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Commitment to improving Indigenous health

Commitment to improving Indigenous health Dean, Faculty of Medicine, The University of SydneL: and Chair, NHMRC Health Advisory Committee urgency of developing courses and modules appropriate to their needs. The vital connection of Indigenous people to their land is emphasised in the paper by McDermott et al. They found superior health and health service usage among Indigenous people living in homelands as compared to those in centralised communities in central Australia. Access to preventive services such as Pap smears (Hunt et al.) and immunisation (Hanna et al.) is another matter that symbolises the need for Indigenous people to be covered not only by locallyrelevant and distinctive services, but also by mainstream Australian health care. This may lead to adaptations of prevailing systems (Reath and Ushenvood) by community participation methods, methods which may not be limited to Indigenous communities in their effectiveness. As is often the case in less developed settings, mainstream hospital services can come to be a substitute for preventive care, as Stamp et al. point out. The problem here is that, because hospitals have to mount rescue operations in the absence of effective prevention, a Catch-22 can be set up whereby they gobble the resources for rescue that should be invested in prevention. Recently, in Port Moresby General Hospital ICU, I saw one woman desperately ill on a ventilator after suffering a ruptured uterus and two patients with severe consequences of snake bite. In PNG, 30% of the aid posts which previously provided primary care services to local communities are shut. Many others are unsupervised. PNG’s maternal mortality rate has risen in the international league chart to secondfrom-the-top. Well organised and integrated services can come unstuck: we need to remember that with Indigenous health it is always possible that it could get worse and not better. While PNG now has undoubtedly better hospitals than when I worked there in 1968,the same cannot be said for its public health and primary care facilities. How can these wonderfully varied contributions be brought together coherently? First, the papers in combination establish the possibility and value of sensitive public health research in this most difficult of all public health challenges. I find that immensely reassuring and a strong antidote to those who argue that research is irrelevant, impossible or useless in this setting. Second, together the papers reinforce the view that there are many opportunities for improving Indigenous health without waiting for the revolution. These opportunities extend all the way from educational support and development of local Indigenous health workers, doctors and nurses, to the enhanced use of readily available preventive interventions including prompt treatment for sexually transmitted diseases and immunisation, through to support for Indigenous people seeking stronger affinity with their land. There is also value in seeking better connections of Indigenous people to adaptations of mainstream services. Although not referred to in these papers, there has been progress recently in improving access for Indigenous communities to the Pharmaceutical Benefits Scheme. While an immense amount remains to be done - improving 635 This issue of the Journal contains a wealth of evidence of the commitment of public health researchers to the improvement of the health of Aboriginal people and Torres Strait Islanders. This is immensely encouraging. Each paper adds weight to the view that public health research that is ethical and locally helpful can be, and has been, done with Aboriginal people and Torres Strait Islanders, thus putting to rest the assertion that research has no place in improving the health of these people. Four years ago, I served briefly on an NHMRC committee concerned with establishnng standards and competences for education of local Aboriginal health workers. I was vetoed by the largely Indigenous group because when asked about my background and professional interests I mentioned public health. Public health was definitely ‘out’ whereas ‘primary health care’ was equally strongly ‘in’. To those present, the experience of public health was associated with white-dominated efforts to control infectious disease, and not far removed from ithe paternalistic error of those who tookAboriginal children from their homes and about whom much has been written and said. Public health thus starts with a heavy bag on its back. So does research more generally, often because it has been conducted insensitively and without perceptible gain to the community whose tissues and habits have been used as the substrate for publications. Thus to have an entire issue of the Journal devoted to successful public health research among Aboriginal people and Torres Strait Islanders is indeed encouraging. It is not the facts about Indigenous health that are in question more broadly in the community - it is the interpretation of these facts. My encounters with several federal bipartisan parliamentary committees to whom Indigenous health was said to be of interest left me in no doubt about the diversity of views held by these representatives of ourAustralian people. Some were broadly sympathetic and keen to discuss ways in which remedies might be effected. Far more had heard it all before and were of the view that unless and until Indigenous people began to ‘help themselves’ nothing would change. To many, they were hopeless, spongers, wasters of government money, corrupt, untrustworthy and unpleasant. So what if their life expectancy was 20 years less than that of white Australians? What would you expect? ‘They live among dogs, you know’, one especially unpleasant parliamentarian told our group, and laughed. What can we gleari from the papers in this issue? M a k et al. reinforce the point that even something as simple as a morbidity survey has value only if the methods are sound and the results are fed back to the local Indigenous community. Another survey, this time of Indigenous workforce educational needs by Sibthorpe et al., points to the huge need for support of these people and the 1998 VOL. 22 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Editorials