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Improving Aboriginal health and well-being: a view from the north

Aboriginal people living in remote communities have much worse health status and longevity than other Australians. And this imbalance will not be remedied until governments work with Aboriginal leaders…

Australian Aboriginals are at most risk of bad physical and mental health and they have the worst health services in the country. publik16/Flickr

Aboriginal people living in remote communities have much worse health status and longevity than other Australians. And this imbalance will not be remedied until governments work with Aboriginal leaders and communities to address inequalities in education, economic opportunities, and housing.

Offering Australians at most risk of bad physical and mental health the worst health services is a social justice issue. Poorly-designed mental and child health service models and the lack of adequately specialised staff is compounded by the absence of Aboriginal community leadership. And without leadership, Aboriginal people struggle to access effective and culturally safe treatment.

Between us, we have spent 38 years working in Aboriginal health. Lesley Barclay has recently been working on a project aiming to inform improvements in maternal and infant health care, while Tricia Nagel has been exploring Aboriginal and Torres Strait Islander perspectives of mental health.

In recent years, we have worked together on research lead by Tricia Nagel around remote mental health services. Here are some of the things we have learnt and think deserves attention.

A poor reflection

We know that complex chronic disease starts in the womb and we know social distress contributes to mental illness and self-harm.

But Aboriginal infants in northern Australia still begin life lighter than other Australian babies and nearly 30% require admission to a neonatal nursery for care. This figure is more than double the rate of other babies elsewhere in Australia.

At six months, 68% of Aboriginal infants are anaemic, and 86% show faltering growth in their first 12 months.

Rates of anxiety and depression symptoms among Aboriginal people are between twice and three times higher than for non-Indigenous Australian adults. Loaf/Flickr

Surveys of Aboriginal and Torres Strait Islander people show consistently higher rates of psychological distress; their rates of anxiety and depression symptoms are between twice and three times higher than for non-Indigenous Australian adults.

Despite all this, our research shows many Northern Territory clinicians struggle to identify and treat anaemia and low weight in infants. Nor do they deal adequately with the persistent grief and mental and social distress of many Aboriginal people.

This is a poor reflection on our health system’s performance.

Potential and problems

A poor start to life can be modified, to an extent, by natural resilience, and at least some individuals do have the ability to bounce back. But good quality health care is essential.

There are effective treatments to mitigate some of the consequences of Aboriginal disadvantage, but government-run services do not always provide them. The skills and knowledge of health practitioners and their capacity to work effectively across cultures is sorely lacking.

We could promote healthy weight gain in underweight infants and identify problems of mental health and well-being before they become severe. But we need accessible, culturally safe assessments and appropriate interventions to do this.

Stigma in relation to mental health problems reduces “help seeking” by community members. Sensitive screening can identify needs and institute treatments before a minor problem becomes a crisis.

But this requires a community-based and client-centred approach to care, rather than the current health-centre focused model.

Such cultural challenges persist because there are so few Aboriginal health professionals available to provide care and teach their non-Aboriginal colleagues.

Medical staff in remote communities are generally few in number and under-qualified to deal with the volume and acuity of care in child and mental health. There are no full-time, qualified child health workers devoted solely to the hundreds of children under five in large communities, for instance.

Similarly, the burden of mental disorders is so severe in remote communities that it will require skills and confidence to engage in care, early intervention and provision of culturally-appropriate treatment. These skills are rarely present among the generalist staff.

A possible model

But it’s not all bad news. Despite facing the same challenges as the rest of northern Australia, the Northern Territory’s health system has considerably improved how it deals with chronic disease, maternity care and substance misuse recently.

Continuity of care is improving the quality of anetnatal and post-natal care in the Northern Territory. Kristy/Flickr

What it has achieved could guide system improvement within mental and child health across northern Australia.

Midwives now work with pregnant women and new mothers in larger communities in the territory; and one known midwife provides consistent care for women transferred to regional centres for birth.

This continuity of care has improved the quality of services – fewer women have no antenatal care and testing and smoking cessation has advice improved; there’s been a reduction in fetal distress during labour; and, a higher proportion of women receive postnatal contraception advice.

How women engage with the health system has improved, resulting in midwives receiving text messages reporting baby weight many weeks after birth. A cost-consequences analysis has shown savings based mainly on significantly reduced birthing and neonatal nursery costs.

The remote substance misuse workforce receives daily supervision from staff in health centres, as well as face-to-face supervision, training and advocacy support from specialist alcohol and other drug-use nurses and psychologists.

A specific chronic disease worker role has recently been established, alongside improved data monitoring and skilled clinical governance. This appears to be making a significant difference in the quality of care by using locally-managed treatments.

The underlying issue

The Northern Territory health system has made good progress in chronic disease management and maternity care, and is investigating better ways to provide child health services. But there is still a long way to go to improve infant care and promote mental health and well-being.

The underlying issue is equity – a significant number of already vulnerable Australians are getting much worse health care than they need and deserve.

The lack of staff adequately prepared to deal with the volume and acuity of infant illness and the lack of physical and mental wellness in remote Aboriginal communities would not be acceptable elsewhere in Australia.

