Aboriginal and Torres Strait Islander health: Failing to close the gap
On Thursday, 15 March 2018 we recognise National Close the Gap day. Close the Gap is a government-driven strategy that aims to achieve Indigenous health equality by the year 2030. It has been 10 years since the federal and state/territory governments committed to meeting agreed targets to close the gap for Indigenous health. However, very little progress has been made in improving outcomes for Indigenous Australians.
The health inequality experienced by Aboriginal and Torres Strait Islander peoples continues to be a subject of national concern. In this article, we explore the Close the Gap strategy and the role of research in improving health outcomes for Indigenous Australians.
The dramatically poorer health and wellbeing of Indigenous Australians compared to other Australians has been a topic of national concern for quite some time. On average, Aboriginal and Torres Strait Islander peoples are dying approximately 10 years younger than non-Indigenous Australians. Health conditions that disproportionately affect Indigenous peoples include:
- chronic illnesses, including renal failure, cardiovascular diseases, diabetes and asthma
- communicable diseases, including tuberculosis, hepatitis, sexually transmissible infections and HIV/AIDS
- ear disease and hearing problems
- disability and injury
- oral health problems
- mental illness.
Factors contributing to Indigenous health inequality
Several key factors when combined affect the health of individuals. However, the gap in health outcomes between Indigenous and non-Indigenous Australians is perhaps best explained by social determinants. Social determinants of health are the conditions in which people are born, grow, live, work and age, and include factors such as income, education, employment, physical environment, social support and access and use of health services.
The health of Indigenous Australians is also largely affected by complex systemic and cultural factors, including separation from family and community, loss of language and connection to the land, environmental deprivations, disconnectedness and racism. In their 2012 discussion paper on the effects of racism on Indigenous health, Deakin University’s Associate Professor Yin Paradies and colleagues described some of the ways in which racism leads to ill-health, including:
- reduced and unequal access to the societal resources required for health
- increased exposure to risk factors associated with ill health
- direct effects of racism on health, including racially motivated physical assault
- stress and emotional reactions that contribute to mental ill health and adverse affects on the immune, endocrine and cardiovascular systems
- responses to racism, such as smoking and consumption of alcohol and other drugs, that contribute to ill health
Close the Gap
‘Close the Gap’ was founded on the understanding that population health outcomes are fundamentally the result of underlying structural factors and social determinants.
Beginning as a grassroots movement in April 2007, Close the Gap was spearheaded by a coalition of non-government organisations including Oxfam, GetUp and Australians for Native Title and Reconciliation (ANTaR). This campaign led to the National Indigenous Health Equality Summit, held on 20 March 2008, at which representatives of the federal government, peak Indigenous health bodies and the Aboriginal and Torres Strait Islander Social Justice Commissioner signed an historic ‘Close the Gap Statement of Intent’:
…. to work together to achieve equality in health status and life expectancy between Aboriginal and Torres Islander peoples and non-Indigenous Australians by the year 2030.
The Australian government now firmly sets the agenda for policy formulation, performance monitoring and the reporting of outcomes for closing the gap in Indigenous disadvantage. In its first report, Closing the Gap on Indigenous Disadvantage: The challenge for Australia, the federal government specified a series of ‘gaps’ for action and monitoring. It has been 10 years since federal and state/territory governments committed to agreed targets to close the gap for Indigenous health, yet very little progress has been made. The Prime Minister’s 2017 report found we are failing on six of the seven key targets.
Criticisms of Close the Gap
Concerns have been raised about the approach of the Close the Gap strategy, which may in part explain why little progress has been made to date. While these concerns do not render Close the Gap an invalid or worthless approach, it does suggest critical reflection and debate are needed.
Focus on statistical equality
The Close the Gap strategy focuses on achieving Indigenous health equality, measured by change across a number of health indicators. The core intent of achieving statistical equality is not a particularly new concept. In reality, the goal of achieving statistical equality for Indigenous Australians has a long history with a fairly disappointing track record. This is likely because using health indicators as evidence for population health interventions tends to measure shifts in individual attitudes and behaviour and misses changes in the broader social dynamic.
Pholi and colleagues have suggested that a potentially better measure of performance in closing the gap could involve measuring and monitoring progress in the delivery of power and control over Indigenous affairs into the hands of Indigenous Australians. Indeed, The Close the Gap – 10 Year Review noted that not including programs to systematically address the underlying causes of Indigenous health equality was a major shortfall of the Close the Gap strategy.
Another view about the focus on statistical equality is that it reduces Indigenous Australians to a range of indicators of deficit, to be monitored and rectified towards government-set targets.
