1. Preamble

Aboriginal peoples and Torres Strait Islanders make up Australia's Indigenous population. Torres Strait Islanders represent a distinct Indigenous Australian population group from Aboriginal peoples. Aboriginal peoples and Torres Strait Islanders across Australia face similar health problems. Like Indigenous peoples in other countries, Aboriginal peoples and Torres Strait Islanders suffer a disproportionate burden of illness and social disadvantage when compared with the general population. However, the situation in Australia is much worse than other countries. Life expectancy at birth remains 20 years less than that for non-indigenous Australians and the gap has not closed over the past decade. The percentage of the Aboriginal population expected to live to age 65 is less than in many developing countries (see Appendices).

The AMA has spoken out on Aboriginal and Torres Strait Islander health issues over many years. This Position Statement provides a framework within which the organisation will develop specific policy initiatives and assess government action and inaction.

2. Background

2.1 The history of Aboriginal and Torres Strait Islander Peoples Health

Understanding the present health situation of Aboriginal and Torres Strait Islanders requires knowledge of the historical background (see Appendix 1: The History of Aboriginal and Torres Strait Islander peoples since colonisation). What data we have of Aboriginal and Torres Strait Islander health in 1788 would indicate that the situation today is much worse than it was then. The history of the Aboriginal health policy development has been documented extensively.^1,2,3,4,5 The Aboriginal community controlled health movement represents a significant advance in Aboriginal health policy development. The first National Aboriginal Health Strategy (NAHS) was developed by an Aboriginal-led and Aboriginal-dominated working party in 1987. Its development involved wide consultation through 1988 and 1989 with Aboriginal communities and organisations, government departments, and other interested individuals and organisations.⁶ In 2003, the National Strategic Framework for Aboriginal and Torres Strait Islander Health' was released and aims to address the many developments in Aboriginal health since the original NAHS.⁷

2.2 The population

The Aboriginal and Torres Strait Islander population has a significantly different age structure to the non-Indigenous population. It tends to be younger, with 39.2% of the Indigenous population being 14 years or under, compared to 20.4% for the non-Indigenous population. Only 0.9% of the Indigenous population is over the age of 75 compared to 5.6% for the rest of the population. Thirty-one per cent of Indigenous people live in the major cities, 20% in inner regional areas, 22% in outer regional areas, 9% in remote and 18% in very remote areas. 29% of Indigenous people live in New South Wales, 27% in Queensland, 14% in West Australia, 12% in Northern Territory, 6% in Victoria, 5% in South Australia, 4% in Tasmania and 1% in the Australian Capital Territory. Although there is slightly increased mortality in the very remote areas there is otherwise no significant difference in mortality across geographic areas or by state and territory.

2.3 Health concepts and determinants

Aboriginal concepts of health are holistic. In fact there is not even a specific word for health, let alone for body part specific diseases. The nearest translation in an Aboriginal context would probably be a term such as 'life is health is life'.⁸ It is better to look at the word "well-being" as this concept is well developed in all Aboriginal groups. The Aboriginal worldview of well-being is socially rather than biologically or pathologically, determined. It begins, and ends, with the land and its indigenous inhabitants: the people, the animals, and the plants.⁹ This concept is in fact well supported by the accumulated research data from Australia and across the world that acknowledges a wide range of social as well as physical determinants of health¹⁰: income and social status^11,12; social support networks^13,14; education and literacy^15,16,17; employment/working conditions^18,19; social environments^20,21,22,23; physical environments/housing/nutrition^24,25; personal health practices and coping skills^26,27; healthy child development²⁸; biology²⁹; health services; gender and culture^30,31. With this concept of well-being it is impossible to expect changes in health service provision to Aboriginal and Torres Strait Islanders alone to transform the present health reality. An integrated approach across all departments of government is required. 'Appendix 2: Determinants of Health - Comparative Statistics 2004' provides the most up to date comparative data, for each of the determinant areas mentioned above, for Aboriginal peoples and Torres Strait Islanders/non-Indigenous Australians³². Some of this data is 5 years old but although there has been some increase in funding to the Aboriginal and Torres Strait Islander Health sector to date there has been no great change in the reality and some data even suggests the health reality is deteriorating.

