Introduction

The health status of Indigenous Australians remains a health issue of the greatest importance for this country. The morbidity and mortality rates for Indigenous peoples are higher than those of any other group in Australia. In the more remote areas these rates are similar to those found in third world countries that have no basic health infrastructure.

Successive Australian Governments have attempted to identify the underlying problems associated with Indigenous health status. This has resulted in a number of reports and inquiries in recent years. In many instances solutions have been identified and implemented but with mixed results.

So why does the problem persist? Is it solvable merely by allocating more resources to it? Are existing resources being allocated to the most effective solutions? The National Rural Health Alliance accepts that the problem of Indigenous health is complex. However, it also believes that there are viable solutions and this paper addresses some of the avenues for these solutions.

Indigenous Health Status

Before any solutions can be considered, an indication of the extent of the problem is necessary. The relative lack of comparative measures in health status between Indigenous and Non-Indigenous population is indicative of the basic attitude toward Indigenous health issues that have pervaded Australian thinking in the past. More recently there has been the establishment of the National Aboriginal and Torres Strait Islander Health Information Plan that is expected to improve the future availability and quality of data.

The Australian Institute of Health and Welfare (AIHW), in its publication Australia's Health 2000, uses the following basic measures for gaining an insight into the relative health status of Aboriginal and Torres Strait Islander peoples. The data used in the analysis are predominantly from Western Australia, South Australia and the Northern Territory where the data collections are considered to be of reasonable quality.

Life Expectancy and Age at Death
The following table shows the life expectancy at birth for Indigenous males and females compared with Non Indigenous males and females. It shows an incredible difference of 20 years.

The age at death statistics further emphasise the fundamental difference in health status between the Indigenous and Non Indigenous population.

	Indigenous Males	Non Indigenous Males	Indigenous Females	Non Indigenous Females
Life Expectancy at Birth	56.9 years	75.2 years	61.7 years	81.1 years
Age at Death	53% < 50 years	72% > 65 years	41% < 50 years	83% > 65 years

Mortality

Age specific death rates exceed those for all Australians in every age group and are greatest for those aged 35 - 54 years

Causes of Death

The major causes of death for Indigenous males and females tend to follow the major causes of death for Non Indigenous Australians. However the rates for Indigenous Australians in the five main causes of death are alarming in the extent to which they exceed that of Non Indigenous Australians as follows:

Causes of Death per 100,000 population	Indigenous Males	Non Indigenous Males	Indigenous Females	Non Indigenous Females
Cardiovascular	610	300	400	210
Neoplasms	260	220	180	135
Respiratory	260	70	180	35
Injury/Poisoning	180	60	70	20
Endocrine/Nutritional	120	20	165	15

In addition infant mortality for Indigenous Australians is over 3 times that for all Australians.

Morbidity

Morbidity data in relation to hospitalisation among Indigenous people are grossly understated in the available data due to the high level of under-identification in hospital records. Despite this under-counting, hospitalisation rates for Indigenous people are twice that for all Australians.

The most common cause of hospitalisation for Indigenous males and females, accounting for 25% of theses admissions, is dialysis.

Health Risk Factors

The provision of direct health care services plays only a small part in improving health status. Health risk factors have a significant impact on health status. These factors include socio-economic factors, living conditions, nutrition, the use of drugs and other harmful substances and the incidence of violence.

Socio Economic Factors

A strong relationship has been established by countless studies internationally between low health status and low socio economic status. The generally low socio economic status of Indigenous people is evidenced by a number of factors. The unemployment rate for Indigenous people in 1996 when the last reliable data were available was 23% compared to 9% for other Australians. The number of Indigenous people having tertiary education is only one fifth of that of other Australians. Weekly median incomes for Indigenous people are approximately 75% of that of other Australians.

Housing and living Conditions

Indigenous households represent around 2% of all Australian households. Approximately 7% of Indigenous people live in large households, defined as 10 or more people in a dwelling, compared with 0.14% of other people. Indigenous households are more likely to live in smaller dwellings. Approximately one third of all improvised dwellings, such as sheds and humpies, are occupied by Indigenous households.

