Volume 170 Issue 9

Research An analysis of the causes of adverse events from the Quality in Australian Health Care Study Ross McL Wilson, Bernadette T Harrison, Robert W Gibberd and John D Hamilton MJA 1999; 170: 411-415 For editorial comment, see Vincent Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Administration and health services The Quality in Australian Health Care Study (QAHCS), published in the Journal in 1995,1 reported that 16.6% of hospital admissions were associated with an iatrogenic patient injury, termed an adverse event (AE) (see Box 1). This compares with the rate of 3.7% for AEs in the Harvard Medical Practice Study (HMPS),2 and a rate of 17% in a more recent study with an alternative observational method of determining AEs.3 Fifty per cent of the AEs in the QAHCS were judged to have a high preventability score (4 or more on a scale of 1-6 of increasing likelihood of preventability).1 The disability caused by these adverse events ranged from temporary disability (fully resolved in one month) in 46.6% of AEs, to death in 4.9% of AEs. Although recording AEs emphasises only the "complications" of rather than the benefits derived from healthcare, AEs are of great significance to individual patients as well as to the whole healthcare system. Abstract Objective: To examine the causes of adverse events (AEs) resulting from healthcare to assist in developing strategies to minimise preventable patient injury. Design: Descriptions of the 2353 AEs previously reported by the Quality in Australian Health Care Study (QAHCS) were reviewed. A qualitative approach was used to develop categories for human error and for prevention strategies to minimise these errors. These categories were then used to classify the AEs identified in the QAHCS, and the results were analysed with previously reported preventability and outcome data. Results: 34.6% of the causes of AEs were categorised as "a complication of, or the failure in, the technical performance of an indicated procedure or operation", 15.8% as "the failure to synthesise, decide and/or act on available information", 11.8% as "the failure to request or arrange an investigation, procedure or consultation", and 10.9% as "a lack of care and attention or failure to attend the patient". AEs in which the cause was cognitive failure were associated with higher preventability scores than those involving technical performance. The main prevention strategies identified were "new, better, or better implemented policies or protocols" (23.7% of strategies), "more or better formal quality monitoring or assurance processes" (21.2%), "better education and training" (19.2%), and "more consultation with other specialists or peers" (10.2%). Conclusion: The causes of AEs or errors leading to AEs can be characterised, and human error is a prominent cause. Our study emphasises the need for designing safer systems for care which protect the patient from the inevitability of human error. These systems should provide new policies and protocols and technological support to aid the cognitive activities of clinicians. Introduction An additional analysis of data from the Quality in Australian Health Care Study (QAHCS)1 was undertaken in order to understand more fully the causes of the adverse events (AEs) identified and to assist in developing prevention strategies. Here, we describe the error or errors in the delivery of healthcare which led to the AEs. This contrasts with our previous report,1 which focused on the patient characteristics associated with AEs and the nature and consequences of the AEs. Methods The method of determining AEs in the QAHCS has been described previously.1 The AEs were re-examined with the specific goals of determining the causes for, or the underlying errors leading to, each AE. In addition, strategies that were judged to have the potential to prevent AEs were recorded. To obtain this information the first and subsequent review forms (RF1 and RF2 forms1) collected during the QAHCS were re-examined. The source material for these forms had been the hospital medical records, but neither the hospitals nor the medical records were revisited in this analysis. Categories for the causes of the AEs were devised by an iterative process during a three-day workshop. For this, we sought additional expertise in clinical epidemiology and qualitative research methods. Using these categories, the AEs recorded on the review forms were assessed by three of the senior medical specialists who had originally reviewed the medical records in the QAHCS. All the material from each AE was reviewed by only one reviewer, as the agreement between the medical reviewers in determining the presence or absence of an AE during the QAHCS was 80% (kappa, 0.55). A proforma was completed which asked the reviewer to identify the error and then classify it by human cause and preventive strategy. All AEs were also categorised into some of the processes of clinical care. Results for the "delay", "treatment" and "investigation" categories are presented. The categories were not mutually exclusive. These data were then entered into a database, merged with the original data from the QAHCS for each case and analysed. Two of the original total of 2353 AEs were missed in this review; thus, results are given for 2351 AEs. Our analysis provides the frequency of occurrence of each of the categories of causes of AEs, together with the proportion in each category resulting in permanent disability (including death) and the proportion with high preventability. Results Human error categories Box 2 shows the frequency of occurrence of each of the human error categories, and the proportion of the AEs in each category judged to have permanent disability and high preventability. Of the 2351 AEs, 1922 (81.8%) were associated with one or more human error categories. As the error categories were not mutually exclusive, the 1922 AEs were associated with 2940 causes. "Complication of, or failure in, the technical performance of an indicated procedure/operation" was the most frequent cause of AEs; examples of this category are shown in Box 3A. Human errors associated