infrastructure, strengthening community-controlled health services, educating Indigenous people in the art and science of western health care for their own local adaptation and application - these papers give hope to the sagging spirit. All is not doom and gloom. Public health research workers are out there, working with Indigenous communities, giving public health and research a better name, and most importantly, lifting some of the heavy fallen beams of illness and injury off the lives and limbs of our Aboriginal people and Torres Strait Islanders. On the other hand, the non-Indigenous Australians with whom we have worked closely in the mainstream for a number of years now have begun to understand ‘an Aboriginal way of doing things’. They have begun to listen to our perspective, they have been able to set much more realistic time frames, they realise that we have a number of bosses besides them (most importantly, our communities and our elders) and they have been able to provide many resources with which to build an infrastructure which has been shown to be working. The provided resources have been more than just wages and have included venue hire, the use of vehicles, an exchange of skills, and provision of stationery and equipment. The way we have worked together in building equal partnerships has been a productive way of developing and delivering services and programs which meet the cultural needs of both the mainstream and our communities. It has been a two-way learning process. Of course, Australia will never be a classless society, and the health and well-being of all Australian people is not determined by class alone. .But, regardless of which legislative Acts are in place, Australian society is still determined by race and the unequal distribution of power, continuing the ethnocentric and Paternalistic practices which reek of colonisation and assimilation. These practices deny culture and spirituality; do not provide resources; prevent ownership of Indigenous land on which to build a strong economic base; and build bamers preventing access to mainstream services (often caused by racism alone). They do not encourage or allow strong Indigenous voices in policy and practice, at both the top end and at the grass roots level. The results of these practices are shown in increased rates of unemployment; in cuts to CDEP funding (Aboriginal people working for the dole); in the unnecessarily high rates of incarceration (which may lead to unnecessary and preventable deaths in custody); in failure to provide culturally relevant legal representation; in inappropriate education and training opportunities; in failure to provide safe, appropriate and affordable housing; and in the development and delivery of ethnocentric and culturally ineffective programs and services. The noticeable improvement in the health and well-being of other Indigenous nations around the world has largely been due to a reversal of these practices. To support such a philosophy in Australia would require a huge shift in the thinking of non-Indigenous Australians. It most certainly would mean a shift in power and control. The provision of resources and the services, programs and training opportunities must be developed and sustained by Indigenous Australians themselves. Everywhere today, there is talk of collaboration, partnership agreements, evidence-based research, strategic planning, consultation, advisory groups and the like. They all operate on the understanding that programs cannot function alone. In the development of the best practice model you must investigate who has a stake in the program or partnership - including those with a role to advise, consult or plan strategically - and who has the most to lose as a result of change. This model differs from past practices and we suspect that it is far too threatening for most nonIndigenous Australians to accept. For the past 2% years, we have had a government which should have had a mandate to empower Indigenous people, but which has made only a half-hearted attempt to address the inequities between 1998 VOL. 22 NO.6 Planning for better health outcomes requires Indigenous perspective Sandy Angus Department of Public Health and Community Medicine, University of Sydney; New South Wales Traven Lea Australian National University; Australian Capital Territory Indigenous health is often described and determined by an array of words, models, concepts, principles, practices, notions, themes and philosophies which usually have unrealistic time frames or lack cultural understanding. As a result, most are seen by the Indigenous Australians they are meant to assist as being ‘a white way of doing things’ rather than as relevant and effective. The rhetoric which continues with this discourse often means nothing more to us as Indigenous Australians than does the paternalistic concept of ‘we will fix your health’. Nevertheless, this discourse and these time frames are used time and time again to determine or to describe our health status. If the health (and well-being) of Indigenous Australians is to improve at all, then the Indigenous perspective needs to be heard especially at all levels of the bureaucratic hierarchy - and, perhaps as importantly, we need to be given the resources with which we can go about ‘fixing our own health’. As an alternative to the ‘we will fix your health’ philosophy, we - as practitioners in our own right - can demonstrate examples of where our own health interventions are working. These interventions are similar to those which are also being used successfully by other Indigenous peoples around the world. They work to build an infrastructure which supports programs, services, and education and training opportunities, all of which have been developed, implemented and evaluated by Indigenous people themselves and which go a long way towards an Indigenous person’s notion of holistic health and well-being. If, when asked to give our opinion (as we were in this instance) on where our health will be by the year 2000, we voice our cynicism and concern, we often are judged as being negative and wanting ‘special treatment’ or labelled as being “hard to get along with’. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Commitment to improving Indigenous health

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Publisher
