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Indigenous health: chronically inadequate responses to damning statistics

Ian T Ring and Ngaire Brown
Med J Aust 2002; 177 (11): 629-631.

The recent pioneering Public Report Card 2002 — Aboriginal and Torres Strait Islander health, entitled No more excuses,1 outlines where we are today and how the health of our Indigenous population compares with that of other similar countries — New Zealand, Canada and the United States. Produced by the Australian Medical Association, it is a "warts-and-all" assessment which is designed to show what is working and where we need to do better.

Where do we stand on health?

There have certainly been some gains. The health of Indigenous infants has improved dramatically, although from a low baseline, and most of the gains occurred 20–30 years ago.2 The current infant mortality rate for the Aboriginal and Torres Strait Islander population is almost three times that of the general Australian population, twice that of the Maori, and 50% higher than the mortality rate of US Indigenous infants.3 This is some improvement on previous rates, but we can and should do better.

Death rates overall for Indigenous people in Australia are still three times as high as for the rest of the population: diabetes death rates are eight times as high, respiratory deaths four times as high and circulatory conditions almost three times as high.4 These are unacceptable statistics for treatable and preventable conditions.

On the other hand, there are number of recent good news stories. Programs in the Northern Territory and elsewhere have shown that birthweight, the critical factor in the survival of newborn infants, can be improved.5,6 More dramatically, death rates from pneumonia have dropped by around 40% since 1996 (derived from Australian Bureau of Statistics data). This is important, because this reduction is likely to be due, in part, to recent government initiatives for promoting pneumococcal vaccination. This is a real indication of the kind of rapid and substantial gains that can be achieved through application of knowledge we already have. (Well done, even if long overdue.)

Progress in providing access to health services for Aboriginal and Torres Strait Islander communities is much too slow. There is a gross shortage of doctors working in Indigenous health, with an estimated 60% increase required (ie, at least 500 doctors). The number of nurses also needs to increase by 25%, and there are sizeable deficits in all the other health professions.7

There has been some improvement in basic services and facilities to some areas, but too many Aboriginal and Torres Strait Islander communities still lack adequate water, electricity and sewerage services.8,9 In other fields influencing health, there has been some modest improvement in educational benchmarks, but still only a third of Aboriginal and Torres Strait Islander children reach Year 12 at school.10

Most tellingly, however, are the data for the most reliable overall measure of health — median age at death, currently 51 years for the Aboriginal and Torres Strait Islander population. There has been no improvement at all in this measure in the last 10 years.3 In this same period, the median age at death for the total Australian population increased by three years, so that the gap in median age between Indigenous people and the rest of the population has now increased to a staggering 26 years. Median age at death is much higher for the Indigenous populations of New Zealand (59 years), Canada (65 years) and the United States (63 years) and, in contrast to the situation in Australia, has been progressively increasing for the last 25 years,11 and probably for much longer.

What about health spending?

Spending on Aboriginal and Torres Strait Islander health is increasing, but, incredibly, the Commonwealth Government, through programs under its direct control, still spends less per capita on Indigenous people than it does on the rest of the Australian population — 74c on Indigenous Australians for every $1 spent on the rest of the population! The real increase in spending on Indigenous health between 1995–96 and 1998–99 was 15%.12 This is worthwhile, but nowhere near enough to cater for the higher levels of illness among Indigenous people. There has been a major new initiative, the Primary Health Care Access Program, with three key features: needs-based funding, funds pooling and community control. However, the funding for the program is totally inadequate, and at this stage only selected communities can participate in a program which is needed for Indigenous people throughout Australia.13 The consequences of the funding shortfall are major deficiencies in the crucial prevention and early treatment services required to break the cycle of ill-health.

Why do we do so much worse than other countries?

What is it about Australia that stops us from achieving the gains seen in the health of the Indigenous populations in other Western democracies, or, for that matter, in developing countries around the world? There is, after all, nothing absolutely unique either about the disease pattern or the history and circumstances of the Australian Indigenous population. Heart disease, respiratory conditions, injuries and diabetes are also the major conditions for the Indigenous populations of other countries. Dispossession, forcible relocation, removing children from their families, and heavy-handed paternalism are certainly not unique to Australia.

Nor is Australia incapable of doing well with health and health services. Depending on which measurement you take, Australia is arguably the second- or third-healthiest country in the world, with a proud record in confronting difficult and complex issues such as AIDS and cancers in women.14

Why is the government not doing more?