with categories of failure of cognitive function were the next most frequent cause of AEs (Box 2). These included "Failure to synthesise, decide and/or act on available information", "Failure to request or arrange investigation, procedure or consultation", and "Misapplication of, or failure to apply, a rule; or use of a bad or inadequate rule". The most frequent error category, "complication of, or failure in, the technical performance of an indicated procedure/operation", had a lower proportion of AEs with permanent disability (14.2%). The next five most frequent human error categories all had a high proportion of AEs with permanent disability (25% or more) (Box 2). This pattern was also seen in the proportions of AEs with death as the outcome: 2.2% in the first category, and 8% or more in each of the next five categories. Of the 1201 AEs having high preventability, 9 (0.7%) were not associated with a human error category; for the remaining 1192 AEs, 2051 causes were identified (Box 2). Delay categories The importance of timeliness to the quality of healthcare led to further analysis of all AEs to ascertain the nature and role of delay in their causation (Box 4A). Delays contributed to 20.0% of AEs: of these, delays in diagnosis accounted for 56.8% and treatment delays for 40.6%. Diagnostic delay was usually the failure to make, or attempt to make, a diagnosis of a patient's condition rather than just providing symptomatic or even no treatment. Treatment delay was when the diagnosis had been made but there was a delay in initiating specific therapy. Examples of AEs in the delay category are included in Box 3B. The AEs with delay categories were judged to have very high preventability (86%-90%) compared with the average (51.2%) for all AEs (Box 4A). Treatment categories AEs categorised as caused by a treatment error were also analysed (Box 4B). In 19.6% of all AEs, treatment error contributed to the cause. The majority of AEs in this group fell into the categories of "no or inadequate treatment" (51.5%), or "wrong or inappropriate treatment" (27.4%). As with AEs caused by delay, these AEs were judged to have much higher preventability than the average for all AEs. Examples of AEs involving treatment errors are shown in Box 3C. Investigation categories Analysis of the AEs caused by patient investigation issues is shown in Box 4C, and examples are given in Box 3D. There was a problem with clinical investigation in 10.7% of AEs. Paralleling the results in the treatment category, most (78.6%) of these AEs were in this category because an investigation was not done, rather than the investigation being inappropriate (3.6%), or not acted upon (15.5%). Consistent with other AEs that are attributed to cognitive failure, there was a very high percentage of these AEs rated as high preventability. Strategies for preventing AEs When describing AEs, preventability refers to the identification of an avoidable error that led to the adverse event. This is not to say that the error could be avoided on every occasion, and that the adverse event would not occur. Rather, it implies that, with the current state of knowledge and technology, it is possible to identify and avoid that particular error, and hence reduce the probability of an AE. The reviewers were making a judgement, having identified the error, on the particular strategy for a change in the healthcare system that could have prevented the AE. The outcomes of these judgements are given in Box 5. Nineteen (1.6%) of the 1201 high preventability AEs did not have a prevention strategy category. Of the 2613 prevention strategies identified in the 1182 AEs with high preventability, 24.7% (646) were for "better education and training", 20.9% (545) were for "new or better implemented policies or protocols" and 18.6% (486) were for "more or better formal quality monitoring or assurance processes". Discussion AEs are important to patients, healthcare providers and to the custodians and funders of health services. One estimate of the national cost to the Australian healthcare system of just the additional hospital bed-days (as a result of the AEs identified in 19921) is in excess of $800 million dollars per year.4 This estimate ignores any subsequent hospital admissions and out-of-hospital healthcare expenses, loss of productivity of the patients involved, and long term community costs of permanent disability from AEs. It also ignores the benefits received from healthcare. Providing insights into how AEs occur can help in developing prevention strategies to reduce the frequency and severity of patient injuries during healthcare. Our review and analysis of the AE data from the QAHCS have shown that the causes of AEs or errors leading to AEs can be characterised, and that human error is a prominent cause. It is important to recognise that human error is inevitable for even the best-trained and best-qualified healthcare providers. Weed has recently pointed out that the unaided human mind is incapable of performing consistently at the necessary level to provide optimal healthcare.5 However, other studies6 have noted that the label "human error" is prejudicial and non-specific; it may retard rather than advance our understanding of how complex systems fail. It is postulated that within complex systems error is a symptom of organisational problems, and this is likely to apply to healthcare. Therefore, we need a healthcare-system response to error that moves the system towards being as "failsafe" as possible rather than one that blames the clinician who may have erred. Examples from the more frequently studied area of adverse drug events7 would be decision-support technology for antibiotic prescribing,8 with its demonstrated benefits, and electronic prescribing to reduce prescribing and transcription errors in hospital.9 Our analysis identified broad functional categories that are linked to the processes that make up the system of healthcare delivery and hence cut across specialties, diagnosis-related groups (DRGs) and particular patient groups. The sample size is large enough to provide useful information even when several AEs could