CRCAH - Guest Editorial

The CRC for Aboriginal Health's newsletter has a regular guest editorial featured in each edition for all the editorials see below.

Self Determination in the Murdi Paaki

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The Murdi Paaki Regional Partnership Agreement is the first for NSW and significantly, the agreement highlights the first real evidence of recognition of an Aboriginal governance model, by governments of any persuasions, since the abolition of ATSIC nearly five years ago.

The RPA will see significant engagement and investments into:

governance and leadership via the Murdi Paaki Regional Assembly and Community Working Parties,
building strategic relationships with local governments, and
young leaders through the Murdi Paaki Aboriginal Young Leaders program.

The RPA is the overarching strategic document that lays out the foundations on which a significant partnership will operate.

The underpinnings to the RPA are the Murdi Paaki Regional Plan and major regional strategies encompassing over 1000 action items in Education, Health, Housing, Employment and Economic Development, Law and Justice and Community and Regional Governance.

These strategies are the investment framework through which targeted resources can be delivered and have been created by sub-groups, led by lead agencies, co-ordinating core business agencies and providers responding to identified priorities.

The agreement gives action to Australian and NSW Government commitments to be more co-ordinated, collaborative and responsive to priority issues identified by Aboriginal people through the delivery of programs and services.

The Murdi Paaki Health Project (MPHP) is unique in that the project has been developed through priorities set during a community planning process.

The MPHP is one example on how government agencies and local service providers have aligned the delivery of programs and services against priority actions determined by Aboriginal people.

The programs and services are normally developed through funding submissions from service organisations whereas the community planning process provides a broader, more comprehensive identification of community priorities which enable resources to be better targeted to meet needs.

The NSW Department of Education and Training, Western Region and Western Region Schools are implementing the Murdi Paaki Education Strategy in 2009.

The strategy is also a compilation of priority actions identified through a community planning process.

Both the health and education strategies are evidence of the MPRA varying normal service delivery to become more inclusive of things that are important to local Aboriginal families and individuals.

Community priorities and needs would have received less, if any, consideration under the usual service delivery process.

The other impacting feature of the education strategy is the new relationship that has been developed between school Principals and community via the community governance model which has seen more emphasis of community issues than previous consultative mechanisms which often proved to be more obstructive than engaging.

The Murdi Paaki Aboriginal Young Leaders Project (MPAYLP), another key feature of the RPA, was developed through the Murdi Paaki Council of Australian Governments Trial to provide young Aboriginal people an avenue for effective participation in their communities, to identify and develop role models and take on leadership and roles of responsibility in their community.

The project has been implemented over the last 3 years with outstanding results in leadership development.

More than 100 Young Leaders from sixteen communities have been participating in MPAYLP and the program will continue for a further three years to develop young Aboriginal people into community leaders.

The other significant aspect of the project is implementing succession planning so that, as people move out of the governance arrangements, there is a pool of capacity to fill the void.

The concluding component of the agreement is the provision of resources to allow normal business of the Murdi Paaki Regional Assembly and Community Working Parties to be carried out, including resources to provide MPRA with newly created executive support and administrative assistance.

The past 12 months saw the first period in eighteen years that no agreement existed in the Murdi Paaki region between Aboriginal people and government.

During this period resources for the Assembly to continue to do its business came from mixed sources including Maari Ma Aboriginal Health, Murdi Paaki Regional Housing, Murdi Paaki Regional Enterprise Corporation and philanthropic grants.

2008 has been the most autonomous period for the Murdi Paaki governance model and the new regional partnerships agreement will allow for maintenance of that autonomous role while fulfilling obligations to and with governments.

Sam Jeffries
Chair
Murdi Paaki Regional Assembly

For more information go to:
http://www.daa.nsw.gov.au/news/18.html
http://www.atns.net.au/agreement.asp?EntityID=3227

To view agreement visit: http://www.crcah.org.au/communication/downloads/MURDI-PAAKI-REGIONAL-PARTNERSHIP-AGREEMENT-FINAL-220109.pdf

Reliable health data is integral to ‘closing the gap’
- Associate Professor Jane Freemantle

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Reliable health data about Aboriginal and Torres Strait Islander people are needed to inform health policy and program development, to evaluate policies aimed at improving service delivery and health status, and to assess the effectiveness of programs and interventions.

Currently, Indigenous people are relatively invisible in global health statistics due to major deficiencies in the health data describing them. Such deficiencies have been acknowledged in New Zealand , Canada and the USA, and in a number of Australian states and territories. These deficiencies are in part due to: misclassification of Indigenous people; inconsistencies in the collection, sources, completeness, and classifications in statutory and administrative data collections; and inconsistencies in analysis, interpretation and ownership of the data in each jurisdiction.

Prior to 1976, no Australian jurisdiction separately identified Indigenous persons in vital statistics or hospital-based collections. In 1984, the Australian Government initiated moves to identify all Indigenous Australians in births and deaths data collections. By the end of 1997, all major vital statistics and hospital-based collections included the Indigenous status of persons who are born, die or are admitted to hospital in every state and territory. However, there is an acknowledged under-identification of Aboriginal and Torres Strait Islander people in statutory and administrative data collections, due to a general lack of recognition of the importance of collecting accurate data, ineffective processes for the collection of data and the absence of mandates to insure that accurate data are collected. Thus, the complete ascertainment of Indigenous people is questionable. Those states where the ascertainment is of concern are Victoria, New South Wales, Australian Capital Territory, Tasmania and Queensland (before 1998), which makes it impossible to provide a complete and accurate profile of the mortality of Australia’s Indigenous people.

