|
|
Health profiles for indigenous people across Australia in parallel with those of the Northern Rivers |
INTRODUCTION
In essence, the struggle of Koori culture to survive throughout history is a mirror reflection of the picture of its health: from the perfectly balanced portrait of its adaptation to the Australian landscape where life and death were an accepted product of the ‘survival of the fittest’ doctrine of the hunter-gatherer lifestyle, to the chaotic canvas of its forced assimilation and overt opposition, which has resulted in a higher burden of illness and death for every type of disease at every comparable stage of life.
In this highly industrialised developed country where old and new public health initiatives, from hygiene standards to preventative screening, have seen a gradual overall decline in death rates, infant mortality rates and other infectious and non-infectious morbidity markers, it is notable that indigenous health remains at a fourth world standard. That is, the deplorable conundrum of third world-associated health problems, eg. higher infant mortality rates, higher maternal mortality rates, lower average life expectancy and an increased prevalence of malnutrition and a variety of infectious diseases, in combination with higher rates of western lifestyle problems, eg. diabetes, heart disease, cancer, chronic respiratory disease, drug and alcohol abuse and mental ill health.
“The health status of Aboriginal and Torres Strait Islander people continues to be much worse than that of other Australians. In some cases, it appears that the gap may be widening, especially for women.” (1)
Although a majority of the research has been performed in the ‘desert’ states of NT, WA and SA, recently improved census data and an increase in interest in the south-eastern states show that these health problems are geographically independent and require our attention at a local level. Thus, I will also be presenting comparative figures for the Northern Rivers area of NSW (NRA).
HISTORICAL CONTEXT
Pre-contact Aboriginal health was determined by the surrounding environment and the existence of a complex social support network. Their intimate knowledge of the ecology enabled them to harvest and hunt the high protein, high fibre, high complex carbohydrate and low fat ‘bush tucker’ diet we all now aspire to in the western world. (2)
Being semi-nomadic, their lifestyle was active and the well developed kinship system ensured their psychological integrity and family support. According to similar palaeolithic cultures, 40-60% of deaths occurred in children < 5 years of age, which related to low adult morbidity rates in association with isolation from the western culture.
With the advent of European colonisation, which resulted in a dramatic change of environment as its ecology was displaced by stock farming, nomadic groups gradually adopted a more sedentary lifestyle, often settling on the outskirts of European settlements in order to have the desirable products distributed by the Europeans. Of the more undesirable products distributed were a variety of infectious diseases such as smallpox, measles, whooping cough, influenza, typhoid, tuberculosis, leprosy and of course, STDs, which had a devastating effect on the non-immune population.
Violent conflicts resulting in about 20,000 deaths in the SE states alone by the 1920s, and the forced assimilation and child displacement programs of the Aboriginal Protection Council between 1909 and 1969, predictably contributed to the cultural and social disintegration of Aboriginal communities. “With the loss of their land and its heritage and dependency on social security benefits based on a model which is inappropriate to their culture had a disastrous effect on family and social life”. (3)
Efforts to target public health issues of the combination and association of infectious diseases with nutritional and environmental factors, eg. immunisation programs, provision of water and housing and rural access schemes in the 1960s-1980s, have had an effect with lower infant mortality and death rates overall, but when compared with non-indigenous Australians, the long-term disadvantages for this 1.6% of the population is obvious (1.1% in NSW but 1.8% in the Northern Rivers area).
Significant health problems still exist as will be shown, and public health targets are yet to influence the Koori community where poor self-esteem, lack of education, poor employment opportunities, associated drug, alcohol and violence issues and lack of access to health services, both in physical distance and cultural insensitivity, prevent any further improvement in health statistics.
STATISTICAL SUMMARY
Life expectancy
The average life expectancy of an Australian male is ~75 years of age and for a female is ~81 years of age, both of which have gradually risen over time. In 1992-94 the life expectancy of indigenous men and women in Australia were 15-20 years lower: 57-61 years and 61-65 years respectively.
Death rates
From 1988 to 1994 the crude death rates did drop by ~10% among all Australians. Crude annual death rates for NSW: males ~800/100,000 and females ~693/100,000. Age standardised rates were much the same with similar numbers seen in the Northern Rivers area.
Over this time crude death rates for Aboriginal men remained steady and actually increased for Aboriginal women, which translates as a 3.5-4% increased risk of death overall. Age standardised rates show an increased risk of 5-7% in most age groups but in the age group of 25-34, death rates are 6-8 times higher.
Causes of death
For Australia, NSW and the Northern Rivers area, the most common causes of death (reflected by morbidity profiles) were due to circulatory disease, cancer, respiratory disease, endocrine and metabolic disease, eg. diabetes and injury and poisoning in the younger age groups.
Similarly, three quarters of Koori deaths are due to these illnesses. Expectantly, these disease specific death rates occur at rates higher than among other Australians, eg. diabetes related deaths in 1992-94 were 12 times higher for men and nearly 17 times higher for women for proportion of population, eg. 6.9% vs 2.3% for men and 8.1% vs 2.4% for women in the NRA.
