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Inquiry into hearing health in Australia (2009)

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Inquiry into hearing health in Australia

Australian Human Rights Commission
Submission to the Senate Community Affairs Committee

16 October 2009

Table of Contents

1 Introduction

  1. The Australian Human Rights Commission (the Commission) makes this
    submission to the Senate Community Affairs Committee in its Inquiry into hearing
    health in Australia.

2 Summary

  1. This submission is based on research conducted by the Commission into
    hearing impairment and deafness in Aboriginal and Torres Strait Islander
    communities in 2009. The submission therefore focuses exclusively on hearing
    health in Aboriginal and Torres Strait Islander communities. The Commission only
    commenced this research recently but it is expected to be completed by December
    2009.

  2. Aboriginal and Torres Strait Islander peoples experience disproportionately
    higher levels of hearing impairment and deafness when compared with the
    Australian community generally. This limits their rights to health, as well as
    related rights to education, livelihood and participation.

  3. The high levels of socio-economic disadvantage and discrimination faced by
    Aboriginal and Torres Strait Islander peoples raise specific barriers to
    accessing necessary health, education, housing and other services to prevent or
    accommodate hearing impairment and deafness.

  4. Hearing impairment and deafness contributes significantly to the social
    exclusion of Aboriginal and Torres Strait Islander peoples affected by it. This
    exclusion can manifest in the spheres of health, education, training,
    employment, the criminal justice system and social and cultural
    participation.

  5. A rights-based analysis of hearing impairment and deafness in Aboriginal and
    Torres Strait Islander communities highlights the specific contributing factors
    and impacts, as well as appropriate measures to address specific
    needs.

3 Recommendation

  1. The Australian Human Rights Commission recommends that the Australian
    Government address the specific needs of Aboriginal and Torres Strait Islander
    peoples with hearing impairment and deafness by supporting and providing for
    measures that:

    • Address the socio-economic determinants of hearing impairment and deafness,
      such as housing, diet and education;

    • Address the discrimination faced by Aboriginal and Torres Strait Islander
      peoples with hearing impairment and deafness primarily in terms of disability
      and race;

    • Ensure adequate provision of accessible, affordable and culturally
      appropriate services in the areas of health, housing, education, employment and
      the criminal justice sector; and

    • Support further research in Indigenous hearing and communication and develop
      the evidentiary base for understanding the impact of hearing impairment and
      deafness on Aboriginal and Torres Strait islander communities.

4 Incidence of hearing
impairment and deafness in Aboriginal and Torres Strait Islander
communities

  1. Aboriginal and Torres Strait Islander peoples experience disproportionately
    higher levels of hearing impairment and deafness in comparison to non-Indigenous
    peoples:

    • In 2004-2005, a higher proportion of Aboriginal and Torres Strait Islander
      peoples than non-Indigenous people reported ear and hearing problems for all age
      groups under 55.[1]

    • The prevalence of hearing conditions for Aboriginal and Torres Strait
      Islander children (prenatal to three years of age) was three times higher than
      for non-Indigenous children.[2]

    • For children aged 0-14, the comparative rate was similar, except for
      deafness which was 5 times
      higher.[3]

    • Up to 40 percent of Indigenous children in remote areas suffer from a
      chronic form of otitis media
      (CSOM).[4] The World Health
      Organization states that a prevalence of CSOM of greater than four percent is a
      major public health
      problem.[5]

  2. However, the Productivity
    Commission has noted that there is still a lack of sufficient data which has
    made it difficult to assess the full extent of ear infections and consequent
    hearing loss in Indigenous and non-Indigenous
    populations.[6]

5 Specific
contributing factors and impacts of hearing impairment and deafness in
Aboriginal and Torres Strait Islander communities

5.1 Contributing
factors

  1. One of the primary causes of hearing impairment and deafness in Aboriginal
    and Torres Strait Islander children is otitis media. In its milder forms, otitis
    media causes temporary hearing impairment and is generally painless. For this
    reason, people with the infection often do not to realise they have a hearing
    impairment. However, permanent hearing damage can result if it re-occurs
    regularly and becomes a chronic
    condition.[7] The condition is
    particularly harmful when it is carried from childhood into
    adolescence.[8]

  2. Aboriginal and Torres Strait Islander children frequently experience
    re-occurring infections from very early ages (within weeks of birth) and in
    higher levels of severity. Aboriginal and Torres Strait Islander children and
    young adults between the ages of 2 and 20 years experience an average of 32
    weeks of middle ear disease compared with two weeks for non-Indigenous children
    and young adults.[9]

  3. The reasons for such a high prevalence of ear infections among Aboriginal
    and Torres Strait Islander children are closely tied to the broader
    socio-economic disadvantages commonly experienced in Aboriginal and Torres
    Strait Islander communities. The Productivity Commission noted that high rates
    of recurring ear infections are associated with poverty, crowded housing
    conditions, inadequate access to clean water and functional sewerage systems,
    nutritional problems and access to health
    care.[10]

    • Poverty can limit the capacity of families to maintain healthy and hygienic
      environments, particularly in terms of housing and diet, which in turn places
      family members, especially children and youth, at increased risk of disease.

    • Houses without working taps and showers, or with poor access to water,
      sewage and waste removal systems make living with good hygiene very difficult
      and increase the exposure of children to bacteria that lead to ear
      infections.[11]

    • Overcrowding exposes children to other family members who may have ear
      infections and poor health
      conditions.[12] Overcrowding also
      increases the noise level of the home environment, which may cause further
      hearing damage and render hearing aids ineffective as a result of the increased
      background noise.[13]

    • Poor diet can contribute to lower immunity
      levels.[14]

  4. The other significant contributor to high levels of otitis media and
    consequent permanent hearing damage is the lack of access to affordable and
    culturally appropriate health services.

