” In mainstream settings, there is no battle for recognition or resources for environmental health from finance departments. There is nothing more to prove and a fully resourced framework is in place.
But Aboriginal environmental health is something else again.
Aboriginal environmental health combines deep cultural knowledge of how things work in Aboriginal communities with these hard scientific facts about disease.
Aboriginal environmental health must forge high-trust partnerships with community.
Aboriginal environmental health is a community asset.
And Aboriginal environmental health is needed now more than ever. Why is this so?
Public housing and public utilities have largely been taken out of Aboriginal control. In some locations, funding for the Aboriginal Environmental Health workforce has evaporated.\
Sometimes, the power to make the simplest decision on the ground has been ripped away from local communities.
Instead, this power is with someone far away who doesn’t even know us.
This is nowhere more manifest than in Aboriginal housing.
Effective Aboriginal environmental health programs must be in Aboriginal hands.
Community controlled organisations must drive the necessary knowledge exchange between those who hold technical expertise and those who have been denied it.
The very nature of this work means that Aboriginal communities must retain the reins – and retain the knowledge
Selected extracts NACCHO CEO Pat Turner addressing the National Aboriginal and Torres Strait Islander Environmental Health Conference in Perth this week
As an Aboriginal woman of Gudanji-Arrernte heritage, I wish to acknowledge the Whadjuk people of the Noongar nation as traditional owners of the land where we meet today.
I also acknowledge our continuing and vibrant First Nations cultures. I am grateful for the contributions of our past, present and emerging leaders.
Our cultures, our leaders and our country give us collective strength and resilience as Aboriginal and Torres Strait Islander peoples.
Just a note for about language conventions in Western Australia. I tend to use the term Aboriginal in recognition that Aboriginal people are the original inhabitants here. This is not out of any disrespect to Torres Strait Islander colleagues and communities.
I have discovered that the first NATSIEH conference was held in 1998. Every second year or so since, the aim of these national conferences is to increase the understanding and awareness of environmental health issues in our communities.
This year, your theme is ONE GOAL: MANY PATHS. There must be a huge diversity of backgrounds, professions and experiences in the room. I am delighted to be here. I hope I have something for everyone in my address to you today.
I will begin with recent CHANGES in the way governments must now work with Aboriginal and Torres Strait Islander people.
Then I’ll cover some CHALLENGES that we can no longer ignore.
And finally, I’ll explain how Aboriginal LEADERSHIP will show the right path that we must take together.
How has our political landscape changed?
Please cast your minds back to 2008 when the original Closing the Gap policy was agreed by the Council of Australian Governments – known as COAG.
There was never full ownership of Closing the Gap from Aboriginal and Torres Strait Islander peoples. CLOSING the Gap was always considered to be an initiative of Governments. Frankly, it was governments talking to other governments ABOUT us. WITHOUT us.
Many Aboriginal and Torres Strait Islander Peak bodies supported Closing the Gap in good faith, particularly with new funding given to specific issues including housing, health and education.
But was Closing the Gap ever going to work with its genesis in the bureaucratic backrooms of Canberra?
Our people were always going to be configured as ‘the problem’. Not as allies, not as experts, not as partners, not as equals. It was not surprising to Aboriginal people to see that progress was patchy.
As Prof Marcia Langton, a leading Aboriginal academic of Yiman and Bidjara heritage, said in February this year at the Australian and New Zealand School of Government Indigenous conference:
“You can’t have administration of very complex matters from the Canberra bubble. It’s not working and lives are being lost.
… We must push for policies that give formal powers to the Indigenous sector and remove incompetent, bureaucratic bungling.”
Marcia made a specific request of those who were listening:
“Please do not feel personally offended by what I have to say to you” she said.
I also ask this of you today. And as Marcia continued to say:
‘… we must all take responsibility and be courageous enough to take action, to put an end to the policies and programs that disempower Aboriginal and Torres Strait Islander people, not just causing a decline in their living standards, but accelerating them into permanent poverty.
Especially the vulnerable. The children and youth are victims of a failed view of the Indigenous world and Indigenous people. This is a dystopian nightmare. We must imagine a future in which Indigenous people thrive and we must do whatever it takes to reach that future. This is urgent.”
It is not surprising then, that after 10 years, not much progress against the Closing the Gap targets had been made.
As the Closing the Gap targets were expiring, COAG announced a “Refresh” of Closing the Gap. This “refresh” kicked in during 2017. As various conversations took place however, it became clear that governments were still not listening properly or engaging in a genuine way, and they only wanted to talk about new targets.