Failure to partner with Indigenous people
Despite the federal government stating in 2009 that new partnerships with Indigenous Australians was fundamental to its Close the Gap strategy, there has been little involvement of Indigenous groups to date. The 10 Year Review of Close the Gap recognises that there needs to be a far greater effort working with Indigenous Australians on the approaches that can reduce health inequalities.
The involvement of Indigenous Australians is vital to the success of services and programs developed to improve their health. As David Kennedy, former chief executive officer of the Galambila Aboriginal Medical Service expressed:
[When] Aboriginal and Torres Strait Islander Peoples have a real say in the service that they’re getting [it] will be much more appropriate to their needs.
Ngangkari healers in South Australia
In South Australia, Traditional Aboriginal Healers, known locally as ‘Ngangkari’, work hand in hand with medical staff in community clinics and hospitals. Ngangkari healers complement the work of doctors and could play a vital role in bridging the gap in health outcomes between Indigenous and non-Indigenous Australians.
In the 2016 report Hand-in-Hand, Francesca Panzironi drew on interview data demonstrating the benefits of Ngangkari services. These included:
- positive health outcomes for patients
- building community trust in the western health care system
- increasing cost-effectiveness of health care
- reducing cases of misdiagnosis
- enhancing quality health care
- calming effect on patients
- enhancing compliance with western medical treatment
The Ngangkari model is one example of how Indigenous involvement can strengthen health service delivery and improve health outcomes for Indigenous Australians. While the model of Ngangkari has been shown to be effective in South Australia, Australia’s Indigenous population is diverse and the needs of populations in particular regions and locations are likely to differ. Engagement at the local level is needed to ensure services are relevant and appropriate.
The role of Indigenous health research
It is widely accepted that research in the area of Indigenous health is needed to identify how best to implement actions outlined by government. Indigenous health research offers a sound evidence base for future interventions and is critical to closing the gap.
History of Indigenous health research
In Australia, and elsewhere, the concept and practice of research with Indigenous people are intimately tied up in the histories of colonisation. As Australian Indigenous peoples were systematically colonised in the 18th and 19th centuries, their communities and cultures were subjected to study from the point of view of researchers and groups with more power and privilege resulting, in some instances, in exploitation, theft of Indigenous knowledge and the misrepresentation of Indigenous communities.
According to Pat Dudgeon and colleagues, historically, Indigenous health research has provided little benefit to those groups who were researched and, instead, has served to benefit the careers and reputations of researchers. Research efforts have also typically adopted deficit-based approaches, focusing on problems and highlighting differences in health status. There is limited research highlighting the strengths, successes and what works well in Indigenous health.
Aboriginal and Torres Strait Islander peoples have long been critical of the research undertaken on their communities and about their cultures, and it is unsurprising that there is residual mistrust, animosity and resistance from Indigenous people to contemporary research initiatives.
Considerations for researchers
To close the gap, culturally appropriate research is required that empowers Indigenous people to have a key role in discovery and decision-making about their own health reforms. Non-Indigenous researchers are well positioned to actively contribute to capacity building for Indigenous researchers, and should endeavour to make this a priority.
It is essential that contemporary research acknowledges the power relationships within the research setting and ensures that Indigenous peoples are the primary beneficiaries of that work. Jamieson and colleagues propose 10 principles relevant to all Indigenous health-related research.
1. Addressing a priority health issue as determined by the community
2. Conducting research within a mutually respectful partnership framework
3. Capacity building is a key focus of the research partnership, with sufficient budget to support this
4. Flexibility in study implementation while maintaining scientific rigour
5. Respecting communities’ past and present experience of research
6. Recognising the diversity of Indigenous Australian populations
7. Ensuring extended timelines do not jeopardise projects
8. Preparing for Indigenous leadership turnover
9. Supporting community ownership
10. Developing systems to facilitate partnership management in multi-centre studies
Strong and sustained public support for action has put Indigenous health equality on the agenda of state/territory and federal governments, and continued support is needed to maintain the pressure on governments to meet their commitments in closing the gap. Research has an important role to play in addressing the issues faced by Aboriginal and Torres Strait Islander peoples.
Locally, Western Alliance is providing funding support for a participatory action research study to establish community driven methods to increase care planning and improve the management of chronic health conditions for Aboriginal people in south-western Victoria (Gunditjmara country). Let’s have a yarn about chronic disease is a partnership of Dhauwurd Wurrung Elderly and Community Health Service and Deakin Rural Health.