Naming and framing Indigenous health issues
Anne M McMurray
Emeritus Professor, School of Nursing and Midwifery, Griffith University, Gold Coast, QLD; Emeritus Professor, Faculty of Health Sciences, Murdoch University, Perth, WA
Australian Institute for Health and Welfare. (2008). Australia's Health 2008. Canberra: AIHW, Cat. NO. AUS 99.
Bramley, D., Hebert, P., Tuzzio, L., & Chassin, M. (2005). Disparities in Indigenous health: A cross-country comparison between New Zealand and the United States. American Journal of Public Health, 95(5), 844-850.
Commonwealth of Australia. (2007). Department of Family and Community Services. Canberra: National Indigenous Housing Guide.
Cripps, K. (2008). Indigenous family violence: A statistical challenge injury. International Journal of Care of Injured, 39(S5), S25-S35.
Cripps, K., & McGlade, H. (2008). Indigenous family violence and sexual abuse: Considering pathways forward. Journal of Family Studies, 14(2-3), 240-253.
Draper, G., Somerford, P., Pilkington, A., & Thompson, S. (2009). What is the impact of missing Indigenous status on mortality estimates? An assessment using record linkage in Western Australia. Australian and New Zealand Journal of Public Health, 33(4), 325-331.
Hudson, S. (2009). Closing the accountability gap: The first step towards better Indigenous health. Melbourne: Centre for Independent Policy Studies CIS Monograph 105.
McDonald, E., Bailie, R., Grace, J., & Brewster, D. (2009). A case study of physical and social barriers to hygiene and child growth in Australian Aboriginal communities. BMC Public Health, 9, 346. doi: 1186/1471-2458-9-346.
National Rural Health Alliance. (2009). Editorial: the 'climate change debate': Clarion call, media proxy or red herring. Partyline, 37, 2-4.
Pearson, N. (2004, September). The Cape York substance abuse strategy. Brisbane: Griffith University Centre for Governance and Public Policy.
Priest, N., Mackean, T., Waters, E., Davis, E., & Riggs, E. (2009). Indigenous child health research: A critical analysis of Australian studies. Australian and New Zealand Journal of Public Health, 33(1), 55-63.
Puzan, E. (2003). The unbearable whiteness of being (in nursing). Nursing Inquiry, 10(3), 193-200.
Torzillo, P., Pholeros, P., Rainow, S., Barker, G., Sowerbutts, T., Short, T., & Irvine, A. (2008). The state of health hardware in Aboriginal communities in rural and remote Australia. Australian and New Zealand Journal of Public Health, 32(1), 7-11.
Vincent, K., & Eveline, J. (2008). The invisibility of gendered power relations in domestic violence policy. Journal of Family Studies, 14(2-3), 322-333.
World Health Organization. (2008). World Health Report 2008 Primary Health Care, Now More Than Ever. Retrieved July 14, 2009 from http://www.who.int/whr/2008/whr08_en.pdf
Zhao, Y., Connors, C., Wright, J., Guthridge, S., & Bailie, R. (2008). Estimating chronic disease prevalence among the remote Aboriginal population of the Northern Territory using multiple data sources. Australian and New Zealand Journal of Public Health, 32(4), 307-313.
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This issue of Contemporary Nurse provides a powerful forum for Indigenous and non- Indigenous nurses to reflect on nursing's commitment to advancing knowledge of Indigenous health. As a second edition of Advances in Indigenous Health Care (ISBN 978-1-921348-89-1) it is an opportunity to extend the dialogue of the first edition and ensure that we share what has been learned as the impetus for further understanding. My comments on Indigenous health issues are offered here from the standpoint of a non-Indigenous nurse, and my frame of reference is the social justice agenda of primary health care and nursing. At the heart of this agenda is equity. As a society, our failure to create equitable conditions within which Indigenous people can live healthy lives is a tragedy. It is also a source of professional and personal distress to nurses everywhere. The inequities embedded in Indigenous lives live in our collective conscience as moral obligations, and few nurses take this responsibility lightly. The challenges and frustrations of trying to promote equitable conditions for Indigenous people are experienced daily, especially by nurses in rural and remote areas. For others it is a subconscious dilemma, never far from the surface, creating a disquiet that leaves us to ponder how we can transcend the past and move towards a fairer future. The issues that have impeded our work with Indigenous communities are complex, yet they warrant close and ongoing perusal.
