Case study of a decolonising Aboriginal community controlled comprehensive primary health care response to alcohol‐related harm

Objective: This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches.

B oth Aboriginal and Torres Strait Islander peoples' use of alcohol and policy responses to address it are linked to Australia's history of colonisation. 1 While Brady has documented precolonisation Aboriginal and Torres Strait Islander use of fermented, intoxicating drinks including those made from pandanus plants, banksia cones, and coconut tree buds, 2 European settlers brought with them the practice of heavy drinking 2 and used alcohol as wages and to control and trade with Aboriginal and Torres Strait Islander people. 3 When heavy drinking by Aboriginal and Torres Strait Islander people began to produce visible harms, the Europeans prohibited the supply of alcohol to Aboriginal and Torres Strait Islander people. 2 Langton 4 recounts how the Europeans constructed the colonial stereotype of the "drunken Aborigine", and prohibited alcohol to Aboriginal and Torres Strait Islander people out of fear, exempting those who did not live in camps and mixed with "good" company. 2 This prohibition was repealed between 1957 and 1972 in different states and territories. 2 While, among Aboriginal and Torres Strait Islander people who drink, a higher proportion drink at risky levels than non-Indigenous people 5,6 and disproportionately suffer from alcohol-related harms including violence, hospitalisations and death, 6,7 the context around this disparity is vitally important. 8 Colonisation is a root cause, or underpinning social determinant of health for Indigenous peoples, providing the social and political context that drives inequities in the intermediate and proximal determinants of health such as education, health and other systems, employment, housing, interpersonal and institutional racism, discrimination and alcohol use. [9][10][11] There is a large shortfall in alcohol treatment services for Aboriginal and Torres Strait Islander people, 12 and extensive unmet needs for wider social and emotional wellbeing services. 13 Alcohol-related harms among Aboriginal people are particularly prevalent in the Northern Territory (NT), where the alcoholattributable death rates are considerably higher than the national average. 14 Policy responses, particularly the Northern Territory Emergency Response (NTER, 2007(NTER, -2008, have often continued the same logic and power relations of colonisation, problematising Aboriginal and Torres Strait Islander communities. 15  a key NTER target, which included racial place-based alcohol restrictions, compulsory income management, increased policing and temporary acquisition of Aboriginal townships. 16 Aboriginal Community Controlled Health Services (ACCHSs) have been established across Australia, often as a result of local, grassroots movements by Aboriginal and Torres Strait Islander peoples in response to poor access and discrimination in mainstream health care. 17 Today, 150 ACCHSs serve onethird to one-half of the Aboriginal and Torres Strait Islander population. 18 ACCHSs are an expression of self-determination that aim to improve health and wellbeing and mitigate the processes of ongoing colonisation. 19 This is not to suggest a dichotomy between community controlled services versus government services, but to acknowledge that ongoing colonisation is a critical part of the context within which all efforts to improve Aboriginal and Torres Strait Islander health take place. 11 This paper seeks to investigate the extent to which a community controlled model of comprehensive primary health care has the potential to contest and provide an alternative to ongoing colonisation using alcohol as an example.
ACCHSs are a world-leading model of Primary Health Care 4 -pre-dating but embodying the Alma Ata Declaration's 20 vision of comprehensive primary health care. Key to the Alma Ata vision is that primary health care (PHC) ought to not only engage in treatment of diseases and rehabilitation, but also prevent diseases and promote health. 20 How this comprehensive PHC approach can be specifically applied to alcohol is illustrated in Table 1.
While ACCHSs often demonstrate these four pillars of PHC in action, we acknowledge that this Alma Ata terminology is Western and does not necessarily capture Aboriginal and Torres Strait Islander concepts of health and healing. This paper investigates the potential of an ACCHS approach to address alcohol-related harm among Aboriginal and Torres Strait Islander peoples in a way that encourages self-determination rather than ongoing colonisation. It focuses on an example of one ACCHS's actions on alcoholrelated harm, Central Australian Aboriginal Congress Aboriginal Corporation (Congress), in a regional town in the Northern Territory (Alice Springs).
Two research questions guided the study: 1. How does the health service implement a community controlled comprehensive primary health care response to alcoholrelated harm?
2. How does this comprehensive approach challenge the logic and processes of ongoing colonisation in responses to Aboriginal and Torres Strait Islander alcohol-related harm?