Nutrition

There is little information available about the food intake of Indigenous people. However there is national data available that indicates that based on body mass index (BMI) approximately 27% of adult Indigenous people would be classified as obese compared with 19% of all adult Australians.

Drugs and Other Harmful Substances

Cigarette smoking is almost twice as prevalent in Indigenous adults than Non-Indigenous adults. This adds a greater proportion of Indigenous people to the higher risk groups for heart disease, cancer and respiratory diseases in particular. Although there is little data regarding the use of illicit drugs and other harmful substances such as petrol there is growing concern on these issues by Indigenous people.

Violence

Evidence based on deaths and hospital admissions as a result of injury resulting from violence indicates that Indigenous people are at much greater health risk from these causes than Australians as a whole. In 1997/98 Indigenous females suffering physical violence represented 46 % of all female hospitalisations. The available data are only an indicator of the prevalence of physical violence. Not all victims are admitted to hospital and not all suffer physical violence.

Expenditure On Aboriginal Health

Total expenditure on health services to Indigenous people from all sources is approximately 8% higher than that for all other Australians. This is considered much less than the total of the adverse health factors and cost factors indicate. Per person health expenditure for Indigenous people is higher than the general population for public hospitals and community services but much less for Medicare, PBS, Nursing homes and dental. This distribution is indicative of the access difficulties Indigenous people have to many of the mainstream primary health care services.

In summary the health status of Indigenous people is poor compared with the remainder of the Australian population. Almost every risk factor leading to poor health status is present. In many instances the extent of the risk factors have never been reliably measured on a national scale.

Previous Reports Addressing Indigenous Health Issues

There have been a number of reports over the past decade that have dealt with Indigenous health issues. The most significant of these are:

• Royal Commission into Aboriginal Deaths in Custody
• Bringing them Home; Report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families

The following are the major findings and recommendations of the reports as they relate to Indigenous health issues:

Royal Commission into Aboriginal Deaths in Custody (1987 to 1991)

• Implement more training courses for non Aboriginal health professionals about Aboriginal people, their cultural differences, specific socio economic circumstances and their history.
• Improve the training of health professionals in primary health care particularly those interested in working in localities with concentrations of Aboriginal people.
• Develop more effective communication between non-Aboriginal health professionals and patients in mainstream services through specific training that identifies the communication barriers likely to arise.
• Aboriginal people be involved at every level in the development, implementation and interpretation of research into patterns, causes and consequences of Aboriginal alcohol use and in the application of the results of that research.
• The inadequacy of 'single factor' explanations of the cause of alcohol dependence and misuse by individuals
• Provide non-Aboriginal health professionals with access to skilled interpreters in the Aboriginal languages encountered.
• Through improved training, supervision and selection of staff show that the negative stereo-typing of Aboriginal people and those with drinking problems will not be tolerated in the health care setting.
• Increase the number of Aboriginal staff employed as health care workers by mainstream health services.
• Improve long distance medical diagnosis through widening the use of standard diagnostic protocols.
• Aboriginal organisations be encouraged to further implement programs to employ multi purpose Aboriginal drug and alcohol community workers including the training of Aboriginal people in these roles.

• Establish and fund Indigenous community-based family tracing and reunion services in all regional areas with significant Indigenous population.
• Establishment of a referral network of health care professionals including professional counsellors, psychologists and psychiatrists.
• The establishment of an Indigenous well-being model that emphasises local Indigenous healing and well-being views.
• Government operated mental health services to work towards delivering specialist services in partnership with Indigenous community-based services and employ Indigenous mental health workers and community members respected for their healing skills.
• That health services including Indigenous health services develop in service training for all employees in the history and effects of forcible removal.
• That Indigenous mental health worker training be instituted by all state and territory governments through Indigenous run programs to ensure cultural and social appropriateness.
• That funding be provided for the establishment of parenting and family well being programs by relevant Indigenous organisations

There have been extensive criminal justice reforms in some jurisdictions since the Royal Commission into Aboriginal Deaths in Custody reported in 1991. However, many of these reforms did not begin until after a National Summit in 1997 at which all States and Territories agreed to develop strategic plans in partnership with Indigenous people to reduce the over representation of Indigenous people in the criminal justice system. There has also been a significant increase in the funding of Indigenous legal aid services.

