Introduction

I am a doctor who has worked in hospital settings of varying sizes including the Western Sydney Local Health District which is home to the largest urban Aboriginal population. However, I have not worked in a community setting or in a dedicated Aboriginal or Torres Strait Islander medical service. Prior to my medical training I completed my education in New Zealand, where welfare of the indigenous people of New Zealand was compulsory in our curriculum, which informs some of my pre-existing beliefs surrounding Indigenous Health in Australia.

My previous exposure in the area of indigenous health in Australia- as a medical student, doctor and member of the general community- had led me to the belief that there were very large disparities between the health of Aboriginal and Torres Strait Islander Peoples and the health of the general population. Statistical measures of health and wellbeing such as life expectancy, maternal and infant mortality and death rates to my understanding were comparable to developing world conditions, as were morbidity and mortality from chronic health conditions such as diabetes, cardiovascular disease, renal disease, infectious diseases and liver disease.

Similarly, from both reading and through my observations as a medical practitioner, my views and beliefs of the underlying reasons for the gross health inequalities came from both a biomedical as well as a biopsychosocial model of health incorporating social determinants of health. Socioeconomic inequality, mental health issues, dietary, overcrowding and environmental factors, streptococcal and staphylococcal colonisation, high smoking rates were some of the many risks that stood out to me as relevant to the poor outcomes in comparison with the general population.

This I viewed in the context of historical segregation, dehumanisation (via the Flora and Fauna & Aborigines Acts) and assimilation policies, political, institutional and media racism as well as the ongoing racism and discrimination that I had seen both in the workplace by colleagues and in the wider community.

However, although I felt that I had a some ideas and knowledge about why a large health disparity exists, I did not feel that my understanding was particularly complex or equipped to answer questions of how best to address this disparity. I also felt that without either formal education or direct experience of the complexities of the situation, I was unlikely to be able to interpret statistics such as why a large disparity existed in mortality from liver disease despite a similar chronic alcohol abuse rate to the general population.

Having now consumed subject readings and participated in the intensive workshops, have a more nuanced, evidence based and complex perspective on indigenous health issues.

Defining Health

Understanding of health requires adequate definitions and evidence.

A concept I have become familiar with is the WHO definition of Health:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 1946)

This is a holistic concept which encompasses biopsychosocial understandings of wellbeing rather than just a biomedical understanding of disease.

The definition of Aboriginal Health in the National Aboriginal Health Strategy (1989) shares similar concepts but also includes community and cultural understandings of wellbeing:

“’Aboriginal health’ means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole Community in which each individual is able to achieve their full potential as a human being, thereby bringing about the total well-being of their Community. It is a whole-of-life view and includes the cyclical concept of life-death-life.

Health care services should strive to achieve the state where every individual is able to achieve their full potential as a human being and this bring about the total well-being of their community.”(National Aboriginal Health Strategy Working Group, 1989)

The concept of cultural loss as a risk factor in mental health is also mentioned in Hunter (2002) and the health of the environment in Kingsley, Townsend, Phillips, & Aldous (2009).

Thus, my view of Indigenous Health and health in general has expanded to include not just the biomedical and biopsychosocial concepts of health but also cultural and community concepts and the life-cycle as important for wellbeing.

Historical Context

Pre-Colonial Era

Franklin & White (1991) note that prior to the colonisation of Australia by European settlers in 1788, that “the average Aborigine, in fact, enjoyed better health than the average Englishman” . The Aboriginal population and semi-nomadic hunter-gatherer culture was certainly ancient, settlement having occurred at least 50,000 years prior to colonisation (Franklin & White, 1991 p. 1). Life expectancy was estimated at roughly 40 (Abbie, 1969), significantly greater than the corresponding life expectancy of the mid-30s in England at the same time (Mokyr, 1993) and comparable to life expectancy in England in 1900 (Kinsella, 1992).

Even allowing for the health problems and epidemiology of crowded urban living, this longevity surprised me. Unfortunately, although both Abbie (1969) is widely cited, I was unable to find many other objective estimates of Aboriginal life expectancy prior to colonisation.

