The current state of health of Indigenous Australians is a cause for
national shame, and has its roots in the wholesale exclusion of
Indigenous people from Australian society since 1788. A
comprehensive approach to improving the health of Aboriginals and
Torres Strait Islanders involves understanding the close
relationships between their social and economic status and their
health. At some point in our growth as a nation there must be a
commitment by all Australians to social and educational equity and
economic prosperity for Indigenous Australians. Only then will
there be significant improvements in the health of Indigenous
There is a growing body of knowledge about the social determinants of
health,1-3 and evidence that relates
disease patterns to the organisation of society and the way society
invests in its human capital. Evidence worldwide shows a clear
relationship between poverty, deprivation, social exclusion and
ill-health. Socioeconomic disadvantage in childhood, inadequate
nutrition, poor education, unemployment, and psychosocial factors
(such as lack of self-esteem and social support, often associated
with addictive behaviours) are causative of ill-health, and
this can occur with or without access to good-quality medical
A child raised in an affluent home is likely to succeed educationally,
which in turn favours entry to more privileged sectors of the labour
market, with financial security in old age. A child from a
disadvantaged home is likely to achieve few educational
qualifications, leave school at the minimum age, and enter the
unskilled labour market, where pay is low, the work often hazardous,
and old age means reliance on the welfare system. A number of
longitudinal studies confirm these relationships and show that they
result in higher morbidity and mortality for the more socially
There are biologically plausible links between social and economic
disadvantage and health. If the biological stress response is
activated too often and for too long, there are multiple health
effects -- depression, increased susceptibility to infection,
glucose intolerance leading to diabetes, and high blood pressure and
accumulation of cholesterol in blood vessel walls leading to heart
attack and stroke. A life-course perspective views a person's
physiological status as a marker of their past social position. Thus,
past social experiences become written into the body's physiology
The situation for Indigenous Australians is further exacerbated by
racism and prejudice, which have marginalised them from various
aspects of social and community life, with additional detrimental
effects on health.
What evidence is there that this relationship between health and
social disadvantage has adversely affected Australia's Indigenous
people? Life expectancy at birth, which is an overall measure of
health status, is 56.9 years for Indigenous men and 61.7 years for
Indigenous women, compared with 75.2 years and 81.1 years,
respectively, for non-Indigenous men and women.4 In 1997, fewer
than 31% of Indigenous students remained in Year 12, compared with
over 72% of non-Indigenous students. In the 1996 Census, while
Indigenous people made up only 2.1% of the Australian population,
they accounted for 19% of the adult prison population,4,5 and 41% of the
inmates of juvenile corrective institutions4 (and the proportion of young
Indigenous people in detention has increased further since the
introduction of the mandatory detention laws in Western Australia
and the Northern Territory5). The unemployment rate for
all Indigenous Australians is likely to increase from 39% to 47% by the
year 2006.6 Indigenous households are
more likely to be overcrowded, but, despite this, have a lower median
weekly income. Similarly, other measures of social disadvantage
also show an over-representation of Indigenous people.
Understanding the social determinants of health and these
disturbing figures and taking the Indigenous health debate to the
next level has always been fraught with misconceptions. A common myth
concerns the high levels of spending on Indigenous health, and this
has been debunked in a recent report showing that, for all health
services, recurrent expenditure on a per-person basis was only 8%
higher for Indigenous compared with non-Indigenous people.
Furthermore, Indigenous people benefit very little from Medicare
and the Pharmaceutical Benefits Scheme, with drawing rates only 27%
and 22%, respectively, of non-Indigenous levels.7
Another major myth is that Indigenous people do not want to help
themselves. It is true that you cannot help people unless they want to
help themselves, but, in relation to education, numerous reviews,
inquiries and consultations in recent years have reported that,
contrary to popular belief, Indigenous people do place a high
priority on education: "They want for themselves and their children
no less than is afforded other Australians. They expect that
educational processes should lead them to acquire the knowledge and
skills necessary to realise their individual potential, lead
satisfying lives, and contribute actively to the
The current approach to Indigenous health is exemplified by the
Western Australian Indigenous Child Health Survey. This is a
population survey of an estimated 3150 children, aged from 0 to 17
years, which aims to improve our understanding of the health and
educational needs of Indigenous children. The results will be used to
develop a planned approach to the desired improvements in this area.