    Despite strong evidence of
    the high prevalence rates for hearing impediments in Indigenous children,
    particularly in remote areas, the hospitalisation rate for middle ear and
    mastoid disease for Indigenous 0–3 year olds (8.9 per 1000) was below that
    for non-Indigenous 0–3 year olds (9.7 per 1000) in
    2006-07.[15]

  5. Specifically the lack of access to appropriate health services can include a
    lack of trained professionals with an understanding of conductive hearing loss,
    limited provision of audiological services, as well as lack of access to speech
    therapy, amplification, special education and mentoring services.

  6. Access to hearing screening can be critical to early detection and treatment
    of ear diseases. It can reduce the likelihood of children experiencing chronic
    ear disease and consequent permanent hearing loss and/or auditory processing
    problems in adulthood. Screening for hearing loss is also crucial for children
    to obtain referrals for surgery or rehabilitation.

  7. While most forms of otitis media are preventable and treatable through
    surgery or long-term courses of antibiotics, the lack of access to health
    services prevents such diagnosis and treatment from occurring.

5.2 Impacts

  1. High levels of hearing impairment in Aboriginal and Torres Strait Islander
    communities have been known for some time. What is less well established is how
    hearing impairments impact on whole-of-life outcomes for individuals, families
    and Aboriginal and Torres Strait Islander communities overall. Some data has
    been emerging that indicates the impacts are wide-ranging, significant and
    inhibit the enjoyment of many human rights including the rights to health,
    education, employment and participation.

  2. The Productivity Commission noted that while Aboriginal and Torres Strait
    Islander children under three are at the highest risk of ear disease, this is
    also the most critical development period for speech and language development,
    underpinning communication, learning, and social and emotional
    development.[16]

  3. The Australian Institute of Health and Welfare and the Australian Bureau of
    Statistics has examined the impact of hearing problems on educational
    achievement and noted:

    Poor health among young people may also
    impact on their opportunity to attend and succeed at school. As outlined in the
    2005 edition of this report, health conditions such as otitis media (middle ear
    infection) and poor nutrition have been shown to negatively affect educational
    attainment. In 2004–05, young Indigenous people who had left school at
    Year 9 or below were around twice as likely as those who had completed Year 12
    to have ear/hearing problems and heart/circulatory diseases. These
    conditions—if present from childhood—may have had a significant
    impact on both school performance and
    attendance.[17]

  4. In 2003 National Aboriginal Community Controlled Health Organisation
    (NACCHO) found that school attendance levels were far lower for Aboriginal and
    Torres Strait Islander children with CSOM than for other Aboriginal and Torres
    Strait Islander children.[18] Classroom buildings are often not designed to provide for the needs of children
    with decreased hearing levels.[19] If these needs are not addressed in schools it is likely that children who
    struggle to hear well will become disruptive and poorly behaved. As a result
    children with hearing impairment or deafness are often labelled ‘trouble
    makers’, suspended or expelled, or otherwise inappropriately placed in
    special education classes.[20]

  5. A negative impact on educational achievement can have further negative life
    repercussions as educational achievement has been found to be linked with a
    number of future life outcomes:

    People who have participated in post
    secondary study have greatly improved employment prospects. They are also more
    likely to earn higher incomes. An individual’s education can also affect
    their health, and the health of their children, as well as their ability to make
    informed life decisions.[21]

  6. In relation to a link with health outcomes, ‘ear problems’ have
    been identified as one of seven long-term health conditions responsible for much
    of the ill-health experienced by Aboriginal and Torres Strait Islander
    peoples.[22] Hearing impairment can
    also lead to high levels of frustration and anger, anxiety, depression, stress
    and low self esteem.[23] Consequently, the lack of support and assistance to address these social and
    emotional well being issues can contribute to the high prevalence of mental
    health issues among Aboriginal and Torres Strait Islander peoples with hearing
    impairments.

  7. In relation to employment, a study in a remote Aboriginal community found
    that 60 percent of the Aboriginal workers had some degree of hearing impairment
    and that this impacted upon workplace relationships, ability to communicate with
    others and ability to understand and perform workplace duties. [24] These employees also reported
    experiencing higher levels of frustration and depression compared with other
    employees. The study also found that none of the supervisors or employers had
    any awareness of hearing impairment among their workers.

  8. As far back as 1991, the Royal Commission into Aboriginal Deaths in Custody
    recognised that hearing impairment leading to low levels of education can be an
    indicator for increased contact with the criminal justice
    system.[25] Recent studies also
    indicate high levels of hearing impairment amongst Aboriginal and Torres Strait
    Islander prison populations:

    • A study in Darwin prison found that 90 percent of Aboriginal prisoners had
      some level of hearing
      impairment.[26]

    • A study in 5 prisons across Victoria found that over half the Aboriginal and
      Torres Strait Islander inmates (58%) reported hearing problems sometimes, 4%
      reported a lot of hearing trouble, and 12% of prisoners had a hearing loss in at
      least one ear - compared with 5% in an age-matched Australian adult
      population.[27]

  9. There also appears to be a complex interplay between hearing impairment and
    cognitive disabilities. Recent research on Aboriginal and Torres Strait Islander
    young people with cognitive disabilities involved with the criminal justice
    system suggests that some Aboriginal and Torres Strait Islander young people
    with hearing impairment are incorrectly labelled as having cognitive disability
    because their hearing impairment is not taken into account during
    assessments.[28] This means that
    these Aboriginal and Torres Strait Islander young people are unlikely to receive
    the appropriate support and treatment to address their hearing impairment,
    compounded problems around engagement and participation.

