Minister for Health and Ageing, Tony Abbott MHR, has launched the report, Australia's Health 2006 in Canberra on 21 June.
In launching Australia’s Health 2006, my immediate role is to congratulate the Australian Institute of Health and Welfare for its good work, but my more important duty is to draw some suitable policy lessons from it. By all means let's focus on the generally good state of Australians’ health and the professionalism of our health services, but let's also examine what is probably the biggest and certainly the most intractable challenge we face, as illustrated by the statistics in the report.
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Everyone involved in providing health services can be pleased that Australians’ life expectancy is among the top five countries in the world. Overall, it seems that our massive investment in health services is paying off. Over the past two decades, the infant death rate has almost halved; the death rate for children under 15 has halved; and the death rate for people between 15 and 24 has fallen 30 per cent. By contrast, Indigenous life expectancy today is about the same as Australians’ life expectancy 100 years ago. On average, Indigenous people die 17 years younger than other Australians.
Although health spending per Indigenous person is 18 per cent higher than health spending generally, on almost every indicator Indigenous people’s health outcomes are dramatically worse. Indigenous people have twice the rate of hospitalisation for injury or poisoning, Indigenous children are three times as likely to have ear and hearing problems, and Indigenous people have three times the general rate of diabetes. Fifty per cent of Indigenous people smoke tobacco (compared with 17 per cent for Australians generally). Indigenous people are one-and-a-half times as likely to be physically inactive, and are twice as likely to have experienced victimisation, with 24 per cent reporting physical or threatened violence in a 12-month period.
These statistics have not lost their power to shock but hardly come as a surprise. Regardless of people’s cultural or ethnic background, poorer health and lower life expectancies are generally associated with low educational attainment, high unemployment, poor housing and high levels of substance abuse. As the economist Helen Hughes pointed out recently: "Non-Indigenous welfare ghettoes exhibit the same dysfunctional family and civic characteristics with high substance abuse, violence and crime and low workforce participation as Indigenous (ones). But in non-Indigenous welfare communities the impact of welfare is mitigated by proximity to working Australians ... Some welfare victims see the benefits of working and get jobs."
It seems that the fundamental problem is not lack of spending (although it could always be higher) but the culture of directionless-ness in which so many Aboriginal people live. Hughes estimates that the federal Government alone spends nearly $6000 a year on every Aboriginal person and that each Aboriginal household receives $70,000 a year in federal Government services and transfer payments. This has sustained life but hardly realised the idyllic communes of ‘Nugget’ Coombs’ dream.
Since 1996 the Government has increased Indigenous-specific health spending from about $100 million to over $350 million a year. Indigenous utilisation of Medicare and the Pharmaceutical Benefits Scheme has increased by nearly 80 per cent. Federally-funded Aboriginal health services are providing 86 per cent more consultations than ten years ago. Since 1996, thanks in part to the Puggy Hunter scholarships, there's 50 per cent more Indigenous doctors and 30 per cent more Indigenous nurses. In the recent Budget, the Government committed an extra $40 million to provide an extra 80 health professionals to work with Indigenous people in Aboriginal and mainstream health services and to convert 130 part-time into full-time jobs for Aboriginal health staff. There was also $20 million to provide mental health training to over 1200 Aboriginal health service staff. Perhaps most importantly, there was $55 million to combat petrol sniffing in central Australia and other remote settlements designed to remove and to rehabilitate addicts and to extend the roll-out of Opal fuel.
Of itself, this spending commitment doesn’t demonstrate that the Howard Government is more effective than its predecessors but it should certainly establish the Government's good faith. This Government won’t hesitate to invest more, upgrading services and responding to emerging challenges. Still, poor Indigenous health has as much to do with social factors as inadequate facilities. There are no magic bullets here. It’s easy to spend money but hard to make a difference improving services to deprived people in depressed places. Although Indigenous mortality rates are falling, it seems that general mortality rates are falling at least as fast. In addition, the AIHW reported last year that that there has been an increase in reported poor health and a decrease in reported good health among Indigenous people between 1994 and 2002.
There is much evidence that the extremes of Indigenous ill health result from social conditions that no amount of improvement in health services can ever really deal with. For instance, the Alice Springs Crown Prosecutor, Nanette Rogers, has recently pointed to the endemic violence afflicting central Australian Aborigines, particularly women and children.