This is of great concern, because mortality data is one of the most important ways of measuring community health. Important information about the patterns of illness and deaths for the community as a whole become available when details about the deaths in the community are disaggregated. The excess burden of mortality borne by young Indigenous Australians, and the disparity in the rates of infant and childhood mortality that exists between Indigenous and non-Indigenous Australians, has been reported in the two states—South Australia and Western Australia—and in the Northern Territory where there are accurate mortality data.

In addition, mortality statistics are important indicators of a population’s health, as they provide vital information on the prevalence of serious diseases and injuries. Studies of the trends in mortality and related statistics also demonstrate how the health status of a population is changing, and enable the effect of health policies, services and interventions to be monitored and evaluated.

The catch-cry, ‘Close the Gap’, is being heard throughout the Australian community, in the industrial corridors and boardrooms and in the offices of state, territory and federal governments. However, the transition from talking about closing the gap, to seeing real action in achieving such closure will only occur through the implementation of well thought-out, evidence-based projects that have been developed in close consultation both with the Aboriginal and Torres Strait Islander community and those with knowledge and experience of working with and effective translation of, data in the wider community.

We will also need to know the impact of such initiatives and policies on addressing the disparities in mortality and on the social determinants of health experienced by many Aboriginal and Torres Strait Islander people. Thus, we need to be sure of the accuracy of the baseline from which we measure the changes in the current status. Improving the accuracy of Indigenous identification in data collections must be achieved at the point of collection, through better informing both those who collect the information, and those about whom the data are being collected, as to the importance of the accurate collection of information about Indigenous status. We need to explain clearly the importance of these data to forming policies, practice and strategies, and how they can provide communities with more accurate information about the health and wellbeing status of their community.

We also must develop methods to better identify the number of Aboriginal and Torres Strait Islanders included in existing administrative and statutory datasets. Several initiatives are currently being explored including:

The Australian Bureau of Statistics (ABS) Census Data Enhancement Project—Indigenous Mortality Quality Study http://www.abs.gov.au/ausstats/abs@.nsf/mf/4723.0?OpenDocument.
An ABS discussion paper that considers further methods for calculating life expectancy estimates and population projections: http://www.abs.gov.au/ausstats/abs@.nsf/mf/3302.0.55.002?OpenDocument
A project commissioned by the National Advisory Group on Aboriginal and

Torres Strait Islander Health Information—A Comparative Analysis of Indirect Methodologies for Estimating Indigenous Life Expectancy by Tony Barnes, Len Smith, Yuejen Zhao and Steven Guthridge.

An Australian Research Council-funded project that will develop an accurate picture of Aboriginal births and infant and child deaths in Victoria—A Mortality Profile of Victoria’s Aboriginal (and non-Aboriginal) Children 1988–2010 Using an Innovative Method and Research Process.

Incomplete and inaccurate data lead to inaccurate policy and program development, an inability both to evaluate policies aimed at improving service delivery and health status, and to assess the effectiveness of programs and interventions. Programs designed to improve the completeness and accuracy of data describing the health, and indeed the social determinants of health, of Aboriginal and Torres Strait Islander people must be adequately resourced and implemented. Until this occurs we will never really know if we have ‘closed the gap’ of Aboriginal and Torres Strait Islander disadvantage.

Senator Kim Carr, Minister for Innovation, Industry, Science and Research talks to Gwalwa-Gai

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What is the Federal Government hoping to achieve by the CRC Review?

endorses the Government's decision to restore public good as a key objective;
argues for more engagement with SMEs, the humanities and social sciences, and the services sector;
agrees with the Productivity Commission's view that social and environmental benefits should be pursued along with economic ones; and
argues for more emphasis on the application of CRC research by industry and less on CRCs trying to commercialise it themselves.

The CRC is one of Australia’s leading Aboriginal health research organisations – committed to excellence in Aboriginal-led research, building strong partnerships in research, and disseminating the latest research results. Good quality research based on solid evidence is absolutely critical. A substantial library of research has been created that will be a valuable resource for future researchers and health care professionals, not to mention policy makers. An example of this is the excellent work the CRC is conducting in the Social and Emotional Wellbeing Program. This is such a complex area of research which involves individuals, families and groups and the social relationships which impact on them.

setting research priorities;
being fully involved in research activities;
being encouraged and supported to undertake study to create a supply of skilled Aboriginal researchers;
a research role carrying out culturally appropriate research in Aboriginal health; and
community organisations and policy positions using research to improve policy and practice.

I would like to acknowledge the great work that the CRCAH has done over recent years. It is one of Australia’s leading Aboriginal health research organisations, committed to excellence in Aboriginal-led research, building strong partnerships in research, and disseminating the latest research results. I appreciate that the CRCAH wants to build on its success and stand as an independent body during the next phase of its development. Any discussions for the establishment of this independent body would have to be negotiated with a range of players, the most important of which is the Office for Aboriginal and Torres Strait Islander Health (OATSIH).