It is symptomatic of our lack of progress that this report card, and its call for action, comes not from the government, but from health professionals. Surely one would hope that some response, some soul searching, some rethinking would be evoked by the fact that over the last 10 years, despite some good news, the overall mortality of the Australian Indigenous population, alone among Western nations, has not improved, is much worse than for the Indigenous populations of New Zealand and North America, and that the gap between the mortality rate of the Indigenous population and that of the rest of the Australian population is becoming wider. But no, there is simply a deafening silence; a case of industrial deafness.

Shortfalls in medical services for rural areas have produced major government programs and initiatives, and a massive injection of funds. Where is the response to the huge shortage of doctors and nurses to work in Indigenous health, and the major gaps in the workforce of all the other health professions? For any other section of the population there would be a massive outcry and appropriate remedial action.

In fact, for Aboriginal and Torres Strait Islander health, the Commonwealth Government seems to be tied up with a curious logic that requires "good news" from spending less on people with worse health before it will fully rectify the health service deficiencies needed to address the worse health!

Australia is locked into a cycle of endless consultation, policy and strategy formulation and measurement. Report after report is produced showing that Indigenous health is poor, improvement patchy at best, and that, overall, the gap between Indigenous and non-Indigenous health is widening. These reports reach the highest levels of Australian public and political life and are simply noted, or evoke defensive bureaucratic responses. We must act on the reports, not just note them. Flat-lining for 10 years is not good enough!

Many worthwhile activities are under way, but would any informed observer really claim that current or planned prevention and treatment services, staff provision and training plans, and environmental improvements, will do the job, or are anywhere near sufficient to bring about the Indigenous health gains seen in other countries most like Australia?

What do we need to do?

We don't need new solutions, new strategies, some magic bullet. We need to implement strategies, like the National Aboriginal Health Strategy,15 that have been around for more than a decade. The Report Card reinforces previous calls for a national program to build up the necessary community-controlled health services for prevention and treatment; for the Primary Health Care Access Program to be given the funds required to provide those services; for a National Training Plan to train the staff, particularly Indigenous staff, required to deliver those services; and for a National Infrastructure Plan to rectify the continuing deficiencies in water supply, sanitation, education and other basic services.

Australia spends over $50 billion per annum on health for its total population.16 It isn't that the modest funds required for adequate health services for Aboriginal and Torres Strait Islander people are out of reach, or that the services required are beyond our technical capacity. It is ultimately a commitment to implement the recommendations of the endless reports, and this is what the AMA, in support of Aboriginal and Torres Strait Islander organisations, is urging on the nation.

Straws in the wind?

Despite the general lack of progress, there are straws in the wind. The appointment of a new Health Minister and a new head of the Commonwealth Department of Health provides a fresh opportunity for dealing with the issues highlighted in the Report Card. Death rates of the NZ Maori and the Indigenous peoples of Canada dropped by 30% in the 1970s.17 Over a 40-year period, the health of the Indigenous populations of the United States improved twice as rapidly as that of the non-Indigenous population.14 Australia can do the same, and that should be our aim.

Summary of the AMA Report Card on Aboriginal and Torres Strait Islander health

Status

Comment


Infant mortality rate

Indigenous rates are 2 times the total population rate

Rapid fall in the 1970s. Rates in Indigenous Australians almost twice as high as those of the NZ Maori and US Indigenous populations

Low birthweight

Indigenous babies are twice as likely to have low birthweight.

Little overall improvement since 1991, but effective programs developed and implemented in the Northern Territory and South Australia

Expectation of life

The gap between Indigenous and non-Indigenous people is 20 years

In North America and New Zealand, the life expectancy gap (Indigenous v non-Indigenous) is 5–7 years

Median age of death

For Indigenous people this is 25 years less than for non-Indigenous people

There has been no improvement in the median age of death in the Indigenous population in Australia in the past 10 years

Standardised mortality ratios

Indigenous rates are three times those of the total population

High rates for diabetes, respiratory, circulatory and other conditions in the Indigenous population

Mortality from pneumonia

A dramatic decline in Indigenous rates since 1996

Pneumoccocal and influenza vaccines may be contributing to the decline in mortality from pneumonia

Health workforce

Estimated at least 59% increase in doctors required, and a 25% increase in nurses

Required increase related to difficulties in accessing preventive and early treatment services

Infrastructure

21 communities lack water, 80 lack electricity and 91 sewerage

Some improvement, but significant gaps

Education

Year 12 retention rates are 36% for Indigenous people v 73% for the total population

Some improvement, but significant gaps

Health funding

15% real increase in government funding between 1995–96 and 1998–99

Level of health spending is 22% higher for Indigenous people but a needs index of 200% is required

Aboriginal Community Controlled Health Services (ACCHS)

OATSIH funding of community-controlled services increased by 50% between 1995–96 and 1999–2000

ACCHS with a network of culturally appropriate healthcare services provides a model for Indigenous health services


OATSIH = Office for Aboriginal and Torres Strait Islander Health.