One of the major problems in working towards Indigenous health is the way problems are framed. Current government policy rhetoric revolves around closing the gap in health status and life expectancy between Indigenous and non-Indigenous people. This is based on an assumption that there are deliberate health interventions that can equalise health status and life expectancy. Measuring the gap is problematic in itself. In 2008 the gap was declared to be 11 years, a reduction from the previous figure of 17 years. Even the statisticians from the Australian Bureau of Statistics (ABS) acknowledge that this may be an artefact of a radical change in the calculation methods rather than any real reduction (Hudson, 2009). Placing the focus on the 'gap' is as distracting as concentrating on the emissions trading scheme (ETS) in the climate change debate, rather than attending to population policy, the availability and distribution of fresh water, alternative sources of energy and how best to ensure food security (National Rural Health Alliance, 2009). The 'gap' will only shrink when there is a common commitment to inclusive social policies that work towards redistributing resources and opportunities where they are most needed. These include resources for maternal and child health care, safe, affordable and well- maintained housing, education, food and water, safe communities, and preservation of the environment. Concentrating on 'the gap' and dispatching bureaucrats and untargeted bucket funding to various Indigenous communities may make health authorities feel better, but it does not get the resources or opportunities to where they are most needed (Hudson, 2009). Equity of access can only be achieved where people are empowered to identify their needs, make decisions, and attract respect for their capacity to do so.
A more progressive and accountable approach to considering the health challenges faced by Indigenous people is to focus on the source of the disparities. This is also congruent with the principles of primary health care. The WHO's commitment to Indigenous people was re-affirmed in their 2008 report 'Primary health care: Now more than ever', which reminded health service providers that many Indigenous people continue to be disadvantaged by their remoteness and lack of health services, not their Aboriginality (World Health Organization, 2008). In Australia, Indigenous people are over-represented in the incidence of chronic illness, not only because of the difficulties of accessing health services but because of the lack of a healthy start to life and exposure to some communicable diseases prevalent in remote communities (Australian Institute for Health and Welfare, 2008). Many Indigenous adults were low birth weight infants, and therefore have lived their lives with both biological and social disadvantage (Zhao, Connors, & Wright, 2008). Their health as adults is exacerbated by crowding and poorly maintained homes, which prevent some from engaging in the fundamental elements of hygiene that would help prevent infectious diseases (McDonald, Bailie, & Grace, 2009). Families living in these conditions have neither the freedom to protect their living space from the poor hygiene of others, nor appropriate role models to secure even basic healthy living practices.
In Australia, public statements about inadequate housing and overcrowding have created media attention in relation to land rights, and this is important. However, this also frames the problem as an Indigenous problem rather than a health promotion challenge. A multidisciplinary team of researchers from South Australia have attempted to shed a realistic light on the housing problem, compiling a list of basic healthy living practices that are linked to housing safety and the environments within which people are expected to keep their families safe and healthy in remote areas (Torzillo, Pholeros, & Rainow, 2008). The researchers adopted an ecological approach, investigating the 'health hardware' and maintenance processes available in the environment to support healthy living practices. They found that electricity was unsafe. It was impossible to wash a child in a tub or bath. A functioning shower was available in only 35% of houses. Only 6% of houses had adequate facilities to store, prepare and cook meals. Their data dispelled the myth that it is Indigenous people who create damage and 'house failure'. Their recommendations urged regionally planned housing projects with maintenance processes integrated into funding mechanisms. The logical conclusion, supported by other researchers, is that health education and health promotion programmes will not be successful unless they are combined with sustainable infrastructure that will help enable a healthy family environment (Commonwealth of Australia, 2007; McDonald et al., 2009; Torzillo et al., 2008). This important research underlines the need to peel back the layers of environmental factors that support or prevent people's attempts to achieve health and wellbeing, including the life sustaining environments that have been destroyed by dispossession and displacement.
