Health outcomes for Indigenous Australians are often likened to those experienced in the developing world.1 The underlying determinants of these poor health outcomes are similar and reflect a complex interaction of poverty, gender disparities, low educational attainment, limited employment opportunities, overcrowded and unsatisfactory housing, racism and social, cultural and political disempowerment.2 Despite a widespread understanding that these ‘social determinants’ of health reflect structural disadvantage at the community, national and even global levels,3 advocacy and interventions in both the international and Indigenous health arenas have tended to focus on easily measurable targets that are amenable to change at the individual level.4 The global Millennium Development Goals (MDGs) and the Australian ‘Close the Gap’ initiative are two examples.
The MDGs were adopted by the international community in 2000 as aspirational targets for development to be achieved by 2015 (see Table 1). Over the past decade, they have shaped the international development agenda with advocacy, funding and in-country policy making increasingly focused on high-impact short-term strategies to achieve these goals by the ‘deadline’.5 The result has been acceptable progress towards those goals responsive to vertical programmes targeted at individuals, such as child survival, communicable disease control and primary school enrolment, while goals such as gender quality, maternal and reproductive health, and environmental sustainability, which depend on strengthening government systems and community-level empowerment, have lagged behind.6
|1. Eradicate extreme hunger and poverty|
|a. Halve, between 1990 and 2015, the proportion of people whose income is less than $1 a day|
|b. Achieve full and productive employment and decent work for all, including women and young people|
|c. Halve, between 1990 and 2015, the proportion of people who suffer from hunger|
|2. Achieve universal primary education|
|a. Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling|
|3. Promote gender equality and empower women|
|a. Eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015|
|4. Reduce child mortality|
|a. Reduce, by two thirds, between 1990 and 2015, the under-five mortality rate|
|5. Improve maternal health|
|a. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio|
|b. Achieve universal access to reproductive health|
|6. Combat HIV/AIDS, malaria and other diseases|
|a. Have halted by 2015 and begun to reverse the spread of HIV/AIDS|
|b. Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it|
|c. Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases|
|7. Ensure environmental sustainability|
|a. Integrate the principles of sustainable development into country policies and programmes, and reverse the loss of environmental resources|
|b. Reduce biodiversity loss, achieving, by 2010, a significant reduction in the rate of loss|
|c. Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation|
|d. Have achieved by 2020 a significant improvement in the lives of at least 100 million slum dwellers|
|8. Develop a global partnership for development|
|a. Address the special needs of least developed countries, landlocked countries and small island developing states|
|b. Develop further an open, rule-based, predictable, non-discriminatory trading and financial system|
|c. Deal comprehensively with developing countries' debt|
|d. In co-operation with pharmaceutical companies, provide access to affordable essential drugs in developing countries|
|e. In co-operation with the private sector, make available benefits of new technologies, especially information and communication|
A similar phenomenon is evident in Australia's response to Indigenous health through ‘Close the Gap’.7 Like the MDGs, the social determinants of health are expressly mentioned and the subject of targets for investment (see Table 2).8 However, also like the MDGs, ‘success’ is defined in terms of individuals with no scope to measure the impact of interventions aimed at altering the structural determinants of Indigenous disadvantage such as disempowerment, social exclusion and racism.3 As has occurred in the international arena, this will potentially create incentives to reach for the ‘low hanging fruit’ in order to achieve targets rather than engage in comprehensive community development.
|Six measureable indicators|
|1. Close the life expectancy gap within a generation|
|2. Halve the gap in mortality rates for Indigenous children under five within a decade|
|3. Ensure access to early childhood education for all Indigenous 4-year-olds in remote communities within 5 years|
|4. Halve the gap in reading, writing and numeracy achievements for children within a decade|
|5. Half the gap for Indigenous students in year 12 attainment or equivalent attainment rates by 2020|
|6. Halve the gap in employment outcomes between Indigenous and non-Indigenous Australians within a decade|
|Seven ‘building blocks’ for each indicator|
|1. Early childhood|
|4. Economic participation|
|5. Healthy homes|
|6. Safe communities|
|7. Governance and leadership|
For those of us who have worked in both Indigenous and international health, these conclusions are both self-evident and frustrating. Below, we detail our own journeys in international and Indigenous health to illustrate how we have learned that ‘success’, whether in clinical medicine or public health, in urban or remote Indigenous or international settings, depends as much on empowering communities by engaging them in the development of their own solutions as it does on delivering services to improve individual outcomes.
Even as a small child I was intrigued by travel and by difference, traits that were carefully cultivated by my parents. It surprised nobody when, after turning from a career in law, I entered medical school declaring that I wanted to work in international health.
It wasn't so much the clinical aspects of medicine in resource poor settings that attracted me. Rather, it was the opportunity, the privilege, to get to know and try to understand the perspectives of people who think and experience life differently to myself.
My first encounters with health in developing countries were in Africa – a medical elective in a township hospital in South Africa followed by a stint in Malawi. Working in hospitals where tuberculosis (TB) was the top differential diagnosis for virtually every presentation, and seeing first-hand the mismatch between our strict DOTS programs and patient needs, I finally understood the impact of poverty, gender, stigma, and culture on health-seeking behaviour. I was shocked to find that communities were powerless to demand health services that met their needs, circumstances, and preferences. Given the high likelihood and consequences of treatment default, persisting with our ‘evidence-based’ programs without ever involving communities in their design or implementation appeared to me to be futile.