Unlike diabetes, where there is a comparable increased incidence in the Aboriginal community, cancer incidence rates are much the same across the
Australian population, but indigenous people who get cancer are more likely to die from it. (4) Deaths from infectious diseases and genitourinary disorders are decreasing in rate but again occur at much higher rates than for other Australians.
Infant and maternal mortality
Aboriginal women make up about 2.8% of all confinements but account for ~30% of pregnancy related death, with a rate of 90/1000,000, “a rate higher than that of many developing countries, including most of Asia”. (5) This means Aboriginal women are ~8 times more likely to die around pregnancy and childbirth than non-Aboriginal women in Australia.
Associated figures in the NRA show this discrepancy: 2.7% versus 0.03% over the 1988-92 time period.
This appalling state of ill-health is directly translated to their babies, where infant mortality rates continue to be 3-5 times higher than those of babies born to non-indigenous mothers, regardless of an overall drop of 47.5/1000,000 in 1981 to 34.0/1000,000 in 1994. This of course differs in different communities but as a whole Australian IMRs ~7/1000 compared to Aboriginal IMRs of 10-16/1000 in urban communities and 20-30/1000 in rural communities.
Morbidity
As identification of Aboriginality continues to be a problem in most statewide assessments of both morbidity and mortality, morbidity is made even more difficult to assess by lack of differentiation, as well as decreased rates of presentation for medical treatment, so hospital admission rates are likely to be substantial underestimates of the problem.
In general, indigenous people are ~2-3 times more likely to be hospitalised than would be expected on rates for other Australians, eg. in NSW and SA alone, hospital separation rates in 1991-92 were 60% higher for men and 50% higher for women, where the differences were largest among infants and older people >50 years.
Respiratory disease, injury, pregnancy and childbirth are the most common causes of admission (accounting for 4/10 hospital admissions for indigenous females alone), and as seen with mortality figures, circulatory diseases, diabetes and gastrointestinal/ genitourinary tract problems also contribute significantly to morbidity. NRA figures support this trend.
“Aboriginal and Torres Strait Islander people also suffer higher rates of infectious diseases, including TB and STDs. There were 4-5 times more hospitalisations and 15-18 times more deaths from infectious diseases than expected, based on rates for all Australia.”(4) Again this is likely to vary from state to state and once again the figures need to be interpreted with caution, as most have not even been age standardised. It is notable that rates for infectious diseases in the Koori community of NRA have been persistently more elevated when compared to both the non-Aboriginal population in the area and the whole indigenous population of Australia: 8.6% versus 6.1% in males and 7.03% versus 4.5% in females. HIV prevalence rates have been observed to be similar across the whole Australian population in 1992-94, but incidence rates among indigenous people are rising while the incidence rate for Australia falls.
Expectantly, risk factors for the chronic degenerative diseases of the western lifestyle are rife among the Koori community:
Obesity: 60% of males and 57% of females
Smoking: 52-56% of males and 41-52% of females.
Alcohol: a smaller proportion of indigenous people drink alcohol than their non-indigenous countrymen, but those who do drink are more likely to drink at harmful levels. Again this proportion varies widely across communities but the Northern Rivers estimate is ~20-30%.
Illicit drugs: about 24% of the indigenous population are current users of an illicit drug, compared to 15% of the general population. This was most commonly marijuana and users more likely male.
Mental health including depression, self and family harm, and substance abuse, is proving to be an increasingly prevalent manifestation of individual and society dysfunction, although there are several difficulties in obtaining data, such as variable definitions for diagnosis, non identification of Aboriginality and lack of access, especially in rural communities.
This trend is also being seen in the general community but the rates of hospital separations remain higher in the indigenous community. For example, in the NRA admissions for mental illnesses were ~4.25% versus ~2.85% with a more evident difference in males. “In 1992-93 there were about three times more public hospital separations than expected for mental disorders among indigenous people in WA, SA, NT and Queensland combined.” (6)
ACCESS TO HEALTH SERVICES
As a whole, indigenous people are more likely to live outside urban areas than non-indigenous people and are thus at a marked disadvantage for accessing appropriate health care. Availability of transport, as well as frequency of health professional visits, limits the likelihood of an indigenous person using available services. Perceptions about health and the quality of certain services, eg. availability of indigenous staff, can also be influential. In the ABS survey of 1996, 1 in 7 indigenous people in rural areas did not have a doctor or nurse available within 25 km of their community on either a permanent or visiting basis, 1 in 5 did not have an Aboriginal health worker assigned to their care and 3 out of 5 were reported to have no dental service.
CHILD AND MATERNAL HEALTH
Cultural taboos sometimes make reproductive health difficult to assess in a patriarchal, institutionalised health service, and indigenous women avoiding contact with mainstream medical care is, not surprisingly, common and makes statistical evaluation difficult. For example, NT data show ~ 50% of indigenous mothers had a medical condition complicating their pregnancy compared to 17% of non-indigenous mothers. (4) How can we say that this is not confounded by presentation rates as well as health standards? Thus in vague terms it could be said that indigenous mothers were more likely to be teenagers and tend not to have their partners with them at births as often reported in the NRA.