Rogers’ account of the routine sexual abuse of children and horrific violence against women was, as she said, "beyond most people’s comprehension". Aboriginal people’s incapacity to address these issues was, she speculated, the result of constantly being overtaken by new tragedy: "It might be the suicide, it might be the fatal car accident, it might be the death of the 20-year-old from heart disease, because of diet, failure to thrive, lots of grog, petrol or whatever. All of those tragedies ... overtake a community," she said. "So yes, it was a dreadful thing that the six-year-old was anally penetrated and killed but then something new takes its place within a very short time."
Rogers is just the latest highly credible witness to attest to the gothic horror of aspects of life in some remote Aboriginal settlements. It can be misleading to use the term “community” to describe these places, which often comprise traditionally antagonistic clans congregated in a particular locality because this was where the nearest mission station distributed its goods. In at least some of them, thinly assimilated notions of universal obligation struggle against grog, traditional concepts of pay-back, and deference to "big men".
A 1998 academic study of Woorabinda, a largely welfare dependant township of 1300 Aboriginal people near Rockhampton, showed that residents had twice the death rate and four times the hospitalisation rates of other Queenslanders. In a 12-month period, 598 people reported 1130 injuries to the local health clinic. Twice as many injuries were reported on Saturdays as Wednesdays and assault was by far the largest cause. A 2001 follow-up study showed that "capacity-building" measures such as reduced hours for the local pub had reduced injuries by a third. Still, without strong local leadership, the provision of a new clinic can lead to another vandalised building, with fatalistic health staff rotating through on a short-term basis rather than much long-term improvement in local Aborigines’ health.
Nanette Rogers’ statement has sparked a new flurry of interest and a new bout of concern about the plight of Aboriginal people. My colleague Mal Brough, the federal Minister for Indigenous Affairs, has convened an important summit on violence prevention in Aboriginal communities. Plainly, Wadeye, a strife-torn Northern Territory town of 2200 Aboriginal people currently with eight police, is at a disadvantage compared to (say) Walgett, in NSW, which has 32 police for 2300 people, half of whom are Aboriginal.
This is far from the first time a spotlight has been cast on Aborigines’ appalling living conditions. The violence characterising some Aboriginal settlements has been widely known for years. Lateline host Tony Jones unwittingly drew attention to the basic flaw in the way officialdom has dealt with Indigenous people in his otherwise perceptive Rogers interview. "How do you actually deal with this without pulling apart the traditional culture which is sustaining it?" he asked at one point. At another point he asked: "Are you worried that the information may be abused by tabloids and racists even?" Not much has changed because of misplaced tact, and fear of imposing what are now seen as outside standards, rather than universal ones.
Northern Territory Chief Justice Brian Martin’s sentencing of an Aboriginal man to just one month’s detention for repeated rape of a 14-year-old promised him in marriage has come to symbolise the triumph of political correctness over justice. To the extent that traditional Aboriginal culture enshrined exploitation and violence it must change. Freedom from rape is not a Western invention but a universal standard of decency. Enforcing it is no more imposing arbitrary Western values on Aborigines than it was cultural imperialism to outlaw widow burning in India and foot binding in China.
Modern Australians are understandably embarrassed about our forebears’ failings towards Aboriginal people. British settlement of Australia meant that Aboriginal culture was bound to change. It meant tragedy for hundreds of thousands of people and their descendants. In the long run, however, modernity - with its benefits as well as its excesses - has been as inescapable for Aborigines as for the rest of us.
Australians’ sense of guilt about the past and naïve idealisation of communal life may now be the biggest single obstacle to the betterment of Aboriginal people. Having rejected the paternalism of the past, we now insist on forms of self-management for Aboriginal people that would be totally unworkable even in places where people are much more used to them. Because it was wrong to treat Aboriginal people like wayward children it isn’t necessarily right to expect Aboriginal people to thrive through endless management committee meetings.
As the historian John Hirst put it in 2004: "The last oppressor of the Aborigines is the belief that they are a cooperative people naturally suited to self-government in small communities." Hirst says it is wrong to expect small, remote communities to organise their own water supply, sanitation, home maintenance, road construction and retail services and laments that self-determination has required Aboriginal people to master skills that are a "cross between a hippie and an accountant".