Other issues that need to be reframed include the impression that Indigenous people engage in all kinds of unhealthy behaviours. This is a pervasive and racist view often fuelled by the media. As nurses it is our imperative to be mindful of the evolving body of research and the intellectual debates that will help redress the inaccuracies. For example, the AIHW (2008) notes that Indigenous Australians are less likely to consume alcohol than non- Indigenous Australians. For some who do, like teenagers, they tend towards high risk patterns of drinking. The problem, then, is not an Indigenous problem. It is a problem of alcohol abuse. As Noel Pearson argues, where alcohol abuse occurs, the problem needs to be confronted realistically, not distorted, and treated with intolerance from within the community. Like other risky conditions that have a major impact on families and communities, such as tobacco smoking, poor environmental health and poor nutrition there is a need for social intervention. Pearson's (2004) solution to the problem is to reduce the precipitating factors that provide perverse incentives to abuse alcohol or drugs. These are typical for anyone who abuses substances, and include availability of the substance, permissiveness, the influence of others in the immediate environment, and spare time to engage in the behaviour with no consequences. He suggests that a community- determined, community-managed strategy would be a better focus to help put hope into people's hearts, and improve governance in their communities. This involves rebuilding tolerance, controlling the supply, managing money and time, instituting treatment and rehabilitation programmes, and fixing up homes and the community to restore social and cultural capital (Pearson, 2004). It also involves making the family and community viable, as places where young people can develop their capacity and personal self-esteem, and importantly, their Indigenous identity.
This type of approach also applies to other issues that compromise inequitable health conditions. Violence against women and children is one that also attracts disproportionate media attention, situating the problem as one of Indigenous culture. This is damaging not only as a racist approach, but in inappropriate health planning. It is also a failure to acknowledge that interventions have quietly been taking place in communities confronting sexual violence (Cripps & McGlade, 2008). This is unhelpful in that it fails to inspire by linking successes in one community with the potential for success in another. It also represents the wider problem of researching in Indigenous communities, where inadequate data linkage and poor dissemination of findings does not reflect the reality of people's lives or provide the basis for comparison of findings or consistent development of the knowledge base (Cripps, 2008; Draper, Somerfield, & Pilkington, 2009; Priest, Mackean, & Waters, 2009). Research linking birth weight to smoking illustrates: when maternal smoking and Indigenous status are disentangled and shown as separate risk factors, the difference between non-Indigenous and Indigenous low birth weight infants disappears (Hudson, 2009). Yet, aggregated health data consistently report low birth weight as an Indigenous problem. Framing this problem accurately, identifying violence against women as a gender issue, linking communicable diseases with the appalling state of housing of remote living Indigenous people is the only way appropriate solutions are going to be developed (Hudson, 2009; McDonald et al., 2009; Vincent & Eveline, 2008). Masking these serious health issues as Indigenous problems will simply maintain the status quo.
As nurses, we understand the need for culturally safe health care. Our mandate begins with self-awareness, reflecting on our own culture in relation to that of others. This approach is nurtured in nursing curricula, and is expected to be reinforced as an ongoing expectation of the professional role. Maintaining cultural safety helps connect practice with an inclusive, culturally competent caring approach that does not ignore, override, discount, reject or violate the integrity of any group of people (Puzan, 2003). It involves consideration of the notions of 'other' and 'whiteness'; what it is like to feel different, how those residing at the margins of society must experience their world (Puzan, 2003). In a socially just environment, health services would be adequate and social conditions promote equity. Policies and practices support dignity and inclusiveness, and recognise the negative effects of racism and discrimination on health (Bramley, Hebert, & Tuzzio, 2005). Where this does not occur, we have an obligation to lend our voices to help achieve social change by developing innovative models of care, culturally safe practices, advocacy for all members of disadvantaged Indigenous society, and research that captures the continuity of Indigenous people's lives and the factors that will help sustain their health over time and across generations.