In Australia today, the implications of colonisation continue to influence the health and wellbeing of Aboriginal and Torres Strait Islander (ATSI) communities (Eckermann, et al., 2010, p. 170). Australian history demonstrates the attempted destruction of ATSI culture through assimilation policies, racist social concepts, and systemic disadvantage through 1788 at European settlement to present day (Eckermann, et al., 2010, p. 22-24). For these groups, the relationship between health and traditional culture is of distinct importance. Neglect to such by the Commonwealth and the Australian Government, has directly attributed to the ongoing Indigenous health crisis, which remains one of the main inequities between ATSI communities and non-Indigenous Australians (NACCHO, 2018).
ATSI peoples comprise 3% of the Australian population, however the Australian Institute of Health and Welfare (AIHW) report that Indigenous Australians over the age of 15 were 2.1 times more likely than non-Indigenous Australians to report their health as fair or poor, on a ‘fair or poor’ to ‘very good or excellent’ gradient (2015). This is reflected in life expectancy predictions, whereby Indigenous women live 9.5 years less than non-Indigenous women, and Indigenous men lives 10.6 years less than non-Indigenous men. In addition to this, statistics found ATSI are twice as likely to live with a severe or profound disability. As a population, they are at significantly increased risk of living with diabetes, with 21% of Indigenous Australians living with the disease compared to 9.4% of non-Indigenous Australians. Further, mental health complications attributed to 11% of GP consultations attended by ATSI patients; 1.3 times more than non-Indigenous members of the population. This figure is reinforced when considering suicide rates, whereby between 2008 and 2012, the rate for ATSI suicides was almost double that of non-Indigenous Australians, and alarmingly 5 times more likely for 15 to 19-year-olds. In 2012-2013 almost 31% of the ATSI population reported living with chronic respiratory disease, which accounted for 5.4% of ATSI hospitalisations within the same period; 1.2 times, and 2.4 times more likely than non-Indigenous Australians respectively. 13% of ATSI over the age of 2 reported chronic cardiovascular disease; a rate 1.2 times higher than non-Indigenous Australians (AIHW, 2015). With consideration to such figures, the inequities between Indigenous and non-Indigenous health are clear, however determining the cause is comprehensive, multisystemic, and not confined to The World Health Organisations determinants of health entirely (Eckermann, et al., 2010., p. 170).
The health of ATSI peoples does not independently adhere to western definitions, expectations and the biomedical model of health. This notion has been neglected previously in the management of ATSI health resources and services since health assimilation initiatives were introduced in 1967 (Eckermann, et al., 2010, p. 170; NACCHO, 2018). Additional determinants relevant to tradition are of higher cultural importance to such communities, and include cultural survival, affirming cultural ceremony, oral history, family support and connection, spiritual and emotional wellbeing, native title, sites recognition, self-determination, and community control. While these are all factors present in ATSI decolonisation actions within their own communities focussed on regaining control of culture and health, they are not represented within Australia’s mainstream health system and primary health care resources (Eckermann, et al., 2010., p. 170).
Primary health care (PHC) is a health system philosophy built on community participation, accountability, a holistic approach to health, and health outcomes aligned with empowerment, self-reliance, and improved health. The intention of PHC is to provide a community sustained, balanced health care system in which relationships with health professionals and community members underly. The principles of PHC align with ATSI determinants of health in highlighting the importance of community involvement and autonomy. However, in Australia, the biomedical mainstream health model lacks the structure and systems that allow community participation, ultimately reducing the efficacy, accessibility and cultural relevance of health care resources (Eckermann, et al., 2010, p 171-175). As a direct result of this, many ATSI communities have called for an increase in commitment to funding, improving and increasing self-controlled health resources in line with the foundations of PHC. This is based on research affiliated with the Close the Gap campaign, an Australian government initiative targeted towards reducing the systemic inequality between ATSI peoples and non-Indigenous Australians implemented in 2008 (Gooda & Higgins, 2016; Commonwealth of Australia, 2018). Such findings indicate specific ATSI models of health service deliverance result in improved relationships with healthcare providers, accessibility and cultural relevance. Subsequent to such, better health outcomes, disease prevention and control, chronic disease treatment and management, and maternal and child health care is incurred to the benefit of communities (Gooda & Huggins, 2016).