For example, the initial WA Child Health Survey resulted in an
improved range of State and national programs. These programs placed
an emphasis on early intervention and prevention in child and
adolescent mental health services, parenting strategies and
programs, school programs for students at educational risk and
promotion of mental health in schools. These data are also required
for Australia to meet its obligations to the United Nations to report
on the health status of Indigenous children.
At a national level one of the most significant recent developments
has been the establishment of the Office for Aboriginal and Torres
Strait Islander Health Services in the Commonwealth Department of
Health. Since it was established in 1995, there has been a more
comprehensive planning and funding strategy targeting Indigenous
health issues, with improved focus on primary healthcare and
Aboriginal community involvement in healthcare delivery.
While these efforts in health and education are encouraging, they do
not address the prevailing attitudes in Australian society which
marginalise and disempower Indigenous people. T S Eliot wrote:
Since arriving in Australia, the non-Indigenous population have
wanted to believe that this was a "Terra Nullius", an uninhabited land
that they could possess and use to their advantage without
recognising the rights of the Indigenous peoples.9 Non-Indigenous
Australians might gain a better understanding of Australia when they
fully appreciate the inherent truth in Indigenous people's claims to
land, justice and livelihood in this nation. Recognition of
Indigenous people's prior ownership of the land is central to their
achieving social and economic equity in Australia.
In March 1999 the United Nations Committee on the Elimination of
Racial Discrimination found that the Federal Government's 1998
amendments to the Native Title Act 1993 are in breach of
Australia's obligations under the Convention on the Elimination of
All Forms of Racial Discrimination. It is argued that these
amendments fail to respect the cultural identity of Indigenous
people and fail to promote the preservation of their culture, as
required by the United Nations.10
The Council for Aboriginal Reconciliation continues working to
achieve its vision of "A united Australia which respects this land of
ours; values the Aboriginal and Torres Strait Islander heritage; and
provides justice and equity for all."11 The cause of
reconciliation has been furthered in recent years by improved
spending on health services and health programs, particularly by the
Commonwealth Government. These efforts need to continue and to
become more appropriate and focused. The major challenges of the
future centre on the reconciliation process, and the willingness of
all Australians to take the actions that bring symbolic and material
change. Facing these challenges with integrity and courage will
benefit Australia's Indigenous people and the nation as a whole.
Sandra J Eades
Indigenous Health Research Unit, Population Sciences Division
Telethon Institute for Child Health Research
Health Service; and Department of Paediatrics
University of Western
Australia, Perth, WA
- Marmot M, Wilkinson RG, editors. Social determinants of health.
New York: Oxford University Press, 1999.
Keating DP, Hertzman C, editors. Developmental health and the
wealth of nations: social, biological and educational dynamics. New
York: The Guildford Press, 1999: 25-35.
The relationship between fetal malnutrition and chronic diseases
in later life [editorial]. BMJ 1997; 315: 825-826.
Australian Bureau of Statistics. Health and welfare of
Australia's Aboriginal and Torres Strait Islander peoples.
Canberra: ABS, 1999. (Catalogue No. 4704.0.)
Human Rights and Equal Opportunity Commission. Mandatory
detention laws in Australia.
(Accessed 19 April 2000).
Commonwealth Department of Education, Training and Youth
Affairs. Indigenous school to work transitions, 1998.
<http://www.detya.gov.au/publications/schooltowork/default.htm> (Accessed 19 April 2000).
Commonwealth Department of Health and Family Services.
Expenditure on Health Services for Aboriginal and Torres Strait
Islander People. Canberra: DHFS, 1998.
Four Quartets: Little Gidding: V, lines 26-29. The complete poems
and plays of TS Eliot. London: Faber & Faber, 1969: 197.
Reynolds H. Why weren't we told? A personal search for the truth
about our history. Ringwood: Penguin books, 1999.
Human Rights and Equal Opportunity Commission. Submission to the
United Nations Committee on the Elimination of Racial
Discrimination: Response to the request for information in relation
to Decision 1(53) concerning Australia 1998.
(Accessed 19 April 2000).
Council for Aboriginal Reconciliation.
(Accessed 19 April 2000).