Indigenous health an unfolding tragedy

Professor Ngiare BrownThe harsh tragedy at the centre of indigenous health in Australia is anchored to shortened life expectancy and a greater predisposition to chronic illness for Aboriginal and Torres Strait Islander people than the general population.

For indigenous men, life expectancy is 11.5 years less than someone of non-indigenous background. Women are barely 1.5 years better off, with indigenous women having 10 years less than their non-indigenous counterparts.

“The figures can vary,” said Professor Ngiare Brown, executive director of research at the National Aboriginal Community Controlled Health Organisation. “That’s because there are ­different methods of calculation. But it’s anywhere between 12 and 15 years and that’s an unacceptable disparity.”

Much of the disparity in life expectancy comes down to chronic disease, much of it preventable, including kidney disease, cardiovascular disease and a rise in some forms of cancer.

For younger Aboriginal and Torres Strait Islander people, there’s also a high preponderance of self harm, ­suicide and injuries.

“With adolescents and young people, it’s hard for them to develop a social identity, so the levels of suicide and substance abuse are very high. Dealing with that in a social and medical context is very hard,” Professor Brown said.

So if much of the difference in life expectancy comes down to preventable disease, why isn’t more being done about it? According to Joshua Creamer, a barrister and president of the Indigenous Lawyer’s Association Queensland, who has been active in indigenous health, much of the problem comes down to a lack of access to services.

Access to services

“There are many factors,” he said. “But it generally comes down to access to healthcare and health services. People are living in remote communities and there simply isn’t the same level of service that there is for people living in larger population centres.”

Professor Brown concurs. “There are real problems associated with access to health services and the prevention of disease and maintenance of good health,” she said.

There are also intergenerational factors at work, Professor Brown noted. “There is the exposure of parents and grandparents and this continues down through the generations,” she said.

“Mental health, social and emotional and cultural wellbeing are also issues,” she continued. “There are the usual pressures of family and community education and employment. Layer that with complexities [in terms of] ­exposure to policies, extermination, identity and cultural responsibility and indigenous health becomes a very hard area to deal with.”

Professor Brown and Mr Creamer were concerned about the effect of the recent budget on Aboriginal and Torres Strait Islander populations.

Professor Brown said a completely free system is becoming unsustainable. “It was meant to be a safety net, but ­people have become accustomed to completely free care,” she said.

Yet on the other hand, she noted, people who can already afford private care will use it in any case. The impact of introducing co-payments and increasing the pension age to 70, will be on ­people and populations that cannot already afford private primary care.

Budget harm

“It’s going to be a mess,” she stated. “The impact will be more on the people who cannot afford it. There needs to be detailed and careful consideration of intended and unintended consequences of fee for services [if the changes] are going to be a success and not hurt people who cannot already afford healthcare.”

In terms of the budget measures, Brown continued, the impact on indigenous people is twofold. “We are the most disadvantaged population in Australia and secondly, we have the highest burden of morbidity and mortality. Our services rely on MBS and medicare rebates to provide affordable services.

“If you reduce Medicare rebate and charge a fee, for people with multiple visits, chronic disease, children with special needs, the families will not be able to afford it.”

On a positive note, Mr Creamer said under the budget funding for Aboriginal Community Controlled Healthcare will continue and that type of healthcare remains a bright spot when it comes to dealing with the healthcare issues of Aboriginal and Torres Strait Islander people.

Professor Brown said she remains an optimist, despite the harrowing life expectancy and disease statistics. “If it was that bad, I would not continue doing what I do. I remain an optimist because community health centres are locally led responses to local priorities. In the end, however, what we need is collaboration, between policymakers and government to address indigenous health in a more integrated manner.”

Joshua Gliddon

Fears Tony Abbott will widen Indigenous health gap


THE deputy chairman of Tony Abbott’s indigenous advisory council, doctor Ngiare Brown, has denounced budget cuts to indigenous affairs and says the $7 GP co-payment will hurt indigenous people and other vulnerable Australians who desperately need help to close the health gap.

Professor Brown will use next week’s meeting of the council to warn that the cuts to indigenous health will inevitably affect frontline services.

She told The Australian she would use her role on the council to push for reconsideration of the co-payment scheme and exemptions for vulnerable Australians and indigenous people based on income and burden of disease.

On overall cuts to the indigenous budget, she said she was determined to get detailed answers on where the cuts would come from and what they would affect.

“There have been anticipated cuts across the board for each portfolio and department,” Professor Brown said. “But what is most concerning is that there is talk about cuts to essential portfolios like health and education but currently there is no clarity on what this means.

“The Coalition claim they want to cut red tape, duplication and the bureaucracy, for example, but I’m concerned there are actually going to be cuts to frontline services, which we were promised would absolutely not be the case”.

On the cuts to preventative programs such as indigenous smoking campaigns, Professor Brown, one of the first group of Aboriginal medical graduates in Australia, said she considered this a frontline service.

“Public health and … prevention are absolutely frontline services, particularly in comprehensive primary care contexts like Aboriginal and Torres Strait Islander health,” she said. “So whether they are specific smoking programs or whether they are brief interventions delivered by our health workers, nurses and general practitioners, public health prevention programs are absolutely frontline services.

“How will departments define what a frontline service is, and then how will they make consistent determinations about what gets funded and what doesn’t.”

Indigenous Affairs Minister Nigel Scullion has vowed that the $239 million being cut from the general indigenous affairs budget will be achieved through “efficiencies” and less red tape and duplication — and not reductions to frontline services.

But with an additional $165m being cut from indigenous health, peak indigenous lobby groups fear that efforts to close the gap are being compromised.

Warren Mundine, chairman of the Prime Minister’s indigenous council, has said the Coalition originally intended to cut the portfolio’s budget by 10 per cent. The eventual 4.5 per cent cut announced in last week’s budget would come from ‘inefficiencies”, not frontline services, he said.

Professor Brown, who was previously the Australian Medical Association’s indigenous health adviser, said she was also concerned that the impact of the GP co-payment on indigenous people and closing the gap had not been taken into consideration.

“I don’t think there has been consideration of any kind for the financial, economic or social impacts or the intended and unintended consequences of co-payments,” she said. “Obviously the most vulnerable are going to be the ones that are hit the hardest: the young, the old and those with chronic diseases in particular. People needing multiple visits over long periods to manage their chronic disease or palliative care or children with special needs or disabilities for example — how are they going to afford multiple consultations at $7 a pop?

“One of my greatest concerns is not only that the most vulnerable will bear the brunt of a poorly conceived co-payment initiative, but that the health care system will not cope.

“The policy makers need to think very carefully about whether to go ahead with the co-payment and if they do, who will pay and who will have exemptions.

“It is already difficult enough for the Aboriginal community-controlled health sector to provide comprehensive care on the limited resources that we have. If you couple charging co-payments, which we may or may not collect, and getting less money in to the sector for public health and clinical care, then that is an extraordinary additional burden bear, particularly when we were promised that there would be no cuts to the frontline in health and education.”