Despite recommendations that facilitate action to improve the lives of ATSI, the Close the Gap campaign has come under considerable scrutiny in recent years for its lack of achievement in addressing the social, environmental and economic determinants that relevantly influence the lives of ATSI peoples (Higgins, et., 2018). Following the Prime Minister’s Report in 2018, it was highlighted that a decade on, only 3 of 7 targets have been met over the majority of Australian states and territories. These include halving the gap of childhood mortality rates, achieving 95% enrolment in early childhood education, and halving the gap in attainment of year 12 or equivalent by 2020. Those not met include improved school attendance, reading and numeracy, employment, and life expectancy (Commonwealth of Australia, 2018). While systems are in place and improvement have been made in working towards meeting these goals, present failure to do so has been attributed to several causes. The most notable include the lack change to Indigenous policy allowing change, limited ATSI control and leadership within Australian parliament, and failure to recognise and integrate traditional and western determinants of health (Markham & Biddle, 2018; Reconciliation Australia, 2018).
In response to the Closing the Gap downfalls, additional recommendations have been made to the Australian government to facilitate a comprehensive enquiry into systemic and institutionalised racism in Australian health care (Gooda & Huggins, 2016). The implications of poor race relations based on stereotyping, cognitive conflict, history and prejudice, encompass dehumanisation and enforced hopelessness at the core of the discriminated populations standard of living (Eckermann, et al., 2010). Unequivocally, systemic racism in not only a healthcare setting but in a broad social setting, is detrimental to the wellbeing of ATSI peoples and maintains a direct influence on the socioeconomic gradient (Oscar & Little, 2018).
The World Health Organisation divulge that “the social conditions in which people are born, live and work is the single most important determinant of good health or ill health”, whereby high standing on the socioeconomic gradient from birth increases the chances of employment, education, housing, good health outcomes, and life expectancy (AIHW, 2016). While socioeconomic determinants of health are not the soul determinants that influence the health of ATSI communities, they are vital in understanding the health inequities between Indigenous and non-Indigenous populations, particularly in a setting focussed on the ongoing implications of colonisation (AIHW, 2018).
As reported in the 2018 Close the Gap report improvements have been made to ATSI education enrolment and participation from early childhood through to the completion of year 12 or equivalent certification (Commonwealth of Australia, 2018). In 2016 96% of ATSI peoples between ages 4 and 14 regularly attended school (ABS, 2016). These figures forecast an improvement in outcomes through future generations and as the current population ages, however the cyclical nature of poverty has an ongoing influence on current employment, housing, domestic and family violence, incarceration and health behaviour statistics require attention.
With 60% of ATSI peoples aged 15 to 64 employed, the unemployment rate for ATSI peoples is 4.2 times higher than that for non-Indigenous Australians (AIHW, 2017). 36% of ATSI live in a home they own, however ATSI families are 6 times more likely than non-Indigenous families to live in social housing (AIHW, 2017). The rate of homelessness was 14 times higher for ATSI peoples in 2011, and in 2014-15 29% of ATSI peoples reported experiencing homelessness in their lifetimes (AIHW, 2014, ABS, 2016). With consideration to such, ATSI people who were employed and residing in secure housing reported better health and life satisfaction (AIHW, 2017).
