Indigenous health: sorry is not enough

Social determinants of Indigenous health is a collection of papers which shows once and for all that severe ill-health among Indigenous Australians has its basis in loss of culture, racial prejudice, social inequality, poverty.

It is not an ideological statement - although there are important political implications - but a comprehensive, compelling account of serious health problems told by 18 Indigenous and other scholars in the medical and social sciences.

Indigenous Australians have lived on this continent for more than 50,000 years but have had difficulties surviving the past 200 years. Why? The average lifespan for all Australians is 80 years but for Indigenous folk only 60 years (shorter than Indigenous life-spans in New Zealand, USA and Canada). Why? Australia is the world’s third richest country but many Indigenous people struggle with serious poverty and associated diseases. Why? An adequate living standard is a principle of international human rights agreements but has not become part of Australian law. Why?

The 13 essays are based on a series of courses in Darwin in 2004-5, and with 50 pages of references, chapter summaries and questions for discussion, they are ideal for further study up to the highest academic levels. It is much more than a study guide, however. It has serious messages for social justice and should be compulsory reading for all members of parliament: state, federal, and local.

Indigenous leader Lowitja O’Donoghue puts the issues in a nutshell: “When considering health, you need a model that … acknowledges a history of oppression and dispossession, and a history of systematic racism”. She refers to the Bringing Them Home report, racism that is “still deeply embedded in the structure of our society”, felt powerfully in economic disadvantage, young people alienated from family and community, the lack of Aboriginal representation at all levels of government.

Indigenous health “has been aptly described as Third World health in a First World nation”, and she quotes the National Aboriginal Health Strategy: “health encompasses the social, emotional, spiritual and cultural well-being of the whole community.”

The Universal Declaration Of Human Rights states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control”.

This principle was also the basis of other International Covenants and Conventions. However, unless such treaties are incorporated into Australian law by domestic legislation they are not enforceable in this country. And Federal Governments have chosen not to incorporate them.

Indeed, the United Nations Committee on Economic, Social and Cultural Rights placed specific obligations on the Australian government and required it to “refrain from interfering … with the enjoyment of the right to health … and adopt appropriate … measures towards the full realisation of the right to health”.

But there remains no statute which imposes a responsibility on Australian government to ensure Indigenous people have access to the social determinants of good health. Indeed, by dismantling the Aboriginal and Torres Strait Islander Commission and limiting the power of the Human Rights and Equal Opportunity Commission, the current government “has largely disabled any formal and independent criticism of its approaches to human rights and the Indigenous population”.

It is argued the forced separation of children from their natural families as described in the Bringing Them Home report had human rights implications which could have “breached international conventions to which Australia was a signatory”. But in one case the High Court held that as the policy of the time cited that the removal of Aboriginal children from their families was “in their own best interests”, the necessary intention to harm them was not established.

One author concludes pessimistically, “it is highly unlikely [the Australian government] will choose to consider itself bound … by the human rights implications of its public health and social policy”.

Politicians have often gone AWOL on Indigenous matters, so should pay particular attention to a message from a former prime minister:

It begins with the act of recognition. Recognition that it was we who did the dispossessing. We took the traditional lands and smashed the traditional ways of life. We brought the disasters. The alcohol. We committed the murders. We took the children from their mothers. We practised discrimination and exclusion.

It was our ignorance and our prejudice. And our failure to imagine these things being done to us. With some noble exceptions, we failed to make the most basic human response and enter into their hearts and minds. We failed to ask - how would I feel if this were done to me? Paul Keating, Australian Launch of the International Year for the World’s Indigenous People, Redfern, Sydney, 1992.

Indigenous Australians suffered illnesses common in tropical climes prior to 1788, but British colonists brought new diseases like tuberculosis and venereal infections. There was even some controversy “within the general climate of frontier violence” as to whether smallpox was spread deliberately. Introduced illnesses were a major cause of Indigenous depopulation during the 18th and 19th centuries.

Aboriginal Protector James Dredge in the 1840s said “While we hesitate they die. Their condition is indescribably awful and perilous”, and he blamed government incompetence and settler maliciousness.

From the mid-19th century to the 1930s, there was a dominant European belief in the “doomed race” theory, that Indigenous extinction was “natural and unavoidable”, part of “natural evolution” with Europeans emerging as the highest form of human development (a view still heard in 1960s London). Even government and mission compounds were often characterised by poor hygiene, inadequate nutrition, and epidemic illness, described as stemming from “colonial attitudes”. Some cattle stations were also notorious for high levels of infectious disease.

