Context of Indigenous health Essay

Historical context and social determinants of Indigenous health There is a clear relationship between the social disadvantages experienced by Indigenous people and their current health status [1]. These social disadvantages, directly related to dispossession and characterised by poverty and powerlessness, are reflected in measures of education, employment, and income. Before presenting the key indicators of Indigenous health status, it is important, therefore, to provide a brief summary of the context within which these indicators should be considered. The historical context of Indigenous health Indigenous peoples generally enjoyed better health in 1788 than most people living in Europe [2][3][4][5][6]. They did not suffer from smallpox, measles, influenza, tuberculosis, scarlet fever, venereal syphilis and gonorrhoea, diseases that were common in 18th century Europe. Indigenous people probably suffered from hepatitis B, some bacterial infections (including a non-venereal form of syphilis and yaws) and some intestinal parasites. Trauma is likely to have been a major cause of death, and anaemia, arthritis, periodontal disease, and tooth attrition are known to have occurred. The impact of these diseases at a population level was relatively small compared with the effects of the diseases that affected 18th century Europe. All of this changed after 1788 with the arrival of introduced illness, initially smallpox and sexually transmissible infections (gonorrhoea and venereal syphilis), and later tuberculosis, influenza, measles, scarlet fever, and whooping cough [3][4][7][8]. These diseases, particularly smallpox, caused considerable loss of life among Indigenous populations, but the impacts were not restricted to the immediate victims. The epidemic also affected the fabric of Indigenous societies through depopulation and social disruption. The impact of introduced diseases was almost certainly the major cause of death for Indigenous people, but direct conflict and occupation of Indigenous homelands also contributed substantially to Indigenous mortality [7][9][10]. The initial responses of Indigenous people to the arrival of the First Fleet were apparently quite peaceful. It didn’t take long, however, before conflict started to occur – initially over access to fish stocks and then over access to other resources as non-Indigenous people started to plant crops and introduce livestock. This pattern of conflict was almost certainly widespread as non-Indigenous people spread across the country. Conflict escalated in many places, in some instances resulting in overt massacres of Indigenous people. The 1838 massacre at Myall Creek (near Inverell, NSW) is the most infamous [11], but less well-known massacres occurred across Australia [10]. As Bruce Elder notes, as ‘painful and shameful as they are’, the massacres ‘should be as much a part of Australian history as the First Fleet, the explorers, the gold rushes and the bushrangers’ ([10], p. vi). Prior to 1788, Indigenous people were able to define their own sense of being through control over all aspects of their lives, including ceremonies, spiritual practices, medicine, social relationships, management of land, law, and economic activities [12][13][14]. In addition to the impacts of introduced diseases and conflict, the spread of non-Indigenous peoples undermined the ability of Indigenous people to lead healthy lives by devaluing their culture, destroying their traditional food base, separating families, and dispossessing whole communities [3][4][7]. This loss of autonomy undermined social vitality, which, in turn, affected the capacity to meet challenges, including health challenges; a cycle of dispossession, demoralisation, and poor health was established. These impacts on Indigenous populations eventually forced colonial authorities to try to ‘protect’ remaining Indigenous peoples. This pressure led to the establishment of Aboriginal ‘protection’ boards, the first established in Vic by the Aboriginal Protection Act of 1869 [15]. A similar Act established the NSW Aborigines Protection Board in 1883, with the other colonies also enacting legislation to ‘protect’ Indigenous populations within their boundaries. The ‘protection’ provided under the provisions of the various Acts imposed enormous restrictions on the lives of many Indigenous people. These restrictions meant that, as late as 1961, in eastern Australia ‘nearly one-third of all Australians recorded as being of Aboriginal descent lived in settlements’ ([16], p. 4). The provisions of the Acts were also used to justify the forced separation of Indigenous children from their families ‘by compulsion, duress or undue influence’ ([15], p. 2). The National Inquiry into the separation of the children concluded that ‘between one-in-three and one-in-ten Indigenous children were forcibly removed from their families and communities in the period from approximately 1910 until 1970’ ([15], p. 31). It was the 1960s, at the earliest, when the various ‘protection’ Acts were either repealed or became inoperative. The importance of contemporary social determinants and cultural concepts of Indigenous health The health disadvantages experienced by Indigenous people can be considered historical in origin [14], but perpetuation of the disadvantages owes much to contemporary structural and social factors, embodied in what have been termed the ‘social determinants’ of health [1][17][18]. In broad terms, economic opportunity, physical infrastructure, and social conditions influence the health of individuals, communities, and societies as a whole. These factors are specifically manifest in measures such as education, employment, income, housing, access to services, social networks, connection with land, racism, and incarceration. On all these measures, Indigenous people suffer substantial disadvantage. For many Indigenous people, the ongoing effects of ‘protection’ and the forced separation of children from their families compound other social disadvantages. It is also important in considering Indigenous health to understand how Indigenous people themselves conceptualise health. There was no separate term in Indigenous languages for health as it is understood in western society [19]. The traditional Indigenous perspective of health is holistic. It encompasses everything important in a person’s life, including land, environment, physical body, community, relationships, and law. Health is the social, emotional, and cultural wellbeing of the whole community and the concept is therefore linked to the sense of being Indigenous. This conceptualisation of health has much in common with the social determinants model and has crucial implications for the simple application of biomedically-derived concepts as a means of improving Indigenous health. The reductionist, biomedical approach is undoubtedly useful in identifying and reducing disease in individuals, but its limitations in addressing population-wide health disadvantages, such as those experienced by Indigenous people, must be recognised. Indicators of Indigenous social disadvantage. The key measures in these areas for Indigenous people nationally include: Education According to 2011 Australian Census [20]: 92% of 5 year-old Indigenous children were attending an educational institution 1. 6% of the Indigenous population had not attended school compared with 0. 9% of the non-Indigenous population 29% of Indigenous people reported year 10 as their highest year of school completion; 25% had completed year 12, compared with 52% of non-Indigenous people 26% of Indigenous people reported having a post-school qualification, compared with 49% of non-Indigenous people 4. 6% of Indigenous people had attained a bachelor degree or higher, compared with 20% of non-Indigenous people. An ABS school report [21] revealed, in 2011: the apparent retention rate for Indigenous students from year 7/8 to year 10 was 99%, from year 7/8 to year 12 it was 49% for non-Indigenous students, the apparent retention rate from year 7/8 to year 10 was 101%; and from year 7/8 to year 12 it was 81%. The 2011 national report on schooling in Australia [22] showed: 76% of Indigenous students in year 3 and 66% in year 5 were at or above the national minimum standard for reading, compared with 95% and 93% respectively of all Australian students 80% of year 3 Indigenous students and 69% of year 5 Indigenous students were at or above the national minimum standard for persuasive writing, compared with 96% of all year 3 students and 94% of all year 5 students 72% of year 3 Indigenous students and 69% of year 5. Indigenous students were at or above the national minimum standard for spelling, compared with 94% of all year 3 students and 93% of all year 5 students 71% of year 3 Indigenous students and 65% of year 5 Indigenous students were at or above the national minimum standard for grammar and punctuation, compared with 94% of all year 3 students and 94% of all year 5 students 84% of Indigenous students in year 3 and 75% in year 5 were at or above the national minimum standard for numeracy, compared with 96% and 96% respectively of all Australian students. Employment According to the 2011 Australian Census [20]: 42% of Indigenous people aged 15 years or older were employed and 17% were unemployed. In comparison, 61% of non-Indigenous people aged 15 years or older were employed and 5% were unemployed the