Wiley
Copyright
Copyright © 1998 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1998.tb01457.x
Publisher site
See Article on Publisher Site

Abstract

Dean, Faculty of Medicine, The University of SydneL: and Chair, NHMRC Health Advisory Committee urgency of developing courses and modules appropriate to their needs. The vital connection of Indigenous people to their land is emphasised in the paper by McDermott et al. They found superior health and health service usage among Indigenous people living in homelands as compared to those in centralised communities in central Australia. Access to preventive services such as Pap smears (Hunt et al.) and immunisation (Hanna et al.) is another matter that symbolises the need for Indigenous people to be covered not only by locallyrelevant and distinctive services, but also by mainstream Australian health care. This may lead to adaptations of prevailing systems (Reath and Ushenvood) by community participation methods, methods which may not be limited to Indigenous communities in their effectiveness. As is often the case in less developed settings, mainstream hospital services can come to be a substitute for preventive care, as Stamp et al. point out. The problem here is that, because hospitals have to mount rescue operations in the absence of effective prevention, a Catch-22 can be set up whereby they gobble the resources for rescue that should be invested in prevention. Recently, in Port Moresby General Hospital ICU, I saw one woman desperately ill on a ventilator after suffering a ruptured uterus and two patients with severe consequences of snake bite. In PNG, 30% of the aid posts which previously provided primary care services to local communities are shut. Many others are unsupervised. PNG’s maternal mortality rate has risen in the international league chart to secondfrom-the-top. Well organised and integrated services can come unstuck: we need to remember that with Indigenous health it is always possible that it could get worse and not better. While PNG now has undoubtedly better hospitals than when I worked there in 1968,the same cannot be said for its public health and primary care facilities. How can these wonderfully varied contributions be brought together coherently? First, the papers in combination establish the possibility and value of sensitive public health research in this most difficult of all public health challenges. I find that immensely reassuring and a strong antidote to those who argue that research is irrelevant, impossible or useless in this setting. Second, together the papers reinforce the view that there are many opportunities for improving Indigenous health without waiting for the revolution. These opportunities extend all the way from educational support and development of local Indigenous health workers, doctors and nurses, to the enhanced use of readily available preventive interventions including prompt treatment for sexually transmitted diseases and immunisation, through to support for Indigenous people seeking stronger affinity with their land. There is also value in seeking better connections of Indigenous people to adaptations of mainstream services. Although not referred to in these papers, there has been progress recently in improving access for Indigenous communities to the Pharmaceutical Benefits Scheme. While an immense amount remains to be done - improving 635 This issue of the Journal contains a wealth of evidence of the commitment of public health researchers to the improvement of the health of Aboriginal people and Torres Strait Islanders. This is immensely encouraging. Each paper adds weight to the view that public health research that is ethical and locally helpful can be, and has been, done with Aboriginal people and Torres Strait Islanders, thus putting to rest the assertion that research has no place in improving the health of these people. Four years ago, I served briefly on an NHMRC committee concerned with establishnng standards and competences for education of local Aboriginal health workers. I was vetoed by the largely Indigenous group because when asked about my background and professional interests I mentioned public health. Public health was definitely ‘out’ whereas ‘primary health care’ was equally strongly ‘in’. To those present, the experience of public health was associated with white-dominated efforts to control infectious disease, and not far removed from ithe paternalistic error of those who tookAboriginal children from their homes and about whom much has been written and said. Public health thus starts with a heavy bag on its back. So does research more generally, often because it has been conducted insensitively and without perceptible gain to the community whose tissues and habits have been used as the substrate for publications. Thus to have an entire issue of the Journal devoted to successful public health research among Aboriginal people and Torres Strait Islanders is indeed encouraging. It is not the facts about Indigenous health that are in question more broadly in the community - it is the interpretation of these facts. My encounters with several federal bipartisan parliamentary committees to whom Indigenous health was said to be of interest left me in no doubt about the diversity of views held by these representatives of ourAustralian people. Some were broadly sympathetic and keen to discuss ways in which remedies might be effected. Far more had heard it all before and were of the view that unless and until Indigenous people began to ‘help themselves’ nothing would change. To many, they were hopeless, spongers, wasters of government money, corrupt, untrustworthy and unpleasant. So what if their life expectancy was 20 years less than that of white Australians? What would you expect? ‘They live among dogs, you know’, one especially unpleasant parliamentarian told our group, and laughed. What can we gleari from the papers in this issue? M a k et al. reinforce the point that even something as simple as a morbidity survey has value only if the methods are sound and the results are fed back to the local Indigenous community. Another survey, this time of Indigenous workforce educational needs by Sibthorpe et al., points to the huge need for support of these people and the 1998 VOL. 22 NO. 6 