegative social determinants of health in Australia.

Now this reflects the inter-relationship and ‘chicken and egg’ relationship between social determinants and mental health, particularly in small and closed communities. In fact, so interrelated are these problems that it is my belief that without addressing mental ill-health and the social determinants of poorer mental health as issues in their own right, efforts to improve life in many Indigenous communities, both urban and remote, are likely to come undone.

What is needed is a two pronged attack that addresses improving the mental health of Indigenous peoples as an issue in its own right (that is mental health services), and also on improving the negative social determinants that contribute to poorer mental health.

So how do we address the negative social determinants in Indigenous communities?

First of all, at least, we need substantial commitments to address Indigenous disadvantage. Just as my last Social Justice Report proposes a 25-year timeframe to addressing health inequality, I believe that similar programs must be put in place to address the long term economic sustainability of communities as places of real employment, not just CDEP, and income generation. Further, efforts must continue to ensure Indigenous peoples receive the same standard of education as that in the general community. Indeed, COAG have committed to creating long term plans that address these areas, but we are yet to see any materialise.

Now, I am sure I am not telling you here anything you doesn’t already know when I point out the associations between an individual’s social and economic status and their health, whether they are Indigenous or not. I will therefore not dwell on these other than to note that poverty is clearly associated with poor health and poorer mental health. In terms of mental health impacts, research demonstrates that poorer people also have less financial and other forms of control over their lives and this can contribute to a greater burden of unhealthy stress.

However, there are also a range of collectivehealth determinants that may also be impacting on Aboriginal and Torres Strait Islander peoples’ mental health in ways that do not impact on the general population:

• Racism is a collective stressor that has been reported to affect both mental and physical health. A 2003 review of 53 studies in the United States found a decline in mental health status as racism increased.

• In relation to Aboriginal and Torres Strait Islander peoples, it may be that the lack of collective control acts as a determinant of poor health. This might manifest at a community level, providing another reason for effective community governance and community control of services. However, there may be wider ramifications still. Aboriginal and Torres Strait Islander peoples, like Indigenous peoples around the world, have long asserted that their health is linked to their collective ability to control their lives and cultures and the recognition of their rights. I note that in the National Aboriginal Health Strategy of 1989, Aboriginal and Torres Strait Islander peoples linked their health to ‘control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines nor the absence of disease and incapacity.’

• Access to traditional lands can also act as a determinant of health status, particularly where that land is culturally significant and/ or provides sources of food, water and shelter.

And indeed, while Australian governments since the 1989 national Aboriginal Health Strategy have accepted, inhealth frameworks, the need to address Aboriginal and Torres Strait Islander health in a holistic manner that takes into account these unique social determinants, they have not always engineered their health programs consistent with this understanding nor considered the impact of their broader policy and program approach on Aboriginal and Torres Strait Islander health, in the broadest sense.

And indeed, while ‘dysfunctional communities’ have been the subject of media attention over the past few years, it is interesting to note that the Western Australian Aboriginal child health survey found that the environmental safety and health of Indigenous children improved with isolation (that is, those in remote communities had better mental health). Children living in Perth had significantly poorer (in fact, five times worse) environmental safety and health than those living in very remote communities. The WA evaluation concludes that traditional cultures and ways are protective against poor environmental safety and health.

Strengthening communities and culture clearly has potentially positive implications for the mental health of community members. Likewise, policies and programs that erode the strength and culture of communities can be considered as having negative impacts on community members.

Further, we may need to consider the socio-political situation of Indigenous peoples in Australia as having mental health impacts:

As the National Aboriginal Health Strategy notes:

The Australian state by way of its governments must address the very real issue of Aboriginal peoples’ Indigenous rights.

Internationally, Indigenous peoples have linked their health to the recognition of their human rights. The Geneva Declaration on the Health and Survival of Indigenous People (1999) issued after an international consultation on the health of Indigenous peoples, organised by the World Health Organization, declared Indigenous health to be a ‘collective and individual inter-generational continuum encompassing a holistic perspective’ and that the:

Philosophy and principles contained in the United Nations Draft Declaration on the Rights of Indigenous Peoples and all existing international instruments dealing with human rights and fundamental freedoms [were] essential for the attainment of the health and survival of Indigenous peoples.

To this end, so-called ‘symbolic’ aspects of reconciliation, addressing and attempting to heal the wounds of the past, treaties and so on may have an important role to play,

I will not discuss the right to health further as we have a number of prominent speakers who will do this over the coming days.

But I do have one point to make about rights and health and that is that the Australian government must at very least address the issue of human rights and their relationship to Aboriginal and Torres Strait Islander peoples’ health. They must at least indicate whether they accept or reject the proposition that mental health has a rights dimension.

Before concluding I would like to speak to the issue of mental health itself and what needs to happen?

The first issue is data. We need to know how big the problem is to target resources and meet needs. No one is really sure how big an issue mental ill-health is in communities or in the Indigenous population, although anecdotal evidence and smaller studies suggests it is a significant problem.