With regard to domestic and family violence ATSI women are considered one of the most vulnerable and at risk population groups in Australia. In the year 2014-15, 14% ATSI women experienced physical violence, with 1 in 4 of such encounters perpetrated by a cohabiting partner. In addition, ATSI children were 7 times more likely than non-Indigenous children to be the subject of abuse or neglect (AIHW, 2018). Such violence and abuse is attributed to the cause and effect relationship of social disadvantage and cultural, intergenerational trauma. Also causal to this, is the incidence of poor health behaviours, whereby Indigenous Australians are 4.2 times more likely to use tobacco, with pregnant mother 4 times more likely to use tobacco than non-Indigenous pregnant mothers. 54% of ATSI people aged 15 and over consumed alcohol to excess on a single occasion in a 12 month period; a rate considerably higher than non-Indigenous Australians. Further, low levels of physical activity in combination with accessibility for healthy foods for rurally living ATSI communities, 2 in 5 ATSI people over 15 are considered overweight or obese (AIHW, 2017).
Cyclical poverty, intergeneration trauma, systemic racism and cultural assimilation policies associated with colonisation have implications on the health of ATSI communities in Australia today. In order to continue to work towards effectively closing the gap, sustained culturally relevant, accessible and community involved leadership is required. In conjunction, to overcome the related health outcomes and statistics, it is imperative that a holistic ATSI primary care system be integrated into Australian health policy to enable the implementation of traditional determinants of health and wellbeing.
ABS. (2016). National Aboriginal and Torres Strait Islander Social Survey 2014-2015. Retrieved 14th July 2018, from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4714.0~2014-15~Media%20Release~Key%20Aboriginal%20&%20Torres%20Strait%20Islander%20data%20released%20(Media%20Release)~1
Australian Institute of Health and Welfare. (2014) Australia’s Health. Retrieved 14th July 2018, from: https://www.aihw.gov.au/getmedia/d2946c3e-9b94-413c-898c-aa5219903b8c/16507.pdf.aspx?inline=true
Australian Institute of Health and Welfare. (2015). The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples: 2015. Retrieved 3rd July 2018, from: https://www.aihw.gov.au/reports/indigenous-health-welfare/indigenous-health-welfare-2015/contents/table-of-contents
Australian Institute of Health and Welfare. (2016). Australia’s Health 2016. Retrieved 13th July 2018, from: https://www.aihw.gov.au/reports/australias-health/australias-health-2016/contents/population-groups
Australian Institute of Health and Welfare. (2018). Family, Domestic and Sexual Violence in Australia. Retrieved 14th July 2018, https://www.aihw.gov.au/getmedia/d1a8d479-a39a-48c1-bbe2-4b27c7a321e0/aihw-fdv-02.pdf.aspx?inline=true
Commonwealth of Australia. (2018). Closing the Gap – The Prime Ministers Report 2018. Retrieved 4 July 2018, from: https://closingthegap.pmc.gov.au/sites/default/files/ctg-report-2018.pdf
Eckermann, A., Dowd, T., Chong, E., Nixon, L., Gray, R., & Johnson, S. M. (2010). Binan Goonj : bridging cultures in aboriginal health. Retrieved 3rd July 2018, from https://ebookcentral-proquest-com.ezproxy.laureate.net.au
Gooda, M., Huggins, J. (2016). Our national shame: Closing the Gap for Indigenous Australians is More Important than Ever. Retrieved 13th July 2018, from: https://www.smh.com.au/opinion/our-national-shame-closing-the-gap-for-indigenous-australians-is-more-important-than-ever-20160316-gnkquf.html
Markham & Biddle. (2018). Three Reasons Why the Gaps Between Indigenous and non-Indigenous Australians Aren’t Closing. Retrieved 4th July 2018, from: https://theconversation.com/three-reasons-why-the-gaps-between-indigenous-and-non-indigenous-australians-arent-closing-91561
Reconciliation Australia. (2018). Failure to Close the Gap is Proof of Need for Indigenous Voice. Retrieved 14th July 2018, from: https://www.reconciliation.org.au/failure-close-gap-proof-need-indigenous-voice/
Oscar, J., Little, R. (2018). Closing the Gap on Indigenous Health: This is our National Shame, but it can be fixed. Retrieved 14th July 2018, from: http://www.abc.net.au/news/2018-02-08/closing-the-gap/9407824