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Editorials infrastructure, strengthening community-controlled health services, educating Indigenous people in the art and science of western health care for their own local adaptation and application - these papers give hope to the sagging spirit. All is not doom and gloom. Public health research workers are out there, working with Indigenous communities, giving public health and research a better name, and most importantly, lifting some of the heavy fallen beams of illness and injury off the lives and limbs of our Aboriginal people and Torres Strait Islanders. On the other hand, the non-Indigenous Australians with whom we have worked closely in the mainstream for a number of years now have begun to understand ‘an Aboriginal way of doing things’. They have begun to listen to our perspective, they have been able to set much more realistic time frames, they realise that we have a number of bosses besides them (most importantly, our communities and our elders) and they have been able to provide many resources with which to build an infrastructure which has been shown to be working. The provided resources have been more than just wages and have included venue hire, the use of vehicles, an exchange of skills, and provision of stationery and equipment. The way we have worked together in building equal partnerships has been a productive way of developing and delivering services and programs which meet the cultural needs of both the mainstream and our communities. It has been a two-way learning process. Of course, Australia will never be a classless society, and the health and well-being of all Australian people is not determined by class alone. .But, regardless of which legislative Acts are in place, Australian society is still determined by race and the unequal distribution of power, continuing the ethnocentric and Paternalistic practices which reek of colonisation and assimilation. These practices deny culture and spirituality; do not provide resources; prevent ownership of Indigenous land on which to build a strong economic base; and build bamers preventing access to mainstream services (often caused by racism alone). They do not encourage or allow strong Indigenous voices in policy and practice, at both the top end and at the grass roots level. The results of these practices are shown in increased rates of unemployment; in cuts to CDEP funding (Aboriginal people working for the dole); in the unnecessarily high rates of incarceration (which may lead to unnecessary and preventable deaths in custody); in failure to provide culturally relevant legal representation; in inappropriate education and training opportunities; in failure to provide safe, appropriate and affordable housing; and in the development and delivery of ethnocentric and culturally ineffective programs and services. The noticeable improvement in the health and well-being of other Indigenous nations around the world has largely been due to a reversal of these practices. To support such a philosophy in Australia would require a huge shift in the thinking of non-Indigenous Australians. It most certainly would mean a shift in power and control. The provision of resources and the services, programs and training opportunities must be developed and sustained by Indigenous Australians themselves. Everywhere today, there is talk of collaboration, partnership agreements, evidence-based research, strategic planning, consultation, advisory groups and the like. They all operate on the understanding that programs cannot function alone. In the development of the best practice model you must investigate who has a stake in the program or partnership - including those with a role to advise, consult or plan strategically - and who has the most to lose as a result of change. This model differs from past practices and we suspect that it is far too threatening for most nonIndigenous Australians to accept. For the past 2% years, we have had a government which should have had a mandate to empower Indigenous people, but which has made only a half-hearted attempt to address the inequities between 1998 VOL. 22 NO.6 Planning for better health outcomes requires Indigenous perspective Sandy Angus Department of Public Health and Community Medicine, University of Sydney; New South Wales Traven Lea Australian National University; Australian Capital Territory Indigenous health is often described and determined by an array of words, models, concepts, principles, practices, notions, themes and philosophies which usually have unrealistic time frames or lack cultural understanding. As a result, most are seen by the Indigenous Australians they are meant to assist as being ‘a white way of doing things’ rather than as relevant and effective. The rhetoric which continues with this discourse often means nothing more to us as Indigenous Australians than does the paternalistic concept of ‘we will fix your health’. Nevertheless, this discourse and these time frames are used time and time again to determine or to describe our health status. If the health (and well-being) of Indigenous Australians is to improve at all, then the Indigenous perspective needs to be heard especially at all levels of the bureaucratic hierarchy - and, perhaps as importantly, we need to be given the resources with which we can go about ‘fixing our own health’. As an alternative to the ‘we will fix your health’ philosophy, we - as practitioners in our own right - can demonstrate examples of where our own health interventions are working. These interventions are similar to those which are also being used successfully by other Indigenous peoples around the world. They work to build an infrastructure which supports programs, services, and education and training opportunities, all of which have been developed, implemented and evaluated by Indigenous people themselves and which go a long way towards an Indigenous person’s notion of holistic health and well-being. If, when asked to give our opinion (as we were in this instance) on where our health will be by the year 2000, we voice our cynicism and concern, we often are judged as being negative and wanting ‘special treatment’ or labelled as being “hard to get along with’. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Oct 1, 1998

There are no references for this article.