It has also been demonstrated that Aboriginal babies have a pre-term (<37 wks) rate of 7-22% again varying across states and methods of assessing gestation, thus reflecting the difficulty in comparing the non-Aboriginal rate of ~5-6%.
What has been well documented is that “babies born to Aboriginal and Torres Strait mothers are, on average ~200 gms lighter at birth than babies born to other Australian women and twice as likely to be classified as low birth weight (<2,500 gms), a state which carries a higher risk of poor perinatal outcome.” (7) In one study (8) 27% of babies with an Aboriginal ancestor were below the 10th centile of birth weight for gestational age, compared with 14.2% of babies with anon-Aboriginal ancestor.
DISCUSSION AND SUMMARY
As Sir William Deane, the Governor General said in his speech to health practitioners in NT in 1996, “It is sometimes said that statistics lie. They do not lie when they identify the extent of those health problems. Nor can those statistics be discounted as bare figures without human content. They tell the story of present human sickness, suffering, dying and death which can be traced to the past dispossession, oppression and injustice.” (9)
The information presented here about illnesses and conditions is clearly limited but it is an attempt to quantify the extent of the burden of disease suffered by the indigenous people of this country. In a holistic sense, health is the capacity of the individual, the group and the environment to interact with one another in ways that promote subjective well-being and optimal achievement of individual and collective goals. The National Aboriginal Health Strategy Working Party (NAHSWP) defined it as “not just the physical well-being of the individual, but the social, emotional and cultural well-being of the whole community.” (1989)
It is notable that Aboriginal people have in themselves a whole-of-life view of their health and understand that their psychosocial problems relate in real terms to the state of their physical health. In an increasing number of surveys, Koori perceptions of health show an increased level of knowledge, understanding and concern about various issues. Alcohol and alcohol related violence were ranked as the two most serious health issues, followed by high unemployment and illegal drugs. Given alcohol consumption has been linked with numerous health conditions such as road accidents, depression and suicide, domestic violence, liver disease, obesity and associated trends in smoking, which help contribute to the main causes of mortality, ie. circulatory disease, respiratory disease and cancer, their assessment of the gravity of these issues is perceptive.
In one study (10), classifications of illnesses were translated into the local language from description of underlying causes to groupings around strategic statements on what community members could do to address these causes. These were:
Group 1
Physical Environment - shelter, water, sewerage and pollution problems linked to diaorheal and respiratory diseases, plus common infections of the ear, eye and skin.
"We can look after the land.”
Group 2
Nutrition/Exercise - including dietary changes and lifestyle diseases of ischaemic health disease, hypertension, diabetes and renal disease.
“We can eat good food.”
Group 3
Social/Mental - economic disadvantage, loss of traditional land and unemployment linked to problems with alcohol, petrol sniffing, STDs, violence and mental illness.
“We can look after each other.”
This was named the ‘Land, Body and Spirit’ system of classification and holds the key to cross-cultural communication, inter-sectoral involvement and community self empowerment, all of which are crucial for any change at an individual or statistical level. “Essential health care should be based on practical, scientifically sound, socially and culturally acceptable methods and technology made universally accessible to individuals and families in the communities in which they live through their full participation at every stage of development in the spirit of self-reliance and self determination.” (NAHSWP 1989)
“Poverty and powerlessness create circumstances in people’s lives that predispose them to the highest indexes of social dysfunction, the highest indexes of morbidity and mortality, the lowest access to primary care, and little or no access to primary preventative programs. Poverty of the spirit and of resources remains the antecedent risk factor of preventative disease.” (11). It has been recognised that this sense of powerlessness in the Aboriginal community directly relates to their acceptance of an oppressive culture and that it is imbedded and reinforced by the fabric of our social institutions. We must be careful when developing indigenous community public health programs that we do not attempt to socially engineer the community according to our own priorities but instead, identify indigenous health concerns and modify our targets with cultural awareness and community aims and resources. Thus we can help create a more joyous ‘Koori’ picture of Aboriginal health.
REFERENCES
1. Australia’s Health, 1996:21.
2. McMichael AJ, Planetary Overload (1903):88-95
3. Vimpani G, Parry T, Community Child Health (1989): 27.
4. Australian Bureau of Statistics. Health and Welfare, Aboriginal & Torres Strait Islander People (1997).
5. Aboriginal maternal mortality: Whose problem?, MJA Nov.1993, 159: 571-572.
6. Australian Bureau of Statistics. Health and Welfare, Aboriginal & Torres Strait Islander People (1997): 81
7. Australia’s Health, 1996:22
8. Birth size of Australian Aboriginal babies, MJA Nov.1993, 159: 586-590.
9. Deane, Sir W, Vincent Lingiari Memorial Lecture, Darwin, 22/08/1996
10. Land, Body & Spirit – Talking about adult mortality in an Aboriginal community, Australian Journal of Public Health 1994, 18(2): 197-200
11. Community empowerment as a strategy for health promotion for black and other minority populations, JAMA 1989, 261(2): 282-283
Copyright 1999 Dr Jacqueline Boustany MBBS (Hons), Dip Paeds, MPH.
|
|
|
|