As citizens, we find the situation is inexcusable; as health practitioners we can see the reasons for it, as well as its impacts; and as researchers, we hope that the data we’ve gathered is used to stimulate debate, generate much-needed changes and contributes to improving the health-care system.

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13 Comments sorted by

  1. Michael Sheehan

    Geographer at Analyst

    "Aboriginal people living in remote communities have much worse health status and longevity than other Australians."
    Isn't it more accurate to say 'ANY people living in remote desert communities, without any employment opportunities, naturally have much worse health status and longevity than ANY people who live in urban communities'.

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  2. Peter Wundersitz

    retired

    I have to agree with Michael; no matter where you live, if there is no employment you will not have the support that people living where there is an income to be earned will get.
    I used to watch the teachers come and go in the NT. They were dedicated people, but there is no future in those places.

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  3. Stephen Ralph

    carer

    Hospitals have closed and are closing in rural areas across the country.
    Access to quality rural medical services have deteriorated over the decades.

    Aboriginal health is a national disgrace.

    TA made much of his "association" with indigenous Australians. he needs to step up and do what should have been done eons ago..........make progress not only in health, but practically every area of community life.

    No-one seems to be able to address these issues....doesn't seem for lack of money or lack of trying. It only improves marginally, or not at all.

    If there are no aboriginal leaders able to step up, they need to mentored, created, educated or whatever else needs be.

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    1. Michael Sheehan

      Geographer at Analyst

      In reply to Stephen Ralph

      Maybe the best thing we can do is provide luxury coaches, so they can get the flock out of those desert hell-holed.

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  4. Tim Senior

    logged in via Twitter

    Thanks for an interesting article.
    There are two additional important points to make, I think.
    One is the importance of community controlled health services. Being owned and run by local Aboriginal people, they have the trust of the local community inn a way that non-Indigenous services often don't. They also take a very broad view of health and offer a range of essential services not found in other settings.
    The second, linked, point, is on the causes of the problems described in the article…

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    1. Michael Sheehan

      Geographer at Analyst

      In reply to Tim Senior

      "One is the importance of community controlled health services."
      The article says there is no Aboriginal leadership. And what do you think the upper educational/IQ limit would be?

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    2. Tim Senior

      logged in via Twitter

      In reply to Michael Sheehan

      "The article says there is no Aboriginal leadership."
      It does, but that doesn't make it true! There are plenty of excellent Aboriginal leaders out there, especially in the health sector. There is enough to be able to form a large Indigenous leadership group of the Close the Gap coalition at a national level, who are advising the First People's Congress (yet more leadership). There is Aboriginal leadership at AMSANT in the NT, and at state and local levels right across Australia in the community controlled sector. Other sectors also have active Aboriginal leadership - eg in education, law, academia. You could follow @IndigenousX on twitter (and the accompanying profiles on the Guardian website at http://www.theguardian.com/commentisfree/series/indigenousx - each week another Aboriginal leader.)

      Racial understandings of IQ testing have been thoroughly discredited, and IQ isn't used in any organisations I know as a proxy for leadership ability either.

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  5. Max Kamien

    Emeritus Professor of General Practice & Corlis Fellow of the RACGP at University of Western Australia

    Almost exactly the same findings as in the ARID Zone Project of Prof John Cawte from UNSW from 1968-1980. If you are poor, mal-nourished, functionally illiterate, live in overcrowded conditions, in a dysfunctional community with high rates of substance abuse, anger, depression and a pervasive culture of passivity and victimization, you are never going to be healthy.
    Health care workers have long known the social determinants of ill health in Aboriginal people. What we lack is the know how to involve…

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    1. Trevor Kerr

      ISTP

      In reply to Max Kamien

      How to do what, Max? If it's "closing the gap", are we sure that Aboriginal people want a better chance of staying alive into their 80s with the last ten years incapacitated by dementia?

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    2. Michael Sheehan

      Geographer at Analyst

      In reply to Trevor Kerr

      'Closing the gap' will never occur without closing the desert camps.

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  6. Paul Prociv

    ex medical academic; botanical engineer

    So, wot’s new? This is the same old, same old . . . Instead of needing more research, we need to look at the big picture a little bit more realistically, honestly and maturely.
    Health is not some commodity that governments or health services can give you, or that you can buy off a shelf – it is integral to one’s entire lifestyle. To gain a better idea of where the problems might lie, it would be far more useful to compare health among different indigenous groups, rather than the “average…

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    1. Greg Miles

      Conservation lobbyist

      In reply to Paul Prociv

      Beautifully said Paul!

      After 30 plus years of working in the west Arnhem region I could not agree more with what you say. Having tormented myself, dwelling on this, for decades - the best plan that I can come up with are regional boarding schools that take most children from an early age. But I don't mean "take" in that negative sense, but fiercely urge the parents to offer their children up. Parents would have visiting rights and children would have a choice of going home for holidays, or going on irresistibly enriching holiday excursions. Expensive - yes - but in the longer term maybe less expensive than where we are heading at the moment. Especially true when one looks at the indigenous birth rate.

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    2. Michael Sheehan

      Geographer at Analyst

      In reply to Paul Prociv

      "urban whites"!!??
      I don't know how long it's been since you've visited the big smoke, but it ain't 1955 anymore.

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