  10. As hearing and listening problems can impact on a persons ability to
    communicate, learn and socialise, hearing impairments have the potential to
    cause negative impacts, both in the short- and long-term, over a wide range of
    life outcomes. These may include, amongst other outcomes:

    • Negative impact on emotional and social wellbeing

    • Negative impact on the early development of children and social
      interaction

    • Negative impact on education

    • Negative impact on employment

    • Increased chances of involvement with the criminal justice system

    • Exclusion and limited participation in community life

  11. In relation to emotional and social well being, there is emerging evidence
    of widespread hearing loss in Aboriginal and Torres Strait Islander communities
    contributing to the higher incidence of mental health problems among Aboriginal
    and Torres Strait Islander
    peoples.[29]

  12. Conductive hearing loss can also impact on a person’s ability for
    intercultural communication. Aboriginal and Torres Strait Islander peoples with
    conductive hearing loss can often cope with their communication difficulties by
    avoiding or minimizing their involvement in intercultural communication. This
    can mean they are less likely to engage with service providers that are
    culturally unfamiliar.[30] Local
    programs, based on what is culturally familiar, will have more success than
    externally imposed, one-size-fits-all, national programs that are inevitably
    unfamiliar.

  13. While hearing problems commonly emerge as a result of health issues, they
    ultimately have an impact on education, training, employment, judicial, social,
    emotional and cultural outcomes. Hearing impairment and deafness needs to be
    addressed not only in the health sector, but through all of these
    sectors.

6 Human rights analysis
of hearing impairment and deafness in Aboriginal and Torres Strait Islander
communities

  1. Six of the important human rights instruments that Australia has agreed to
    be bound by identify the human rights standards which are relevant to Aboriginal
    and Torres Strait Islander peoples with hearing impairments and deafness. These
    human rights instruments are:

    • International Covenant on Economic, Social and Cultural Rights (1966)

    • International Covenant on Civil and Political Rights (1966)

    • Convention on the Rights of Persons with Disabilities (2006)

    • UN Declaration on the Rights of Indigenous Peoples (2007)

    • Convention on the Rights of the Child (1989)

    • Convention on the Elimination of all forms of Racial Discrimination (1965)

  2. At the individual level, Aboriginal and Torres Strait Islander peoples with
    hearing impairments and deafness may have their individual rights to health,
    education, employment and participation affected. Individually, they can also
    face discrimination on the basis of their disability.

  3. The multiple levels of disadvantages faced by Indigenous peoples with
    hearing impairment and deafness are acknowledged by a number of international
    human rights instruments, as well as human rights bodies:

    UN
    Declaration on the Rights of Indigenous Peoples    : ‘particular attention
    shall be paid to the rights and special needs of indigenous ... persons with
    disabilities in the implementation of this
    Declaration’.[31]

    Convention on the Rights of Persons with Disabilities: The State
    Parties to this Convention...‘Concerned about the difficult
    conditions faced by persons with disabilities who are subject to multiple or
    aggravated forms of discrimination on the basis of race, colour, sex, language,
    religion, political or other opinion, national, ethnic, indigenous or social
    origin, property, birth, age or other
    status.[32]

    Committee on the Rights of the Child: 'The Committee, through its extensive
    review of State party reports, notes that indigenous children are among those
    children who require positive measures in order to eliminate conditions that
    cause discrimination and to ensure their enjoyment of the rights of the
    Convention on equal level with other
    children’.[33]

  4. At a systemic level, the high levels of socio-economic disadvantage and the
    low level of accessible, and culturally appropriate services for Aboriginal and
    Torres Strait Islander communities increases the prevalence and compounds the
    impacts of hearing impairment and deafness in these communities.

  5. For government to meet its human rights obligation, Federal, State,
    Territory and local governments need to meet the specific needs of Aboriginal
    and Torres Strait Islander peoples with hearing impairments and deafness and
    ensure their rights are realised without discrimination. Some of the
    international human rights instruments and bodies outline what kinds of measures
    State parties can take to realise such specific needs:

    Convention
    on the Rights of Persons with Disabilities    , Article 25 – Health:
    States Parties recognize that persons with disabilities have the right to the
    enjoyment of the highest attainable standard of health without discrimination on
    the basis of disability. States Parties shall take all appropriate measures to
    ensure access for persons with disabilities to health services that are
    gender-sensitive, including health-related rehabilitation. In particular, States
    Parties shall:

    1. Provide persons with disabilities with the same range, quality and standard
      of free or affordable health care and programmes as provided to other persons,
      including in the area of sexual and reproductive health and population-based
      public health programmes;

    2. Provide those health services needed by persons with disabilities
      specifically because of their disabilities, including early identification and
      intervention as appropriate, and services designed to minimize and prevent
      further disabilities, including among children and older persons;

    3. Provide these health services as close as possible to people’s own
      communities, including in rural areas;

    4. Require health professionals to provide care of the same quality to persons
      with disabilities as to others, including on the basis of free and informed
      consent by, inter alia, raising awareness of the human rights, dignity, autonomy
      and needs of persons with disabilities through training and the promulgation of
      ethical standards for public and private health care;