Colonisation

Franklin & White (1991) and Saggers & Gray (1991) both outline the history of post-colonial Indigenous Affairs in various major stages.

Firstly, the early contact & colonisation era, in which European settlers indulged in brutal treatment of local people- as competitors for land, or as employees- despite Indigenous Australians having rights as British subjects, and despite official government statements regarding their welfare. Australia was not considered to be inhabited or owned prior to colonisation despite its inhabitants. Infectious diseases, some still major contributors to Indigenous burden of disease were introduced, either accidentally or intentionally. The result was a significant decline in health. (Franklin & White, 1991)

Following this, a period of “segregation” and “protection”, initiated by missionaries and the British colonial government with the stated aim of improving the health and welfare of Indigenous Australians via forced resettlement, with the expectation that eventually they would either be “assimilated” into lower echelons of European-Australian society or die out as a race. “Assimilation” also encompassed the removal of “half-caste” children from their families during the Stolen Generation. These policies were economically beneficial due to minimisation of clashes between settlers and Indigenous peoples, employment of otherwise unemployable people to “look after” Indigenous people, reduced social welfare and infrastructure costs and generation of a compliant, dependent, underpaid workforce of Indigenous people (Franklin & White, 1991; Saggers & Gray, 1991).

Within this context, it struck me that several familiar themes emerged which are still evident in the political discourse surrounding Indigenous health and affairs:

• Discordance between official government policy and actual behaviour
• Indigenous dispossession, maltreatment and disempowerment at the expense of economic profit
• Persistent stereotypes dating back to the early colonial era
• Assumptions of European cultural norms as “superior” and “healthier”
• Dissent with discriminatory policy & behaviour from Indigenous and non-Indigenous Australians leading progressive change
• If one is to believe that government actions are benign and follow the official policy, then one (incorrect) line of reasoning is to disbelieve the reality of mistreatment and instead to state that Indigenous people are responsible for their own ill-health as they have failed despite benign government intervention.

While I did know that there was historical context, I was surprised and shocked to find how eerily similar the arguments of past generations were to beliefs I hear expressed by some politicians, healthcare workers and educated people now.

Post World War Two Australia & the Modern Era

Following greater community exposure to the plight of Indigenous Australians and greater empowerment of Indigenous Australians during World War Two, more progressive policies and changes were implemented. In 1967 was the referendum which recognised Indigenous Australians as citizens with equal rights.

“Self Determination” was the next broad policy direction, with community-run Aboriginal and Torres Strait Islander Peoples organisations receiving funding and autonomy for provision of Aboriginal health services to run in parallel with “mainstream” services.

Unfortunately, partially due to the structure of federal and state governments in healthcare in Australia as well as changes of government, there was frequent restructuring of government and community organisations with dilution of responsibility and funding and erosion of community autonomy.(I. Anderson & Sanders, 1996; I. Anderson, 1997)

The Howard Federal Government in 2004 abolished the Aboriginal and Torres Strait Islander Commission (ATSIC) and took control of Indigenous health funding,  a process labelled “mainstreaming” due to diversion from community organisations to “mainstream” organisations.

I was unaware of the context of complex bureaucratic restructuring, waste and gradual erosion of self-determination in the recent history of Indigenous health provision. Certainly in the light of the historical context of cultural loss, assimilationist policies, racist stereotypes and the cultural and community definitions of Aboriginal health, I now perceive a significant set of barriers and an additional risk factor.

