NACCHO Aboriginal health political alert:’PM for Indigenous affairs’ has his task cut out on that front

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EARLY life experiences become hard-wired into the body, with lifelong effects on health and wellbeing.”

A very important statement – but not news. Research demonstrating the complex interplay of “givens” (genetics) and early-life “contingent factors” (the environment of pregnancy and early childhood) in determining lifelong risk of ill-health dates back to the middle of the last century.

From diabetes to depression, the intra-uterine and early childhood environments critically influence the quality and length of our lives.

FROM THE AUSTRALIAN Ernest Hunter is a medical practitioner in north Queensland.

Photo courtesy Apunipima Cape York Health Council Photovoice project. Photographer Grace Morris’.

The quote opens the Australian Medical Association’s Aboriginal and Torres Strait Islander Health Report Card 2012-2013, with Steve Hambleton, president of the AMA, commenting in the introduction on “gaps in preventive child health care, the promotion of early childhood development, and the alleviation of key risks for adverse developmental outcomes, especially in remote communities”.

Download report card here

In fact, it can reasonably be argued that developmental adversity is the main contributor to the continuing poor health status of indigenous Australians. That’s the bad news; to the extent that those effects “become hard-wired into the body”, it may not be possible to rectify – at times even to modify – the harms done.

In my role as a psychiatrist and public health physician in Cape York, most of my work is about mitigating the downstream consequences, be it psychosis, depression, interpersonal violence, self-harm, alcohol abuse or chronic disease. There is no shortage of work for clinicians.

While indigenous developmental vulnerability and its effects should be cause for alarm, it is not a reason for fatalism. Indeed, the good news is that the scope for intervention and prevention is enormous and, broadly, we know what needs to be achieved: equity in pregnancy and early childhood health and social outcomes.

Unfortunately, we do not know how to get there – although, clearly, it’s not through business as usual. Even if it is achievable it will take generations for the full effects of healthy pregnancies and early childhoods to be reflected in a reduction in the burden of chronic disease from midlife on, particularly in remote Aboriginal communities.

Imagine if somehow the pregnancies of young indigenous women, right now, were no more likely than non-indigenous pregnancies to be exposed to smoking, alcohol consumption, other drug use, the effects of violence, high levels of maternal stress hormones and inadequate nutrition; if the babies were born to women at no greater risk of prematurity and labour complications, who have had access to the same quality of antenatal and birthing services. Don’t stop – imagine if those babies, now as healthy as their peers across Australia – could spend their infancies in safe, nurturing and stimulating environments in which they were nourished and cherished by their parents, no more likely to be exposed to abuse, neglect or removal from their families; if they did not live in overcrowded houses and were protected from the waves of chaos and stress that wash through homes in remote communities. Imagine.

Even if this miracle did occur, service demands will remain unchanged for a long time as the developmental adversity experienced by older relatives works its effects through the population. Indeed the consequences are evident already among their older siblings, let alone those suffering chronic diseases in middle age.

Educational disadvantage has received a lot of media attention, as has fetal alcohol exposure, both of which predispose affected children to a range of additional risks that will follow them through their lives. Lives that in many cases will be much shorter: the Commission for Children and Young People and the Child Guardian annual report on the deaths of children in Queensland records that between 2004-05 and 2012-13 the suicide rate of indigenous children aged 10 to 17 was more than 5.5 times higher than that of their non-indigenous peers.

The Australian public was given cause for some optimism with the announcement by Tony Abbott prior to the federal election that he intended to be the “prime minister for indigenous affairs” and that he would be “hands on”. Since becoming PM he has appointed, with fanfare, an Indigenous Advisory Council, which first met in December under the leadership of Warren Mundine. Unsurprisingly, this move has been divisive in the wider indigenous population (indeed there is a petition initiated by writer Ken Canning for it to be replaced by an elected body).

Abbott has many other pressing demands; he has alluded also to the sobriquet of “the infrastructure PM” and he could be a contender for the title of “tow/push the boats back PM” too – and much more. But his statements about indigenous affairs were clearly broadcast, and the implication was that he would brook no obstruction to pursuing it as a national – and personal – priority.

So it is surprising to hear rumours, just months after his seemingly heartfelt assurance, that he has reconsidered (or been forced to reconsider) his and the Coalition’s political investment.

While the Indigenous Advisory Council is now at the table and constitutional reform placed back on it, the setting is, so far, pretty humble. The main course may be a way off but the entrees are hardly satisfying.

Following on the heels of the announcement of funding cuts for legal services, Mundine has anticipated that Aboriginal and Torres Strait Islander Australians may have to share the pain of national economic recovery.

In Queensland, of course, they are already sharing it. Among the outcomes of the cuts and divestments since the change of the Queensland government has been a reduction in human resources and institutional capacity in population health and social programs which will have the greatest consequences for those most disadvantaged, the residents of remote Queensland Aboriginal communities.

As they have less visibility and voice, and as the effects will be delayed, it’s a safe political strategy. And, of course, it can always be passed off as a commonwealth responsibility.

Who should pay – commonwealth or state – has been argued ad nauseam. That has been and remains a major obstacle to effective action. But, in terms of responsibility, Abbott made a commitment – to the nation – that he would personally take on the challenge of making a difference for indigenous Australians.

I want to believe that it was sincere and that he understood, in making it, that it will require broad support and long-term effort. Whether he is sufficiently inclusive or overly reliant on particular individuals will be debated and will play out. But if he really is the “PM for indigenous affairs” then he needs to lead and be seen to do so – “hands on”. And he needs to be in there for the long haul.

These two issues, developmental determinants and opportunities, and assertive political leadership, are linked. Sufficient and sustained investment in the former is the surest means to effect significant gains in indigenous health (though perhaps not the most politically visible in the short term) and is dependent on the latter.

In election mode Abbott also frequently commented that “we say what we mean and we do what we say”. Now it’s time for doing.

Ernest Hunter is a medical practitioner in north Queensland.

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