Indigenous Health

1. Indigenous Health The problem facing us: Delivering health services to a local Koori community. The approach: Exploring practical Koori-Friendly options. The solution: Is different in every case.

2. Indigenous Health I believe we need to provide opportunities to access health services in ways that local communities want and will utilise. The National Strategic Framework outlines 9 basic principles towards providing this access, some with which I do not agree or believe should be seriously rethought. They don’t work! The principles seem to be paid lip service only…

3. National Strategic Framework Principles • Cultural respect • A holistic approach • Health sector responsibility • Community control of primary health care services • Supporting community decision-making, participation and control • Working together • Localised decision making • Promoting good health • Building the capacity of health services and communities • Accountability

4. Indigenous Health The policy makers provide these solutions. They still don’t ask the local communities what they want, and what will work for them. The most important principle is community control. Cultural respect and a holistic approach I believe will follow naturally from that They never really give community control to the community. Support is usually conditional. They never really persuade mainstream facilities to co-operate and share with the AMS. They don’t provide the training to enable local communities to manage things like accountability. When it works it’s a government success, but when it fails it’s the bad management of the local community

5. History of Australia 70,000 years ago Aboriginal exodus into Australia Land sensitive subsistence, trade, art, history, valuing the land and it’s resources 200 years ago European invasion, murders, rapes, dispossession, slavery Resistance groups destroyed Reservations/Protection Acts 40 years ago, referendum and vote, now citizens of the country Mabo returns land rights Reconciliation gathers steam

6. OrHistory of Australia Terra Nullius Dutch identify northern coast and Van Diemen’s Land Cook finds east coast and claims continent for George III, 1770 Phillip lands First Fleet 1788 and colonises Terra Nullius Dispossession of primitive savages Isolated resistance groups killed off Survivors granted citizenship 1967 Terra Nullius doctrine abandoned (Mabo) Reconciliation movement gains steam

7. European Contributions 1788 - 1890: decimation, stealing the land, exterminating the tribes 1890 - 1950: segregation, missions Protection Acts 1950 - 1967: assimilation - better housing, health, education - make them white 1967 - : positive relations, choice, a chance to speak and be heard (but not necessarily responded to…)

8. Indigenous Health History is written by the winners Things are improving after a pretty disgraceful start. 200 years is a big accumulation of distrust and anger…

9. Indigenous Health • Prejudice is still with us • Patronizing is also with us • Asking, rather than telling is today’s message • Never fear asking unless you really fear the answer

10. Kevin Gilbert wrote: Taree Hospital Patient: Hugh Ridgeway Christian Non-drinker Black Deceased

11. continued They said that you were drunk man spewing with the pain vomit scattered on the door your urine starts to drain white nurses stood there laughing while you crawled on the floor your heart gave one last beat. They’d seen black drunks before! Kevin Gilbert, The Blackside

12. Population Breakdown

13. Indigenous Health Mortality and morbidity in the Koori Communities around Australia is high: • Diabetes • Heart Disease • Renal Disease • Mental Illness • Drugs and Alcohol All far commoner than in the European community.

14. Chronic Disease - the big killer

15. Diabetes • Onset age 25-35 - 10 years earlier • 10-14% more common than in non-indigenous populations • Higher level of co-morbidities • Higher level of complications • Limited access to support services/complication screening?

16. Heart Disease • Age at infarct 10 years younger than non-indigenous populations • Peak at 30-40 in males, rather than 40-50 years • Higher mortality rates post infarct • Co-morbidities

17. Communicable DiseaseRates of hospitalisation, Australian Institute of Health and Welfare, Australia’s Health 2004

18. Dual Diagnosis • Dual diagnosis of drugs and/or alcohol, AND mental illness • Falls in to the big crack in the floorboards • Depression, low self esteem, unemployment, racism - a spiral down. • Lack of facilities and dedicated workers • Often results in justice system involvement, detention, probation and parole

19. Key message • These are not special diseases or problems, unique to the indigenous patient. • What is unique is how badly we seem to be managing it.