not be classified into the categories chosen, or insufficient information was available to indicate cause. On the other hand, several factors bias the information available for assessing AEs because of an emphasis on procedures and short term outcomes and possible under-reporting of the contribution of the supporting systems to the cause of the AEs. Firstly, because the original data source was the hospital medical record, the information available about AEs is biased towards the patient involved and away from other potentially important contextual events at the time. Further, the medical record often focuses more on the actions of clinicians involved in direct or procedural patient intervention, and less on the actions of other staff or systems with a more supportive role. These and other factors will lead to an emphasis on procedures and short term outcomes, and a possible under-reporting of the contribution of supporting systems in causing AEs. Finally, information about subsequent or prior hospitalisations is usually only available if the patient attended the same hospital on all occasions. Having acknowledged these potential limitations, cognitive failure (Box 2) appears to have a role in 57% of all the causes of AEs, and most of the AEs involved were judged to be of high preventability and to have caused significant disability. These AEs were largely associated with errors of omission rather than commission. Does this represent a minimum "obligatory" error rate resulting from a combination of human error and our healthcare system, and hence which cannot be improved? Our data are not able to answer this question unequivocally, but we believe they show sufficient opportunities for moving the system towards a failsafe mode to suggest that the answer is no. Until recently there has been an under-recognition of the role and responsibilities of the healthcare system and its custodians in providing a "safe environment" using systems-improvement tools.10 One response to these data should be to look at the factors in healthcare delivery that may interfere with the cognitive or technical performance of healthcare providers. Insufficient use of information technology to assemble the necessary information at the time of decision-making may increase error. Another important factor is fatigue, which has already been shown to increase error in doctors.11 Sleep deprivation may have a much more significant role in human error in healthcare than the current work-load patterns pay heed to, but more research is needed. Other factors that may be important include the level of supervision provided to junior staff, and the pervasive effect of the culture of medical practice, which can unhelpfully portray error as individual failure or deviation from perfection.12 Our study method does not provide direct information about the role of these factors. The high proportion of causes of AEs involving cognitive failure must represent a manifestation of human error occurring in a system that is not patient protective, if one accepts that these practitioners are appropriately trained and competent by international standards. Our study provides clear guidance on methods for improvement, with "new, better, or better implemented policies or protocols" accounting for 24% of prevention strategies identified for the AEs, "quality monitoring and assurance processes" accounting for 21%, and "better education and training" for a further 19%. In summary, improvement is needed in the agreed processes of care, supported by information systems that allow general dissemination of current knowledge of diseases or treatments, and information on outcomes of care for each patient, through appropriate quality processes. Simple examples are the availability of practice guidelines and protocols at the point-of-care, and the use of automated reminders for patients and practitioners when a particular test or follow-up is required. In addition, having adequate patient "outcome" information in a form that can be benchmarked is a powerful tool in identifying unacceptable variation. Acknowledgements We acknowledge the contributions of Professor B Armstrong, Professor W R Runciman, Professor R Holland, Dr T Robertson and Dr A Hobbes. References Wilson RMcL, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. <eMJA pdf> Brennan TA, Leape LL, Laird N, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 377-384. Andrews LB, Stocking C, Krizek T, et al. An alternative strategy for studying adverse events in medical care. Lancet 1997; 349: 309-313. The Final Report of the Taskforce on Quality in Australian Health Care. Appendix 7. Canberra: AGPS, June 1996. <http://www.health.gov.au/pubs/hlthcare/toc.htm> Weed LL. New connections between medical knowledge and patient care. BMJ 1997; 315: 231-235. Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. Human performance in anaesthesia: a corpus of cases. Report to the Anaesthesia Patient Safety Foundation, 1991. Columbus, Ohio: The Ohio State University: 255-307. Classen DC, Pestonick SL, Evans RS, et al. Adverse drug events in hospitalised patients: excess length of stay, extra costs and attributable mortality. JAMA 1997; 227: 301-306. Evans RS, Pestonick SL, Classen DC, et al. A computer-assisted management program for antibiotics and other anti-infective agents. N Engl J Med 1997; 338: 231-238. Bates DW, Boyle DL, Vander Vliet MB, et al. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995; 10: 199-205. Leape LL. A systems analysis approach to medical error. J Eval Clin Pract 1997; 3: 213-222. Nocera A, Khursandi DS. Doctors' working hours: can the profession afford to let the courts decide what is reasonable. Med J Aust 1998; 168: 616-618. Leape LL. Error in medicine. JAMA 1994; 272: 1851-1857. (Received 4 May 1998, accepted 20 Jan 1999) Authors' details Royal North Shore Hospital, Sydney, NSW 2065. Ross McL Wilson, MB BS, FRACP, Senior Specialist in Intensive Care; Director of QARNS (Quality Assurance Royal North Shore); Bernadette T Harrison, RN RM, Manager QARNS. University of Newcastle, Newcastle, NSW 2308. Robert W Gibberd, PhD, Associate Professor, Department of Statistics; and Director of Health Services Research Group. John D Hamilton, MB BS, FRCP, Professor of Medicine, Faculty of Medicine and Health Sciences. Reprints: Dr R McL Wilson, Director of QARNS, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065. Email: rwilsonATdoh.health.