Spotlight
Feature Indigenous Australians and the struggle for health equality For more on Lung Foundation Australia see http:// lungfoundation.com.au/ For Close the Gap Campaign see http://www.naccho.org.au/ aboriginal-health/close-the-gapcampaign/ For the Statement of Intent 2008 see https://www. humanrights.gov.au/ publications/close-gapindigenous-health-equalitysummit-statement-intent For more on the National Congress of Australia’s First Peoples see http:// nationalcongress.com.au/
Lonely Planet/Getty Images
For more on lung disease in Indigenous children see Pediatric Res Rev 2014; 15: 325–32
188
Health inequality is a global concern—systematic differences in health status between different population groups have substantial social and economic costs to individuals and societies. In affluent Australia, the most affected communities are Aboriginal and Torres Strait Islander people, known as Indigenous or First Peoples, who face discrimination and poor health outcomes. Efforts to close the health gap have so far fallen short; to achieve a level playing field, campaigners argue, well-meaning health policies have to be acted on, and not only talked about. About 670 000 (3%) Australian domiciles are Aboriginal or Torres Strait Islanders, according to data from the 2011 census. Many Indigenous Australians live on the east coast, and about 8% live in remote areas and 14% in very remote areas—compared with a combined total of 2% for nonIndigenous people—where health status and social wellbeing tend to be worse than in less remote parts of the country. Health disparities are clearly seen in the high prevalence of mortality and morbidity due to chronic disease in Indigenous communities. According to Lung Foundation Australia, mortality from respiratory illnesses are 2·4 to 24 times higher in Indigenous people than non-Indigenous people, dependent on disease type. Heather Allen, the organisation’s chief executive officer (CEO), told The Lancet Respiratory Medicine that the death rate from chronic obstructive pulmonary disease in Indigenous Australians is five times that for non-Indigenous Australians and affects 20% of Indigenous adults, with a higher prevalence in remote regions. The Foundation comments that respiratory illness is the second most common cause of hospital admission for Indigenous people nationwide (after renal dialysis), and that respiratory diseases are among the most common long-term health disorders reported in young Aboriginal children. For Indigenous Australians, health encompasses the social, emotional, and cultural wellbeing of the whole community—a cyclical and holistic view that incorporates broader issues of social justice and connection to land,
culture, language, and ancestry. Providing access to appropriate health care that embodies this whole-of-life philosophy is at the core of the Aboriginal Community Controlled Health Services (ACCHS), a network established in 1974 to provide cross-disciplinary primary health care across Australia to address the health disparities facing First Peoples. Since 2006, Close the Gap Campaign, an initiative driven by Australia’s health bodies, NGOs, and human rights organisations, has set its sights on ending health inequities “within a generation”. In 2008, the then Australian Government and opposition parties signed the Campaign’s Statement of Intent, a declaration and commitment to “work together to achieve equality” by the year 2030—an ambitious, and welcome goal, but regarded by some as long overdue. The National Congress of Australia’s First Peoples aims to adopt a rights-based approach to align the health status and life expectancy of Aboriginal and Torres Strait Islander people with those of non-Indigenous Australians. Geoff Scott, the CEO of the National Congress, notes, “As regards health outcomes, apart from improvements in the levels of low birthweight and infant mortality, the health of Aboriginal and Torres Strait Islander peoples has changed very little in the past 5 years, despite government targets and expenditure to reduce the gap in life expectancy, morbidity, and mortality.” Anne Chang (Charles Darwin University, Brisbane, QLD) is an established researcher and evidence-based practitioner in paediatric respiratory health in Indigenous populations. Her work uses disease patterns of respiratory infections and illnesses in both groups as indicators of health disparity. She believes that Indigenous groups can achieve better health outcomes than they do at present. For example, asthma prevalence is similar in Indigenous and non-Indigenous populations, but hospital admissions and mortality are two to three times higher for Indigenous children. Such differentiation in health outcomes has been attributed to the longstanding paucity of culturally appropriate specialist respiratory care, particularly in rural and remote