A former teacher on the Tiwi Islands, Veronica Cleary, has described how “the schools in Nguiu were constantly asking the Community Council to make children go to school, the Community Council was constantly organising community meetings to tell the parents to send their children to school and the parents were constantly demanding that someone else should collect their children each morning, provide breakfast and lunch and provide school uniforms. The frequent community meetings often ended in chaos as the leaders who had been so keen for them to be arranged could not be found to speak and if they were, immediately handed over to the non-Indigenous executives of their organisations to speak about the issue."
An official evaluation last year of the "Meeting Challenges, Making Choices" programme running in five Aboriginal townships in Queensland shows why a form of paternalism - paternalism based on competence rather than race - is really unavoidable if these places are to be well run. "Negotiation Tables," the report said, "were not observed to be operating well in all communities ... Reasons for the limitations of the Negotiation Table process appeared to be largely structural. While the Tables served to bring different government agencies and sectors within the community to a common meeting place, decisions ... were frequently actioned and funded through the usual government processes. In many communities the Tables operated as ‘government to government’ meetings with community members not being actively included."
The Pitjantjatjara Lands of northern South Australia are home to 2500 people spread across eight significant settlements in an area half the size of France. Almost none of the Aboriginal people have jobs other than in various work-for-the-dole schemes. The median age of death is 49 years. Petrol sniffing and binge drinking are rampant. There is currently one police station with three officers at Umuwa (an administrative centre where hardly any Aboriginal people actually live). Attendance at school and at work projects is desultory but attendance records for each settlement are not published, presumably because this might reinforce stereotypes about Aboriginal people. Outsiders, including federal Government Ministers, cannot visit without a permit.
The Lands are part of the Council of Australian Governments’ "whole of government" initiative which is designed to overcome the confusion and paralysis associated with different federal and state government departments (as well as local councils and land councils) all trying to solve similar problems in different ways. So far, this initiative has led to a nutritionist joining the local Nganampa Health Service and community stores doing more to stock healthy food. There's a regional transaction centre with outlets in each settlement and a potential tourist business thanks to better guest accommodation. On the other hand, police stations with resident officers have not yet been constructed at the larger townships because of cost, staffing difficulties, and the delays associated with obtaining all the relevant permissions, even though this would seem to be the obvious precondition of effective governance. Only tranquil townships are likely to have the high rates of school attendance and strong participation in work projects necessary to equip people to leave remote areas or to take real jobs in a local economy.
Normally, dysfunctional local government would mean sacking the particular council concerned and imposing an administrator to sort out the mess. In the Lands in early 2004, something like this was briefly attempted but not persisted with. Vesting authority in an administrator makes sense but only when combined with the power to take decisions and make them stick. Someone has to be in charge.
In the places where Aboriginal people form the bulk of the population, traditional authority has given way to mission authority and mission authority has been replaced with a vacuum. These days, such authority as exists rests with local "big men" often in conflict with each other and white managers usually dependent on unstable alliances in the local council. In some places, indigenous people might choose to substitute for existing bodies an administrator with authority to direct all government funding and government services. In other places, state and territory governments might think that conditions give them no choice but to appoint an administrator.
Clare Martin has just pinpointed the policy of self-determination as successive governments' biggest mistake. As the NT Chief Minister said this week, “the heart of the failure” has been saying to small Aboriginal communities, "manage (your) own affairs". The challenge faced by all levels of government is to go beyond acknowledging that a decades-old policy has largely failed and to build workable governance structures against the pressure of vested interests and the inevitable cries of racism.
Indigenous townships can rarely produce the kind of local leadership necessary for modern service delivery needs. Noel Pearson once called for outsiders such as Marcia Langton to take charge of Aboriginal education in Cape York, Tiga Bayles to take charge of communication, and Peter Yu economic development. He’s also called for judges to lend the authority of the Crown to the work of community justice groups. This sounds like his way of saying that only so much can be expected of local people. Pearson’s clarion call for Aboriginal people to take responsibility for their personal lives and families should be matched by government officials taking more responsibility for standard governmental functions in Aboriginal townships.