    5. Prohibit discrimination against persons with disabilities in the provision
      of health insurance, and life insurance where such insurance is permitted by
      national law, which shall be provided in a fair and reasonable manner;

    6. Prevent discriminatory denial of health care or health services or food and
      fluids on the basis of disability.

    Committee on the Rights of the
    Child: ‘...State parties are urged to consider the application of special
    measures in order to ensure that indigenous children have access to culturally
    appropriate services in the areas of health, nutrition, education, recreation
    and sports, social services, housing, sanitation and juvenile
    justice’.[34]

    Committee on Economic, Social and Cultural Rights: ‘The right to
    physical and mental health also implies the right to have access to, and to
    benefit from, those medical and social services - including orthopaedic devices
    - which enable persons with disabilities to become independent, prevent further
    disabilities and support their social integration... Similarly, such persons
    should be provided with rehabilitation services which would enable them to
    “reach and sustain their optimum level of independence and
    functioning”... All such services should be provided in such a way that
    the persons concerned are able to maintain full respect for their rights and
    dignity’.[35]

  6. A rights based approach requires setting targets and indicators for the
    progressive realisation of these
    rights.[36] In March 2008, the
    Australian government signed the Close the Gap Statement of Intent at the
    National Indigenous Health Equality Summit. The government committed to work
    together with Indigenous and non-Indigenous health organisations to achieve
    equality in health status and life expectancy between Indigenous and non-
    Indigenous Australians by the year 2030. As a part of this effort they agreed to
    ensuring the primary health care services and health infrastructure for
    Indigenous Australians were capable of bridging the gap in health standards by
    2018. Importantly, they also committed to measuring, monitoring, and reporting
    on their joint efforts in accordance with a range of supporting sub-targets and
    benchmarks.

  7. The Steering Committee of the Close the Gap Campaign on Indigenous Health
    Equality, has developed the Indigenous Health Equality Targets to guide policy
    decisions and target-setting for Indigenous health equality over the next 25-
    years. The specific health targets for aural health include:

  • By 2013: Performance indicators for hearing service providers under the
    Commonwealth Hearing Services Program are developed to improve hearing services
    provision and rehabilitation services;

  • By 2013: That the capacity of all State and Territory health services to
    monitor ear disease and ensure the testing of the hearing ability of Indigenous
    Australian children by 3 years of age, shall form part of the criteria for
    service accreditation;

  • By 2013: Targets for State and Federal bilateral financing agreements on
    health equity within mainstream programs are developed and agreed to under the
    Health Care Agreements including for Commonwealth Hearing Services Program;

  • By 2018: 90% of Aboriginal and Torres Strait Islander children have a
    hearing assessment prior to school
    entry.[37]

7 Specific measures
required for preventing and accommodating hearing impairment and deafness in
Aboriginal and Torres Strait Islander communities

7.1 Positive
government policies

  1. There
    are elements of the current government policy framework that can positively
    contribute to addressing hearing impairment and deafness in Aboriginal and
    Torres Strait Islander communities. These include:

    1. Social Inclusion Policy: There are three priority areas that the government
      has identified within the social inclusion policy which are relevant to
      Aboriginal and Torres Strait Islander peoples with hearing impairment and
      deafness:

      • Closing the gap between Indigenous and non-Indigenous Australians and
        overcoming Indigenous disadvantage has been identified as a priority area.
        Within this priority area, the government has set targets related to life
        expectancy, child mortality, access to early childhood education, educational
        attainment and employment
        outcomes.[38]

      • Employment for people with a disability. This includes increasing the
        opportunities for people with disabilities to participate actively in society
        through better access to education and training. In addition the government is
        aiming to build stronger community understanding and support for people living
        with a disability.[39]

      • Supporting children at greatest risk of long term disadvantage. This
        includes protective measures to address the serious ways in which multiple
        levels of disadvantage faced in childhood impact upon whole-of-life
        outcomes.[40]

    2. 2009-2010 Budgetary commitments:

      • $58.3 million over four years to expand eye and ear health services to
        improve education and employment outcomes for Aboriginal and Torres Strait
        Islander people. The measure commenced in July 2009 and will be administered by
        the Department of Health and
        Ageing.[41]

      • $131.1 million over three years to fund increased primary health care and
        health-related services as part of the Closing the Gap commitments in the
        Northern Territory.



        The measure also provides for the completion of
        follow up services for dental and ear, nose and throat conditions that were
        identified through Northern Territory Emergency Response child health
        checks. In addition, the measure provides for the expansion of the current
        Mobile Outreach Service to respond to child abuse-related trauma and for the
        continuation of alcohol and other drug treatment and rehabilitation
        services. [42]

    1. The National Disability Strategy aims to address the barriers that are faced
      by Australians with disability and promote social inclusion. The Strategy will
      be an important mechanism in ensuring the principles underpinning the Convention
      on the Rights of Persons with Disabilities are integrated into policies and
      programs affecting people with disability, their families and
      carers.[43]

7.2 Successful
Projects

In addition there are examples of successful projects that have made a real
difference in the lives of Aboriginal and Torres Strait Islander peoples with
hearing impairments and deafness. The Productivity Commission has profiled
several such projects in its recent report entitled Overcoming Indigenous
Disadvantage: Key Indicators 2009:

  • An education and screening program for otitis media in Aboriginal children.
    The program is providing a culturally appropriate health service for Aboriginal
    children resulting in improved access to early intervention and early treatment
    for ear disease, improved hearing and learning for children and an improved
    health status of children;