most common occupation classification of employed Indigenous people was ‘labourer’ (18%) followed by ‘community and personal service workers’ (17%). The most common occupation classification of employed non-Indigenous people was ‘professional’ (22%). Income According to the 2011 Australian Census [20]: the mean equivalised gross household income for Indigenous persons was around $475 per week – approximately 59% of that for non-Indigenous persons (around $800). Indigenous population Based on information collected as a part of the 2011 Census of Population and Housing, the ABS has estimated the Aboriginal and Torres Strait Islander population at 669,736 people at 30 June 2011 [23]. The estimated population for NSW was the highest (208,364 Indigenous people), followed by Qld (188,892), WA (88,277), and the NT (68,901) (Table 1). The NT has the highest proportion of Indigenous people among its population (29. 8%) and Vic the lowest (0. 9%). Table 1: Estimated Indigenous population, by jurisdiction, Australia, 30 June 2011 JurisdictionIndigenous population (number)Proportion of Australian Indigenous population (%)Proportion of jurisdiction population (%) Source: ABS, 2012 [23] Notes: Preliminary estimates are subject to revision; population projections are expected to be finalised by 2014 Australian population includes Jervis Bay Territory, the Cocos (Keeling). Islands, and Christmas Island Proportions of jurisdiction population have used total population figures estimated from demographic information for June 2011 NSW208,36431. 12. 9 Vic47,3277. 10. 9 Qld188,89228. 24. 2 WA88,27713. 23. 8 SA37,3925. 62. 3 Tas24,1553. 64. 7 ACT6,1670. 91. 7 NT68,90110. 329. 8. Australia669,736100. 03. 0 There was a 21% increase in the number of Indigenous people counted in the 2011 Census compared with the 2006 Census2 [24]. The largest increases were in the ACT (34%), Vic (26%), NSW (25%) and Qld (22%). For all jurisdictions, the 55 years and over age-group showed the largest relative increase. There are two ‘structural’ reasons contributing to the growth of the Indigenous population: the slightly higher fertility rates of Indigenous women compared with the rates of other Australian women (see ‘Births and pregnancy outcome’); and the significant numbers of Indigenous babies born to Indigenous fathers and non-Indigenous mothers. Two other factors are considered likely to have contributed to the increase in people identifying as Indigenous: changes in enumeration processes (i. e. more Indigenous people are being captured during the census process); and changes in identification (i. e. people who did not previously identify as Indigenous in the census have changed their response). Based on the 2011 Census, around 33% of Indigenous people lived in a capital city [25]. Detailed information about the geographic distribution of the Indigenous population for 2011 is not yet available, but figures from the 2006 Census indicated that the majority of Indigenous people lived in cities and towns [26]. Slightly more than one-half of the Indigenous population lived in areas classified as ‘major cities’ or ‘inner regional’ areas, compared with almost nine-tenths of the non-Indigenous population. (As well as these two classifications of ‘remoteness’ in terms of access to goods and services and opportunities for social interaction, the Australian Standard Geographical Classification (ASGC) has four other categories: ‘outer regional’, ‘remote’, ‘very remote’, and ‘migratory’ [27]. ) Almost one-quarter of Indigenous people lived in areas classified as ‘remote’ or ‘very remote’ in relation to having ‘very little access to goods, services and opportunities for social interaction’ ([28], p. 3). Less than 2% of non-Indigenous people lived in ‘remote’ or ‘very remote’ areas [26]. In terms of specific geographical areas, more than one-half (53%) of all Indigenous people counted in the 2011 Census lived in nine of the 57 Indigenous regions (based largely on the former Aboriginal and Torres Strait Islander Commission (ATSIC) regions) [25]. The three largest regions were in eastern Australia (Brisbane, NSW Central and the North Coast, and Sydney-Wollongong), which accounted for 29% of the total Indigenous population. According to the 2011 Census, around 90% of Indigenous people are Aboriginal, 6% are Torres Strait Islanders, and 4% people identified as being of both Aboriginal and Torres Strait Islander descent [25]. Around 63% of Torres Strait Islander people3 lived in Qld; NSW was the only other state with a large number of Torres Strait Islander people. The Indigenous population is much younger overall than the non-Indigenous population (Figure 1) [23]. 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