Introduction

While analogous, there are many differences between the way in which community and individual health are practiced. In this short essay, I will outline some of these differences.

Definitions

The World Health Organisation in 1946 defined health as:

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

This definition uses a biopsychosocial and inclusive model of health and can equally be applied to individuals as to communities, although the health of the individual is implied.

The NPHP in Australia defined public health in 1997 as:

 “the organised response by society to protect and promote health and prevent illness, injury and disability.”(National Public Health Partnership, 1997)

This encapsulates the modern, multidisciplinary approach to public health.

Ethical Differences

In treating patients, healthcare practitioners generally use “principles” and deontological frameworks such as beneficence, non-malfeasance, equity and fairness. One strives to improve a person’s health without harming them, in a fair and just manner. In particular we advocate for an individual patient when engaging with other stakeholders rather than necessarily making a decision that takes other individuals into account- responsibility for community health is usually handed over to public health agencies and administrative bodies. However in community health, measures such as disability-adjusted life years (DALY) are used to allocate resources & design interventions in a utilitarian manner as the aim is the greatest good for the greatest number.

This distinction however is not altogether clear-cut. While traditionally, utilitarianism is cited as the underlying ethical principle in community health and a deontological framework the underlying ethical principle for individual treatment, there is evidence that a mixture of models is what is used in practice.(Fortes & Zoboli, 2002; Hedner & Hansson, 1988)

In addition, sometimes these two methods clash. Surgical intervention for an individual with many complex medical problems may in fact be very expensive and improve community outcomes only slightly in comparison with inexpensive population measures such as vaccination programs. A 2001 study of American publicly-insured elderly patients estimated that the 5% of the population of elderly people who were in their last year of life contributed roughly 30% of the medical expenditure, 6 times the expenditure when compared with their surviving counterparts (Hogan, Lunney, Gabel, & Lynn, 2001).

Measuring Health

Health status of an individual can be assessed in several ways. Health practitioners assess symptoms, signs and the results of diagnostic tests. Medical and psychosocial wellbeing can be evaluated qualitatively during a consultation as well as using various quantitative tools designed to, for example, evaluate risk of depression, functional score or pain scores. Further investigations can also be used to measure health via methods such as blood tests, radiology, pathology, exercise tolerance and other physical components.

In comparison, analysis and measurement of community health is less straightforward and is conducted on a larger scale. Health surveys are analogous to using qualitative and quantitative tools applied to many representative individuals rather than a single individual. Incidence and prevalence of disease conditions may be collected via disease & death registers, hospital & general practitioner databases (eg coding discharge summaries after inpatient stays), surveillance systems where data is compulsorily submitted to a central authority such as for notifiable illnesses. Demographic data, economic and educational data that are continuously measured also give information as to social determinants of health.(Baum, 2003; Canadian Public Health Association, 1986; Lin, Chaplin, Robinson, Fawkes, & Smith, 2007)

Health Interventions

Health interventions for individuals are generally more focussed on secondary and tertiary prevention, ie treatment of risk factors & disease states that already exist rather than prevention in healthy individuals. An example would be that of someone who presents to their healthcare practitioner with ischaemic chest pain. While risk factor reduction such as diabetic control, cessation of smoking and initiation of an exercise regimen may all be appropriate, the initial response will be targeted to treatment of the underlying cause of chest pain and its psychosocial effects. The “history of presenting complaint” is the focus of what we often do.

In contrast, much of community intervention is primary prevention. Legislation and regulation, health promotion and education, screening, vaccination, treatment of risk factors, environmental management, socioeconomic and education policy are some of the many ways in which public health interventions are practiced. There is a “bigger picture” approach that emphasises prevention and often requires a co-ordinated and multidisciplinary approach to the health of the system.(Baum, 2003; Canadian Public Health Association, 1986; Lin et al., 2007)

Conclusion

Public health is not just individual health on a bigger scale. While the healthcare of individuals is increasingly holistic, public health necessarily has a “bigger system” perspective involving not just healthcare workers and departments but also legal, economic and educational systems.

The focus is on prevention, surveillance and maintenance of wellbeing rather than on treatment of ill-health.

Bibliography

Baum, F. (2003). The new public health. Oxford University Press. Retrieved from http://www.cabdirect.org/abstracts/20043034459.html

Canadian Public Health Association, W. (1986). Ottawa charter for health promotion. Ottawa: Canada.

Fortes, P. a. C., & Zoboli, E. L. C. P. (2002). A study on the ethics of microallocation of scarce resources in health care. Journal of Medical Ethics, 28(4), 266–269. doi:10.1136/jme.28.4.266

Hedner, T., & Hansson, L. (1988). A Utilitarian or Deontological Approach Toward Primary Prevention of Cardiovascular Disease? Acta Medica Scandinavica, 224(4), 293–302. doi:10.1111/j.0954-6820.1988.tb19587.x

Hogan, C., Lunney, J., Gabel, J., & Lynn, J. (2001). Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life. Health Affairs, 20(4), 188–195. doi:10.1377/hlthaff.20.4.188

Lin, V., Chaplin, S., Robinson, P. M., Fawkes, S. A., & Smith, J. (2007). Public health practice in Australia: the organised effort. Retrieved from http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:24280

National Public Health Partnership. (1997). Memorandum of Understanding. National Public Health Partnership.

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).

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