communities. This recognition has led to the development of the Indigenous Respiratory Outreach Care programme in Queensland. So far it has been implemented in 13 communities, reaching about 43 000 Aboriginal people. The aim is to develop a sustainable model directed by community protocols and roll it out across Australia. Some experts believe that identifying what respiratory health means to Aboriginal people is crucial to improve respiratory health outcomes. Availability of health literacy— through the provision of Indigenous-based self-management resources—could be key to helping communities with a high burden of respiratory disease. Jennifer Alison (Faculty of Health Sciences, University of Sydney, Sydney, NSW) and www.thelancet.com/respiratory Vol 3 March 2015
Graeme Maguire (Baker IDI Central Australia, Alice Springs, NT) teamed up with Lung Foundation Australia to develop Breathe Easy Walk Easy, a programme that aims to train rural and remote health workers (both Indigenous and nonIndigenous) to provide optimised management of chronic lung disease. Alison is keen to test the success of pulmonary rehabilitation in rural and remote Aboriginal communities. “Pulmonary rehabilitation has high-level evidence of efficacy in improving exercise capacity and quality of life, reducing hospital admissions and length of hospital stay, as well as reducing mortality”, she notes. But, she continues, “In reality, we haven’t really been able to roll this programme out [to Aboriginal health workers]…for reasons such as lack of funding and insufficient traction through Aboriginal communities.” Low socioeconomic status and environmental factors such as exposure to occupational dust, vapours, and fumes, indoor and outdoor air pollutants, and recurrent bacterial and viral childhood infections contribute to premature mortality and disability among Indigenous people. Maguire supports a holistic approach that addresses respiratory illness across health determinants, risk factors, and secondary and tertiary prevention. “Respiratory health in this setting is by nature a disease of poverty influencing all these stages of disease development and progression. It doesn’t mean other factors aren’t important, it’s just that poverty is driving them.” Maguire also suggests that the value of spirometric screening for Indigenous communities is questionable. He asks whether a test that relies on a genetically homogenous group when they are, in fact, heterogeneous is “physiologically legitimate or merely institutional racism to conceal the burden of disease”. Scott recognises that contributing factors such as “substandard and overcrowded housing, racism and discrimination, education, and health infrastructure” cannot afford to be overlooked to tackle health inequality. He also stresses the need for “more Aboriginal and Torres Strait Islander health professionals at all levels, and health education which takes account of our histories and cultures.” Some successes have been achieved, with Indigenous health projects, such as Tackling Indigenous Smoking, a health initiative that arose from the Close the Gap Campaign. However, despite a decline in smoking rates, an estimated 44% of daily smokers in the Indigenous population compares to 16% in non-Indigenous people. Smoking remains the single biggest cause of death for Aboriginal and Torres Strait Islander people. As of June, 2013, the project had community teams operating in 57 locations nationwide, but with hardhitting government funding cuts, the ambitious targets of halving rates by 2018 are unrealistic. In a move towards promoting effective governance, the National Aboriginal Community Controlled Health Organisation (NACCHO) was established in 1992 to increase the capacity of Aboriginal people to participate in national health policy. NACCHO is the national body that www.thelancet.com/respiratory Vol 3 March 2015
represents more than 150 Aboriginal Community Controlled Health Services, which in turn deliver comprehensive and culturally appropriate primary health care to the Aboriginal communities that set up and control them. Ngiare Brown, an Aboriginal from the Yuin country, South Coast, NSW, has been engaged in research, policy, and advocacy at NACCHO for more than 20 years. She told the The Lancet Respiratory Medicine that NACCHO is the “anchor” for community-controlled health-care services. “We are a collective providing individualised care—a continuity of care for whole-of-life. NACCHO formed as a political response to a total lack of culturally and clinically appropriate and competent services.” NACCHO continue to address the growing trend of exclusion and sidelining in health issues. Despite decades watching governments drag their feet and contending with institutional racism and discrimination, Brown’s spirit is one of self-determination—resolutely committed to what she