  • Swimming pools in remote communities - have reduced prevalence of skin
    infections and rates of ear disease;

  • Ear health programs - that increase awareness of the importance of ear
    disease and hearing loss as issues in health and education;

  • Educational tools - Development of in-class hearing assessment tools for
    teaching staff, hearing assessment games for parents and professional
    development for both teachers and parents to identify any hearing loss. This has
    resulted in early detection of students with conductive hearing loss. This has
    meant that students receive educational support and referral for treatment more
    quickly. It has also resulted in a reduction in behavioural problems in the
    classroom.[44]

The
Northern Territory Health Department’s video on ear surgery procedures is
an example of a successful program for the provision of ear surgery:

NT Health developed an innovative video that walks children and family
members through what is involved in an ear surgery. Children and adults with
hearing loss often become anxious about participation in unfamiliar processes.
One way of coping with this is to avoid involvement such processes.

This type of information resource is an important means of making the surgery
process familiar, thereby relieving the anxieties, and improving both rates of
participation in surgery as well as after treatment compliance. The video is the
first health information resource that addresses this largely unrecognised link
between hearing loss, anxiety and non-attendance/non-compliance of Indigenous
patients. [45]

Successful programs have also been conducted in the area of employment:

A study found that 60 percent of remote Aboriginal workers experience
occupationally significant conductive hearing loss and as a result, in
comparison with their colleagues, were experiencing: poorer overall work
performance; less proficiency in oral English and literacy; and more difficulty
following verbal instructions and learning on the job.

In response the Group Training Northern Territory was funded by the Federal
Department of Education, Science and Training to deliver the ‘Better
Aboriginal training and employment outcomes’ Project. The Project involved
developing and delivering a model of organisational and individual intervention
consisting of:

  • Audits of workplace acoustics and communications processes.
  • Supervisor training and mentoring.
  • Wellness planning with workers.

The occupational disadvantages experienced by Aboriginal workers
with hearing loss were shown to be minimised when supervisors understood
communication problems related to hearing loss and used more effective
communication strategies. Workers also received help to address the social and
emotional challenges related to listening
problems.[46]

  1. The Productivity Commission has clearly identified a need
    to collect data to enable the assessment of the true burden of hearing loss and
    the type and severity of ear infections in the Aboriginal and Torres Strait
    Islander population.[47]

  2. There would also be value in the government supporting further research in
    Indigenous hearing and communication. There is a need to develop further
    multidisciplinary, cross cultural research and reviews of different
    jurisdictions (i.e. in health, education, criminal justice and employment). Such
    research could promote awareness of Indigenous hearing loss and its outcomes,
    inform evidence based government policy and service delivery, and support the
    highly mobile non Indigenous workforce, especially in remote areas, to improve
    service delivery.

7.3 Additional
measures to close the gap

  1. Addressing the specific needs of Aboriginal and Torres Strait Islander
    peoples with hearing impairment and deafness requires a comprehensive and
    integrated range of culturally appropriate measures.
  2. Taking time to understand local perspectives and contexts is an essential
    part of developing services or supports in partnership with individual, family
    or community that are culturally relevant, acceptable and likely to be
    effective.[48] Given the
    difficulties with intercultural communication faced by Aboriginal and Torres
    Strait Islander peoples with conductive hearing loss it is critical that
    culturally responsive services are made
    available.[49]
  3. The Aboriginal Disability Network of NSW provided the following description
    of the problems associated with previous strategies to address disability within
    Indigenous communities:

    Historically much of the focus on Aboriginal
    people with disability has been from a health perspective...(this) has come at
    the cost of failing to recognise the social aspects of Aboriginal disability.
    This has meant that the barriers that produce discrimination against Aboriginal
    people with disability remain firmly entrenched and the general well-being of
    Aboriginal people with disability has not improved in any meaningful way.

    The experiences of many Aboriginal people with disability is that their
    disability is often medicalised. Interventions often simply treat the
    individual’s health condition without considering the broader implications
    of their condition, i.e. the social barriers to participation. This is an
    ongoing problem as significant funds are continually poured into Aboriginal
    health programs without the foresight to consider the broader social needs of
    Aboriginal people.

    As one Aboriginal person with disability put it at one of the community
    consultations, ‘getting a wheelchair helps me around my home but it
    doesn’t help my whole life; I still can’t get down to the shops and
    go to places I want to go because the footpath is too bad’. This response
    acts as a powerful analogy for the problem of dealing with only one aspect of
    the life of an Aboriginal person with disability, that is dealing only with the
    health aspects through the provision of a technical aid without addressing the
    systemic barriers that impact the person’s life, such as an inaccessible
    community.

    Aboriginal people with disability are significantly under-represented on a
    population basis in participation in beneficial social programs (including
    health, community and disability services) due to a number of policy and
    structural failures. These failures include services that are poorly targeted
    and located, as well as culturally insensitive or inappropriate. Furthermore,
    there are very few Indigenous specific disability services, or non-Indigenous
    disability services with Aboriginal staff. In many cases, particularly in rural
    and remote communities, Aboriginal people with disability are the victims of
    institutional racism that often results in little or no service provision. Today
    sadly this remains a major barrier for Aboriginal people with disability in
    their desire to be able to meaningfully participate in the wider
    community.[50]

  4. The range of additional measures required, which combine health and medical
    interventions with social and economic strategies, include:

  • Addressing the socio-economic determinants of hearing impairment and
    deafness, such as housing, diet and education. This could include programs that
    focus on improving overcrowding, personal hygiene and water and sanitation
    systems in houses, encouraging breastfeeding, discouraging smoking and
    encouraging swimming and vaccination;

  • Addressing the discrimination faced primarily in terms of disability and
    race;

  • Ensuring adequate provision of accessible, affordable and culturally
    appropriate services including:

    • Diagnosis and effective medical and audiological management of Aboriginal
      infants with otitis media and conductive hearing loss;

    • Community education regarding strategies for reducing adverse
      developmental consequences associated with hearing
      loss;

    • Early intervention services at health clinics - conducting otoscopic
      examinations for otitis media at least every 3 months at well-baby visits, and
      including otoscopic examinations for otitis media in any assessment of a sick
      child; implementing a universal neonatal hearing screening as part of a
      comprehensive population-based approach to family, maternal and child health
      (see the National Aboriginal and Torres Strait Islander Child and Maternal
      Health Policy Framework, which is currently under
      development);[51]

    • Providing
      support services for families with children with hearing difficulties;

    • Providing regular hearing screening in child care facilities;

    • Developing school-based strategies to help prevent and combat the effects
      of ear disease such as: regular hearing screenings; health screenings and ear
      examinations in schools; installation of sound field amplification systems in
      classrooms to create enhanced listening
      environments;[52] teacher training
      should include components on identifying hearing impairment among students and
      communication skills and teaching strategies to support students with hearing
      impairment and deafness; and establishing mechanisms for the direct involvement
      of parents, carers and other associates of students with disability in
      determining their needs – including communication between health and
      education services for particular students identified with hearing impairment
      issues;[53] and

    • Developing and funding employment based programs that provide for audits
      of workplace acoustics and communications processes, supervisor training and
      mentoring and wellness planning with workers.

  1. The Commission recommends the government address the specific needs of
    Aboriginal and Torres Strait Islander peoples with hearing impairment and
    deafness by supporting and providing for measures that:

    • Address the socio-economic determinants of hearing impairment and deafness,
      such as housing, diet and education;

    • Address the discrimination faced primarily in terms of disability and
      race;

    • Ensure adequate provision of accessible, affordable and culturally
      appropriate services in the areas of health, housing, education, employment and
      the criminal justice sector; and

    • Support further research in Indigenous hearing and communication and develop
      the evidentiary base for understanding the impact of hearing impairment and
      deafness on Aboriginal and Torres Strait islander
      communities.

[1] Australian Bureau of Statistics
and Australian Institute of Health and Welfare, The Health and Welfare of
Australia's Aboriginal and Torres Strait Islander Peoples 2008, ABS Release
4704.0 (2008), p 134. At http://www.aihw.gov.au/publications/ihw/hwaatsip08/hwaatsip08.pdf (viewed 1 October 2009).

[2] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2007, (2007) p 5.25. At http://www.pc.gov.au/__data/assets/pdf_file/0004/64750/keyindicators2007.pdf (viewed 14 January 2009).

[3] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2007, (2007) p 5.25. At http://www.pc.gov.au/__data/assets/pdf_file/0004/64750/keyindicators2007.pdf (viewed 14 January 2009).

[4] Australian Indigenous Health Info Net, Review of ear health and hearing, (2006) par 2. At http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews/our-review (viewed 13 January 2009).

[5] Australian Indigenous Health Info Net, Review of ear health and hearing, (2006) par 2. At http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews/our-review (viewed 13 January 2009).

[6] Steering Committee for the Review of Government Service Provision, Overview:
Overcoming Indigenous Disadvantage, Key Indicators 2009, (2009), p 6.47. At http://www.pc.gov.au/__data/assets/pdf_file/0003/90129/key-indicators-2009.pdf (viewed 1 October 2009).

[7] Australian Bureau of Statistics
and Australian Institute of Health and Welfare, The Health and Welfare of
Australia's Aboriginal and Torres Strait Islander Peoples 2005, ABS Release
4704.0 (2005), p 22. At http://www.aihw.gov.au/publications/ihw/hwaatsip05/hwaatsip05.pdf (viewed 14 January 2009).

[8] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2007, (2007) p 27. At http://www.pc.gov.au/__data/assets/pdf_file/0004/64750/keyindicators2007.pdf (viewed 14 January 2009).

[9] Australian Bureau of Statistics
and Australian Institute of Health and Welfare, The Health and Welfare of
Australia's Aboriginal and Torres Strait Islander Peoples, 2008, ABS Release
4704.0 (2008) p 134. At http://www.aihw.gov.au/publications/ihw/hwaatsip08/hwaatsip08.pdf (viewed 13 January 2009).

[10] Steering Committee for the Review of Government Service Provision, Overview
- Overcoming Indigenous Disadvantage, Key Indicators 2009, (2009), p
32. At
http://www.pc.gov.au/__data/assets/pdf_file/0013/90130/overview-booklet…
(viewed 1 October 2009).

[11] In
the 2006 Census there were 20,739 Indigenous households that were
experiencing

moderate overcrowding, representing 14% of Indigenous Australian
households. At 30 June 2008 there were 295 (2%) Indigenous community housing
(ICH) dwellings not connected to an organised supply for water, 402 (2%)
dwellings not connected to an organised supply of sewerage, and a further 338
(2%) dwellings not connected to an organised supply of electricity. Australian
Institute of Health and Welfare, Indigenous Housing Needs 2009 (2009), pp
13, 33. At http://www.aihw.gov.au/publications/hou/hou-214-10635/hou-214-10635.pdf (viewed 12 October 2009).