Unfortunately the number of deaths of Indigenous people in custody in recent years is rising despite reductions immediately following the release of the Royal Commission's findings. There was a peak in 1995 and there has been a steady climb since 1998. Indigenous Australians, and in particular female Indigenous Australians, are still over represented in jails.

Clearly the impetus in this area has been lost. The links between such socio economic reforms and health status determinants of Indigenous people are clearly established. The anticipated flow on in improved health status linked to socio economic and cultural determinants has also been lost.

Bringing them Home also resulted in an initial flurry of changes and reforms. These resulted in a start on the establishment of referral networks for health care professionals and the development of training for health care professionals in Indigenous cultural and social areas. Many of the initiatives recommended in the report appear to have been subsumed into the broader Indigenous portfolio of services. This has resulted in a reduced impetus for these reform programs and has tended to keep the programs out of the forefront of activity.

The danger is that there may be calls for further reports because these reports may be seen as dated. However, this merely extends the process and further delays the implementation of many of the solutions already identified.

Conclusions

The morbidity and mortality rates for Indigenous Australians are higher than for any other population group in Australia. In the more remote areas of the country these rates are similar to those applying to third world countries. The situation where health statistics for Indigenous people in some jurisdictions are not maintained separately from the remainder of the population is untenable. Without this data the true extent of the Indigenous health problems remain hidden. The AIHW's 2002 work for the Office of Rural Health will assist in this matter.

The issues involved in Indigenous health are complex and challenging. The importance of working in partnership with Indigenous people and organisations is critical. The involvement of the community controlled sector that includes in excess of 90 rural and remote Aboriginal Medical Services is vital.

There have been two major reports on Aboriginal issues in the last decade that have addressed a number of the determinants of health status. The major recommendations of these reports relate to health service infrastructure, intersectoral collaboration, social justice and self determination, land and cultural integrity, training and education, juvenile justice, women's business, alcohol and substance mis-use, family reunion, violence and racism, and physical infrastructure such as housing, sewerage, water supply and communications. The majority of the recommendations from these reports are still to be implemented and the targeted outcomes are yet to be achieved in many areas. The reports emphasise the need for primary health care services that recognise the value of community leadership. Further reports should not be initiated until more recommendations of the current reports are implemented.

There is an urgent need to expand resources in both Indigenous and Non Indigenous staff in the provision of health care services. Chronic disease in Indigenous Australians is not adequately addressed.

Many Indigenous health programs have been subsumed into larger government programs and are in danger of being further relegated in priority. The issue of Indigenous health and the required improvements in health status need to be kept at the forefront of public policy. Only in this way can any action and results be seen.

Recommendations

Strong and open bipartisan commitment to the attainment of improvement in the health status of Indigenous Australians is required.

The Alliance sees the need for a national campaign that will actually achieve measurable improvements in the health status of Indigenous people. The Alliance believes the catalysts for the success of such a campaign are self-determination for Indigenous people and an emphasis on primary health care services and community capacity building. Such work will benefit from the existence of high profile and effective nation al champions and Regional leaders.

The Department of Health and Aged Care should provide appropriate resources for addressing all Aboriginal and Torres Strait Islander health issues, including chronic disease and secondary prevention, engaging the principles of self determination.

These resources need to include the provision of primary health care services with an emphasis on:

• community leadership;
• capacity building for Aboriginal and Torres Strait Islander and Non-Indigenous staff; and
• health staff positions identified and funded specifically for treatment and prevention of chronic disease.

The current emphasis should be on the implementation of the findings of the major reports rather than extending the process with further reports.

Improved data collections that accurately identify the health status of Indigenous people across all jurisdictions are still required.