Do Indigenous Australians receive poorer health care?
- Dr Lawrence

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Among the most universal and persistent inequalities in health are those based on race and ethic group. In Australia, we are all too familiar with the extreme health disadvantage of Indigenous people. Explanations range from differences in genetic susceptibility to the experiences of dispossession and removal. Poverty is frequently invoked as a major causal factor.

The sneaking suspicion that the poorer health of racial and ethnic minorities is partly due to the fact that they actually receive poorer quality care has only recently attracted serious attention. The authors of one US review of more than 100 studies on healthcare delivery reported that they were ‘struck by the consistency of findings’ that ‘minorities are less likely than whites to receive needed services, including clinically necessary procedures’.(1) The disparities occurred irrespective of disease type or type of procedure, appearing in the treatment of cancer, cardiovascular diseases and mental illness and in major interventions as well as routine procedures for common health problems.

Similar results have been obtained in Australia. Despite excess mortality and morbidity, Indigenous people actually receive less specialist healthcare both as inpatients and outside hospitals. Cunningham(2) showed that Indigenous patients were less likely than other patients to have a major procedure, even after adjusting for patient, episode and hospital characteristics. These findings held for most diseases and conditions and the author concluded that there were ‘systematic differences in the treatment of patients identified as Indigenous’. Other studies have also shown differences in treatment, including for cancers, and unequal access to cardiovascular healthcare. A recent exploratory study in Western Australia reported that Aboriginal people with lung or prostrate cancer were less likely to receive a surgical procedure for their cancer than the non-Indigenous population.(3)

It is now generally agreed that the phenomenon of fewer and poorer health care services for racial and ethic minorities is real, and not explained by the behaviour of the recipients. As well as systemic factors prevalent in the operation of many health care systems—such as cultural and linguistic barriers and fragmentation of care—provider behaviour in the clinical encounter also appears to be implicated. When doctors and other health care workers interact with people from racial and ethnic minorities, both uncertainty and stereotyping appear to influence their behaviour.

There is a considerable body of evidence from a variety of countries that health care providers do hold stereotypes based on patient race, class, sex and other characteristics and that these stereotypes do influence their interpretation of patient communications and symptoms, and inevitably their clinical decisions, often to the detriment of the minority group member. One US study found that doctors rated black patients as less intelligent, less educated, more likely to abuse drugs and alcohol, less likely to comply with medical advice, lacking in social support and less likely to participate in cardiac rehabilitation.(4)

Even people who express explicitly egalitarian views may hold negative ethnic and racial stereotypes of which they are unconscious. Such unconscious biases—sometimes called aversive racism—may be just as destructive as those which are more obvious. Usually, such attitudes do not result in expressions of hatred or open contempt, but rather in anxiety and discomfort, which lead to avoidance. Whites tend not to recognise when their actions are racially biased but they inevitably provide non-verbal cues which may signal negativity and produce distrust. One of the common findings in the US research on prejudice is that whites often report feeling anxious while interacting with blacks, leading them to seek to avoid such occasions.

In the clinical encounter, this may result in white doctors engaging in avoidance behaviour, including spending less time with the patient. The discrimination is subtle yet systematic, influencing judgments and interaction, including cues to friendliness or lack of it. Such responses are especially likely when practitioners are under time pressure to solve complex diagnostic problems. If the patient is alert to signs of prejudice, then such avoidance will be interpreted as reflecting hostile attitudes and so compromise the patient–provider relationship.

Aversive racism in this more subtle and indirect form, which we know also occurs among Australians, is most likely to produce poorer treatment when doctors are required to exercise considerable discretion—such as recommending a test or making a referral—and least likely when little discretion is involved—such as emergency surgery. For example, black women are less likely than white women to be tested for osteoporosis and less likely to receive appropriate medication, once they have been diagnosed.(5)

One study(6) found that doctors were less likely to refer black female patients—actually videotaped actors trained to display the symptoms of cardiac disease—for cardiac catheterization than white females ‘exhibiting’ the same symptoms. Similarly doctors(7) presented with hypothetical descriptions of cardiac patients showed more implicit negative attitudes toward blacks and stronger stereotypes of blacks as uncooperative patients. The more negative the attitudes, the less likely they were to recommend appropriate drug therapy. There is a lack of similar research in Australian medical settings, but no reason to believe that our responses would differ markedly.

A major review(8) of studies of consultations involving minority group members concluded that such patients are less likely to engender empathetic responses from doctors, less likely to receive adequate information and less likely to be engaged partners in medical decision making. Comparisons of videotaped recordings of white doctor–black patient interactions with white-on-white interactions have also shown shorter consultations, greater verbal dominance by the doctor, the provision of less information and fewer attempts to engage the black patient in joint decision making.(9)

Given such experiences, it is not surprising that members of minority groups have been shown to have less trust in the health care system and in health care providers than the rest of the community. This is all the more important because there is evidence that the worse the doctor–patient relationship, the poorer the recall of medical information, the poorer the adherence to recommended treatment and the poorer the health outcomes. Added to this, of course, are the direct effects that experiences of racism and discrimination have on health and wellbeing.(10)

Although I have focused on health, this is not to condemn healthcare providers, many of whom work very hard under challenging conditions to ensure that patients get the best care possible, nor is it to suggest that they alone are likely to exhibit such bias. The same tendencies almost certainly exist within all of us, including other professionals who have been less extensively studied. It is certain that stereotypes and prejudice toward Aboriginal people, both overt and covert, operate in most areas of policy development and service delivery. Without acknowledging such behaviours, we are unlikely to do anything to reduce them. But even when prejudicial ideas are largely unconscious, strategies and skills can be taught(11) to reduce their effect in relationships between service providers and racial and ethnic minorities. Hiding out collective heads in the sand certainly won’t help.