deems to be an exemplary model of health care, and one that might benefit mainstream health-care services worldwide. Other non-Indigenous clinics are starting to spring up, Brown adds, that “replicate the comprehensive, holistic view of health and wellbeing that we provide for our mobs”. Alwin Chong, a Wakamin man from Far North Queensland, recruits and provides support for Aboriginal students entering health-care professions. He has high praise for the ACCHS, in which he worked for 13 years. However, he notes, mainstream hospitals also have a responsibility to provide appropriate health care for Indigenous people. Chong has contributed to The Lowitja Institute’s Improving the Culture of Hospitals for Aboriginal and Torres Strait Islander People project, which aims to deliver cultural reform and assist hospitals to engage with local Indigenous communities. Collaborative working environments can build much-needed trusting relationships within clinical settings. Nationally, however, social justice issues are far from being reconciled. Ongoing calls for the ratification of a treaty—a settlement or agreement—in line with other First Nation countries such as Canada and New Zealand, have not been answered. However, a treaty would not necessarily act as a magic bullet to achieve health equality. One promising development is the National Aboriginal and Torres Strait Islander Health Plan, the implementation of which promotes leadership within Indigenous communities. The plan includes decision-making responsibility, and a whole-of-government commitment to address and progress health equality. Scott is unequivocal about what needs to happen: “unless Aboriginal and Torres Strait Islander peoples are fundamentally brought into health-care planning, funding decisions, programme implementation, and evaluation, little is likely to change. We must be given a seat at the table at which decisions are made about our own health.”
Heide Smith
Spotlight
For Breathe Easy Walk Easy see http://lungfoundation.com.au/ health-professionals/trainingand-education/breathe-easywalk-easy/ For NACCHO see http://www. naccho.org.au/ For the Lowitja Institute see http://www.lowitja.org.au/ For the National Aboriginal and Torres Strait Islander Health Plan see http://www.health.gov. au/internet/main/publishing. nsf/Content/natsih-plan For more on Aboriginal healthcare see Country in Focus Lancet Respir Med 2013; 1: 193–94
Jules Morgan 189
Feature Indigenous Australians and the struggle for health equality For more on Lung Foundation Australia see http:// lungfoundation.com.au/ For Close the Gap Campaign see http://www.naccho.org.au/ aboriginal-health/close-the-gapcampaign/ For the Statement of Intent 2008 see https://www. humanrights.gov.au/ publications/close-gapindigenous-health-equalitysummit-statement-intent For more on the National Congress of Australia’s First Peoples see http:// nationalcongress.com.au/
Lonely Planet/Getty Images
For more on lung disease in Indigenous children see Pediatric Res Rev 2014; 15: 325–32
188
Health inequality is a global concern—systematic differences in health status between different population groups have substantial social and economic costs to individuals and societies. In affluent Australia, the most affected communities are Aboriginal and Torres Strait Islander people, known as Indigenous or First Peoples, who face discrimination and poor health outcomes. Efforts to close the health gap have so far fallen short; to achieve a level playing field, campaigners argue, well-meaning health policies have to be acted on, and not only talked about. About 670 000 (3%) Australian domiciles are Aboriginal or Torres Strait Islanders, according to data from the 2011 census. Many Indigenous Australians live on the east coast, and about 8% live in remote areas and 14% in very remote areas—compared with a combined total of 2% for nonIndigenous people—where health status and social wellbeing tend to be worse than in less remote parts of the country. Health disparities are clearly seen in the high prevalence of mortality and morbidity due to chronic disease in Indigenous communities. According to Lung Foundation Australia, mortality from respiratory illnesses are 2·4 to 24 times higher in Indigenous people than non-Indigenous people, dependent on disease type. Heather Allen, the organisation’s chief executive officer (CEO), told The Lancet Respiratory Medicine that the death rate from chronic obstructive pulmonary disease in Indigenous Australians is five times that for non-Indigenous Australians and affects 20% of Indigenous adults, with a higher prevalence in remote regions. The Foundation comments that respiratory illness is the second most common cause of hospital admission for Indigenous people nationwide (after renal dialysis), and that respiratory diseases are among the most common long-term health disorders reported in young Aboriginal children. For Indigenous Australians, health encompasses the social, emotional, and cultural wellbeing of the whole community—a cyclical and holistic view that incorporates broader issues of social justice and connection to land,