Methods
Data were drawn from a larger study on comprehensive PHC that partnered with five South Australian services and Congress. 4,[21][22][23] The six PHC services were selected to maximise diversity and because they had existing relationships with the research team that would make participation in a five-year research project (2009-2014) feasible. The research used participatory action methods 24 where participating services were partners in the research. Its aim was to understand how the principles of comprehensive PHC were implemented on the ground by these services. The South Australian services did not have a comprehensive approach to alcohol, but Congress' activity stood out as a well-resourced, comprehensive response to alcohol-related harm in the community it serves.
Data on Congress' response to alcohol-related harm were drawn from a) six-monthly service reports of activities; b) interviews with staff; c) interviews with partners in the People's Alcohol Action Coalition; and d) community assessment workshops with service users: a) Service reports. From 2009 to 2013, service data were collected from the services in a biannual audit that provided details of budgets, types of services offered, organisational documents and staff numbers. b) Congress staff interviews. There were two rounds of staff interviews, one in 2009-2010, including 14 interviews with Congress staff and board members 25 and one in 2013-2014, including 15 interviews with Congress staff and board members. 22 The first round explored implementation of comprehensive PHC principles at the service, while the second round focused on how this had changed in the intervening four years.
c) People's Alcohol Action Coalition. We interviewed two Congress staff, three staff from partner organisations and one community member who were all active in the alcohol action coalition. 26 We also collected reports and media releases from the coalition.

d) Community assessment workshops.
Workshops were held at each service with community members, 27 including three workshops at Congress with a total of 13 community members, including some who had attended Congress' alcohol treatment program. Community members were asked to rate services' achievement of nine different comprehensive PHC service qualities and provide reasons for those ratings.
All interviews and workshops were audio recorded. Transcripts were imported into NVivo for analysis. A priori codes based on comprehensive PHC elements and context factors including colonisation and racism were developed and applied to the transcripts. Congress' activities related to alcohol were categorised according to the PHC strategies of treatment, rehabilitation, prevention, and promotion based on the service reports and staff interviews and checked with the chief executive officer in a telephone interview.

Rehabilitation
Rehabilitative support for people who have experienced alcohol-related harm, including addiction, injury, illness Treatment Treatment of alcohol-related harm, including addiction, injury, illness Prevention Prevention of alcohol-related harm, e.g. through screening, brief intervention, health education and early childhood programs Health promotion Promotion of health and wellbeing through addressing structures and environmental factors that contribute to alcohol-related harm, including addressing alcohol policies, alcohol availability, housing 30

Results
Congress' history and context is presented, followed by the service's responses to alcoholrelated harm. The extent to which these responses challenge colonial approaches to alcohol-related harm is then considered.

Context
Congress is situated in the remote township of Alice Springs in the Northern Territory with a population of approximately 28,000 people, 19% of whom are Aboriginal. 28 Congress was established in 1973 at a public meeting of Central Australian Aboriginal people and was initially formed as an advocacy organisation for Aboriginal people's rights. In 1975, after lobbying the Minister for Aboriginal Affairs and the Minister for Health, it came to provide a primary health care service that was "comprehensive, not selective", included treatment, prevention, and health promotion, and was controlled by the Aboriginal community. 29

Policy context
Congress is addressing alcohol-related harm in a very challenging policy context. In 2007, the Federal Government instigated the NTER, which included alcohol restrictions ("nearblanket ban on possession and consumption of alcohol on all Aboriginal land" 30(p462 ), increased policing, compulsory acquisition of some townships, suspension of the Racial Discrimination Act and a range of other interventionist measures. 31 Importantly, nothing was done to reduce the supply of take-away alcohol; instead there was a punitive, place-based approach to the location where drinking could take place. Northern Territory Government approaches to alcohol are heavily politicised and are affected by vested interests relating to the tourist economy. The Australian Hotels Association is the single biggest funder of both major political parties 30 and, in response to the advocacy on supply reduction, industry-sponsored groups emerged to protect the profits resulting from alcohol. Australian Government policies continue to focus on public drunkenness, rather than health and wellbeing, 30 reminiscent of Langton's account of the fears of the "drunken Aborigine". 3 A range of punitive policies have been enacted in the NT, some with roots in the legacy of the NTER, 30 including the Alcohol Mandatory Treatment Act, which allows people to be held for up to four days without legal representation, the Alcohol Protection Orders Act, which allows for increased custodial sentences for individuals where alcohol is felt to be a factor in the crime, and Temporary Beat Locations, where police stand outside take-away alcohol outlets and can question patrons, ask for identification and confiscate alcohol. 30 An evaluation of the Alcohol Mandatory Treatment initiative found that it lacked a program logic and failed to impact on health, re-apprehension into custody or homelessness. 32 The Temporary Beat Locations dramatically reduced the supply of alcohol, showing effectiveness in spite of their discriminatory nature. 33