2.4 Health situation

Aboriginal peoples and Torres Strait Islanders have the poorest health of any group living in this country. Standardised mortality ratios are more than three times the expected rate and death rates between 25-54 years of age are 5-8 times that seen in non-Indigenous Australians. Infant mortality rates are three times that of the Australian total. Chronic diseases are the leading causes of premature death in both Indigenous and non-Indigenous Australians. These include diseases of the circulatory system (including hypertension, heart disease and stroke), respiratory disease, chronic renal failure, diabetes and cancer. Aboriginal peoples and Torres Strait Islanders have higher levels of chronic disease, which occur much earlier in life. Such chronic diseases, together with injuries, are also responsible for the increased rates of hospitalisation which are approximately 2.5 times that seen in non-Indigenous Australians.

2.5 Health service inequity

Health service inequities put populations who are already socially disadvantaged (through poverty, illiteracy, ethnicity or other reasons) at further disadvantage with respect to their health³³ through institutional or other barriers to health services and programs. The Aboriginal population has reduced access to a range of health services relative to other Australians. Reduced access by the Aboriginal population to the Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and preventative and acute services in hospitals and in the community have all been documented. The reasons for reduced access range from geographic and social barriers, institutional barriers, poor policy development, public mistrust and lack of education, as well as racial discrimination by health providers. 'Hard to reach' populations are often blamed when conventional public health programs fail to improve their health status. Rather, they are often 'locked out' of meaningful participation in more appropriate program design and development³⁴. The Government's approach to improving access is based on two complementary strategies: increasing the capacity of Aboriginal Community Controlled Health Services and other Indigenous-specific services, and enhancing the accessibility of mainstream services. Both strategies are essential³⁵. However, health services alone cannot fully address health inequities (see Appendix 2).

3. Informed by the situation described above, the AMA affirms the following principles:

3.1 That Aboriginal peoples and Torres Strait Islanders have a leading role in identifying and responding to the nature and challenges of Aboriginal and Torres Strait Islander health, and that the medical profession has a responsibility to partner and support these efforts.

3.2 That all Australians, including Aboriginal and Torres Strait Islanders, have the right to good health as defined by the World Health Organisation's Declaration of Alma Ata which states that health is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity.

3.3 That income and social status; social support networks; education and literacy; employment and working conditions; social environments; physical environments, housing and nutrition; personal health practices and coping skills; healthy child development; biology; health services; gender and culture all a have significant impact on health and well-being.

3.4 That Aboriginal peoples and Torres Strait Islanders will not achieve equal health outcomes until their economic, educational and social disadvantages have been eliminated. Nevertheless, while social disadvantage continues, Aboriginal people and Torres Strait Islanders should not be doubly disadvantaged by the neglect of potential medical solutions arising from health sector inequities.

3.5 That all efforts should be made to ensure that Aboriginal and Torres Strait Islanders achieve the same life expectancy as other Australians. Significant improvements can be made in the short term with present knowledge.

3.6 That in line with the late Dr. Puggy Hunter's statement that "The "body parts" approach has been a complete failure in Aboriginal health. There is no use treating the heart or the ears alone, when the whole person is in danger of breaking down." (July 1999) the AMA advocates that a holistic, culturally appropriate approach informs all areas of government policy development which supersedes the current disease-based and fragmented policy and funding strategies.

3.7 That within the health system, the crucial mechanism for improving Aboriginal and Torres Strait Islander health is the availability of comprehensive primary health care services³⁶.

3.8 That Aboriginal community control must be supported and appropriately resourced in recognition of its demonstrated effectiveness in providing appropriate and accessible health services to a range of Aboriginal communities and its role as a major provider within the comprehensive primary health care context³⁷.

3.9 That all health services provided specifically for Aboriginal peoples and Torres Strait Islanders should be designed, developed and controlled by the communities they serve in collaboration with mainstream processes.

3.10 That Services provided specifically for Aboriginal and Torres Strait Islanders, should be increasingly provided by Aboriginal and Torres Strait Islanders.

3.11 That all measures are taken to endorse equity of access to healthcare services that are culturally appropriate and free of racism.

3.12 That health services should be funded to a level required to achieve outcomes agreed by the community rather than at some benchmarked "fair" level. Only once parity in life expectancy have been achieved would any such sense of "fair" be appropriate.

4. The AMA resolves to:

4.1 Health programs and services

4.1.1 Speak out on all matters that are seen to be having a negative impact on Aboriginal and Torres Strait Islander health and acknowledge successful initiatives. (See also the AMA Position Statements on Preventable Chronic Disease Strategies in Aboriginal and Torres Strait Islander Peoples (2001) and The Links Between Health and Education For Indigenous Australian Children (2001)). and acknowledge successful initiatives.

4.1.2 Work in partnership with Aboriginal community-controlled health organisations and Aboriginal and Torres Strait Islander health professional organisations with the aim to eliminate inequities in health service provision to the Aboriginal and Torres Strait Islander population.

4.1.3 Call on the Government to improve access to infrastructure, education and health care services.

4.1.4 Call on health service providers to respond promptly to the healthcare needs of Aboriginal peoples and Torres Strait Islanders.

4.2 Standards, human rights, cultural awareness and safety

4.2.1 Call on the government to jointly with Aboriginal and Torres Strait Islander representatives, set standards of both provision and access across the whole range of government service funding/provision and use these to agree necessary funding.

4.2.2 Support the Australian Declaration Towards Reconciliation and urge the Australian Government to put in place a process which will unite all Australians.

4.2.3 Advocate the recognition that ownership and control of land by Aboriginal and Torres Strait Islanders is one of the important keys to improving the life choices and hence life expectancy of individuals and communities.

4.2.4 Advocate that all government funded and private health services be required to ensure that they are able to provide culturally appropriate services to Aboriginal and Torres Strait Islanders.

4.2.5 Advocate that all government and private health services providers have:

• a policy on recruitment and retention of Aboriginal and Torres Strait Islander staff;
• a Charter setting out the level of service an Aboriginal and Torres Strait Islander will receive including arrangements to ensure cultural issues are recognised and addressed within each service;
• a system to provide interpretation and cultural support where necessary;
• a cultural awareness and safety training programme to ensure all staff understand and implement the Charter commitments.

4.3 Resource allocation

4.3.1 Call on the government to correct the under funding of primary health care services provided to Aboriginal peoples and Torres Strait Islanders38.

4.3.2 Call on the government to provide additional fully funded training to address the total shortfall of health professionals providing services to Aboriginal and Torres Strait Islanders.

4.3.3 Advocate that the government recognise the need for Aboriginal and Torres Strait Islanders to be represented at the same level as they are in the population in all health related professions and support professions (eg management). To achieve this the government must institute a funded National Aboriginal and Torres Strait Islander training programme including:

• allocation of sufficient places in training programmes to Aboriginal and Torres Strait Islanders to achieve parity by 2010;
• establishment of support units at all those training institutions with these allocated places;
• provision of full scholarships including living expenses for allocated places where necessary;
• establishment of mentoring programmes in schools to identify and support Aboriginal and Torres Strait Islander children from primary school through to training institutions.

4.3.4 Call on the government to implement the joint AMA, NACCHO and Pharmacy Guild proposal to increase Aboriginal and Torres Strait Islander access to PBS³⁹.

4.4 Skills training

4.4.1 Advocate that all health personnel training programmes, including specialist training colleges include, as part of the core curriculum, components on Aboriginal and Torres Strait Islander health including cultural awareness and safety.

4.4.2 Support initiatives aimed at ensuring doctors, student doctors and doctors-in-training receive the right information and skills development in the best interest of improving Aboriginal and Torres Strait Islander health outcomes.

4.4.3 Urge the government to explore incentives for medical officers working in Aboriginal Medical Services and seek support from the relevant medical colleges for registrars to be available and credentialed for working in Aboriginal Medical Services to ensure there are sufficient health staff available to work with Aboriginal and Torres Strait Islander communities.

See also:

AMA Position Statment on Preventable Chronic Disease Strategies in Aboriginal and Torres Strait Islander Peoples

AMA Position Statement on The Links Between Health and Education For Indigenous Australian Children

Appendices:

For a copy of the Appendices listed in this statement please follow the links on this page of the AMA website (/node/2023) or contact the AMA Secretariat.

References:

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32. Overcoming Indigenous Disadvantage 2003: Report of the Steering Committee for the Review of Government Service Provision, November 2003. Published by Commonwealth of Australia. ISSN 1448 9805. 2003

33. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 57(4):254-8. 2003.

34. Carr, Matheson, tipene-leach. Hard top reach populations. In: Oxford Handbook of Public health practice. 2001.

35. Dwyer, Silburn, Wislon. National strategies for improving Indigenous health and health care. http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oaTorres Strait Islanderh-pubs-reviewphc.htm-copy7

36. National Strategic Framework for Aboriginal and Torres Strait Islander Health. 2002.

37. National Strategic Framework for Aboriginal and Torres Strait Islander Health. 2002.

38. /web.nsf/doc/WEEN-63Q9J7

39 http://www.naccho.org.au/FinalJointProposal.html and http://www.health.gov.au/internet/wcms/Publishing.nsf/Content/nmp-pdf-apac17jun-cnt.htm

40. Final report of the Council for Aboriginal Reconciliation to the Prime Minister and the Commonwealth Parliament. DECEMBER 2000.

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