culture, language, and ancestry. Providing access to appropriate health care that embodies this whole-of-life philosophy is at the core of the Aboriginal Community Controlled Health Services (ACCHS), a network established in 1974 to provide cross-disciplinary primary health care across Australia to address the health disparities facing First Peoples. Since 2006, Close the Gap Campaign, an initiative driven by Australia’s health bodies, NGOs, and human rights organisations, has set its sights on ending health inequities “within a generation”. In 2008, the then Australian Government and opposition parties signed the Campaign’s Statement of Intent, a declaration and commitment to “work together to achieve equality” by the year 2030—an ambitious, and welcome goal, but regarded by some as long overdue. The National Congress of Australia’s First Peoples aims to adopt a rights-based approach to align the health status and life expectancy of Aboriginal and Torres Strait Islander people with those of non-Indigenous Australians. Geoff Scott, the CEO of the National Congress, notes, “As regards health outcomes, apart from improvements in the levels of low birthweight and infant mortality, the health of Aboriginal and Torres Strait Islander peoples has changed very little in the past 5 years, despite government targets and expenditure to reduce the gap in life expectancy, morbidity, and mortality.” Anne Chang (Charles Darwin University, Brisbane, QLD) is an established researcher and evidence-based practitioner in paediatric respiratory health in Indigenous populations. Her work uses disease patterns of respiratory infections and illnesses in both groups as indicators of health disparity. She believes that Indigenous groups can achieve better health outcomes than they do at present. For example, asthma prevalence is similar in Indigenous and non-Indigenous populations, but hospital admissions and mortality are two to three times higher for Indigenous children. Such differentiation in health outcomes has been attributed to the longstanding paucity of culturally appropriate specialist respiratory care, particularly in rural and remote communities. This recognition has led to the development of the Indigenous Respiratory Outreach Care programme in Queensland. So far it has been implemented in 13 communities, reaching about 43 000 Aboriginal people. The aim is to develop a sustainable model directed by community protocols and roll it out across Australia. Some experts believe that identifying what respiratory health means to Aboriginal people is crucial to improve respiratory health outcomes. Availability of health literacy— through the provision of Indigenous-based self-management resources—could be key to helping communities with a high burden of respiratory disease. Jennifer Alison (Faculty of Health Sciences, University of Sydney, Sydney, NSW) and www.thelancet.com/respiratory Vol 3 March 2015
Graeme Maguire (Baker IDI Central Australia, Alice Springs, NT) teamed up with Lung Foundation Australia to develop Breathe Easy Walk Easy, a programme that aims to train rural and remote health workers (both Indigenous and nonIndigenous) to provide optimised management of chronic lung disease. Alison is keen to test the success of pulmonary rehabilitation in rural and remote Aboriginal communities. “Pulmonary rehabilitation has high-level evidence of efficacy in improving exercise capacity and quality of life, reducing hospital admissions and length of hospital stay, as well as reducing mortality”, she notes. But, she continues, “In reality, we haven’t really been able to roll this programme out [to Aboriginal health workers]…for reasons such as lack of funding and insufficient traction through Aboriginal communities.” Low socioeconomic status and environmental factors such as exposure to occupational dust, vapours, and fumes, indoor and outdoor air pollutants, and recurrent bacterial and viral childhood infections contribute to premature mortality and disability among Indigenous people. Maguire supports a holistic approach that addresses respiratory illness across health determinants, risk factors, and secondary and tertiary prevention. “Respiratory health in this setting is by nature a disease of poverty influencing all these stages of disease development and progression. It doesn’t mean other factors aren’t important, it’s just that poverty is driving them.” Maguire also suggests that the value of spirometric screening for Indigenous communities is questionable. He asks whether a test that relies on a genetically homogenous group when they