AFTER THE INTERVENTION: Marilyn Wise from the University of New South Wales and Peter O'Mara from the Australian Indigenous Doctors’ Association ask whether the NT Intervention has made Indigenous communities healthier.
In 2006 the NT Government commissioned the Akelyernemane Meke Mekarle “Little Children are Sacred” report in response to widespread political and community concern. The Northern Territory Intervention followed, aiming to protect the region’s children. But an assessment of its effects on health have found more bad news than good.
The genesis of the Intervention
Aboriginal people in the Northern Territory had long been calling for greater partnership with and investment by governments to support communities to act to improve their living conditions and the opportunities available for their futures.
The Akelyernemane Meke Mekarle ‘Little Children are Sacred’ report was, in 2006, the last in a series that had recommended actions to achieve these goals. But the NT Government did not respond quickly.
Stepping into what it saw as a vacuum, the Federal Government instead announced a “national emergency response to protect Aboriginal children in the Northern Territory”.
Within two months Parliament had passed five acts, including measures that required the suspension of Part II of the Racial Discrimination Act of 1975.
This body of legislation formed the base for the Northern Territory Emergency Response (NTER). Seventy-three communities were “prescribed” as locations where the NTER applied.
How does a Health Impact Assessment work?
The affected NT communities were gravely concerned about the introduction of the NTER legislation without consultation (with communities in particular).
The Australian Indigenous Doctors’ Association (AIDA) decided to undertake a Health Impact Assessment (HIA). This was both to give voice to affected communities, and, as doctors, to facilitate discussion with policy makers and program leaders. The association felt there were ways to improve the NTER in order to increase positive impacts and reduce negative impacts on the health and wellbeing of the affected communities.
AIDA conducted the HIA in collaboration with the Centre for Health Equity Training Research and Evaluation (CHETRE), and with funding from the Fred Hollows Foundation.
HIA is endorsed by the World Health Organization. It is a predictive tool that uses evidence from a variety of sources to assess the potential impacts of policies on the health of a population. It can recommend changes to increase potentially positive and to reduce potentially negative impacts.
For this HIA the evidence was collected through consultation with more than 250 Aboriginal residents of four communities in the NT, and with 25 Aboriginal and non-Aboriginal stakeholders. Six expert appraisals of the research-derived evidence of the impact of six of the measures included in the NTER on the health of populations were also commissioned.
The dance of life
This HIA assessed the potential impact of components of the NTER on Aboriginal health and wellbeing – a definition outlined in the Dance of Life.
The dance of life painting is the last in a series depicting a multi-dimensional model of health and wellbeing from an Aboriginal perspective. The final painting brings all of the dimensions together to reflect the delicate balance of life within the universe.
The dimensions include the biological or physical dimension, the psychological or emotional dimension, the social dimension, the spiritual dimension and finally but most importantly, the cultural dimension.
Within each dimension there are additional layers to consider, including the historical context, the traditional and contemporary view as well as our gaps in knowledge.
Solutions that can heal and restore wellbeing must consider additional factors: education and training, policy, the socio-political context and international perspective. As the final painting suggests, we can only exist if firmly grounded and supported by our community and spirituality, whilst always reflecting back on culture in order to hold our head up high to grow and reach forward to the experiences life has waiting for us.
The stories of our ancestors, the collective grief, as well as healing, begin from knowing where we have come from and where we are heading. From the Aboriginal perspective, carrying the past with you into the future is, as it should be. We are nothing if not for those who have been before, and the children of the future will look back and reflect on us today.
When we enable a person to restore all of the dimensions of their life, then we have achieved a great deal. When all of the dimensions are in balance, within the universe, we can break free of our shackles and truly dance through life.
The NTER legislation included multiple measures, but it was agreed that the HIA would focus on predicting the impacts of compulsory income management, housing, education, alcohol restriction, prohibited material restriction and child health checks on each of the dimensions of health and wellbeing.
However, in the course of conducting the HIA it became clear that the imposition of external leadership, governance, and control would also have significant effects on the health of the affected communities. This was also included in the assessment.
What did the HIA predict?
The HIA predicted that although it was likely that there would be some positive impacts on the physical health of some members of the affected communities, it was also likely that the harmful impacts are likely to outweigh these. The evidence was consistent: the NTER would leave a negative legacy on the psychological and social wellbeing, on the spirituality and on the cultural integrity of the affected communities.
The HIA also predicted that the increasing levels of mistrust in governments that would arise from the imposition of the NTER would limit the ability of governments and communities to work together effectively in the future. In overlooking the need for all Australians to be able to value and work across Aboriginal and non-Aboriginal cultures, the NTER overlooked the centrality of human dignity to health.
The HIA recommended that the negative impacts on health would be minimised if governments committed to working in respectful partnerships with Aboriginal people.
The HIA recommended that two of the measures be overturned immediately; that others be supplemented with additional investment; and that yet others be progressed as planned and as quickly as possible.
What has happened since?
The commitment of long-term, recurrent funding to improve infrastructure and service delivery across multiple sectors has been welcomed. There is evidence that some people and communities have benefitted from some of the measures implemented.
The Labor Government reinstated Part II of the Racial Discrimination Act 1975 but has extended compulsory quarantining of welfare payments to include non-Aboriginal welfare recipients in disadvantaged regions and dysfunctional families and communities.
However, there is little evidence that the harms to health predicted by the HIA have been reduced. Two years after the introduction of compulsory income management, evidence suggested that there had been no increase in healthier food and drink purchases, and no reduction in tobacco sales. Store licensing had some positive effects on food security in communities.
Despite the emphasis placed on children’s health and the ongoing Northern Territory Emergency Response (NTER), data show that in the Northern Territory in 2009-10 only 12.7% of children aged under 15 years had had a health check (that attracted a Medicare reimbursement).
There had been only a very small increase in the number of convictions for child sexual abuse since the implementation of the NTER.
With some few exceptions school attendance at NT very remote schools fell in 2009 and 2010. Fewer than 60% of children enrolled in 2010 were attending school – a decline from 70% at the beginning of 2009. There was little change in attendance rates at Government remote and provincial schools in 2009-2010.
The area of housing and land tenure reforms appeared to have gone from bad to worse, although there is variation among communities – some have been able to build new housing and increase employment opportunities for local residents.
The half-yearly reports on progress in Closing the Gap prepared by the Department of Families, Housing, Community Services and Indigenous Affairs have confirmed some of the predictions of the HIA. The progress toward achieving population-wide improvements in education, housing, employment, nutrition, and children’s early development that are necessary prerequisites to improved health and life expectancy have been slow and small.
Meanwhile, the evidence is growing of harms to health being caused by compulsory income management, by the lack of progress on land tenure and housing, and by lack of progress in improving school attendance.
The HIA recommended a range of changes to the legislation and to its implementation to increase the likelihood of achieving improved population health, and to reduce negative impacts. With the exception of the reinstatement of the provisions of the Racial Discrimination Act these recommendations are still current.
Most important, though, is that there is overwhelming evidence that governments must learn to work in respectful partnerships with Indigenous people and communities. They need to build trust and respect between government and communities; to build strong partnerships to ensure effective local governance; and to develop and implement more effective, local solutions.
The HIA confirmed that to “close the gap”, governments must recognise and act on the fact that there is no substitute for what Aboriginal people have the right to and have been seeking since the beginning of the Intervention (and long before):
The question is how we can work together as equals, coming together to understand each other and work out ways to go forward together. Community member from the NT.
We are asking simply for understanding that in life there needs to be an understanding between two cultures. There needs to be respect between cultures. Yingiya Guyula, Darwin, NT.