Many Aboriginal Peak bodies wanted more time to test the options being put before us in these conversations. Most importantly, Peak bodies needed to be sure that THEIR voices were truly being heard. There was a real concern – AGAIN – that governments had already decided what they wanted to do. That governments were now negotiating behind closed doors to decide new priorities and targets without our input.
As Aboriginal peak bodies, we had to call this out before the country made another momentous mistake. We were very insistent. We formed a Coalition. The Prime Minister and his COAG colleagues had to adopt a better way of working. Without a radical change in approach, the next ten years would be more of the same lack luster approach.
To his credit, Prime Minister Morrison listened.
He opened the door to a new way of working, giving his personal authority to change.
An historic Partnership Agreement on Closing the Gap was signed this year in March between COAG and the Coalition of Peaks. This means that now, for the first time, Aboriginal and Torres Strait Islander people, through their peak body representatives, will share decision making with governments on Closing the Gap.
How is this to be done?
This Partnership Agreement has created a high-level COAG Joint Council. This Joint Council is made up of 22 members. That means a Minister from the Commonwealth Government, a Minister from each State and Territory Governments, and a representative for local government. This makes up ten members.
But significant success was realized when the Coalition of Aboriginal Peak Bodies ensured TWELVE Aboriginal or Torres Strait Islander representatives were on the Joint Council. Chosen by us, in the majority, working for our mobs.
The Joint Council is co-chaired by the current Commonwealth Minister for Indigenous Australians and a representative of the Coalition of Peaks chosen by the Peaks. Currently, that representative is me.
The Partnership Agreement embodies the belief of all signatories that:
- When Aboriginal and Torres Strait Islander peoples are included and have a real say in the design and delivery of services that impact on them, the outcomes are far better;
- Aboriginal and Torres Strait Islander peoples need to be at the centre of Closing the Gap policy: the gap won’t close without our full involvement; and
- COAG cannot expect us to take responsibility and work constructively with them to improve outcomes if we are excluded from the decision making.
So to those public servants in the audience, whether you work in Commonwealth, state, territory or local government institutions, I say this.
If the Director-General, Secretary or CEO of your department or agency is not enabling you to do your work differently and act in accordance with the Partnership Agreement, Principles, then you need to join the movement and shake the tree.
I encourage you to:
- Initiate co-design that looks entirely different to the way your department worked two years ago.
- Give power of veto to communities on priorities. Listen to what THEY say.
- Double the number of Indigenous people on your committees.
- Forget ‘one size fits all’ … because it doesn’t.
- Immerse yourself in this unprecedented opportunity for true equity in our country.
Trust me, your change of practice will be noticed, commended and supported.
Within the Joint Council, we will continue to lead the structural reform that will make your change of practice easier. At our recent meeting in Adelaide, the Joint Council significantly agreed to develop a new National Agreement on Closing the Gap centred on three reform priorities.
The reform priorities seek to change the way Australian Governments work with Aboriginal and Torres Strait Islander peoples and organisations, and accelerate life outcomes for Aboriginal and Torres Strait Islander peoples, these are:
- Establishing shared formal decision making between Australian governments and Aboriginal and Torres Strait Islander people at the State/Territory, regional and local level to embed ownership, responsibility and expertise on Closing the Gap.
- Building and strengthening Aboriginal and Torres Strait Islander community-controlled organisations to deliver services and programs in priority areas.
- Ensuring all mainstream government agencies and institutions undertake systemic and structural transformation to contribute to Closing the Gap.
The Joint Council also agreed to the Coalition of Peaks leading engagements with Aboriginal and Torres Strait Islander people over the next two months to ensure others can have a say on the new National Agreement on Closing the Gap.
The Coalition of Peaks want to hear views from across the country on what is needed to make the reform priorities a success.
I encourage you all to contribute and have your say.
You can find out more on the NACCHO website. Step up and join in!
I know these priorities, especially the first two, are critical to our success as Aboriginal people. And I know this from a lifetime of advocacy and service for my people, including my current role as CEO of NACCHO.
NACCHO is the living embodiment of the aspirations of Aboriginal and Torres Strait Islander communities and our struggle for self-determination. NACCHO is the national peak body representing 143 Aboriginal Community Controlled Health Services or “ACCHOs” across the country. NACCHO has a history stretching back to a meeting in Albury in 1974 in country New South Wales.
For those who don’t know, an “ACCHO” is a primary health care service initiated and operated by the local Aboriginal community to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it, through a locally elected Board of Management.
As a sector, we are especially proud that ACCHOs are the largest employer of Aboriginal and Torres Strait Islanders in the country. Not even the mining sector compares. We also have evidence that ACCHOs are demonstrably better than mainstream in providing culturally responsive, clinically effective primary health care.