Endnotes
1. Institute of Medicine 2002, Unequal Treatment: What Healthcare Providers Need to Know about Racial and Ethnic Disparities in Health Care, Institute of Medicine, Washington DC, p. 2.
2. J. Cunningham 2002, ‘Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous’, Medical Journal of Australia, 176(2):58–62.
3. S. Hall, E. Bulsara, M. Bulsara, T. Leahy, M. Culbong, D. Hendrie & C. D’Arcy, 2004, ‘Treatment patterns for cancer in Western Australia: does being Indigenous make a difference?’, Medical Journal of Australia, 181(4):191–4.
4. M. van Ryn & J. Burke 2000, ‘The effect of patient race and socio-economic status on physicians’ perceptions of patients’, Social Science & Medicine, 50:813–28.
5. J. Dovidio, L. Penner, T. Albrecht, W. Norton, S. Gaetner & J. Shelton 2008, ‘Disparities and distrust: The implications of psychological processes for understanding racial disparities in health care’, Social Science & Medicine, 67:478–86.
6. K. Schulman, J. Berlin, W. Harless, J. Kerner, S. Sistrun, B. Gersh et al. 1999, ‘The effects of race and sex on physicians’ recommendations for cardiac catheterization’, New England Journal of Medicine, 340:618–26.
7. A. Green, D. Carney, D. Pallin, L. Ngo, K. Raymond, L. Iezzone, et al. 2007, ‘The presence of implicit bias in physicians and its predictions or thrombolysis decision for Black and White patients’, Journal of General Internal Medicine, 22:1231–8.
8. W. Ferguson & L. Candib 2002, ‘Culture, language and the doctor–patient relationship’, Family Medicine, 34:353–61.
9. R. L. Johnson, D. Roter, N. R. Powe & L. A. Cooper 2004, ‘Patient race/ethnicity and quality of patient–physician communication during medical visits’, American Journal of Public Health, 94:2084–90.
10. Y. Paradies 2006, ‘A systematic review of empirical research on self-reported racism and health’, International Journal of Epidemiology, 35:888–901.
11. D. Burgess, M. van Ryn, J. Dovidio & S. Saha 2007, ‘Reducing racial bias among healthcare providers: Lessons from social-cognitive psychology’, Society of General Internal Medicine, 22:882–7.

CRCAH Looks to the future - Mick Gooda

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Australia needs a permanent Aboriginal-led health research institution.

As the CRC for Aboriginal Health enters its final two years of existence in its current form, work is well underway to establish a successor organisation which can carry forward the good work achieved by us over the past decade.

For the past 18 months the CRCAH – under the direction of the Board – has been holding workshops, commissioning papers and undertaking literature reviews to plot the best way forward beyond 30 June 2010. Two clear options have emerged: either to seek funding for a further CRC, or to establish an entirely new entity.

Underpinning this desire to progress the CRCAH’s work into the future is the knowledge that the life expectancy for an Aboriginal Australian born today is 17 years less on average than that of a non-Aboriginal Australian born at the same time on the same day in the same hospital.

Despite this ongoing health gap, there is increasing evidence nationally and internationally that suggests positive health outcomes for Aboriginal people are being achieved when Aboriginal peoples have decisive input into the design and delivery of health services.

A terrific example is the Central Australian community of Utopia, where a decentralised model for the delivery of health services has resulted in mortality rates half those of the general Aboriginal population in the Northern Territory.

The CRCAH’s core mission in all of its programs is to direct research dollars towards achieving outcomes in priority areas identified by its Aboriginal stakeholders and particularly by Aboriginal people themselves. By using this ‘bottom up’ model, called the Facilitated Development Approach (FDA), the CRCAH and its partner agencies have been able to bridge the gap between researchers and Aboriginal communities.

Rather than allow these valuable linkages to lapse, the Board believes the time has come for the creation of a permanent and independent National Institute for Aboriginal Health Research (NIAHR) to carry on the work begun by the CRCAH and its predecessor the CRC for Aboriginal and Tropical Health.

The NIAHR would be permanently established and able to speak with a truly independent voice. It would demonstrate in practice the new Australian Government’s commitment to two vital principles:

Its preparedness to be guided by sound evidence of what works and gets results for Aboriginal Australians; and
Its commitment to public sector support of public good research.

The Institute will be strongly networked into the Aboriginal community, listening to and developing research programs that enable the transfer of knowledge from the bottom up. It will provide a brokering role between community, industry, research and decision makers. It will facilitate the development of capacity in Aboriginal health research and in Aboriginal health matters to enable communities to make the changes that save and enhance lives.

In many ways, this is a ‘coming of age’ moment for the CRCAH. I believe that the CRCAH has done exactly what the CRC program was designed to achieve, outgrowing its incubator and standing ready to pursue an independent existence in its own right.

The time for a permanent Aboriginal-led research body has definitely come. I look forward to sharing news of the progess of this aspiration into the future.