Congress responses to alcohol-related harm
Congress has addressed alcohol-related harm since its inception, with methods that include addressing social determinants of alcoholrelated harm and providing treatment services and strategies to minimise alcoholrelated harm. Often these strategies have been driven by the Aboriginal community, not just the health professionals employed at Congress. Past examples include a night shelter and pick-up service to reduce the number of Aboriginal people being charged for public drunkenness, set up in 1975, 29 and an alcohol rehabilitation centre established in the 1980s. In 1990, Congress collaborated with other Aboriginal organisations to produce a comprehensive plan to address alcohol use, including supply reduction measures to reduce take-away trading hours, reduce outlets and remove cheap alcohol from the market, and approaches to rehabilitation, including the establishment of an alcohol programs unit. 34 Implementing this plan, Congress purchased an alcohol outlet in 1991, let the $150,000 license lapse, 35 "ceremoniously poured all the grog down the drain" (Practitioner interview), and converted it to a health service site. More recently, Congress set up an alcohol treatment program including intensive case management, with a medical/ pharmacotherapy stream, psychological therapy stream, and a social and cultural support stream that addresses positive social and cultural determinants of health. 35 Table 2 presents the broad range of treatment, rehabilitation, prevention and health promotion activities Congress undertook to address alcohol-related harms at the time of this study.
As well as the medical, clinical and alcohol services, the One advocacy strategy was the People's Alcohol Action Coalition (PAAC), a community group formed in 1995 from a public meeting organised by the late, influential Arrernte leader, Charlie Perkins. 37 Congress is a leading partner in PAAC, along with other services, church groups, trade unions and Aboriginal organisations, with staff members active participants in the group. The coalition advocates for evidence-based alcohol supply measures, such as a minimum floor price and other sales restrictions.
The staff we spoke to overwhelmingly endorsed this comprehensive approach -"this idea of balancing the here and now with longer-term action to change the social determinants of health" (Practitioner interview). Even if staff did not participate in each aspect of the comprehensive approach, they saw how they fitted in with the larger picture: We [treatment staff] are just one part of the wheel, a spoke in the wheel, but there needs to be a multi-pronged approach. Some of

Indigenous Health Community controlled primary health care response to alcohol the stuff [staff member] is doing with PAAC and that. … None is greater than the other. -Practitioner interview
Staff saw community participation in planning and service delivery as core business. The community board was seen as vital to self-determination and fully endorsed a comprehensive approach. The community control was reported to be vibrant and one community board member was reported as being able to debate with "our mob, our professionals and specialists" on approaches to alcohol-related harm. As well as the board, Congress engaged in community forums and men's forums, and had a cultural advisory council for Alukura and an active complaints process. This community participation allowed a communal approach, where the board "themselves are a part of the community and they are in a position to change it within" (Practitioner interview). This communal approach was seen as critical to the success of alcohol services and other programs: This quote shows the two-way relationship between the control Aboriginal and Torres Strait Islander peoples are able to exert over their lives and their collective selfdetermination. As a result, a practitioner reported a belief that community members were "not powerless here". Empowerment was strongly evident in the community assessment workshops, where participants made comments such as "we as people in this community know, that if we have an issue with Congress, I think we feel like we could go and tell them", and that staff were "supportive" and "good at explaining". The aim of increasing power and control includes the community participation described above, Congress' goals concerning Aboriginal leadership, its aim of creating culturally safe spaces and its employment of Aboriginal Interviewees noted that Congress' ability to advocate was in part due to being outside of government. While PAAC originally received a grant from the NT Government, "as we became more effective, the money dried up completely and we have never had a government grant since" (Practitioner interview).
PAAC was successful in lobbying a previous NT Government to introduce the Alice Springs Liquor Supply Plan in 2006 and supported the Banned Drinkers Register, which was then overturned by the next NT Government. The subsequent NT Government installed the Temporary Beat Locations policy, which was viewed as more discriminatory towards Aboriginal people (whereas the register covered everyone). The Banned Drinkers Register was associated with reducing alcohol-related presentations to the Alice Springs hospital. 33 As well as government, Congress and PAAC also found the need to advocate to and against private companies, particularly alcohol outlets. PAAC has had some success with many supermarkets agreeing to a minimum alcohol floor price at around $1 per standard drink. A key success was the agreement by the current NT Government to undertake the Alcohol Policies and Legislative review, 41 which has seen the Government agree to implement all but one recommendation, representing far-reaching alcohol policy reforms. This has included the successful implementation of a Territory-wide alcohol floor price of $1.30 per standard drink. 42