[12] Australian Indigenous Health Info Net, Review of ear health and hearing (2006) par 11. At http://www.healthinfonet.ecu.edu.au/other-health-conditions/ear/reviews/our-review (viewed 13 January 2009).

[13] S Burrow and N Thomson,
‘Summary of Indigenous Health: Ear Disease and Hearing Loss’ Aboriginal and Islander Health Worker Journal (2006) Vol 30(1), p 10-12.

[14] Aboriginal Disability
Network of NSW, Telling it like it is, a report on community consultations
with Aboriginal people with disability and their associates throughout NSW,
2004-2005 (2007), p 12. At http://www.pwd.org.au/adnnsw/news/telling_it_like_it_is.doc (viewed 19 January 2009). The issues of access to affordable fresh food in
Aboriginal and Torres Strait Islander communities has also been considered by
the House of Representatives Standing Committee on Aboriginal and Torres Strait
Islander Affairs, in the Inquiry into community stores in remote communities.
See a discussion of these issues in Western Australian Department of
Communities, Submission 88, p 2. At http://www.aph.gov.au/house/committee/atsia/communitystores/subs/sub0088.pdf (viewed 3 October 2009).

[15] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2009 (2009), p 6.38. At http://www.pc.gov.au/__data/assets/pdf_file/0003/90129/key-indicators-2009.pdf (viewed 1 October 2009).

[16] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2009 (2009), p 6.40. At http://www.pc.gov.au/__data/assets/pdf_file/0003/90129/key-indicators-2009.pdf (viewed 1 October 2009).

[17] Australian Bureau of Statistics and Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander
Peoples 2008, ABS Release 4704.0 (2008), pp 25-26. At http://www.aihw.gov.au/publications/ihw/hwaatsip08/hwaatsip08.pdf (viewed 1 October 2009).

[18] Steering Committee for the
Review of Government Service Provision, Overcoming Indigenous Disadvantage,
Key Indicators 2007 (2007) p 5.3. At http://www.pc.gov.au/__data/assets/pdf_file/0004/64750/keyindicators2007.pdf (viewed 14 January 2009).

[19] K
Bethune, Impact of ear disease, (Speech delivered at the 3rd National
Deafness Sector Summit, Brisbane, May 2004) pp 1-3. At http://www.deafnessforum.org.au/word/summit04/trans_Kathy%20Bethune.doc (viewed 27 January 2009).

[20] Aboriginal Disability
Network of NSW, Telling it like it is, a report on community consultations
with Aboriginal people with disability and their associates throughout NSW,
2004-2005 (2007) p 22. At http://www.pwd.org.au/adnnsw/news/telling_it_like_it_is.doc (viewed 19 January 2009).

[21] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2007 (2007) p 14. At http://www.pc.gov.au/__data/assets/pdf_file/0004/64750/keyindicators2007.pdf (viewed 14 January 2009).

[22] Australian Bureau of Statistics and Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander
Peoples 2008, ABS Release 4704.0 (2008), p xxii. At http://www.aihw.gov.au/publications/ihw/hwaatsip08/hwaatsip08.pdf (viewed 1 October 2009).

[23] D
Howard, ‘Indigenous hearing loss and the criminal justice system: a
background paper’ p 5. At http://www.eartroubles.com/attachments/Crinal%20justice%20and%20hearing%20loss-%20background.pdf (viewed 27 January 2009).

[24] Howard D, Occupational
issues for the many indigenous workers who are hearing impaired, (Speech
delivered at the 5th National Deafness Sector Summit, Canberra, 24-25 May 2008)
pp 3-4. Available at http://www.deafnessforum.org.au/files/u1/Damien_HOWARD_transcript_0.doc (viewed 4 February 2009).

[25] Royal Commission into Aboriginal Deaths in Custody. Final Report (1991)
Vol 2, p351. Available at http://www.austlii.edu.au/au/other/IndigLRes/rciadic/ (viewed 1 October 2009).

[26] A
Yonovitz, Hearing loss and communication disability within the criminal
justice system (Poster presented at the Australasian Audiology Conference,
Brisbane, 2004), cited in D Howard, Communication, listening and criminal
justice, (Presentation to NT Magistrates, Darwin and Alice Springs, March
2006).

[27] S Quinn and G Rance,
‘The extent of hearing impairment amongst Australian Indigenous prisoners
in Victoria, and implications for the correctional system’,
International Journal of Audiology (2009), Vol 48(3) pp
123-134.

[28] Aboriginal and
Torres Strait Islander Social Justice Commissioner Preventing Crime and
Promoting Rights for Indigenous Young People with Cognitive Disabilities and
Mental Health Issues (2008) p
46.

[29] D Howard, Hearing
loss and Indigenous social and emotional wellbeing (Paper to the 44th
Australian Psychological Society Annual Conference, Darwin, 30 September
2009).

[30] D Howard,
‘Intercultural communications and conductive hearing loss’, First
Peoples Child and Family Review (2007) Vol 3, No 3, pp
96-105.

[31]UN Declaration on
the Rights of Indigenous Peoples, 2007, art 22 (1). At http://www1.umn.edu/humanrts/instree/declaration.html,
(viewed 3 March 2009).

[32] Convention on the Protection and Promotion on the Rights and Dignity of
Persons with Disabilities, 2006, Preamble. At http://www1.umn.edu/humanrts/instree/disability-convention2006.html (viewed 6 May 2009).