Mick Gooda June 2008

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Declaration of commitment to end health inequity between
Aboriginal and other Australians

In light of the signing of the historic declaration on closing the gap at the recent Indigenous Health Equality Summit the regular Gwalwa-Gai guest editorial is being replaced in this edition with the full Statement of Intent signed by Prime Minister Kevin Rudd……

Indigenous Health Equality Summit Statement of Intent

This is a statement of intent – between the Government of Australia and the Aboriginal and Torres Strait Islander Peoples of Australia, supported by non-Indigenous Australians and Aboriginal and Torres Strait Islander and non-Indigenous health organizations – to work together to achieve equality in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2030.

We share a determination to close the fundamental divide between the health outcomes and life expectancy of the Aboriginal and Torres Strait Islander peoples of Australia and non-Indigenous Australians.

We are committed to ensuring that Aboriginal and Torres Strait Islander peoples have equal life chances to all other Australians.

We are committed to working towards ensuring Aboriginal and Torres Strait Islander peoples have access to health services that are equal in standard to those enjoyed by other Australians, and enjoy living conditions that support their social, emotional and cultural well-being.

We recognise that specific measures are needed to improve Aboriginal and Torres Strait Islander peoples’ access to health services. Crucial to ensuring equal access to health services is ensuring that Aboriginal and Torres Strait Islander peoples are actively involved in the design, delivery, and control of these services.

Accordingly we commit:

To developing a comprehensive, long-term plan of action, that is targeted to need, evidence-based and capable of addressing the existing inequities
in health services, in order to achieve equality of health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non- Indigenous Australians by 2030.
To ensuring primary health care services and health infrastructure for Aboriginal and Torres Strait Islander peoples which are capable of bridging the gap in health standards by 2018.
To ensuring the full participation of Aboriginal and Torres Strait Islander peoples and their representative bodies in all aspects of addressing their health needs.
To working collectively to systematically address the social determinants that impact on achieving health equality for Aboriginal and Torres Strait Islander peoples.
To building on the evidence base and supporting what works in Aboriginal and Torres Strait Islander health, and relevant international experience.
To supporting and developing Aboriginal and Torres Strait Islander community-controlled health services in urban, rural and remote areas in order to achieve lasting improvements in Aboriginal and Torres Strait Islander health and wellbeing.
To achieving improved access to, and outcomes from, mainstream services for Aboriginal and Torres Strait Islander peoples.
To respect and promote the rights of Aboriginal and Torres Strait Islander peoples, including by ensuring that health services are available, appropriate, accessible, affordable, and of good quality.
To measure, monitor, and report on our joint efforts, in accordance with benchmarks and targets, to ensure that we are progressively realising our shared ambitions.

Signed by:

the Australian Government
National Aboriginal Community Controlled Health Organisation
Congress of Aboriginal and Torres Strait Islander Nurses
Australian Indigenous Doctors Association
Indigenous Dentists Association of Australia
Aboriginal and Torres Strait Islander Social Justice Commissioner,
Human Rights and Equal Opportunity Commission

Gregory Phillip

Guest Editorial - Gregory Phillips

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Gregory Phillips a Waanyi man and medical anthropologist who previously worked with Medical Deans Australia and New Zealand to develop their Indigenous health curriculum framework. Gregory currently consults in Aboriginal and Torres Strait Islander health as Executive Director of ABSTARR Consulting.

In this editorial Gregory Phillips reports on the challenges faced by Australian medical schools to increase Indigenous student enrolments and to develop curricula that will improve on non-Aboriginal graduates' understanding of Aboriginal health and their skills to address the continuing gap in health outcomes….

Indigenous health workforce development: the role of medical schools

Among the family of health disciplines, medicine is one of the most influential. While the bio-medical model does not offer a solve-all for the health issues confronting Aboriginal and Torres Strait Islander Australia, it certainly is one of the key groups that must engage with and take responsibility for ending health inequity.

Australia 's nineteen medical schools have made some significant advances in recent years in terms of Indigenous health. They have developed a nationally accredited curriculum framework, endorsed changes to accreditation standards, and signed an Agreement for Collaboration with the Australian Indigenous Doctor's Association (AIDA). But will this guarantee changes to graduates' knowledge, skills and attitudes? Will the changes guarantee a significant increase in the number of Aboriginal and Torres Strait Islander medical students and graduates? Most critically, will it have a positive impact on Indigenous health outcomes?

It is of course too early to comprehensively answer any of these questions. The impact of changes to curriculum depends very much on the capacity of a medical school and its staff to adequately implement curriculum. For example, will a senior non-Indigenous clinician in a teaching hospital themselves have the necessary knowledge, skills and attitudes to be able to teach adequately? Challenges remain in ensuring quality and consistency in this area, and it is one the medical colleges, divisions and professional organisations may need to play a role in.

Whether medical schools will be able to create innovative marketing and recruitment programs for Indigenous student intakes remain to be seen, although there are some excellent examples of note where it has been done successfully (see www.limenetwork.net.au ). It should be noted however, that these universities have often managed to increase or maintain their Indigenous student intake on meagre resources, and have some have relied, sometimes unfairly, on the extra blood, sweat and tears of their Indigenous staff. Vague commitments need to transform into action in some medical schools.