At this year’s AMSANT conference, Donna Ah Chee, a Bundgalung woman from NSW and CEO of Central Australian Aboriginal Congress, said precisely what community control means in this context.
- The right to set the agenda and determine what the issues are
- The right to determine which programs or approaches are best suited to tackle the problems in the community
- The right to determine how a program is run, its size and resources
- The right to determine when a program operates, its pace and timing
- The right to say where a program will operate, its geographic coverage and its target groups
- The right to determine who will deliver the program its staff and advisers.
This commitment to equal partnership through COAG has brought us to the table. There’s no going back.
I’d now like to cover some CHALLENGES in environmental health.
Environmental health is a science-based, technical practice. Environmental health takes scientific knowledge to people. It focuses on disease risk and finds the way to limit disease in modern society. Environmental Health Practitioners draw the connection between environmental factors and health outcomes.
Environmental health practitioners take this science and fix environmental hazards to prevent risk. They nip outbreaks in the bud.
They influence and draft legislation, and monitor compliance with public health laws and the regulations to protect people’s health.
Of course, in mainstream Australia, hardly anyone recognizes the role that environmental health plays. For the majority of the population, environmental health is silently present. Water, sanitation, rubbish, housing standards, food safety, everything … it is all taken for granted.
In mainstream settings, there is no battle for recognition or resources for environmental health from finance departments. There is nothing more to prove and a fully resourced framework is in place.
But ABORIGINAL environmental health is something else again.
Aboriginal environmental health combines deep cultural knowledge of how things work in Aboriginal communities with these hard scientific facts about disease. Aboriginal environmental health must forge high-trust partnerships with community.
Aboriginal environmental health is a community asset.
And Aboriginal environmental health is needed now more than ever. Why is this so?
Public housing and public utilities have largely been taken out of Aboriginal control. In some locations, funding for the Aboriginal Environmental Health workforce has evaporated. Sometimes, the power to make the simplest decision on the ground has been ripped away from local communities. Instead, this power is with someone far away who doesn’t even know us.
This is nowhere more manifest than in Aboriginal housing.
First, the evidence. A recent systematic review of the scientific literature has summarized the known causal links between the home environment and health. Here are some examples:
- Skin-related diseases are associated with crowding
- Viral conditions such as influenza are also associated with crowding.
- Ear infections are associated with crowding, lack of functioning facilities for washing people, bedding and sewerage outflow.
- Gastro infections are associated with poorly maintained housing and the state of food preparation and storage.
These are not hypothetical claims yet to be proved. These have academic weight and the verdict is in.
In mainstream Australia, these causal links between the housing and health have been actioned. In mainstream Australia, sustained progress in the social and environmental determinants of health has permanently reduced the rates of preventable infectious diseases. One look at the disease burden tells us that.
BUT … because of the state of OUR environmental conditions, Aboriginal people are denied the health outcomes that non-Indigenous people now enjoy.
The challenge is huge.
- Let’s consider clinic presentations for Aboriginal children for their first year of life. Did you know that research has found that the median number of clinic presentations per child in the first year of life was 21. Twenty-one! Per child! Children in this NT study would typically have six clinic presentations for diarrhea in any one year! SIX! An infectious ear disease known as Otitis Media and skin infections were also high on the list of most frequent reasons for Aboriginal children coming to the clinic in their first year of life. These infectious diseases are NOT caused by bad parents. They are caused by poor living conditions, overcrowding and poverty imposed on our people.
- In the Fitzroy Valley in the Kimberley here in Western Australia, 70% of Aboriginal children have been admitted to hospital at least once before they turn seven years of age. A closer look at the reasons why is shocking. The researchers concluded that most of these admissions would not have happened at all if household disadvantage, poor quality housing and access to primary health care had been addressed.
- Another example comes from the Western Desert region here in Western Australia. This looked at clinic presentations of all children aged 0 to 5 years of age. These children had on average more than 30 clinic visits each per year to their clinic. ……… Think about what that means to the morale of the parents, the attitudes of the clinicians, the health budget bottom line. Infectious diseases explained half of these presentations:
- Ear infections were 15%
- Upper respiratory tract infections, 13%
- Skin sores were 12% of the total.
- And 25% needed treatment for scabies.
- These statistics aren’t just confined to remote communities. Aboriginal children in Western Sydney in homes with 3 or more housing problems were two and a half times more likely than others to have recurrent gastro-enteritis. For every additional housing problem, the odds of infectious disease significantly increased.