The rhetoric of self-determination has enabled officialdom to parade its concerns while evading its responsibilities. It’s still fashionable to scoff at the work of remote area missionaries but none of them were on short-term contracts and many of them had no other home. Service was their life, not just their business philosophy. They took solidarity with Aboriginal people to be their personal responsibility and many of them left their bones in the settlements they created. Their sense of calling did not make them perfect but it motivated them to commit their lives to Aboriginal people in ways that can seldom now be matched.
It’s not clear how much self-determination has helped or hindered the provision of health services for Aboriginal people. John Cleary, a former Tasmanian Health Minister and Tiwi Islands CEO, said recently that the structure of Aboriginal health services reflects many of the same weaknesses as local government. "Since the NT Government took over the running of Tiwi health, the service has new cars and staff accommodation ... previously ... not possible because of a limited budget."
These days, almost every health-related government board comprises at least one "consumer representative" but experts rather than consumers actually run the operation. Obviously, health services have to be sensitive to Aboriginal needs but that doesn’t mean they have to be managed by Aboriginal people. It’s important that Aboriginal people feel that health services are relevant to their lives, not an alien intrusion into them, but it’s equally important that those services are fully professionally run. There are many well-run Aboriginal-controlled community health organisations. Equally, there are some that are consistently poorly managed and others where an Aboriginal governing board seems to have made little impact on local people’s use of the service.
In the Pitjantjatjara Lands, for instance, the Nganampa Health Council has achieved sustainable service delivery and significant health improvements in an environment almost unimaginable to mainstream services. Since 1984, the low birth weight percentage has dropped by a third, there has been a five-fold reduction in perinatal mortality, immunisation rates have risen from 63 to 100 per cent, and rates of sexually transmitted diseases have declined by a third or more. The Government has not the slightest intention of changing the governance of well-run Aboriginal health clinics. Still, this Government is more interested in the delivery of effective health services than in observing ideological pieties and won’t hesitate to intervene where health services are not doing their job.
If, as is generally considered to be the case, abuse is a serious problem among Aboriginal people, there is some ground for concern that abused children are not being brought to clinics or that health services might not be reporting it fully. It's more likely that reports are not being adequately followed-up and prosecuted. There are, of course, legitimate questions over the extent to which health staff can interrogate patients about the real causes of their injuries. If patients insist that bruising is the result of a fall rather than an assault, health staff generally have to take their word for it. Still, it’s hard to see how sexually transmitted diseases in very young patients can be the result of anything other than abuse.
In places where police are reluctant to get involved and often several hours’ drive away, it takes tremendous courage to report suspected abuse (as required by law). To the extent that this problem is successfully tackled, the real heroes will be Aboriginal health workers in the affected communities. In January this year, the Kimberly Population Health Unit Bulletin reported 44 sexually transmissible infections in children under 14 in the previous 18 months. To put this into perspective, in calendar 2004 there were 185 notified sexually transmissible infections in children under 14 throughout Australia. In evidence to a Senate inquiry in April, the head of the Office of Indigenous Policy Coordination, Wayne Gibbons, denied that authorities were turning a blind eye to the problem but stressed the importance of governance in addressing it: "The point I make is that the problem of child abuse which leads to sexually transmitted diseases and petrol abuse is a symptom of a breakdown in social norms and in governance. You have to start with that and you have a consequential effect right up the chain of problems"
If progress is to be measured and problems are to be detected, it’s very important that meaningful records be kept and effectively reported. All states except Western Australia place mandatory reporting requirements on health staff. Particular cases of possible abuse should be reported to the police. The general incidence of suspected abuse and other injuries resulting from violence should be reported to government if policy and administration is to respond to the real social conditions in Aboriginal settlements.
Federally-funded health services should provide regular, accurate information on the health incidents which reflect the social condition of particular places and I have asked my department to consider urgently how this is best done. Such information might reinforce a few people’s prejudices but this can’t be helped if governments are to know what services Aboriginal people most need and to deliver them more effectively. To provide more services for preventable casualties is to miss the point. Accurate information is often the last thing people want to hear because it can so easily challenge established behaviour and settled judgments but it is the only basis on which good policy can ever be sensibly devised and effectively delivered.
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