What will it take for Australia as a nation to ensure Indigenous health workforce development? Although important, leaving recruitment to medical, nursing or physiotherapy schools only is not enough. The Commonwealth and the States and Territories should seriously invest resources to ensure Indigenous students are encouraged to dream in primary school, are supported academically, financially and culturally the whole way through their education, and that education institutions reform their whole operations to be culturally inclusive, rather than relying on ticking boxes at accreditation time.

All that said, Medical Deans Australia and New Zealand as an organisation, along with some individual medical schools, have shown exemplary leadership on Indigenous health workforce development. Now is the time to drive home those commitments with specific focus and resources. As a nation we must ensure non-Indigenous health professionals are comprehensively trained, and that we recruit and graduate every Aboriginal and/or Torres Strait Islander doctor and health professional possible.

As AIDA graduates have already shown, Indigenous doctors' don't think they know it all; they work respectfully with our people to create healthier families and communities. More of them please! gregory@abstarr.com

Guest editorial from the recently appointed Minister for Health and Ageing, the Honourable Nicola Roxon

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The CRC for Aboriginal Health is proud to present the following opinion piece from the recently appointed Minister for Health and Ageing, the Honourable Nicola Roxon. The new Rudd Government has pledged to tackle the life expectancy gap between Aboriginal and other Australians "within a generation". The CRCAH notes with optimism the pledge from Prime Minister Rudd, Indigenous Affairs Minister, Jenny Macklin and Health Minister, Nicola Roxon, that Aboriginal affairs policy will be driven by evidence rather than ideology.

The Rudd Labor Government is determined to see change through policy rigour. We want to see evidence-based programs which avoid bureaucracy and are designed in partnership with Indigenous people.

The challenge that remains is a significant one. The health and wellbeing of Indigenous Australians remains dramatically worse than that of the community as a whole. Aboriginal and Torres Strait Islander Social Justice Commissioner Tom Calma has noted:

What data exists suggests that we have seen only slow improvements in some areas of health status and no progress on others over the past decade. The gains have been hard-fought. But they are too few. And the gains made are generally not of the same magnitude of the gains experienced by the non-Indigenous population, with the result that they have had a minimal impact on reducing the inequality gap between Aboriginal and Torres Strait Islander peoples and other Australians.

There are a number of disturbing trends which have entrenched health problems for Indigenous Australians including:

high rates of infant mortality, and high rates of low birth weight among Indigenous babies

continuing presence of third world diseases, including rheumatic fever, trachoma, and otitis media

high rates of chronic diseases such as renal failure, cardio-vascular diseases and diabetes

continued higher rates of poor health among Aboriginal and Torres Strait Islander infants, as well as far too common occurrence of otitis media (middle ear infection) and eye conditions such as trachoma, which can impact on educationalattainment and employment

a continuing tendency towards poor access to primary health care, as evidenced by high rates of sexually transmitted infections and relatively high rates of HIV/AIDS prevalence, and

high rates of unhealthy and risky behaviour, including an increased prevalence of substance abuse and alcohol and tobacco use.

This continuing concern has led Commissioner Calma, OxFam and the Australian Medical Association, among others, to call for governments to commit to closing the 17-year gap between the life expectancy of Indigenous Australians and the rest of the community within the next twenty five years.

In the fortieth year since the passing of the 1967 Referendum, a Rudd Labor Government committed to closing the gap within a generation.

We supported this commitment with a $260 million downpayment on comprehensive Indigenous child and maternal health services.

As a result of this initiative, Indigenous women will have access to proper antenatal care (including a visit to a midwife or doctor, an ultrasound, and a general health check); practical advice on parenting, breastfeeding and nutrition for their babies; and
home visit services for new Indigenous mothers and children aged 0-8 years.

The Government will be investing $10 million to tackle rheumatic fever in Indigenous kids - a condition almost unknown outside the third world, and a further $10 million for accommodation services for Indigenous women if they’re travelling from remote to urban and regional centres to have their babies.

The Government will ensure that all Indigenous children have access to health and early skills checks – hearing, sight, language – so that children are ready to learn.

We need a bipartisan national commitment to tackle the 17-year life expectancy gap between Indigenous and non-Indigenous people within a generation.

In tackling that gap, we need to develop a sensible set of targets around intermediary program level outcomes, especially those that address those preventable chronic conditions that are responsible for so much of the burden of disease borne by Aboriginal and Torres Strait Islander people. The social determinants of health – such as education, housing, employment – require action across portfolios and across different levels of government, so we need to make sure our coordination efforts are working effectively and efficiently.

While working on prevention and on the social determinants is vital, this does not mean we do not have to increase the effectiveness of the health system itself, especially primary health care services, and in particular those in the community-controlled sector. Initiatives to improve access, sustainability and quality will be high on my agenda as the new minister.

This focus on outcomes will mean that while the Rudd Labor Government is value-driven, we will not be ideologically-driven. Where things are working well, we will look to improve them. For example, we will be working closely with the Northern Territory Government and the Aboriginal community-controlled health sector there to ensure that the $183 million investment made by the previous government as part of its intervention, plus our own $20 million boost to health services in the NT, will be put to good use to improve access and quality of care.

We will also be looking to ensure that in Cape York the welfare reform initiatives underway there are underpinned by adequate health services and infrastructure.