But is this all NEWS? What about the year of your first NATSIEH conference in 1998?
1998 was the year a study was published showing that admissions to hospital for skin disease of Aboriginal children under five years of age was ten times higher than that of their non-Indigenous counterparts.
It was also the year that deaths among Aboriginal men from infectious diseases were calculated to be some 15 times higher than deaths among non-Indigenous men.
1998 was also the year a study measured the precise “wear and tear” on washing machines installed in seven remote communities.
1998 was a year AFTER a study had already been published showing that over one-third of Aboriginal remote communities had water supply or sanitation problems. Seventy percent had housing problems. In the words of the researchers, overcrowding and substandard housing were “commonplace”.
So there we have it. Even this brief snapshot shows we have a disconnect between data and decisions.
From your first conference in 1998 to this one in 2019 …
…. Aboriginal people, their children and now their children’s children have NOT been afforded their DUE HUMAN RIGHTS in response to these “repeat plays” of research data.
Should we have mobilised a more strategic response at the time these research studies were published?
Perhaps data sovereignty is another challenge we need to face.
I regret thinking of the number of children growing up since 1998 who should have been safe from preventable infections IF THERE HAD BEEN ACTION. I think of how many children need not have gone to hospital. Who should NOT have ended up with permanent damage for life from rheumatic heart disease or deafness …
… and would NOT have ended up with these conditions if their houses had been safe, healthy and affordable.
I have been told even mental health problems – including suicide – get worse in overcrowded houses not fit for social purpose.
And please don’t tell me we can’t find the money. My colleagues in the Kimberley estimate that one third of the entire cost of hospital admissions of Aboriginal children is DIRECTLY due to the environmental conditions in which these children live. Let me repeat that. One third of the entire cost.
In one year alone, $16.9 million is the estimated cost for hospitalisations of Aboriginal people directly due to the environment. And that was just the Kimberley.
Maybe all those departments of housing really don’t have the money BUT their colleagues in health departments are spending it hand over fist.
The Australian Indigenous Governance Institute affirms that Aboriginal people have the right to:
- Exercise control of the data “ecosystem” including creation, development, stewardship, analysis, dissemination and infrastructure.
We also have the right to:
- Data structures that are accountable to Aboriginal and Torres Strait Islander peoples and their governance structures.
And the right to
- Data that is protective and respects our individual and collective interests.
- Data that is relevant and empowers sustainable self-determination and effective self-governance.
In my view, Aboriginal people must more clearly set the agenda for the health data story.
As Aboriginal people, WE are vested in the outcomes. WE are accountable to each other, our families and communities. These research studies represent OUR families, OUR loved ones, OUR LOST ones.
I believe the character and foresight of Aboriginal leadership will show the right path.
Should you need convincing, I can think of no better example in environmental health than Yami Lester and the Nganampa Health Council in the APY lands.
Decades ago, these leaders knew that health improvement required medical services AND a healthy living environment. In 1986, they initiated a collaborative project between local Anangu people and technical experts to ‘stop people getting sick’. Some of you may recognise this as the UKP project.
These Aboriginal leaders engaged Paul Pholeros and Dr Paul Torzillo to work together to develop a codified schedule for home assessments and repairs. When assessments were finished, simple repairs to health hardware that could be fixed, WERE fixed. Immediately, over 75% of these assessment and repair teams were local Aboriginal and Torres Strait Islander people trained and assisted by skilled managers and team leaders.
Any requirements for major repairs that were the responsibility of the landlord were submitted, logged and monitored. As this program expanded, data from different locations showed that the reasons for poor housing conditions were shoddy building materials in the first place (22%); inadequate maintenance schedules by the landlord (70%) and less than 8% was due to damage by occupants.
As relevant today, Yami Lester and his Council knew the importance of sharing with their people knowledge about disease transmission and supporting households to adopt new habits to sustain health in circumstances none of us would find easy.
And they succeeded.
Their legacy is the framework of nine Healthy Living Practices about washing, clothes, wastewater, nutrition, crowding, animals, dust, temperature and safety against injury.
Today, housing audits and home hardware assessments conceived by Aboriginal leaders in this UKP project MUST be permanently funded everywhere and combined with culturally responsive support directed by communities to re-build THEIR knowledge about disease transmission.
Every home is different. Every environmental risk assessment is unique. In one, there might be an issue with food-borne diseases. In another, passive smoking that affects the children’s ears, lungs and eyes. In another, it could be …
– a blocked toilet,
– a shower dislodged from a poorly laid wet floor, or
– a washing machine that has collapsed under the pressure from multiple loads and hard water every single day.