Ian T Ring, MB BS, FAFPHM, Adjunct Professor of Public Health1
Ngaire Brown, B Med, MPHTM, Chief Executive Officer2
1 James Cook University, Brisbane, QLD.
2 Australian Indigenous Doctors Association, Manuka, ACT.
Correspondence: 
Reference Text: 
Australian Medical Association. Public Report Card 2002. Aboriginal and Torres Strait Islander Health. No more excuses. Canberra: AMA, 2002. Media releases 24 May 2002. Available at: www.ama.com.au/
Reference Order: 
1
PubMed ID: 
Reference Text: 
Australian Bureau of Statistics. Deaths, 1999. Canberra: ABS, 2000. (Catalogue No. 3302.0.)
Reference Order: 
2
PubMed ID: 
Reference Text: 
Australian Bureau of Statistics. Deaths, 2000. Canberra: ABS, 2001. (Catalogue No. 3302.0.)
Reference Order: 
3
PubMed ID: 
Reference Text: 
Australian Bureau of Statistics, the Australian Institute of Health and Welfare. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples, 2001. Canberra: ABS, 2001. (Catalogue No. 4704.0.)
Reference Order: 
4
PubMed ID: 
Reference Text: 
Mackerras D. Evaluation of the Strong Women, Strong Babies, Strong Culture Program. In: Australian Bureau of Statistics. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples, 1999. Canberra: ABS, 1999. (Catalogue No. 4704.0.)
Reference Order: 
5
PubMed ID: 
Reference Text: 
Commonwealth Department of Health and Aged Care. Better health care: studies in the successful delivery of primary health care services for Aboriginal and Torres Strait Islander Australians. Canberra: Commonwealth Department of Health and Aged Care, 2001.
Reference Order: 
6
PubMed ID: 
Reference Text: 
Estimation of requirements for and supply of the health workforce for Aboriginal and Torres Strait Islander peoples. In: National Strategic Framework Aboriginal and Torres Strait Islander Health Workforce — Consultation Draft, 2001. Canberra: Commonwealth Department of Health and Aged Care; 2001.
Reference Order: 
7
PubMed ID: 
Reference Text: 
Australian Bureau of Statistics. Housing and infrastructure in Aboriginal and Torres Strait Islander communities 2002. Canberra: ABS, 2001. (Catalogue No. 4710.0.)
Reference Order: 
8
PubMed ID: 
Reference Text: 
Aboriginal and Torres Strait Islander Commission. Aboriginal and Torres Strait Islander Commission Annual Report 1999-2000. Available at: www.atsic.gov.au (accessed 19 April 2002).
Reference Order: 
9
PubMed ID: 
Reference Text: 
Australian Bureau of Statistics. Australian social trends 2002. Canberra: ABS, 2002. (Catalogue No. 4102.0.)
Reference Order: 
10
PubMed ID: 
Reference Text: 
Ring I, Firman D. The health of Indigenous populations in Australia, New Zealand and the United States of America. XVI International Epidemiology Association World Congress of Epidemiology. Montreal, August 18–22, 2002.
Reference Order: 
11
PubMed ID: 
Reference Text: 
Australian Institute of Health and Welfare. Expenditures on health services for Aboriginal and Torres Strait Islander people 1998-1999. Canberra: Australian Institute of Health and Welfare, 2001.
Reference Order: 
12
PubMed ID: 
Reference Text: 
Office for Aboriginal and Torres Strait Islander Health. http://www.health.gov.au/oatsih/ (accessed October 2002, link updated Nov 2005).
Reference Order: 
13
PubMed ID: 
Reference Text: 
Ring I. Sidney Sax Oration. Public health in Australia — problems and prospects. James Cook University and Public Health Association of Australia, 2001. Unpublished (available from the author).
Reference Order: 
14
PubMed ID: 
Reference Text: 
Australian Institute of Health and Welfare. Australia's health 2002. Canberra: AIHW 2002. (AIHW Catalogue No. AUS-25.)
Reference Order: 
15
PubMed ID: 
Reference Text: 
Ring I. Inequalities in health. The challenge for the nineties. The 1992 Elkington Oration. Brisbane: Queensland Health, 1993.
Reference Order: 
16
PubMed ID: 
Reference Text: 
National Aboriginal Health Strategy Working Party. A National Aboriginal Health Strategy. AGPS, 1989.
Reference Order: 
17
PubMed ID: