The Social Determinants of Health: the Australian Perspective
SPEECH TO BMA SYMPOSIUM
The Role of Physicians and National Medical Associations in Addressing the Social Determinants of Health and Increasing Health Equity
24 MARCH 2015
AMA PRESIDENT A/PROF BRIAN OWLER
**Check Against Delivery
The Social Determinants of Health: the Australian Perspective
Thank you for the invitation to speak at this excellent international event. I want to acknowledge the esteemed attendees and our hosts for this event.
The Australian connotation of the words ‘social determinants’ in relation to health immediately conjure images of the issues faced by Australia’s first people, our Australian Aborigines and Torres Strait Islanders.
And this is rightly so. The social determinants of health are major issues for Australia as a nation in its attempts to ‘close the gap’ for disadvantage of Indigenous people in relation to a range of outcomes, including health.
The implications of the social determinants are not bound by race, although race might be thought of as a social determinant in itself. Social determinants are important to health outcomes for all Australians.
The issues are much more complex than whether someone has a roof over the head, whether they have access to clean water and nutritious food. What I want to talk about, from the Australian perspective, are two issues.
First, there are deeper issues that underlay the social determinants of health. This comes from a sense of physical, social, and emotional wellbeing, the origins of which have deep spiritual roots for Australia’s Indigenous people.
The second is that the term ‘social determinants of health’ is somewhat misleading. While I know many here understand this, we must not forget that health is a determinant of social and other outcomes.
Australian Indigenous peoples represent about 3 per cent of the Australian population. Indigenous Australians experience poor health outcomes. We have a gap between Indigenous and non-Indigenous Australians in terms of health, but also in many other aspects of life. Indeed, the health outcomes are poorer compared to the Indigenous populations of other nations.
Life expectancy of Indigenous Australians is 10.6 years less for men, and 9.5 years for women. This gap in life expectancy is a serious blight on our nation, and remains unacceptable.
The AMA sees that addressing this issue is a core responsibility of the AMA and the medical profession.
While the gap in life expectancy remains unacceptable, there have been gains in Indigenous health. Life expectancy has increased by 1.6 years and 0.6 years for men and women respectively over the past five years. Mortality rates for Indigenous Australians declined by 9 per cent between 2001 and 2012.
So, what are the main contributors to the gap in life expectancy? Chronic diseases are the main contributors to the mortality ‘gap’ between Indigenous and non-Indigenous Australians.
Four groups of chronic conditions account for about two-thirds of the gap in mortality: circulatory disease, endocrine, metabolic and nutritional disorders, cancer, and respiratory diseases.
Another major contributor to the gap in life expectancy is the Indigenous infant and child mortality rate. These rates remain well above that of the non-Indigenous population.
The infant mortality rate remains high at around five deaths per 1000 live births, compared to 3.3 per 1000 for non-Indigenous children.
External causes, such as injury and poisoning, account for around half of all deaths of children aged 1–4 years. External causes, mainly injury, are also the most common cause of death among Indigenous children aged 5–14, and account for half of the deaths in that age group.
The trend data for most States show a 57 per cent decline in the Indigenous infant mortality rate between 2001 and 2012, and a 26 per cent decline in the non-Indigenous rate.
There has been progress here, but clearly there is much more to do.
Suicide was the third leading cause of death among Indigenous males, at six per cent.
The rate of suicide is about two times higher for males and 1.9 for females, compared to non-Indigenous Australians. Suicide also occurs at a younger age. This is not consistent with Aboriginal culture, in which suicide was thought to be rare.
These sorts of reports highlight several important issues.
First, as is already known, non-communicable diseases, in particular circulatory disease and diabetes, remain very significant issues for the Australian Indigenous people.
Investment in local health services is a must. Delivery of appropriate health services, particularly through Aboriginal community controlled health services, must be culturally safe, and delivered in the right locations by the right people.
Second, the rate of suicide, particularly among young Indigenous males, is unacceptably high. This speaks to something much more difficult to address.
It is an issue of how we address mental health, the need to focus on drug and alcohol problems, but it also raises questions about why so many Indigenous people take their own lives.
Third, our child and infant mortality rates are too high, but are improving. What is disturbing is that many of the deaths remain preventable. That is, they are caused by trauma or injury. Some of these injuries will be non-accidental.
While those with chronic disease need to be cared for, prevention, particularly in the early part of life, is the key if we are going to see a generational change in health outcomes.
As a nation, Australia is conscious of the need to improve the health of Indigenous Australians – to Close the Gap.
Each year, the Prime Minister, in the first week that Federal Parliament sits, delivers a report on Closing the Gap.
In 2008, the Council of Australian Governments, or COAG, set six targets aimed at reducing Indigenous disadvantage in relation to health and education.
The Closing the Gap targets are to:
- close the life expectancy gap within a generation (by 2031);
- halve the gap in mortality rates for Indigenous children under five within a decade (by 2018);
- ensure access to early childhood education for all Indigenous four year olds in remote communities within five years (by 2013);
- halve the gap in reading, writing and numeracy achievements for children within a decade (by 2018);
- halve the gap for Indigenous students in year 12 attainment rates (by 2020); and
- halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade (by 2018).
Despite good intention and considerable investment by successive Governments, the disparity in outcomes remains.
As expressed in this year’s Closing the Gap statement by the Prime Minister: ‘It is profoundly disappointing that most Closing the Gap targets are not on track to be met’.
Closing the Gap is an incredibly difficult task, and it is fair to say that Australia and Australians have learnt much about how to Close the Gap over a number of decades.
There were many mistakes, not only in Closing the Gap, but also in how modern Australia has treated Indigenous Australians. These issues have had to be confronted in order to advance efforts to Close the Gap.
For example, from 1910 to 1970, it is estimated that 100,000 Indigenous children were taken from their families and raised in institutions or fostered to non-Indigenous families.
The ‘Stolen Generation’, as they are termed, was disastrous in its outcome, however well-intentioned it may have been - separating families, but also alienating individuals from their own culture and families.
There have been many examples of Governments trying to address the social determinants of health – but often they have failed. For example, the Australian Government attempted to improve the living conditions of Indigenous people by building houses.
The houses were often inappropriate for the location. The plumbing would block because of the hardness of the water. They would fall into disrepair, and they did not serve the needs of the communities. These initiatives were well meaning, but improvements in health outcomes were somewhat marginal.
We have learnt, unfortunately by mistake, but also through partnership with Indigenous Australians. When it comes to health, there is much more to improving Indigenous health than building houses and sending people to school.
The concept of health for Indigenous Australians is very different from that of Western culture. There is no word for health in many Aboriginal languages. Rather, health is more of a concept of social and emotional wellbeing than of physical health.
Even that statement is a generalisation.
Before the arrival of Europeans, Australia was inhabited not by a uniform nation of Aboriginal people, but rather hundreds of ‘Indigenous nations’, whose language varied tremendously, along with their culture and beliefs.
Despite this variation, a unifying theme in terms of that ‘social and emotional wellbeing’ is the connection of Indigenous people with their land.
Australia’s first peoples have been continuously sustained, both physically and spiritually, by their land for 50,000 years of more. They have a deep connection with the land, and it is an important component of maintaining their spiritual wellbeing.
The close connection with the land also means that Indigenous people often live in remote regions. These remote communities present challenges in delivering health care as well as infrastructure and services that improve the social determinants of health.
For Indigenous Australians, their very existence, let alone their lifestyle, was threatened by European settlement as late as 1788. For Indigenous Australians, the arrival of Captain Cook in 1770, and subsequently the First Fleet in 1788, is not seen as European settlement, but rather as a modern invasion.
It signified displacement, imprisonment, forced adoption and much worse. It has left both emotional and spiritual wounds open and unable to heal. Modern economic solutions will continue to fail until these much more deeply seated issues are confronted.
There have been important steps in our young nation’s history that have attempted to approach these issues.
As I mentioned, the attachment to land is an important part of Indigenous culture. For each Indigenous ‘nation’, certain places hold spiritual importance.
From the land stemmed the basis of Aboriginal ‘dreamtime’, the spiritual conceptualisation of the universe and the basis of human existence for Aboriginal peoples. One might say that their landscape was their religion.
Recognition of the longstanding connection to the land came through a series of legislative changes that largely started under the Whitlam Government in 1972. Whitlam established the Aboriginal Land Rights (or Woodward) Commission to examine the possibility of establishing land rights in the Northern Territory.
In 1975, the Whitlam Government purchased traditional land and handed it back to the Gurindji people. In a now famous gesture, Whitlam poured sand into the hands of Vincent Lingiari, an Elder of the Gurindji people.
The Aboriginal Land Rights Act was passed by the Fraser Government in 1976, and established land rights for traditional Aboriginal landowners in the Northern Territory.