20. Social Determinants of Health • Poor education and literacy • Poorer income - reduces accessibility of health care • Overcrowded and run-down housing - associated with poverty and contributes to spread of disease • Poor infant diet • Smoking and high risk behaviour

21. Income The median weekly gross individual income for Indigenous peoples in 2001 was $226 (a $36 or 19% increase from the 1996 rate). This compares to $380 for the non-Indigenous population in 2001 (an increase of 28.4% from the 1996 figure of $296). Australian Bureau of Statistics, Population Characteristics: Aboriginal and Torres Strait Islander Australians, 2001, op cit. p81

22. In custody

23. The birth of the AMS • In the 60’s there was evidence of the need for change. • After the 1967 referendum self-determination started to become the big issue. • Finally communities were being asked what they wanted, not having it imposed from above • The AMS started to emerge, under control of the communities

24. Access • The AMS has been a positive step but there are still issues around access. • The big question - what can be done at local level to improve outcomes? • Access to services is a start. • Barriers to that access are something we can begin to work on. • Some are simple problems. • Some are inside the community, and some are external issues.

25. Determinants of Health Health – more than good medicine • Housing • Nutrition • Education • Employment • Respect • Understanding and acceptance Priorities may differ!

26. AMS Goals • A good AMS must link in with services that can aid and assist with these other areas - housing, education, employment, nutrition, and promotion of respect, understanding and acceptance. • It must work actively to remove or reduce the barriers to access. • It must by it’s “small fish in big pond” nature, work to build bridges between larger mainstream health facilities • And it must keep working, every single day…

27. Oodgeroo of the Noonuccal Tribe wrote: ‘Give us welcome, not aversion Give us choice, not cold coercion Status, not discrimination, Human rights, not segregation…’

28. Access Barrier Cost • Still some of the most disadvantaged members of our community. Bulk billing may be dead, but Casualty Departments are not Koori-friendly either. • So what can we do? • Cost of ancillary investigations, treatment and medication?

29. Access Barrier Geography • Time and Place is not always Koori Friendly • Transport is difficult for many families, especially those with children. • Difficulty sometimes operating within fixed appointment systems. • Large families equal large logistic problems

30. Access Barrier Cultural Sensitivity Implications of treatment choice extend beyond the patient Whole family group and decisions • Can’t always just involve the patient • Death and Dying issues • Respect of traditions and privacy • Pregnancy Issues

31. Access Barrier Privacy • Sometimes there are problems with some members of the community having access to records or files, or other people (relatives or not), knowing what is going on? • Gender business is a concern. • It is more than what GP’s or Practice Managers might see as issues of Privacy within the Privacy Act, 2001.

32. Access Barrier Respect • from Doctor • from Staff • from Patient • from other patients Can’t have one without the others?

33. Access Barriers The Hospital Stay • Accommodation for family/relatives when members in hospital • Information for family/relatives when members in hospital • Support for family/relatives when members in hospital • Koori-friendly

34. Access Barriers Mental Health Issues • Dual Diagnosis • Outreach services • Aboriginal Mental health workers • Opportunities for treatment and support in community

35. Access Barriers Drug and Alcohol Issues • Dual Diagnosis – really triple diagnosis -social issues as well • Morale factors – respect, work, education, understanding • Outreach services • Community support

36. Access Barriers Antenatal Issues • Pregnancy and care services as outpatient and inpatient • Cost • Antenatal/neonatal risks • Indigenous infant and child health is significantly poorer than non-indigenous infants and children - roughly twice as many low birth rate infants over the period 1998-2000 born of indigenous compared to non-indigenous mothers • Levelling out of infant mortality rates in the mid 1990’s. Rates still 3-4 times the non-indigenous rate in the Northern Territory (ABS: Deaths, 2004)

37. Access Barriers Specific Medical Issues • Dialysis • Support during admissions – patient and family • Long term chronically ill, but sometimes transient patients • Community risk management issues • Diabetes, Heart Disease, Renal Disease, CVA, and others need ongoing support

38. Access Barriers Aged Care Issues • Tolerance and access • Frail aged • Dementia • Support in home/in community • Cultural issues • Death and dying issues

39. Social Organisation Koori society vs. European Society • Extended families including uncles and aunties • Cross family bonds and obligations • Tribal bonds (and fights) • Generally inclusive, rather than an exclusive society

40. Improving Access In defining the problems better maybe we can find solutions • What can Divisions offer • What can individual doctors offer • What can community offer • What can health services offer • What education/”programs”/services are wanted

41. Indigenous health Food for thought… Discussion time? Then some parting words…

42. Finally, from Oodgeroo, in her own words Son of mine (to Denis) My son, your troubled eyes search mine, Puzzled and hurt by colour line. Your black skin soft as velvet shine: What can I tell you, son of mine? I could tell you of heartbreak, hatred blind, I could tell of crimes that shame mankind, Of brutal wrong and deeds malign, Of rape and murder, son of mine; But I’ll tell instead of brave and fine When lives of black and white entwine, And men in brotherhood combine - This would I tell you, son of mine.