The Rudd Labor Government is committed to advancing reconciliation, and taking practical steps to improve the social and economic wellbeing of Indigenous Australians.

This will require action on many fronts – but we know that investing in the health of Aboriginal and Torres Strait islander people is one of the best investments we can make in Australia’s future.

Guest editorial by Dr Chris Sarra

chris_sarraEditorial

The guest editorial writer for the latest edition of CRCAH's newsletter Gwalwa-Gai is Queensland educator, Dr Chris Sarra.

Dr Sarra is the 2004 Suncorp Queenslander of the Year; 2004 QUT Chancellor's Outstanding Alumnus and Faculty of Education Outstanding Alumni Award Winner; and NAIDOC 2006 Scholar of the Year.

The youngest of 10 children Dr Sarra is from Bundaberg and has had an extensive career in education with a particular focus on pursuing his main passion; more positive and productive educational outcomes for Indigenous children.

He was the first ever Aboriginal principal of Cherbourg State School in south-east Queensland where he facilitated many positive changes that saw increasing enthusiasm for student learning through dramatically improved school attendance and increased community involvement in education. Under Chris's leadership the school became nationally acclaimed for its pursuit of the ‘Strong and Smart' philosophy.

Dr Sarra is currently Director of the Indigenous Education Leadership Institute, based in Cherbourg, and designed to pursue stronger, smarter, student outcomes for Indigenous children throughout Australia.

As an educator who has spent eight years working directly with Aboriginal children in a very complex Aboriginal community I welcome any intervention to ensure their wellbeing. If the challenge is to be attended to properly we must invest substantially and seriously in this national crisis that sees Australia's most vulnerable children exposed to harm. They didn't ask to be exposed to this. They don't ask to be continually subjected to this, yet they remain confused and hurting. They definitely deserve to be set free from this!

Let's understand this hurt and confusion; then let's just get on with the task of addressing the challenge, without feeling the need to score political points along the way.

Most of us know, as well as the Prime Minister knows, that political parties do not win votes by fixing things in Aboriginal communities. We know that political parties even run the risk of losing votes by doing so. This brings me to what I think lies at the most fundamental core of this challenge.

In order for this challenge to be seriously addressed in Australia, much of the electorate has a need for this to be done so in a way that sees Aboriginal people portrayed as completely hopeless or completely despicable. It has to be in an election year; and the government must be staring down the barrel of electoral defeat.

This need to ensure that Aborigines are thought of as a hopeless, pitiable, or despicable form of 'other', is what makes it okay for a political party to announce dramatic intervention into child abuse in Aboriginal communities.

If the electorate can have it confirmed that Aboriginal people in communities are so despicable and hopeless, then it is okay for the Prime Minister to announce such dramatic intervention, and be seen as the 'big man on the job'.

This same need is that which has made it acceptable for Aboriginal communities to wallow in third world conditions.

This same need makes it acceptable to deliver second rate education, health, and justice outcomes to Aboriginal communities.

This is the need which validates the hypocrisy with which some say ‘lest we forget', but forget about Australia 's black history.

This need allows Australian Governments and their bureaucrats to treat Aboriginal voices of outrage and expectation with contempt.

This phenomenon is so sophisticated, it even recruits Aboriginal voices to satisfy this insatiable need to see 'my' proud people typecast as helpless, pitiable, or despicable.

Notwithstanding, and sadly, this is the same need that furnishes the desire of many Aboriginal people, not all, to cling to an undignified 'victim status' as a means of survival.

Decent Australians know that we are not hopeless, pitiable, despicable and evil people.

Clearly, there are challenges for all of us here. I won't pretend for a moment that this is an easy challenge to attend to or that many Aboriginal people in communities are without blame here. But show me an Aboriginal man who says it is okay to have sex with a child, and then I will show you a man who should be in jail. I can also show you white police and white magistrates who lack the courage or commitment to deal with such matters in a way that they would in a regular community. I could also probably show you some flash white lawyer trying to sniff out some legal loophole to pretend that there is some cultural dimension to child sexual abuse.

Let me make it abundantly clear there is no cultural dimension to child sexual abuse!

While such justice service providers think they do good things to keep harmony and good relations with communities by basically ignoring or passively condoning such dysfunction, they leave communities to endure a level of dysfunctionality that would never be tolerated in a mainstream community, and worst of all; they leave Australia 's most vulnerable children exposed.

If we are to have any chance of making significant progress to eradicate such disturbing degrees of dysfunction in Aboriginal communities, then we must purge the dysfunctional mindsets of those with real authority to make change and develop real capacity to attend directly with the challenges that we contemplate. We must purge our country of the need to see Aboriginal people as hopeless, pitiable and despicable.

I am not talking here about systems, bureaucracies and policies. I am talking about the mindsets and actions of all of us as individuals that are a part of those structures and processes. Each of us must realise the power and potential for change when an individual, armed with the right mindset, decides that things can be better, and rejects absolutely, the notion that second or third rate is good enough for Aboriginal children.

For more information on the Indigenous Education Leadership Institute: www.strongersmarter.eq.edu.au

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A plea for evidence-based policy

The ninth edition of the CRCAH newsletter includes a newly introduced guest editorial. The first guest editorial writer is Dr Kyllie Cripps, a researcher at the Onemda VicHealth Koori Health Unit at The University of Melbourne. Dr Cripps' 2005 PhD thesis was entitled Enough Family Fighting: Indigenous Community Responses to Addressing Family Violence in Australia & the United States.