I decided on a career in public health and more lessons were to follow. Later, while involved in the development of guidelines for reproductive and maternal health, I saw again the inter-relationship between community and health. I realised that adolescent girls did not only fall pregnant because they were poor, but that too-early pregnancies limited their educational attainment and employment opportunities, reinforced their dependence on their husbands and families and, in turn, contributed to both their poverty and that of their community.
The difference this time was that I was not working in international health but in remote Indigenous Australia. Yet the required approach was the same. To be effective, strategies needed to be developed with adolescents, but also with their families and their communities.
I had first encountered Indigenous health as a medical student when I visited a scabies program in Wadeye, a remote Indigenous community in the Northern Territory. The trip was memorable for my shock at the living conditions in the community. Basic needs like housing, water and sanitation were not met for many inhabitants, violence and substance misuse were rife, and access to health services poor. I had no idea that people in Australia lived like that. I remember thinking that comparisons with parts of Africa were not far fetched.
I later spent nearly five years in the Northern Territory working in TB control and women's health. Many people and experiences stay with me and I now apply the lessons I learned to my current work in international health in Asia and the Pacific. In both contexts, time and time again our attention may be drawn by the plight of an individual but inevitably it must end with the engagement and involvement of the community.
My most important lesson is that illness in these settings is more than individual pathology; it is a reflection of socio-economic circumstances and structural disadvantage.
As a first year medical student I attended a lecture given by a doctor recently returned from Africa. Long bearded and shabbily dressed, he seemed deeply affected by what he had experienced; it didn't inspire me to pursue a career in international health. Similarly Indigenous health seemed ‘too hard’, and there appeared little scope for a junior trainee to make a valuable contribution.
Somewhere between my first and fifth years of medical school my impression of international health changed and I completed my elective in the border region of East Timor. I too was deeply affected. One child we treated for pneumonia died soon after discharge from hospital, his family starving as their crops failed. I realised that treating bacterial infection was relatively simple compared to the other causes of poor health.
In Maliana I met (the late) Vonnie Brown, an Australian teacher volunteering in neighboring Lolotoe. Together we set up the East Timor Education Fund, an organisation supporting people living in the most remote and disadvantaged parts of East Timor to access education and training within their own country. The profound impact that education can make has impressed me greatly.
For most of my Paediatric training I have ‘counted the days’ until I could leave Australia. I have travelled to East Timor on several occasions. In 2007 I worked as a Paediatric registrar in Solomon Islands. I was tempted on several occasions not to return to Australia, good advice eventually bringing me home to sit the Paediatric exams. I entered 2009 with study notes and plans to work overseas as soon as the exam was complete; An email advertising a new training position at the Victorian Aboriginal Health Service (VAHS) was welcome distraction from study. There had previously seemed little opportunity to work in Indigenous Health without travelling to Central Australia (let alone 10 minutes from my home).
I have worked at VAHS now for almost a year, the highlight of my career to date. Health problems seen at VAHS are largely a reflection of poor access; health problems of Aboriginal children living in remote settings (such as rheumatic fever or suppurative otitis media) are uncommon. Housing is a terribly neglected area, and there is unfortunately a lot of child protection. This year has inspired me to continue working in Indigenous health. It is challenging but immensely interesting, rewarding and important work.
Cultural security is essential in delivering health care.9 In both Solomon Islands and East Timor, Australia is largely recognised as a country supporting peace and freedom, and Australians as wealthy and powerful. Providing good clinical care in this context can be challenging. In Australia it is within recent living memory that Indigenous children were removed from hospitals by white Australians like me.
I have come to learn the importance of working with a community and taking the time to listen, be trusted and accepted. In East Timor I worked with an external NGO in a newly independent country finding its feet. There was little consultation with local community and health services were supported by a number of temporary clinics run by NGOs and peace keeping forces. In Solomon Islands I worked within a Ministry of Health staffed by well trained local staff who were committed to improving the health of their country, supported by external technical assistance. At VAHS, I have worked within a community controlled health organisation that ‘listens to and cares for its community’.
Perhaps the greatest lesson I have learned is summarised by an Indigenous colleague: ‘not all Aborigines are dark skinned and we don't all live in Central Australia’.
Just as working in both international and Indigenous health contexts has taught us so much, so too may each learn from the other. International health has much to gain from an examination of the extensive academic literature on the politics of racism and entrenched structural disadvantage emanating from Indigenous Australia. The history may be different, but the impact on communities of lacking power over their future transcends borders. Similarly, lessons learned from the MDGs have much to teach Australia when formulating strategies to achieve its ‘Close the Gap’ targets. In particular, the impact of the MDGs in shaping the international development agenda and the differential outcomes that have resulted are a useful reminder that while vertical interventions may help prevent Indigenous children dying before their fifth birthdays, we will not really have succeeded in ‘closing the gap’ until their communities and nation can provide the conditions necessary for them to lead healthy, safe and economically productive lives.