Evidence Base

Data & Measures of Healthcare

Quality statistical data on health outcomes and interventions for Indigenous Australians is limited. Multiple reasons have been identified including but not limited to:

• Incomplete or incorrect identification of Indigenous status in research
• Lack of studies into Indigenous health and health outcomes
• Reduced participation in studies

(I. Anderson et al., 2007; Madden & Pulver, 2009)

Demographics show that Indigenous Australians are younger overall, have higher birth rates and tend to live in much more remote settings, have lower education and birth weight and much lower health funding.  The statistical evidence that exists paints a picture of gross health disparity with poor outcomes on many key measures including life expectancy and maternal & child mortality. Chronic illness represents the biggest contributor to morbidity and mortality. Most alarmingly given the high rate of diabetes, the rate of smoking is double that of the general population at 45%. (Nettleton, Napolitano, & Stephens, 2007; Ring & Brown, 2002)

Interventions and Future Directions

The approach that has been devised by multiple working groups and endorsed by Indigenous health organisations is that of partnership, shared responsibility, greater funding and research and collaboration.(I. P. Anderson, 2006; I. Anderson, 1997; Australia, 2007; Chapman, 2010; National Aboriginal Health Strategy Working Group, 1989; Thomson, 2003; “Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care,” n.d.)

This holistic and inclusive and culturally appropriate model of intervention is compatible with the Aborignal definition of health and I was very encouraged to find a concrete set of possible interventions which were possible at multiple levels of government and health.

Bibliography

Abbie, A. A. (1969). The Original Australians. Muller. Retrieved from http://www.aiatsis.gov.au/library/documents/Arrente_Aranda_Published_Apr2011.pdf

Anderson, I. (1997). The National Aboriginal Health Strategy. Health Policy in Australia, 119–135.

Anderson, I., Crengle, S., Kamaka, M. L., Chen, T.-H., Palafox, N., & Jackson-Pulver, L. (2007). Indigenous health 1: indigenous health in Australia, New Zealand, and the Pacific. The Lancet, 367, 1775–85.

Anderson, I. P. (2006). Mutual obligation, shared responsibility agreements & indigenous health strategy. Australia and New Zealand Health Policy, 3(1), 10. doi:10.1186/1743-8462-3-10

Anderson, I., & Sanders, W. (1996). Aboriginal health and institutional reform within Australian federalism. Australian National University, Centre for Aboriginal Ecomonic Policy Research. Retrieved from http://caepr.anu.edu.au/sites/default/files/Publications/DP/1996_DP117.pdf

Australia, O. (2007). Close the gap: Solutions to the Indigenous health crisis facing Australia. Oxfam Australia.

Chapman, N. (2010). Partnership Position Paper. Close the Gap Steering Committee for Indigenous Health Equality.

Franklin, M.-A., & White, I. (1991). Chapter 1: The History and Politics of Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 1–33). Houghton Mifflin Harcourt P.

Hunter, E. (2002). “Best intentions” lives on: untoward health outcomes of some contemporary initiatives in Indigenous affairs. The Australian and New Zealand journal of psychiatry, 36(5), 575–584.

Kinsella, K. G. (1992). Changes in life expectancy 1900-1990. The American Journal of Clinical Nutrition, 55(6), 1196S–1202S.

Madden, R. C., & Pulver, L. R. (2009). Aboriginal and Torres Strait Islander population: more than reported. Australian Actuarial Journal, 15(2), 181.

Mokyr, J. (1993). Technological Progress and the Decline of European Mortality. The American Economic Review, 83(2), 324–330. doi:10.2307/2117685

National Aboriginal Health Strategy Working Group. (1989). A national Aboriginal health strategy. Canberra: AGPS.

Nettleton, C., Napolitano, D. A., & Stephens, C. (2007). An overview of current knowledge of the social determinants of Indigenous health. In Symposium on the social determinants of Indigenous health, Adelaide. Retrieved from http://new.paho.org/hq./index.php?gid=12421&option=com_docman&task=doc_view

Ring, I. T., & Brown, N. (2002). Indigenous health: chronically inadequate responses to damning statistics. Medical Journal of Australia, 177(11/12), 629–632.

Saggers, S., & Gray, D. (1991). Chapter 9: Policy and Practice in Aboriginal Health. In J. Reid & P. Trompf (Eds.), The health of aboriginal Australia (pp. 381–394). Houghton Mifflin Harcourt P.

Thomson, N. (2003). Responding to our’spectacular failure’. Retrieved from http://ro.ecu.edu.au/ecuworks/3437/

Time To Remove the Barriers Preventing Indigenous Australians Getting Equal Access To Quality Health Care. (n.d.). Australian Medical Association. Retrieved March 24, 2013, from https://ama.com.au/node/2699

World Health Organization. (1946). www. who. int/bulletin/archives/80 (12) 981. pdf WHO definition of Health. In Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York (pp. 19–22).

“Yotti” Kingsley, J., Townsend, M., Phillips, R., & Aldous, D. (2009). “If the land is healthy … it makes the people healthy”: The relationship between caring for Country and health for the Yorta Yorta Nation, Boonwurrung and Bangerang Tribes. Health & Place, 15(1), 291–299. doi:10.1016/j.healthplace.2008.05.009

Since the former Australian government introduced a tax incentive for private health insurance (or should I say, a tax disincentive for not having it), a lot of people now have some degree of private health insurance.

Most people are, however, somewhat confused at what this actually entitles to them- which is understandable given that it's actually quite confusing.

The bottom line is that although there are now private hospitals that have ICU facilities and emergency departments, they really are set up for low-risk elective admissions, while public hospitals are much, much better at handling sick, complex emergency patients. Public hospitals are geared towards prioritising the sickest patients first (thus why waiting lists for non-urgent things are long). Private hospitals are businesses and are geared towards servicing things that are low-risk and high-gain, such as elective surgery or people who aren't that sick.

There are also often costs that are not obvious to those who aren't familiar with the healthcare system and how it works. The public health system is free. The private health system is not. If you are having an operation or procedure, you will have to pay whoever is doing the procedure (surgeon, dentist, gastroenterologist, cardiologist etc) as well as the anaesthetist and the hospital.

What private health insurance entitles you to:

• Usually some or all of your money back if you have an admission or procedure or consultation at a private hospital (as long as it's been long enough since diagnosis, etc). The amount varies considerably from plan to plan and is often capped at a certain amount. There is also often an excess payment for making a claim.
• "Private in Public" status at a public hospital which usually includes the ability to choose your own specialist, have procedures done by your choice of specialist (if they agree) and extra funding is given to the hospital by your insurer.
• If you have at least "Basic Plus" cover or similar, you can usually get covered 2/3 of the cost of dental care, physiotherapy, other allied health services, massage, acupuncture, other alternative healthcare practitioners. This is of course based on reasonable costs- if your practitioner overcharges you or the "reasonable cost" is actually unrealistic then you may not have the whole 2/3 covered.
• Elective (non-urgent, non-emergency) procedures will usually be performed much faster in the private sector. Good examples include varicose vein surgery, tonsillectomy, tendon repair, carpal tunnel release and arthroscopy.
• Transfer to the public system if you cannot afford the private service or run out of money (depending on resources available)

What private health insurance does not entitle you to:

• A single room. Single rooms are usually reserved for infectious, dying or delirious patients.
• Coverage of costs beyond what your plan covers or beyond what the insurance company deems a reasonable cost- there may be a price gap which you would have to pay out of your own pocket.
• Shorter waiting times for emergency procedures in a public hospital. Emergency procedures are prioritised according to urgency of the case. If you have an abscess on your thigh or a cut on your finger, your operation will be delayed if someone comes in from a car crash or is about to die of dead bowel or a woman in the middle of childbirth has a threat to the safety of the baby.
• Automatic transfer to a private hospital if you are unhappy with your treatment in the public hospital. Being admitted to a private hospital requires that your medical condition suitable for the private hospital, that a specialist is willing to look after you there and that there is a bed available for you.
• Inappropriate medical treatment, procedures or tests just because you think they are a good idea. Ultimately all doctors have to adhere to ethical conduct and the Hippocratic Oath, which forbids doing things that are harmful or unnecessary. Being in the private sector does not mean that you are only a customer. You are still a patient, and your doctor is obliged to act in your best interests.