Dr Cripps writes on the recently announced Australian Government intervention into Northern Territory remote Aboriginal communities and questions the effectiveness of current and previous government interventions aimed at reducing violence in Aboriginal communities.

Dr Cripps makes a plea for better recording and recognition of successful community anti-violence initiatives as apart of a concerted effort to developing an evidence base of what works and does not work, something that for the past decade Indigenous communities across the country have asked for.

Recently significant attention has focussed on Indigenous family violence and child sexual abuse in the Northern Territory. This attention began in 2006 as a consequence of a very explicit and confronting interview given by Crown Prosecutor Nanette Rogers on the Lateline program in 2006. The public outcry resulting from this interview spurred the Federal Government into action, an Intergovernmental Summit on Violence and Child Abuse in Indigenous Communities, involving Ministers from the Australian Government and all States and Territories was convened and in June 2006 the Federal Government offered States and Territories $130 million over four years to address social problems in remote communities. The package included funds to:

build police stations & police housing;
provide drug & alcohol rehabilitation services;
to establish ‘strike teams' to gather intelligence on Indigenous violence through the Australian Federal Police;
provide safe houses & other support for victims;
conduct health checks on approx 2000 children in remote communities; and
establish a national truancy unit to monitor school attendance in Indigenous communities

This funding was conditional on all references to customary law being removed from the Crimes Act in each State and Territory.

Twelve months on and following the release of the “Little Children are Sacred” Report of the Northern Territory Board of Inquiry into the Protection of Aboriginal Children from Sexual Abuse prepared by Rex Wild QC and CRCAH Chairperson Pat Anderson, the Federal Government announced yet more measures to respond to what has now been deemed a national emergency - the abuse of children in Indigenous communities in the Northern Territory. The measures include:

introducing widespread alcohol restrictions in the NT;
introducing welfare reforms;
enforcing school attendance by linking income support and family assistance payments to school attendance and providing meals for children at school at parents' cost;
introducing compulsory health checks for all Aboriginal children to identify and treat health problems and any effects of abuse;
acquiring townships prescribed by the Australian Government through five year leases;
increasing policing levels in prescribed communities, including requesting secondments from other jurisdictions to supplement NT resources;
improving housing and reforming community living arrangements in prescribed communities including the introduction of market based rents and normal tenancy arrangements;
banning the possession of X-rated pornography and introducing audits of all publicly funded computers to identify illegal material;
scrapping the permit system for common areas, road corridors and airstrips for prescribed communities on Aboriginal land, and;
improving governance by appointing managers of all government business in prescribed communities

It is interesting to note that some of these measures are a replication of the Federal Government's 2006 announcements and it begs the question what progress has been made in implementing the 2006 interventions? A Senate Estimates hearing in February 2007 sheds light on this, revealing that six months after the Federal Government announcement of a package of $130 million to combat family violence, not one cent had been spent on the ground to prevent violence in Indigenous communities. When this is put in the context of a further Senate Estimates Hearing in May 2006 in which it was revealed that approximately $5 million, or 15 percent of the $37 million budget allocated to the problem after an Indigenous family violence roundtable convened by the Prime Minister in 2003, had not been spent it begs the further question – how serious is this government about responding to the problem of Indigenous family violence and child abuse?

Already some of the proposed initiatives have been watered down in particular the compulsory health checks which now are now voluntary and do not look for signs of sexual abuse. Legislation relating to some of the other initiatives is due to be tabled in Parliament this week – the details of which have not been made publicly available at the time this article went to press.

It has long been recognised in two decades worth of reports that family violence and child abuse in Indigenous communities is a problem in all jurisdictions across Australia. Responding to the problem requires, as Anderson & Wild stressed in their Little Children are Sacred report, the establishment of collaborative partnerships at all levels of government and service provision so that appropriate joined-up support can be provided to those affected by violence. Of critical importance to this is that “governments commit [in this process] to genuine consultation with Aboriginal people in designing initiatives for Aboriginal communities whether these are in remote, regional or urban settings”. The measures announced by the Federal Government contradict not only the Anderson and Wild report recommendations but more than a decade of recommendations of how to respond to such sensitive issues in an appropriate and coordinated manner.

As Indigenous community members we know that the answers to the problems of violence lie within our communities. These are initiatives that are guided and supported by community autonomy, capacity and development. However, they often operate outside the mainstream and remain largely unrecognised. At best such grassroots and community level programs are poorly documented in one-off newspaper, magazine and/or journal articles, and fail to be noticed in the broader context. It is now time, given the current context that a concerted effort be made by researchers and practitioners to support and promote such initiatives so that an evidence base of what works and does not work can be made available more broadly.

Dr Kyllie Cripps, an Indigenous (Palawa) woman, is a CIPHeR Post Doctoral Research Fellow in the Onemda VicHealth Koori Health Unit at The University of Melbourne. In 2005 she was awarded her PhD entitled Enough Family Fighting: Indigenous Community Responses to Addressing Family Violence in Australia & the United States. She has also been involved in the development of national policy in this area. Her current work focuses on the social context of violence and how policy/programs can support Indigenous communities in responding to the problem. kcripps@unimelb.edu.au