Discussion
This case study illustrates how a comprehensive PHC service can provide care and rehabilitation for alcohol-related harm and can reduce alcohol-related harm through individual prevention activities and addressing the social determinants of alcoholrelated harm. This case provides an example of the full continuum of strategies in the Alma Ata Declaration for comprehensive PHC and concords with other literature indicating that ACCHSs are at the forefront of comprehensive PHC practice. 43 This is also supported by findings that when health services have been transferred to Aboriginal community control, more culturally respectful services and more focus on population health has followed. 44,45 The ACCHS approach is also more in line with the United Nations Declaration on the Rights of Indigenous Peoples, which emphasises Indigenous peoples' rights to "participate in decision-making", "maintain and develop their own [I]ndigenous decision-making institutions", "traditional medicines and to maintain their health practices", and have "access, without any discrimination, to all social and health services". 46 The findings highlight how community control can challenge colonialism, racism and power imbalances through incorporating Aboriginal and Torres Strait Islander knowledges, promoting cultural relevance and safety, empowering people to have more control in their lives, and encouraging Aboriginal and Torres Strait Islander-led advocacy. In so doing, community control promotes evidence-based policy and practice that supports self-determination. It also provides a somewhat protected space that enables political advocacy in ways that are difficult or impossible for government employees to undertake. 21,47 This is especially important for alcohol, where ongoing colonisation and racism and support for industry frames so much of the public discussion and policy making. Increasing people's control over their own lives is fundamental to reducing health inequities so they have the power to challenge these social determinants. 40,48 The need to end the logic of paternalistic control evident in policies such as Stronger Futures, 49 and to instead increase self-determination, community and individual control, is clear in the writing of many Aboriginal and Torres Strait Islander researchers 11,50 and statements such as the Uluru Statement from the Heart 51 and the Redfern Statement. 52 Data have been seen as an instrument of colonialism but control over data can instead make a tool of self-determination. 53 Congress uses data and evidence in all aspects of its work, and community control means that community views can be brought together with professional knowledge and evidence to inform appropriate policy. All of these factors together are critical for effective public health advocacy, and community controlled health services create a unique environment to support this.
Only one ACCHS was included in this research. There are 150 ACCHSs around Australia that are tailored to their local communities. Further studies would yield additional approaches to address alcoholrelated harm, and insights into how these solutions challenge colonialist approaches. Whatever research is conducted in the future should be designed to contribute to decolonisation. This will require incorporation of Indigenous knowledge to inform the epistemology and methods underpinning the research. Examples are that the research could incorporate yarning with people affected by alcohol-related harm and consideration of the extent to which alcohol policies are culturally safe. 54 The research focused on understanding local implementations of the principles of comprehensive PHC and did not seek to measure health outcomes. One study evaluated the alcohol program at Congress 35 and found 79% of clients stopped drinking or reduced their consumption, although 70% of the control group also stopped drinking or reduced their consumption, clouding the evidence for the program. In addition, PAAC have collaborated with research partners to provide data on reductions in alcohol consumption and harms in the community following increases in alcohol pricing, and after the introduction of the Banned Drinkers Register. 33 An evaluation of the alcohol supply measures undertaken in Alice Springs that PAAC advocated for found they were effective in reducing per capita consumption and rates of assaults and hospital admission for alcoholattributable conditions. 55

Conclusion
This case study of a comprehensive, Aboriginal Community Controlled Health Service's evidence-based responses to alcohol-related harm highlighted its strengths. In particular, the service employed a range of actions across the comprehensive spectrum of rehabilitation, treatment, disease prevention, and health promotion. ACCHSs have practiced such comprehensive PHC approaches since before the Alma Ata Declaration, because that was the approach deemed suitable by the community grass roots movements that formed the first ACCHSs. 29 This pioneering of a comprehensive PHC approach further highlights the value of community control to develop locally responsive and appropriate solutions, and to address local determinants of health through advocacy.