In 1992, the doctrine of terra nullius was overruled by the High Court of Australia in Mabo v Queensland, which recognised the Meriam People of Murray Island in the Torres Strait as native title holders over part of their traditional lands.
The Native Title Act was legislated the following year, 1993, by the Keating Government.
Not only did this provide the legal acknowledgement that Indigenous Australians sought, it also provided a source of revenue. The use of land for mining purposes, for example, provided significant funding to Aboriginal people through regional land councils.
More has been done since, but these are important issues to address that underlay social and emotional wellbeing and, therefore, the health of Indigenous people.
In 2008, Prime Minister Kevin Rudd issued a formal apology to Indigenous people for the stolen generation. It had enormous symbolism for Indigenous Australians.
The next likely step is to recognise Australia’s first people in our Constitution.
Constitutional recognition is a vital step towards making Aboriginal and Torres Strait Islander people feel historically and integrally part of the modern Australian nation.
Recognising Indigenous people in the Constitution will improve their self-esteem, their wellbeing, and their physical and mental health.
The AMA is a proud supporter of the Recognise campaign, and is a Foundation Signatory of the campaign.
In 2013, the Abbott Government was elected. Prime Minister Abbott had spent significant amounts of time with Indigenous people, often living for a week at a time in Indigenous communities.
In Government, he ‘ran the country’ for a week from a remote Indigenous community in Arnhem Land of the Northern Territory.
Prime Minister Abbott also took over the responsibilities for many Indigenous policy areas. The coalescence of these responsibilities into the Department of Prime Minister and Cabinet coincided with the reduction of the number of Indigenous programs into five main areas.
The Indigenous Advancement Strategy, or IAS, that began on 1 July 2014 now embodies these aims. The IAS outlines a number of priority areas - getting children to school, adults to work, and making communities safer.
The IAS replaced more than 150 individual programs with five broad programs - Jobs, Land and Economy; Children and Schooling; Safety and Wellbeing; Culture and Capability; and Remote Australia Strategies.
These are all worthy aims. They remain important.
But what is missing from the core of the IAS is a focus on health.
Health, in a modern sense, underpins many of these outcomes. We need to get the balance right and we, the AMA, need to ensure that health is seen as a foundation to these outcomes.
So, what is our role as a national medical association? Our role is to guide politicians and their policies; to shape the national narrative and debate.
The AMA’s Indigenous Health Taskforce, which I chair, draws experts in Indigenous Health together. It highlights the AMA’s commitment to working, in partnership with Indigenous Australians, to improve the health of Indigenous Australians.
Not only do we highlight the problems, but the AMA works on solutions and to highlight the successes as well.
The AMA regularly publishes the AMA Indigenous Report Card.
Last year, we highlighted the importance of a healthy early start to life.
My predecessor, Dr Steve Hambleton stated that: “Robust and properly targeted and sustained investment in healthy early childhood development is one of the keys to breaking the cycle of ill health and premature death among Aboriginal peoples and Torres Strait Islanders.”
Gains can be made by focusing on antenatal care.
In the Pitinjarra lands of north western South Australia there have been major gains in antenatal care, with 75 per cent of all pregnant women seen in the first trimester.
The proportion of children under three years of age with significant growth failure has fallen from 25 per cent in the 1990s to less than 3 per cent today. Immunisation rates approach 100 per cent.
This year, the AMA Report Card will focus on the bigger picture of the importance of health in underpinning the outcomes of education, training, and employment.
We will also focus on the issues of Indigenous incarceration rates, which have continued to escalate.
Law and order policies and health policies are often interlinked. Incarceration leads to a multitude of poorer physical and emotional health outcomes.
Poor health, and a poor start to life, is likely to increase the chances of incarceration. The AMA will be working with the Law Council of Australia on this issue.
To change the health of an entire population is an enormously difficult task. It is too easy for Governments to ignore health, to focus on the economics. Education and economics alone are not sufficient. Health is the cornerstone on which education and economics are built.
If you can’t go to school because you or your family are sick, truancy officers won’t work. If you can’t hear because of otitis media, you won’t learn. If you miss training opportunities because of depression or ill health, you won’t progress to employment. You can’t hold down a job if you keep having sick days.
Spending on health is an investment. Investing in health must underpin our future policies to Close the Gap, and to address what is, for Australia, a prominent blight on our nation.
Governments and other groups that influence policy cannot do this work themselves. It must be a partnership with Indigenous Australians.
The AMA is committed to working, in partnership with our first peoples to Close the Gap in Indigenous health and disadvantage.
25 March 2015
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Published: 25 Mar 2015