The most significant data obtained has been through the emotional and social well-being component of the Western Australian Aboriginal child health survey with a survey sample of approximately 5,000 children. It reported that 1 in 4 Aboriginal children are at high risk of developing clinically significant emotional or behavioural difficulties. This compares to about 1 in 6 or 7 of non-Indigenous children.

Most of the data we have about mental ill-health in Aboriginal and Torres Strait Islander adults is that gleaned after crisis situations, that is, when the mental health issue results in hospitalisation. According to the Australian Bureau of Statistics and the Australian Institute of Health and Welfare, in 2003 – 2004 Aboriginal and Torres Strait Islander males were hospitalised at 3 times the rate of non-Indigenous males for a variety of mental disorders; while for females the rate was twice that of non-Indigenous females and while such data is useful, it is of limited use in quantifying the burden of mental ill-health in communities.

There is currently no national data collection process that is able to provide accurate information on the incidence of mental health disorders or treatment occurring among Aboriginal and Torres Strait Islander peoples in communities. All we know is that suicide, substance abuse and family and community violence are problems and there are services in place in some communities to try and address these issues, but how matched the response is to the problem is impossible to determine.

Understanding the causes of mental ill-health among Aboriginal and Torres Strait Islander peoples is the key to prevention. The information, experiences and learnings that we share over the coming days will be invaluable from the service delivery perspective however, influencing policy makers and Ministers is probably the key challenge if we are to see sustainable programs implemented across Australia. As I have already discussed it is crucial that mental and physical health are not treated as discrete issues but must be considered in a holistic context.

There is also a need for greater research into Aboriginal and Torres Strait Islander mental health – research that is carried out in a manner acceptable to Aboriginal and Torres Strait Islander peoples. Only if Aboriginal and Torres Strait Islander mental health is understood can we begin the task of preventing rather than curing the incidence of mental ill-health we see in Aboriginal and Torres Strait islander peoples today.

Indeed, as Professor Sir Michael Marmot (whom many of you will know is a world authority on the influence of social determinants on health) noted in his contribution to the Social Justice Report 2005:

“Aboriginal and Torres Strait Islanders people are disadvantaged in a variety of ways beyond material disadvantage. The task is urgent to sort out the nature of that disadvantage, how it leads to such an increased burden of non-communicable disease in adults, and what to do about it.

Changing the marginal position in society of Aboriginal and Torres Strait Islanders people will need an approach that takes in the whole of life, starting with women of child bearing age, focussing on the care of infants and young children and proceeding through the life course. The right place to start is documentation of the problem. Its solution will require broad social action that goes well beyond the health sector.”

Finally, we need to address mental health services in Indigenous communities, be they remote or in urban environments.

There are many points that could be made in relation to the provision of mental health services to Aboriginal and Torres Strait Islander peoples and communities. I will briefly mention a few but refer you to the report of the Senate Select Committee on Mental Health and the Not for Service Report for a detailed consideration of these I would identify the following five points as essential:

First; more mental health services are needed in communities.

• 74% of residents of discrete communities have inadequate access to visiting or resident mental health workers;
• Aboriginal and Torres Strait Islander people have disproportionately low access to general practitioners and private medical specialists, such as psychiatrists, because of the cost of such services.
• Only 38% of Commonwealth funded Aboriginal community controlled health services have a dedicated mental health or social and emotional well being worker.

Second; ensuring that mental health services are culturally sensitive and communities be encouraged to collaborate with primary health care providers in order to develop and deliver culturally appropriate services by

• Increasing resources to Aboriginal community controlled health services to meet the increasing mental health and social and emotional well being needs placed upon the Aboriginal and Torres Strait Islander primary health care sector.
• Linking into health services activities, CDEP and SRAs could also be used as vehicles of mental health promotion within communities.
• Reforming mainstream and private provider community based mental health care to better meet the needs of Aboriginal and Torres Strait Islander peoples.
• Training an Indigenous mental health workforce – psychiatrists, psychologists, para-professionals and so on.

Third; breaking down ‘health silos’; for example, all medical and para-professionals working with Aboriginal and Torres Strait Islander peoples should have a basic knowledge of possible mental health issues so to facilitate the prevention or early address of mental health problems before they become a crisis. At very least they should have a copy of the mental health first aid booklet.

Fourth; programs must be put in place to address the needs of Indigenous carers of the long-term mentally ill living in the community.

Fifth; education of the broader community and Aboriginal and Torres Strait Islander communities about mental health issues.

I hope I have raised a number of significant issues for you to take up in your discussions over the remainder of the conference. I would like to conclude by saying that there is evidence to suggest that we can overcome the health inequality experienced by Indigenous Australians. This is an achievable goal, if it is approached with determination – and that means genuine matching of resources to need, fully benchmarked with strong accountability and genuine participatory processes with Indigenous peoples.

I anticipate that speakers will highlight some of the best practice and the examples of what works to contribute to what surely is among the most pressing challenge facing us as a nation.

The real challenge however will then be to get governments to listen, to understand the gravity of the issues and the way forward and to back initiatives.

I wish you a successful conference and look forward to listening and learning.

Thank you