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> 1: Terms and definitions Adverse event (AE): An AE was defined as an injury or complication which resulted in disability or prolongation of hospital stay and was caused by the healthcare received rather than by the disease from which the patient suffered. The AE either occurred during the hospital admission, or during an earlier contact with healthcare services, and was responsible for all or part of the hospital admission. Error: An act of commission or omission that caused, or contributed to the cause of, the unintended injury. for errors of commission this will usually be the immediate morbid consequences of the error for errors of omission this will usually be the continuation of, and consequences of, an existing morbid state that could have been cut short, or had a better outcome, if the error had not occurred. Prevention strategy: Changes in the system in which an error occurred that mayreduce the probability of the error occurring increase the probability that the error would be remedied before an unintentional injury occurredPreventability: Preventability of an AE was assessed by the detection of "an error in management due to the failure to follow accepted practice at an individual or system level"; accepted practice was taken to be "the current level of expected performance for the average practitioner or system that manages the condition in question". Back to textBack to text 3. Examples of categories of causes of adverse events and preventability scoresA. Human error categories Example 1: A 50-year-old man sustained a bowel perforation from colonoscopy for investigation of abdominal pain. Laparotomy required. Category: "Technical performance". Preventability score: 3. Example 2: A 71-year-old man required six operations for femoral hernia repair. Category: "Technical performance". Preventability score: 2. Example 3: A 32-year-old woman had persisting severe back pain after two laminectomies, three myelograms, one decompression/fusion, and three thecal/epidural injections over 18 months. In pelvic traction at the time of review. Category: "Technical performance". Preventability score: 4. Example 4: A failed attempt at percutaneous endoscopic gastrostomy on a 32-year-old woman was followed by an open procedure. The patient died 9 days later. Autopsy revealed acute peritonitis, subphrenic abscess and bilateral pneumonia. There did not appear to have been an antemortem diagnosis of intra-abdominal sepsis, or any specific treatment for it. Category: "Technical performance". Preventability score: 6. B. Delay in diagnosis and/or treatment categories Example 1: Diagnosis of cancer of the colon was delayed until the patient, a 62-year-old woman, presented with a ruptured caecum and peritonitis from an obstructing tumour. In hospital 3 months earlier with a history suggestive of cancer of the colon and iron-deficiency anaemia, but no investigation performed. Categories: Diagnosis delay, violation of protocol or rule; failure to synthesise, decide or act on available information; lack of care/attention. Preventability score: 5.5. Example 2: A 28-year-old man with abdominal pain was treated with cholecystectomy. Gallbladder was macroscopically and histologically normal. Small bowel lymphoma was eventually diagnosed and treated, with resolution of the presenting symptoms. Categories: Diagnosis delay; failure to synthesise, decide or act on available information; failure to request or arrange an investigation, procedure or consultation. Preventability score: 5. C. Treatment categories Example 1: A 52-year-old man with known asthma was prescribed a beta-blocker for hypertension. This resulted in acute respiratory failure leading to artifical ventilation and tracheostomy. Categories: Wrong or inappropriate treatment; misapplication of or failure to apply a rule; failure to synthesise, decide or act on information. Preventability score: 6. Example 2: A 54-year-old man developed gastrointestinal bleeding (haemoglobin level, 45 g/L) while receiving non-steroidal anti-inflammatory drugs and steroids for rheumatoid arthritis. This required hospital admission and blood transfusion, at which time the correct diagnosis of osteoarthritis was made. Categories: Wrong or inappropriate treatment; acting on insufficient information; failure to request or arrange an investigation, procedure or consultation. Preventability score: 5.5. Example 3: Hospitalisation and surgical intervention for septic arthritis that followed steroid injection into a joint. Categories: Unclassified treatment; technical; lack of care/attention. Preventability score: 4.5. D. Investigation categories Example 1: A 75-year-old woman died from acute renal failure after developing gentamicin toxicity. Gentamicin was used to treat an infected pleural effusion, and drug levels were not measured. Categories: Investigation not performed; failure to request or arrange an investigation, procedure or consultation; lack of care/attention. Preventability score: 5. Example 2: A 58-year-old woman had recurrent hospital admissions for chest pain and impaired cardiac function without specific investigation, and hence a reduction in treatment options. Categories: Investigation; violation of protocol or rule; failure to synthesise, decide and/or act on available information. Preventability score: 5. Back to text 4: Contribution of delay, treatment and investigation categories to adverse events (AEs). Values are number (%) of AEsPermanentHighA. Delay categoryFrequencydisabilitypreventabilityDiagnostic delay267 (56.8%)93 (34.8%)231 (86.5%)Treatment delay191 (40.6%)53 (27.7%)172 (90.1%)Administrativedelay12 (2.6%)3 (25.0%)11 (91.7%)Total470 (100%)149 (31.7%)414 (87.9%) B. Treatment categoryNo or inadequatetreatment237 (51.5%)72 (30.4%)176 (74.3%)Wrong/inappropriatetreatment126 (27.4%)35 (27.8%)96 (76.2%)No or inadequateprophylaxis41 (8.9%)9 (22.0%)34 (82.9%)Treatmentunclassified36 (7.8%)7 (19.4%)28 (77.8%)Missed treatment20 (4.4%)4 (20.0%) 16 (80.0%)Total460 (100%) 127 (27.6%)350 (76.1%) C. Investigation categoryInvestigationnot performed198 (78.6%)81 (40.9%)171 (86.4%)Investigationnot acted on39 (15.5%)13 (33.3%)36 (92.3%)Investigationinappropriate9 (3.6%)2 (22.2%)9 (100.0%)Investigationunclassified6 (2.4%)2 (33.3%)5 (83.3%)Total252 (100%)98 (38.9%)221 (87.7%)Back to text 5: Frequency of occurrence of categories of prevention strategies and the proportion of adverse events (AEs) judged as causing permanent disability or having high preventability. Values are number (%) of AEsPermanentHighCategoryFrequencydisabilitypreventabilityNew, better, or better implementedpolicies or protocols884 (23.7%)206 (23.3%)545 (61.7%)More or better formal quality monitoringor assurance processes790 (21.2%)186 (23.5%)486 (61.5%)Better education and training715 (19.2%)160 (22.4%)646 (90.3%)Consultation with other specialistsor peers391 (10.5%)133 (34.0%)294 (75.2%)Don't know341 (9.2%)51 (15.0%)186 (54.5%)Better access to, or transfer of, information135 (3.6%)40 (29.6%)100 (74.1%)Discharge procedures and protocols122 (3.3%)27 (22.1%)100 (82.0%)Other89 (2.4%)22 (24.7%)46 (51.7%)Changes in organisation management88 (2.4%)22 (25.0%)75 (85.2%)Changes in organisation culture77 (2.1%)26 (33.8%)66 (85.7%)More or better personnel72 (1.9%)29 (40.3%)53 (73.6%)More or better equipment or otherphysical resources22 (0.6%)8 (36.4%) 16 (72.7%)Total3726 (100%)*910 (24.4%)2613 (70.1%) * Total is greater than the number of AEs (2351) as the categories were not mutually exclusive. 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Bernadette T Harrison · Robert W Gibberd · John D Hamilton

Viewpoint Aboriginal health: why is reconciliation necessary? Lisa R Jackson and Jeanette E Ward MJA 1999; 170: 437-440 Introduction - Health and land - What is reconciliation? - A populist movement - Acknowledgements - References - Authors' details - - More articles on Aboriginal health Many health professionals are deeply troubled by the persistent health inequities between Aboriginal and non-Aboriginal Australians. From a social and political perspective it is clear that, for there to be appreciable improvement in Aboriginal health, a process of reconciliation which acknowledges the past in the light of the present needs to be adopted across all sectors of society. We give some practical advice for promoting reconciliation. Introduction Before the arrival of Europeans, the Aboriginal peoples of Australia were a strong and healthy race of hunters and gatherers whose active lifestyle promoted good health. Little evidence has been found of widespread illness or disease in Aboriginal people,1 making it unlikely that they suffered from obesity, hypertension, diabetes, renal failure, coronary heart disease, cancer, arthritis or other diseases endemic in Aboriginal people today.2 It is possible that, in 1770, when Cook charted the east coast of Australia, Aboriginal people were healthier than the average person in Britain or other parts of Europe.1 Further, Aboriginal people had a strong oral pharmacopoeia which was passed down from generation to generation.3 The early European colonists, without a means of replenishing their medical supplies, were taught by Aboriginals to use "medicinal plants growing in the new country".4 After at least 50 000 years of a strong and intact culture, the Aboriginal population was decimated by diseases introduced by Europeans, and those remaining were displaced from their lands and forced to change their lifestyle.1 Now, more than 200 years on, and despite attempts to improve Aboriginal health, the health of Aboriginal people is markedly worse than that of other Australians and of the indigenous peoples of New Zealand and the United States.5 While mortality rates for the total Australian population have been improving in recent decades, mortality rates for Indigenous women have not changed and the rates for Indigenous men have fallen only slightly.6 These data are from Western Australia, the Northern Territory and South Australia. Age-specific mortality rates in these three States in 1992-1994 were higher for all age groups of Indigenous people. The difference was most pronounced -- about five to seven times that of non-Indigenous Australians -- for those aged 25-54 years.7 Infant mortality, although decreasing among Aboriginal people over the past decade, also remains a problem, with rates reported in 1996 that are two to four times higher than the national average.7Hospital separation statistics also indicate a greater burden of illness in Indigenous people: during 1992-93, there were 2.5 and 2.7 times more admissions for Indigenous men and women, respectively, than would be expected, based on all-Australian rates.6 Social disadvantage for many Aboriginal people is likely to contribute to their ill-health. At least 20 000 Aboriginal people still live in communities with permanently inadequate or contaminated water supplies.8 Almost a third (29%) of Aboriginal and Torres Strait Islander people older than 15 years who responded to a health survey were worried about having sufficient food.9 Health and land Since the arrival of Europeans there has been very little formal recognition of the profound spiritual links of Aboriginal peoples to their land. The common law principle of Terra Nullius -- a territory belonging to no one -- was applied unilaterally. The British "took possession" of the land because they considered it to be unoccupied. Moreover, unlike the experience of Maori in Aotearoa (New Zealand) or the indigenous peoples in both the United States and Canada, there has never been a formal treaty between the Aboriginal people and the newcomers to Australia. It has been argued that the absence of a treaty with Aboriginal peoples is causally associated with their poor health and social disadvantage.5 Disempowerment has been accepted as a causative factor by the Royal Australasian College of Physicians in its Darwin Declaration (1997): . . . that the