What private hospitals & insurance are good for:

• Elective, low-risk surgery and procedures
• Simple problems and short admissions
• Covering dental care and allied healthcare
• Rehab- physical & otherwise

What private hospitals are not good for:

• Emergencies, critically unwell and complex patients- in the public system there is always a doctor on site and transfer to intensive care or theatre is prioritised for sick patients. Not always the case in a private hospital where there may not be a doctor on site at night time. Additionally, if your stay is complicated in any way, you may end up with large out of pocket costs.
• Trauma. For exactly the same reason. If you fall off a roof, are in a car accident or get stabbed, you are much, much better off in a public hospital where they routinely deal with trauma, sick patients and have the staff to take you for emergency procedures if required.
• Heart attacks, strokes, liver failure, cancer, hepatitis, cyanide poisoning, etc... I think you get the point.

If you choose to go ahead with doing something in the private hospital setting, I'd advise the following:

• Make sure that you know exactly what you are covered for. The insurance company should be able to advise you in advance if you're contemplating an admission under the private system.
• If it comes to having an operation, make sure you get a quote from 1) the person doing the procedure 2) the anaesthetist and 3) the hospital and then go to your insurer to find out what you are actually covered for. A lot of people get stung by the cost of the anaesthetic for the reason that they assume that it's part of the cost or that there will be no gap. In reality a lot of insurers do not pay a lot of money to the anaesthetist, while the anaesthetist actually pays a lot in indemnity insurance due to risk. The gap can be in the hundreds of dollars if not more.
• Discuss the cost of the procedure, the anaesthetic and the hospital with the person doing the procedure if you can't afford it. They may negotiate a different set up or doing it via the public system. Certainly they can't help you if they don't know that you are going to have financial problems.
• Public hospitals have a liaison person assigned to deal with "private in public" admissions. They can usually tell you a fair bit about what you are and are not covered for and entitled to. At the very least they can tell you who to talk to.

Whew. Hope this helps!

I had a fairly disjointed argument on the weekend with a would-be future political type. The crux of this segment was as follows: Him: "The states' power should be preserved because Australia is a federation of independent countries" Me: "But how exactly are Victorians benefited by keeping everything separate?" Him: "They should be separate as a safeguard to the federal government and because of history" Me: "But how does that benefit people?!" &c&c Australia is an odd country. It's one of the least population dense countries and continents in the world. 20 million people most of whom live in cities scattered along the coastline. A huge amount of empty space in which people do actually live, here and there. A great whopping big desert that we try and farm. Mostly developed and first world with one of the highest life expectancies  and best healthcare systems in the world... unless you live in a very remote Australia or are Indigenous. The biggest barriers to healthcare in Australia then?

• Geography
• Race/Indigenous status

Let me explain. There are country towns with a population of 300 which are inland and where the nearest tertiary hospital is greater than 5 hours away. By helicopter. Other towns with a population of 30,000 which have the biggest hospital by road for hours and are very strained. There are towns which are remote or even not that remote but where the closest big centre is in another state. Or where half the town is on one side of the state border and the other on the other side. This is problematic for many obvious reasons. Airlifting trauma patients is difficult. It is difficult to get patients from one state hospital system to another. There are funding issues. Doctors have to ... get this... apply for registration in both states (and pay an exorbitant fee) in order to perform the practicalities of working in a border town. The federal system in Australia is impractical precisely because of the size and geography of the country. Rather than facilitating healthcare in disadvantaged areas by tailoring policy it results in an ad hoc patchwork system where interhospital transfer (something crucial in remote areas where services are difficult to access) is exquisitely painful to organise and results in avoidable delays in getting sick patients appropriate care. The states and their laws are divided by history and accident rather than logic or relevance to modern Australia and its issues. As far as I can tell it only offers disadvantages to its citizens in its current incarnation. Perhaps in a much smaller and more highly populated country the state system would make more sense because it would just be a matter of there existing a protocolled system for treating and transferring patients. However, when you have little choice where to go and what to do and time is critical... it is inefficient, bureaucratic, and furthermore harmful. Conclusion: Whatever you do, just don't get sick in Broken Hill. Or chased by drunk guys because you're a drag queen from Sydney. Whatever.