In 1936 Western Australia’s Chief Protector found rural hospitals that “refused to take Indigenous patients, including women in labour”. In the 1930s authorities often sent leprosy patients to Darwin in neck-chains, sentenced to life imprisonment in leprosariums, a practice continuing until 1955.

Pastor Doug Nichols returned from the Warburton Ranges in 1957 traumatised, saying “My people are starving … everywhere we went they pleaded for food and water ... I wish I hadn’t seen the pitiable squalor … never, never can I forget”. In the 1960s student Freedom Riders on country tours found hookworm, ear and eye infections, unclean drinking water, lack of proper toilet facilities.

Author Frank Hardy wrote in 1963, “No white man, even in the depths of the depression, has suffered as much as the black man suffers now in the height of the nation’s boom”. Increasingly activist groups labelled the system genocidal.

Evidence shows “morbidity, mortality and risk factors … are highest among those living in the most disadvantaged areas”. In 2002 the average Indigenous household income was only 59 per cent of non-Indigenous income. “The prevalence of easily treatable diseases associated with inadequate basic sanitation and living conditions … as well as a lack of access to safe and reliable water supplies in many Indigenous communities provides strong evidence for conditions of absolute poverty” as defined by the United Nations. The authors also conclude Indigenous poverty is different from non-Indigenous poverty.

Inequality in itself also affects health. General research has shown those higher up the chain of command have less sickness than those lower down regardless of finance. There’s not only a difference between the boss and the lowliest office junior, but even between top brass and deputy top brass who might share the same lifestyle.

So if you have little income and also feel you’re at the bottom of the pecking order, so much the worse for your health.

Work is more than income. For Indigenous people the loss of traditional occupations like hunting and fishing all too easily resulted in an existence without meaning or sense of pride. Occupation absorbs the largest amount of active time in adult life, but “Indigenous Australia is still significantly located in the welfare economy”.

This reviewer recalls an isolated Aboriginal group discovered in the 1970s living in the desert as they had for thousands of years: unclothed, no buildings, finding food and water where others would starve, sleeping during the day, walking great distances by night. Extraordinary knowledge. Then into their world came somewhat similar creatures who covered their bodies, moved on noisy, god-like machines, found their food in boxes and bottles, and forced Indigenous folk to move into compounds, issuing some meaningless material called money.

One can only imagine how they would experience “anomie”, a sense of alienation and purposelessness caused by a breakdown in the culture, which, it is argued, can lead to suicide.

It’s not difficult to understand the temptation to ease the pain of so many frustrations with drugs, sniffing, grog.

The importance of this book is that it brings together not only environmental and physical factors like chronic poverty and environment but also social and emotional conditions like unequal chances in life, hopefulness and pessimism, all affecting the physical body, the individual’s state of health and ultimate life-span.

In this whole saga Australian politicians are largely missing in action. They seem much more likely to criticise Indigenous people than seriously examine the social processes they are involved in for which political leaders are ultimately responsible. Government has clearly not invested in communities in such a way that not only do people have a chance to survive economically and provide the wherewithal for their children’s health, but also can create an atmosphere of hope.

It is still surprising to recall Indigenous Australians were not counted in the population Census until after the 1967 Referendum, which also belatedly entitled them to award wages and Commonwealth welfare benefits. However, “progress” can have a paradoxical downside, such as losing a job because the employer refuses to pay a higher wage, or, worse still, insistence on award wages on a cattle station resulting in a worker not only losing his job but the family being forced to leave their traditional country. And “Country is frequently asserted as a fundamental determinant of health and well-being for Indigenous Australians”.

Underlying the research, scientific data and professional judgments in this collection are ethical issues: what is right and just in dealing with fellow human beings, not only in the past but now?

It is not easy to be optimistic when you read in the chapter on human rights: “Given the approach of the Australian Government to date, it is highly unlikely that it will choose to consider itself bound either by an international legal obligation to consider the role of violations of human rights in creating and perpetuating poor health, or by the human rights implications of its public health and social policy”.

The editors of this excellent collection refer to their “next edition”. I encourage them to consider adding a companion volume telling the same story but with translation of some language into forms more accessible to a less highly educated readership. This is not a criticism, more a tribute to the book’s importance and the hope it will be read widely.