health of Aboriginal and Torres Strait Islander Australians is disastrously poor compared with other Australians, and that the fundamental cause is disempowerment, due to various factors including continued dispossession from land, cultural dislocation, poverty, poor education and unemployment.10 To Aboriginal people, ill-health is more than physical illness; it is a manifestation of other factors, including spiritual and emotional alienation from land, family and culture. Aboriginal people have a spiritual link with the land which provides a sense of identity, and which lies at the centre of their spiritual beliefs.11 Land is the crux of Aboriginal health and well-being. In 1990, the National Aboriginal Health Strategy (NAHS) developed a widely accepted definition of health as perceived by Aboriginal peoples: Health does not just mean the physical well-being of the individual but refers to the social, emotional, spiritual and cultural well-being of the whole community. This is a whole of life view and includes the cyclical concept of life-death-life.12 This definition of health places in context our history, the importance to Aboriginal people of their links with the land, and their disenfranchisement, sense of loss and present-day marginalised position within the Australian community. Accordingly, to understand Aboriginal ill-health, one must first acknowledge the impact of dispossession, theft, genocide, lost and stolen generations of families and the attempted decimation of the innumerable cultures of the people inhabiting Australia before 1770 (Box 1). Furthermore, Aboriginal health is not just the domain of the healthcare system. By accepting the need for an approach that is multifaceted and covers all aspects of people's lives, including housing, education, employment and social justice, we can then understand that physical and symptomatic relief of disease will not in itself redress the burden of Aboriginal ill-health. What is reconciliation? There is no agreed definition of reconciliation. It is agreed, however, that reconciliation encompasses reparation, as recommended by the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families.14 In the report, Bringing them home, five components of reparation have been recommended. These have been taken from the van Boven Principles,15 drawn up by the United Nations Commission on Human Rights as guidelines for reparation of victims of gross violation of human rights: Acknowledgement and apology Guarantees against repetition Measures of restitution Measures of rehabilitation Monetary compensation Reconciliation always begins with acknowledgement or, more colloquially, "truth telling". Alexander Boraine, Vice Chair of the Truth and Reconciliation Commission of South Africa, has spoken of the capacity for forgiveness by those who suffered most under apartheid.16 In Australia, there is a need to acknowledge that the benefits now enjoyed by some have been at the expense of incalculable suffering to others. "Truth telling" is unresolved "sorry business" for our nation. If contemporary Aboriginal health is accepted to be a manifestation of a population dying of despair, anger and disillusionment, then reconciliation is fundamental. It has been compellingly argued that "The diseases of anger and despair which wrack Aboriginal communities in Australia clearly have many of their roots in childhood."17 Acknowledgement of the causes of this anger and despair must occur as the first step in the process of reconciliation. Reconciliation is necessary but is not, in and of itself, sufficient to guarantee improved Aboriginal health. Reconciliation becomes the foundation for health services development. The Australian Medical Association has stated that "The process of reconciliation would be incomplete without the provision of substantial additional resources for Indigenous health."18 As we await proper political processes to implement recommendations from the Muirhead Royal Commission into Aboriginal deaths in Custody19 and the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families,14 individuals and organisations can consider their own processes for reconciliation. A populist movement There are many ways reconciliation can be facilitated through a populist movement. The Council for Aboriginal Reconciliation has published eight key issues considered crucial to restoring Aboriginal community and culture.20Box 2 proposes some practical strategies that health organisations and individuals can adopt as part of their commitment to reconciliation with the Aboriginal and Torres Strait Islander peoples of Australia. These processes can be built upon and adapted by healthcare providers according to their needs and expectations and those of their communities. A people's movement of reconciliation is required to encourage and promote better health for Aboriginal Australians. To recognise the link between Aboriginals' burden of illness and their cultural destruction is the first step towards significant and lasting change. Health professionals can consider a proactive partnership to promote reconciliation. Doing what we have always done to improve Aboriginal health will only give us the same health outcomes, and the statistics will continue to show the shameful morbidity and mortality rates of Australia's first peoples. Although the Council of Aboriginal Reconciliation will be disbanded at the end of the year 2000, reconciliation itself will not cease. As many Aboriginal people are currently saying, now is a time for building bridges. It will take an insightful and committed group of people to take on the challenge of restoring the justice which is long overdue. We hope that health professionals adopt reconciliation as a fundamental issue in their workplaces. Acknowledgements We acknowledge the land on which we live and work as belonging originally to Aboriginal people. We thank the generosity of all those who sent us information, read our manuscript and gave us feedback. We also would like to thank the Indigenous Health Workers Network of the CSAHS for their support. This article was written while Lisa Jackson was completing the New South Wales Health Department Public Health Officer Training Program. References Australian Institute of Health. First biennial report of the Australian Institute of Health. June 1988. Canberra: AGPS, 1988: 1-2. Cowlishaw G. Infanticide in Aboriginal Australia. 1978: In: The health of Aboriginal Australia. Reid J, Trompf P, editors. Sydney: Harcourt Brace Jovanovich, 1991: 3. Latz P. Bushfires and bushtucker. Alice Springs: IAD Press, 1995: 44-72. Cribb AB, Cribb JW. Wild medicine in Australia. Sydney: Fontana/Collins, 1981: 10. Ring IT, Firman D. Reducing indigenous mortality in Australia: lessons from other countries. Med J Aust 1998; 169: 528-531. Australian Bureau of Statistics/Australian Institute of Health and Welfare. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. Canberra: ABS/AIHW, 1997: 87-89, 68. (Catalogue No. 4704.0.) Australian Institute of Health and Welfare. Australia's health 1998. Canberra: AIHW, 1998: 29, 32. Dodson M. Linking international standards with contemporary concerns of Aboriginal and Torres Strait Islander peoples. In: Pritchard S, editor. Indigenous peoples, the United Nations and Human Rights. Annandale, Sydney: Federation Press, 1998. Australian Bureau of Statistics. 1994 National Aboriginal and Torres Strait Islander Survey: Detailed findings. Canberra: AGPS, 1994: 10, 11, 13. (Catalogue No. 4190.0.) Royal Australasian College of Physicians. CommuniquŽ of the 1997 Cottrell Conference hosted by the Royal Australasian College of Physicians: Statement on the Delivery of Specialist Services to Remote and Rural Aboriginal and Torres Strait Islander Communities, 1997. http://www.racp.edu.au/open/cottrell.htm Woodward AE. Aboriginal Land Rights Commission Report. Canberra: AGPS, 1974. National Health and Medical Research Council. Promoting the health of Indigenous Australians. A review of infrastructure support for Aboriginal and Torres Strait Islander health advancement. Final report and recommendations. Canberra: NHMRC, 1996: part 2: 4. Independent Commission on International Humanitarian Issues. Proceedings of Conference, 1987: In: The health of Aboriginal Australia. Reid J, Trompf P, editors. Sydney: Harcourt Brace Jovanovich, 1991: xi. Human Rights and Equal Opportunity Commission. Bringing them home. Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families. Sydney: Sterling Press, 1997. Van Boven T. Revised set of basic principles and guidelines on the right to reparation for victims of gross violations of human rights and humanitarian law. United Nations Commission on Human Rights, 24 May 1996. (UN Doc: E/CN4/Sub2/1996/17.) McKendrick JH. Aboriginal reconciliation: a role for psychiatrists? Aust N Z J Psych 1997; 31: 617-621. Bartlett B, Legge D. Beyond the maze. Proposals for more effective administration of Aboriginal health programs. Canberra: National Centre for Epidemiology and Population Health, Australian National University, 1994. (NCEPH Working Paper Number 34.) Australian Medical Association. Australia Day Statement: Greater commitment to indigenous health would boost reconciliation. Media release. Canberra: AMA, 1999. Royal Commission into Aboriginal Deaths in Custody. Reports Vol 1-5. Canberra: AGPS, 1992. Council for Aboriginal Reconciliation. Eight key issues of reconciliation, the community consultative process. Sydney: Australians For Reconciliation, 1996-1967. Horton D, general editor. The encyclopaedia of Aboriginal Australia [CD-ROM]. Canberra: Aboriginal Studies Press, Australian Institue of Aboriginal and Torres Strait Islander Studies, 1994. Aboriginal and Torres Strait Islander Commission. As a matter of fact: answering the myths and misconceptions about Indigenous Australians. Canberra: Office of Public Affairs, 1998. Office of the Minister for Aboriginal and Torres Strait Islander Affairs. Rebutting the myths: some facts about Aboriginal and Torres Strait Islander affairs. Canberra: Office of the Minister for Aboriginal and Torres Strait Islander Affairs, Parliament House Canberra, 1997. Flood S. Essay for the Theosophical Society. Sydney, Public Defenders Office, 1997. Authors' details Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Sydney, NSW. Lisa R Jackson, RN, MPH, Aboriginal Public Health Officer. Jeanette E Ward, PhD, FAFPHM, Director. Reprints: Associate Professor J E Ward, Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Locked Bag 8, Newtown, NSW 2042. Email: jwardATnah.rpa.cs.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> 1: Land is the crux of Aboriginal health and well-being Next to shooting Indigenous peoples, the surest way to kill us is to separate us from our part of the Earth. Once separated, we will either perish in body or our minds and spirits will be altered so that we end up mimicking foreign ways, adopt foreign languages, accept foreign thoughts and build a foreign prison around our Indigenous spirits, a prison which suffocates rather than nourishes as our traditional territories of the Earth do. Over time, we lose our identity and eventually die or are crippled as we are stuffed under the name of "assimilation" into another society. A senior official of the World Council of Indigenous Peoples.13 Back to text 2: Practical strategies for promoting reconciliation between Aboriginal and Torres Strait Islander peoples and other Australians 1. Understanding country Understanding the significance of land and sea to Aboriginal and Torres Strait Islander societies Accept that for Aboriginals and Torres Strait Islanders, their cultural identity is bound up by ties to the land and sea. Acknowledge that Aboriginal peoples inhabited Australia for at least 50 000 years before Europeans came. 2. Improving relationships Building new relationships between Aboriginal and Torres Strait Islander peoples and all other Australians Invite Aboriginal or Torres Strait Islander people to give talks to professional and community groups to which you belong. Ensure that the people with whom you work do not have preconceived notions of Aboriginal people, in accordance with recommendation 9a of the Bringing them home report.14 Allow staff to attend cultural awareness sessions presented by Aboriginal and Torres Strait Islanders. Join a local study circle and join the mailing list for the Council for Aboriginal Reconciliation. Work with local Aboriginal people in your area towards a statement of commitment to reconciliation for your external communications (eg, a sentence on faxes and letterheads). Find out if your local hospital has an Aboriginal Liaison Health Worker; if not, give your written support to the organisation to employ one. 3. Valuing cultures Recognising the valuable contribution the cultures of Indigenous people make to the Australian heritage Acknowledge the strength of Australia's Indigenous cultures and their importance to our national pride and our international image and trade. Find out the name of the traditional owners of the land where you live and work. Attend cultural events where the focus is on Aboriginal and/or Torres Strait Islander people and their lifestyles. Obtain a copy of the Aboriginal Australia map, published by the Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS). Borrow or buy a copy of the Encyclopaedia of Aboriginal Australia.21 Read works by Aboriginal authors, such as Sally Morgan, Monty Prior, Ruby Langford Ginibi, Oodgeroo Noonuccal, Kevin Gilbert or James Miller. Understand that Aboriginal people have had, and some continue to have, a strong traditional health practice. 4. Sharing history Understanding that the history of Australia began long before the arrival of Captain Cook in 1770 Read general textbooks about Aboriginal history: A secret country, Unfinished business, Six Australian battlefields, The world of the First Australians or Invasion to embassy. Read the summary of the Muirhead Royal Commission into Aboriginal Deaths in Custody19 and Bringing them home14 (the Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from Their Families). Read information documents on contemporary Aboriginal issues such as As a matter of fact22 or Rebutting the myths.23 Encourage Aboriginal and Torres Strait Islanders to share their knowledge and perspective of history. Ensure schools attended by your children have Aboriginal and Torres Strait Islander resources in their classrooms and libraries. Watch videos that tell the story, including Women of the sun, Lousy little sixpence and Around the kitchen table (to name just a few), or see movies made by Aboriginal people such as Radiance. 5. Addressing disadvantage Acknowledging that Indigenous people are the most disadvantaged group in Australian society Acknowledge that inequities in such basic areas as education, health, housing and the justice system are very real to Aboriginal people. Having learned from reading, watching and listening, speak up when others voice myths, errors and prejudices about Aboriginal and Torres Strait Islander peoples. Do not allow people speaking untruths to ever believe that your silence means agreement. Support your children when they make friends with Aboriginal and Torres Strait Islander children. Favour businesses that support reconciliation. Encourage affirmative action in your workplace. 6. Custodial levels Drawing attention to the fact that Aboriginal and Torres Strait Islander people continue to be arrested and imprisoned at a rate far above that of the wider community Find out what has been done in your State or Territory to implement the recommendations of the Muirhead Royal Commission into Aboriginal Deaths in Custody.19 Support efforts by the healthcare sector to implement the recommendations of this report specific to health. 7. Destiny Supporting empowerment of Indigenous peoples -- giving them greater control over their own destiny and a right to self-determination Join a study circle or attend local community consultations to discuss ideas and initiatives for self-determination in the spirit of partnership. Phone your local Members to let them know of your support and that of your organisations. Ask what specific actions they have taken during their term in office. Invite Indigenous people to participate and ensure their voices are heard in the formulation and implementation of policy decisions. 8. Formal document(s) of reconciliation Determining whether reconciliation would be helped by a formal document(s) of reconciliation. Support recognition of the unique position of Aboriginal and Torres Strait Islander peoples as the Indigenous peoples of Australia. Put into policy in your organisation a process of reconciliation with an outcome date. Once the formal documents of reconciliation are available, adapt them for your practice and ensure they enter as policy into your organisation. 9. Native Title Recognising the implications of the Native Title debate Realise that matters such as the current Native Title legislation have significant implications in areas (other than land usage), such as health and social justice. The Public Defender, Sean Flood, in a talk given at the Theosophical Society (Sydney) in November 1997, explained this clearly: The Nation's soul is at risk. Extinguishment of Native Title is extinguishment of Indigenous culture and ultimately the cause of sickness and death of Indigenous peoples.24 Learn more about Native Title. Acknowledge a component of restitution, as documented in the Bringing them home14 report, which allows Native Title holders the authority under traditional law to define the content and scope of that title. 10. Stolen generations Acknowledging the injustice and the trauma of forcibly removing Indigenous children from their families and communities, as has been done since the earliest days of European colonisation in Australia Recognise and acknowledge the consequences of the past and seek ways to make amends. Participate in Sorry Day, National Aboriginal Day Organising Committee (NADOC) and National Reconciliation Week activities. Speak out against prejudiced views. Support programs that help Aboriginal and Torres Strait Islander individuals and families overcome the trauma they are still suffering. Listen to Aboriginal and Torres Strait Islander people talking about what has happened and ask what you can do. Back to text

Lisa R Jackson · Jeanette E Ward