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Indigenous health inequality in Australia – What can medical professionals do to make a difference?  How can, and to what degree is it appropriate that, medical professionals act as leaders in the crisis? 

National Leadership Seminar, Australian Medical Students Association, Canberra, 10 September 2007 

Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner

SLIDE 1

I would like to begin by acknowledging the Nganawal people, 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 Australian Medical Students Association and Shayne McArthur for organising this National Leadership Development Seminar, and 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.

Part 1: A snapshot of Indigenous health inequality

SLIDE 2

Now for those of you who don’t know, I am going to begin by providing a snapshot of Indigenous health and health inequality in Australia. And I say ‘ for those of you who don’t know’ with reference to the fact that --  at the moment, despite the development of the national Indigenous health curriculum -- across Australian medical schools there is still an enormous variance at the amount of information provided about Indigenous health. And I will return to this subject later.

The headline indicator is, of course, life expectation. And 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 your future Indigenous patients 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.

Behind this, there is an entrenched health crisis in the Indigenous population. I highlight:

• High rates of chronic diseases. Two of the three leading causes of death for Indigenous people are chronic diseases of the circulatory system and cancer. Hospitalisation for ischaemic heart disease for Indigenous males was double the rate, and for females four times the rate, than for the general population.
• High rates of poor health among Indigenous infants do not bode well for the future adult population. Apart from high infant mortality, in 2000-02, babies with an Indigenous mother were twice aslikely to be low birth weight babies as babies with a non-Indigenous mother.
• 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.

With a significant proportion of Indigenous peoples in younger age groups, there is an additional challenge to programs and services being able to keep up with the future demands of a burgeoning population. Unless substantial steps are taken now, there is a very real prospect that the health status of Indigenous peoples could worsen.

Part II: Why is this happening?

SLIDE III

There are many reasons, most of which I will mention only in passing here due to time restraints. It has, for example, long been recognised that health infrastructure (housing, water supplies and hygiene) in Indigenous communities is generally of a significantly lower standard than in the general community. The quality of food in communities is also a major concern.

Beyond health infrastructure, a wide range of social determinants impact negatively on Indigenous health. Poverty is clearly associated with poor health.  In the last census in 2001 (the 2006 data not yet being available) the average gross household income for Indigenous peoples in Australia is around 62% of the rate for non-Indigenous peoples; the unemployment rate for Indigenous peoples was 20% or over three times higher than the rate for non-Indigenous Australians.

There is too psychosocial stress – a contributing factor to the high rates of heart disease in Indigenous peoples. This is caused by a perceived lack of control over your environment and life. Some sources of this stress will be shared with the non-Indigenous population, for example the stress caused by poverty.

There will, however, be stressors that uniquely affect Indigenous peoples. Racism, the ongoing uncertainty surrounding the issues of land, control of resources, cultural security, the rights of self-determination and sovereignty are all likely to contribute to psychosocial stress to the degree they impact Indigenous peoples’ perception of being in control over their lives.

And I particularly want to highlight that the lack of collective control may act as a determinant of poor social and emotional health. This might manifest at a community level, providing another reason for community self-governance and the community control of services, including health services (as I will discuss).

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 that Indigenous peoples’ poorer health status would they would have much greater access to GPs. However, in a 2004 national representative survey of general practitioners it was estimated that Indigenous peoples enjoyed 40% of the per capita access of the non-Indigenous population to primary health care provided by mainstream general practitioners. There are a number of reasons for this.

In terms of availability: In 2002, there were twice as many medical practitioners per person in major cities than in remote areas and ten times the number of specialists. Because a higher proportion of the Indigenous population live in rural and remote areas, this has a greater impact on Indigenous peoples when compared to the non-Indigenous population.

In terms of accessibility – Many remote communities are simply too far away from hospitals or clinics. However, Indigenous peoples do not tend to use mainstream primary health care even where it is otherwise 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. Australian governments have long accepted the importance of maintaining distinct health services in urban centres for Indigenous people as a consequence of this, and hence there ongoing support for the Aboriginal community controlled health services. Transport too can be an issue, as around a quarter of Indigenous households are without a car to drive to the doctors or hospital in an emergency, or if they are ill.

Finally, in terms of economic accessibility: fees charged for health services (including top-ups charged by general practitioners) will act as a greater barrier to Indigenous peoples’ access to the services than for the non-Indigenous population because of their (as highlighted) lower average income and higher unemployment rates.

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: the National Strategic Framework for Aboriginal and Torres Strait Islander Health. And 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 such an improvement in Indigenous peoples’ health status is 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 Aotearoa/New Zealand over two decades from the 1940s to the 1960s.

We should not be timid about setting a timeframe for achieving Indigenous health equality, reflecting the national priority I believe it should be. The absence of such timeframes promotes a lack of accountability of governments. It sends a tacit message that it is fine for things to simply drift along.

