Indigenous health in Australia

Australia has considerable health disparities between its non-indigenous population and its Aboriginal communities. Victoria Nowak explains the research that aims to narrow the gap

The Menzies School of Health Research is located in Darwin, Australia’s northernmost city, the capital of the Northern Territory. It is the only independent medical research institute in Australia with a primary focus on Aboriginal health.¹ The health status of indigenous Australians is recognised as being among the poorest in the country.¹ Aboriginal mortality in the 20 to 40 year old age group is up to 10 times that for other Australians, and life expectancy is 10 to 20 years lower.²

The importance of healthy skin
One of the programmes currently run by the Menzies School of Health Research is called “Healthy Skin” and the main aim is to reduce the prevalence of scabies and skin sores among people living in remote Aboriginal communities. Until recently, skin diseases in Aboriginal communities have been overlooked because of other health priorities. When it was discovered that the prevalence of scabies in preschool children could be as high as 70%,³ however, there was widespread agreement locally that something had to be done.

The scabies mite burrows under the skin and breeds, causing itching and eventually open skin lesions. These sores often become infected with group A streptococcus—a group of bacteria that thrive in the tropical environment of the Northern Territory and cause a range of diseases including rheumatic fever and glomerulonephritis (major heart and kidney diseases, respectively).⁴

The Healthy Skin Program team is endeavouring to reduce scabies and skin sores by taking a regional approach to tackling the problem. Instead of treating one Aboriginal community at a time, the plan is to provide treatment to five communities simultaneously. The reason for this is that Aboriginal communities are highly mobile and families may visit relatives for months at a time, thus facilitating the spread of infectious diseases.

Field trips to the bush
The Healthy Skin team make regular field trips to visit the five remote Aboriginal communities in Eastern Arnhem land who are participating in the programme. A special permit is required to enter Aboriginal-owned land but the Menzies School of Health Research has endeavoured to recruit indigenous staff wherever possible and this does not pose a problem. The team has tried to involve Aboriginal people at all stages of the programme to ensure compliance. It is particularly important that community leaders such as the council and schoolteachers are behind the programme as they will be instrumental in encouraging people to take part in public health measures.

There is antipathy towards interventions by white people and much suspicion about the motives of people who come in from outside the community to bring about change.

Learning about and respecting cultural differences is of paramount importance for non-indigenous health workers. Differences include conversational styles, for example, maintaining eye contact is considered confrontational rather than polite,⁵ and Aboriginal people like to reach a consensus before making decisions, for which extra time must be allowed.

There is antipathy towards interventions by white people and much suspicion about the motives of people who come in from outside
 

Social problems and their effects on health
Unemployment
Many problems stem from the lack of employment opportunities. Although work is available at the school and health centre, there is not enough for a whole community. Schemes run by the Community Development Employment Program, such as those for rubbish collection, provide jobs for a few individuals but there are considerable problems with retaining people for more than one week, as they may have been unused to work for some time, and they are influenced by their unemployed peers (non-indigenous health worker at Mathakal Homelands Resource Centre Inc, Northern Territory, personal communication). Unemployment has also been associated with a number of mental health problems, notably stress,⁶ which is extremely high in Aboriginal communities.⁷ This is manifested by a high prevalence of mental health problems (suicide is common) and hypertension in communities.⁸

Accommodation, logistics, and infrastructure
The accommodation is quite inadequate to meet the needs of the community. In the community of Galiwin’ku, it is considered normal for a three bedroom, one floor house to house 20 people, and the number may reach 30. The water supply and sewerage facilities have been identified as areas of concern. Because of poor hygiene, diarrhoea, gastroenteritis, eye disease, and respiratory infections are commonplace.

The infrastructure in and around Aboriginal communities is extremely limited owing to their remoteness and poor road networks, which are invariably flooded in the wet season so that air travel is the only option. Supplies, including food, are brought in by barge where possible but it is simply too expensive to charter a barge more than once or twice a week. This has implications for the availability of fresh fruit and vegetables. Prices are 70% more than in other Australian grocers,⁹ and also the quality tends to be worse. Vitamin and mineral deficiencies such as anaemia are common. One study found that at least 20% of all Aboriginal children living in the “Top End” of Australia (the northernmost part of the country, an area of approximately 400000 km2)¹⁰ were malnourished,¹¹ and thus had an increased susceptibility to infection.

Education
The school at Ramingining community has attendance rates of just 55-60%, which is considered relatively good (head of school at Ramingining, personal communication, 11 Aug 2004). The standard of formal education is low. A review conducted in 1999 found “unequivocal evidence of deteriorating education outcomes and… an overall decline in attendance.”¹² Western-educated teachers fail to adapt their methods to make them culturally appropriate. For example, Aboriginal people use different concepts in learning, such as measuring length in terms of number of gates and measuring width in fish. Time is judged from the sun, but there is no equivalent to a calendar timekeeping, or age in years (in Aboriginal culture, it is where you are born that is important).

Problems with literacy are compounded by the difficulties of learning English as a second (or even third or fourth) language after Yolngu Matha, and maybe Walpri and Tiwi. The Northern Territory Aboriginal interpreter service has registered 104 indigenous languages and dialects. The links between lifestyle—for example, smoking and disease—are poorly understood by the Aboriginal community.⁷ This makes it hard to establish health preventive measures because if a patient doesn’t understand medical advice, he or she is unlikely to comply with treatment or lifestyle changes. Late presentation is also a problem.

Drug misuse
Drug misuse is a feature of many remote Aboriginal communities. Petrol sniffing and excess alcohol consumption are particular areas of concern. In an attempt to combat this, petrol is not allowed into the communities, and cars must run on diesel. The most frequently misused drugs include cannabis and kava, a drink used for ceremonial purposes in the Pacific Islands. Kava was introduced in the hope that it would be a less harmful alternative to alcohol, but when drunk in large quantities, it has a number of adverse effects including neurological manifestations.¹³

 Aboriginal communities are highly mobile and families may visit relatives for months at a time, thus facilitating the spread of infectious diseases

Finding solutions
The inequalities in health between indigenous and non-indigenous Australians are recognised by the government and there are frequent reports in the media giving explicit examples of the disparities in health status. Many health professionals are currently engaged in analysing the factors contributing to poor health in Aboriginal people and Menzies School of Health Research is a major centre for these investigations.

To improve the health of Aboriginal people in the long term, it is necessary to improve living conditions, educate people about what constitutes a healthy lifestyle, and effect changes in the economic situation. In the short to medium term, however, the health interventions by MSHR can make a significant difference to the quality of life of Aboriginal communities.

The author spent three months doing voluntary work on the Healthy Skin Program at Menzies School of Health Research, Darwin
 

Victoria Nowak, third year medical student
Email: Cambridge van23@cam.ac.uk


studentBMJ 2005;13:397 - 440 November ISSN 0966-6494

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