Resources enable Aboriginal environmental health workers and families to work together over time to build the household’s confidence and knowledge. The shared goal is self-management in healthy habits ….. AND an assertiveness as tenants to report poor quality building materials, housing problems and urgent repairs to the respective housing landlord.
Effective Aboriginal environmental health programs must be in Aboriginal hands. Community controlled organisations must drive the necessary knowledge exchange between those who hold technical expertise and those who have been denied it. The very nature of this work means that Aboriginal communities must retain the reins – and retain the knowledge.
What Yami Lester envisaged is our unrealized obligation.
Housing programmes will have limited impact UNLESS they are controlled in their design and delivery by Aboriginal organisations with sustained visibility, authority and relationships in the community. Communities have ideas on how to manage overcrowding, maintain housing stock and build new housing through local entrepreneurship. It is time once again for Aboriginal leaders to be heard.
You may know about extensive consultations conducted across the country in 2017 known as “My Life My Lead”.
The purpose of these consultations was to provide an opportunity to shape the next update of the Implementation Plan for the National Aboriginal and Torres Strait Islander Health Plan released originally in 2013.
At these consultations, Aboriginal people spoke up about the fundamental significance of social, economic and environmental determinants affecting their health and wellbeing.
Environmental health was identified as one of seven top priorities for the next Implementation Plan.
Addressing the underlying environmental health conditions that contribute to poor health outcomes in many Aboriginal and Torres Strait islander communities will lead to long-term improved health, education and employment outcomes.
This is why I hope my message to you today is clear. We will get better health by improving housing and environmental health programs. Regaining control over decisions about housing will also lead to better health. Returning authority for decision-making to communities about resources and program design reinvigorates empowerment, autonomy and more equitable power arrangements. Self-determination promotes health.
With a decent investment in Aboriginal housing alongside genuine shifts in who makes decisions about resource allocation, I am prepared to guarantee to you today that the impact on Aboriginal health outcomes will be large, positive and permanent.
If those estimates of the costs from hospital admissions hold true nationally, I am also prepared to guarantee a significant reduction in healthcare budgets.
Our Prime Minister is inclined to miracles … so I think this would be the next miracle he’d very much like to see!
If we believe in public health and preventing the preventable …
If we believe in equity and social justice …
If we believe in community control …
… then we have everything we need to turn this around.
To governments I say let Aboriginal leaders sit down with you and – together in partnership – analyse the current state of environmental health and housing in your jurisdictions.
Let’s establish the level of investment that will reduce the cost of hospitalisations of Aboriginal children, adults and elders due to poor housing and living conditions.
Let’s develop national standards for a safe house. Let’s agree to strict criteria for urgent and priority housing repairs. Let’s audit repair performance. Let’s publish the data.
Let’s get more accountability from public housing for proactive home maintenance schedules and repairs.
Let’s invest in environmental and building programs that will cut the demand in primary health care clinics by a quarter and let these busy staff focus on other priorities.
Let’s grow knowledge in our communities as experts in healthy living.
Let’s train, credential and employ young Aboriginal people as environmental health workers, plumbers, electricians and carpenters to keep houses safe, healthy and ready for climate change ahead.
Let’s ensure a sustainable on-the-ground workforce for effective environmental health employed by Aboriginal organisations.
Here at this conference, let’s create the cross-sectoral approach involving communities, environmental health, primary health care and governments IN PARTNERSHIP to get this moving.
In closing, I’d like to quote Senator Patrick Dodson, a Yawuru man from Broome who, in February this year, asked a very important question:
“Who actually closes the gap?”
He answered this by saying:
“It’s the people working at the grassroots, led by First Nations peoples, with a deep understanding and lived experience of the needs of their communities.”
It is in that spirit that I thank each and every Aboriginal Environmental Health Practitioner at this conference whether it is your 1st or your 12th.
I know you work hard. I know you care deeply about your communities. I know you lead by example.
I respect your hard-earned skills and your expertise to provide a huge scope of professional services ranging from dog control to vector management.
I admire your precise and up-to-date knowledge of disease transmission routes, hazardous chemicals, sanitation and practical engineering.
I am sincerely impressed by the care you take to work with families whose circumstances are complex … and that you find THEIR strengths and work with their capacities.
You respect cultural protocols. You deliver with few resources, a lot of ingenuity and teamwork.
It is enabling YOU to do an even better job for YOUR communities that motivates me to do mine. And I will keep on working just as hard as you do.
It’s been a pleasure sharing my reflections with you all.
Thank you for this opportunity to kick off the second day of your 12th NATSIEH conference here in Perth.