[33] Committee on the Rights of
the Child, General Comment No. 11 (2009) – Indigenous Children and
their Rights under the Convention, UN doc CRC/C/GC/11 (2009), par 25. At http://www2.ohchr.org/english/bodies/crc/docs/GC.11_indigenous_New.pdf (viewed 18 March 2009).

[34] Committee on the Rights of
the Child, General Comment No. 11 (2009) – Indigenous Children and
their Rights under the Convention, UN doc CRC/C/GC/11 (2009), par 25. At http://www2.ohchr.org/english/bodies/crc/docs/GC.11_indigenous_New.pdf (viewed 18 March 2009).

[35]Committee on Economic, Social
and Cultural Rights, General Comment No 5 (1994) – Persons with
Disability, UN doc E/1995/22 at 19 (1994), par 34. At http://www1.umn.edu/humanrts/gencomm/epcomm5e.htm (viewed 18 March 2009).

[36] Committee on Economic,
Social and Cultural Rights, General Comment No 3 (1990) – The antur of
States parties obligations (Article 2, par 1), UN doc E/1991/23, par 2. At
http://www.unhchr.ch/tbs/doc.nsf/(symbol)/CESCR+General+comment+3.En?Op…
(viewed 15 October 2009).

[37] Aboriginal and Torres Strait Islander Commissioner and the Steering Committee
for Indigenous Health Equality, Close the Gap National Indigenous Health
Equality Targets (2008) pp 32, 34-35. At http://humanrights.gov.au/social_justice/health/targets/index.html (viewed 1 October 2009).

[38] Australian Government, Closing the Gap for Indigenous Australians, http://www.socialinclusion.gov.au/Priorities/Pages/ClosingtheGap.aspx (viewed 27 May 2009).

[39] Australian Government, Employment for people living with a disability or a
mental illness, http://www.socialinclusion.gov.au/Priorities/Pages/disabilityormentalillness.aspx (viewed 27 May 2009).

[40] Australian Government, Supporting children at greatest risk of long term
disadvantage, http://www.socialinclusion.gov.au/Priorities/Pages/Supportingchildren.aspx (viewed 27 May 2009)

[41] Australian Government, Department of Families, Housing, Community Services and
Indigenous Affairs, Budget 2009-10, Closing the Gap - Improving eye and ear
health services for Indigenous Australians, At http://www.fahcsia.gov.au/about/publicationsarticles/corp/BudgetPAES/budget09_10/indigenous/Pages/05_ImprovingEyeEarHealthServices.aspx (viewed 27 May 2009).

[42] Australian Government, Department of Families, Housing, Community Services and
Indigenous Affairs, Budget 2009-10 Closing the Gap - Northern Territory -
Indigenous health and related services. At http://www.fahcsia.gov.au/about/publicationsarticles/corp/BudgetPAES/budget09_10/indigenous/Pages/33_NT_IndigenousHealthRelatedServices.aspx (viewed 27 May 2009).

[43] Department of Families, Housing, Community Services and Indigenous Affairs, National Disability Strategy, http://www.fahcsia.gov.au/sa/disability/progserv/govtint/Pages/nds.aspx (viewed 3 Jun 2009).

[44] Steering Committee for the Review of Government Service Provision, Overcoming
Indigenous Disadvantage, Key Indicators 2009, Productivity Commission,
(2009), pp 6.41-6.42. At http://www.pc.gov.au/__data/assets/pdf_file/0003/90129/key-indicators-2009.pdf (viewed 1 October 2009).

[45] D
Howard, Ear disease, anxiety and Indigenous access to health and education
services (Paper to the Kalgoorlie Ear Health Conference, Kalgoorlie, May
2009).

[46] Information provided
to the Commission by D Howard, Phoenix Consulting (2009).

[47] Steering Committee for the
Review of Government Service Provision, Overcoming Indigenous Disadvantage,
Key Indicators 2009, Productivity Commission, (2009), p 76. At http://www.pc.gov.au/__data/assets/pdf_file/0003/90129/key-indicators-2009.pdf (viewed 1 October 2009).

[48] Western Australia Disability
Services Commission, Aboriginal people with disabilities, getting the
services right, (2006) p 7. At http://www.disability.wa.gov.au/dscwr/_assets/main/guidelines/documents/pdf/getting_services_right_(id_3565_ver_1.0.0).pdf (viewed 14 January 2009).

[49] D
Howard, ‘Intercultural communications and conductive hearing loss’, First Peoples Child and Family Review (2007) Vol 3, No 3, pp 96-105.

[50] Aboriginal Disability
Network of NSW, Telling it like it is, a report on community consultations
with Aboriginal people with disability and their associates throughout NSW,
2004-2005 (2007) pp 2-3. At http://www.pwd.org.au/adnnsw/news/telling_it_like_it_is.doc (viewed 19 January 2009).

[51] HealthInfoNet. Review of
ear health and hearing. (2006) pars 31-35. At http://www.healthinfonet.ecu.edu.au/html/html_community/ear_health_community/reviews/ear_our_review.htm (viewed 13 January 2009).

[52] Australian Bureau of
Statistics and Australian Institute of Health and Welfare, The Health and
Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2005,
(2005), ABS Release 4704.0 p 23. At http://www.aihw.gov.au/publications/ihw/hwaatsip05/hwaatsip05.pdf (viewed 14 January 2009).

[53] Aboriginal Disability
Network of NSW, Telling it like it is, a report on community consultations
with Aboriginal people with disability and their associates throughout NSW,
2004-2005 (2007) p 22. At http://www.pwd.org.au/adnnsw/news/telling_it_like_it_is.doc (viewed 19 January 2009).