are, in fact, heterogeneous is “physiologically legitimate or merely institutional racism to conceal the burden of disease”. Scott recognises that contributing factors such as “substandard and overcrowded housing, racism and discrimination, education, and health infrastructure” cannot afford to be overlooked to tackle health inequality. He also stresses the need for “more Aboriginal and Torres Strait Islander health professionals at all levels, and health education which takes account of our histories and cultures.” Some successes have been achieved, with Indigenous health projects, such as Tackling Indigenous Smoking, a health initiative that arose from the Close the Gap Campaign. However, despite a decline in smoking rates, an estimated 44% of daily smokers in the Indigenous population compares to 16% in non-Indigenous people. Smoking remains the single biggest cause of death for Aboriginal and Torres Strait Islander people. As of June, 2013, the project had community teams operating in 57 locations nationwide, but with hardhitting government funding cuts, the ambitious targets of halving rates by 2018 are unrealistic. In a move towards promoting effective governance, the National Aboriginal Community Controlled Health Organisation (NACCHO) was established in 1992 to increase the capacity of Aboriginal people to participate in national health policy. NACCHO is the national body that www.thelancet.com/respiratory Vol 3 March 2015
represents more than 150 Aboriginal Community Controlled Health Services, which in turn deliver comprehensive and culturally appropriate primary health care to the Aboriginal communities that set up and control them. Ngiare Brown, an Aboriginal from the Yuin country, South Coast, NSW, has been engaged in research, policy, and advocacy at NACCHO for more than 20 years. She told the The Lancet Respiratory Medicine that NACCHO is the “anchor” for community-controlled health-care services. “We are a collective providing individualised care—a continuity of care for whole-of-life. NACCHO formed as a political response to a total lack of culturally and clinically appropriate and competent services.” NACCHO continue to address the growing trend of exclusion and sidelining in health issues. Despite decades watching governments drag their feet and contending with institutional racism and discrimination, Brown’s spirit is one of self-determination—resolutely committed to what she deems to be an exemplary model of health care, and one that might benefit mainstream health-care services worldwide. Other non-Indigenous clinics are starting to spring up, Brown adds, that “replicate the comprehensive, holistic view of health and wellbeing that we provide for our mobs”. Alwin Chong, a Wakamin man from Far North Queensland, recruits and provides support for Aboriginal students entering health-care professions. He has high praise for the ACCHS, in which he worked for 13 years. However, he notes, mainstream hospitals also have a responsibility to provide appropriate health care for Indigenous people. Chong has contributed to The Lowitja Institute’s Improving the Culture of Hospitals for Aboriginal and Torres Strait Islander People project, which aims to deliver cultural reform and assist hospitals to engage with local Indigenous communities. Collaborative working environments can build much-needed trusting relationships within clinical settings. Nationally, however, social justice issues are far from being reconciled. Ongoing calls for the ratification of a treaty—a settlement or agreement—in line with other First Nation countries such as Canada and New Zealand, have not been answered. However, a treaty would not necessarily act as a magic bullet to achieve health equality. One promising development is the National Aboriginal and Torres Strait Islander Health Plan, the implementation of which promotes leadership within Indigenous communities. The plan includes decision-making responsibility, and a whole-of-government commitment to address and progress health equality. Scott is unequivocal about what needs to happen: “unless Aboriginal and Torres Strait Islander peoples are fundamentally brought into health-care planning, funding decisions, programme implementation, and evaluation, little is likely to change. We must be given a seat at the table at which decisions are made about our own health.”
Heide Smith
Spotlight
For Breathe Easy Walk Easy see http://lungfoundation.com.au/ health-professionals/trainingand-education/breathe-easywalk-easy/ For NACCHO see http://www. naccho.org.au/ For the Lowitja Institute see http://www.lowitja.org.au/ For the National Aboriginal and Torres Strait Islander Health Plan see http://www.health.gov. au/internet/main/publishing. nsf/Content/natsih-plan For more on Aboriginal healthcare see Country in Focus Lancet Respir Med 2013; 1: 193–94
Jules Morgan 189