Part III: the Indigenous health equality campaign

SLIDE IV

You may have heard of the Indigenous health equality campaign currently underway in Australia based on work contained in the Social Justice Report 2005. Its main thrust 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.

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, and it is in relation to this part of the campaign that medical professionals and students can really make a difference.

Part IV: So how can you make a difference?

There are four ways that come to mind.

(a) Support the rolling out of the national Indigenous health curriculum.

To start on this point, can I acknowledge the work undertaken by the Medical Deans of Australia and New Zealand with Gregory Phillips in developing an Indigenous health curriculum framework for Australian medical schools in 2004. And I also want to commend the Australian Medical Council, the independent national standards body for medical education and training, for linking the accreditation of medical schools to their implementation of the curriculum in all Australian medical schools.

Yet, as I have noted, despite this the development of curricula based on the framework has been patchy with wide variance still evident; and there is no deadline for the implementation of the curriculum by medical schools. Can I propose that targets and deadlines are put in place to ensure the curriculum is adopted by all medical schools as soon as possible in Australia? I believe it is unacceptable that Australian medical students today can still finish 7-years of university education without any in-depth knowledge of what is in my opinion the biggest population health issue in Australia. So I would urge you, if your university is not making sufficient efforts in this direction, to support them in doing so.

(b) Support your university recruiting Indigenous doctors and nurses

An equitable distribution of primary health care to Indigenous peoples rests on a prior effort to increase the numbers of health professionals to provide the services. It was estimated in 2001 that 500 new general practitioners and over 3,000 new nurses and Aboriginal Health Workers were needed.

There is some overlap between the workforce needs shortfall in relation to Indigenous health care with the Indigenous health workforce representation shortfall. With 2.4% of the population being Indigenous, it might be expected that 2.4% of the health workforce would be too. In fact, it is from the case. Rectifying the imbalance requires training 928 Indigenous general practitioners and specialists; 161 dentists; 2,570 nurses and 275 pharmacists.

In 2001, while Indigenous people held 67% of positions in Aboriginal Community Controlled Health Services, 98% of the doctors and 87% of the nurses were non-Indigenous. Significant attention is needed in relation to the recruitment and retention of Indigenous professionals and alongside with the adoption of the curriculum I would urge you to be proactive in ensuring that your university is doing all it can to ensure this gross imbalance is rectified.

(c) Help ensure mainstream services are accessible to Indigenous peoples

I highlight here the stellar example of the work of Noel Hayman at the Inala Health Centre General Practice in urban Brisbane. This Indigenous doctor, by focusing on making the practice more culturally acceptable to Indigenous peoples, increased its Indigenous patient list from 12 to 1200 over five years; and with significant health gains in diabetes, access to specialist services and childhood and adult immunisation to the local Indigenous community.

So, if on graduation you find yourself in a mainstream practice with a low Indigenous patient list don’t simply accept that this how things are, or should be. Work with the community controlled services and other local Indigenous organisations to find out why this may be. Be proactive. Ask local Indigenous community members if your practice is friendly to Indigenous people. It isn’t necessarily rocket science. Are there posters and the like around that signal ‘Indigenous people welcome here’? Have the staff at the practice had any cultural training? Do you have any Indigenous doctors or nurses on staff, or at least an Indigenous face on reception? Is an outreach service appropriate? What health promotion activities are needed by the local Indigenous community – And how can this practice help deliver these?

And to that end, can I recommend that you work with and support the Aboriginal community controlled health services. Community controlled health services are culturally, physically, and economically accessible. Crucially, they empower Indigenous communities and people to look after their own health. They literally speak the language of the community, know the communities problems and are best placed to work out solutions – for example, choosing to invest more of its funds into integrating drunk and alcohol counselling or mental health programs into its practice.

(d) Lend your support to the Indigenous health equality campaign

And finally, lend your support to the Indigenous health equality campaign. As professionals and as members of professional medical bodies you have a chance to make a difference as lobbyists.

Over 40 Indigenous and non-Indigenous organisations are currently working in partnership for Australian governments to commit to the campaign for achieving Indigenous health equality within 25 years. In December 2006, the coalition published an Open Letter calling for an end to Indigenous health inequality in The Australian. In April 2007, Olympians Catherine Freeman and Ian Thorpe helped launch the campaign at the Telstra Stadium, Sydney. The partners are currently working towards hosting a National Indigenous Health Summit in late 2007 where we will formally call for Australian governments to adopt the campaign to mark the 40th anniversary of the 1967 referendum.

And I am pleased to report that Indigenous organisations are taking an active leadership role in this. The main bodies are the National Aboriginal Community Controlled Health Services, and its State and Territory affiliates; and the Australian Indigenous Doctors Association. However, there are others: the Australian Indigenous Dentists Association and the Congress of Aboriginal and Torres Strait Islander Nurses, for example. And I would encourage you to follow the example of bodies like the Australian Medical Association and the Royal College of Australasian Physicians in following the lead offered by the organisations at the national level in your efforts.

Thank you, and any questions?

SLIDE 5