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The context of Indigenous health

The context of Indigenous health

Historical context and social determinants of Indigenous health

There is a clear relationship between the social inequalities experienced by Indigenous people and their current health status [1]. This social disadvantage, directly related to dispossession and characterised by poverty and powerlessness, is reflected in measures of education, employment, and income. Before presenting the key indicators of Indigenous health status, it is important, therefore, to provide a brief summary of the context within which these indicators should be considered.

The historical context of Indigenous health

Indigenous peoples generally enjoyed better health in 1788 than most people living in Europe [2][3][4][5][6]. They did not suffer from smallpox, measles, influenza, tuberculosis, scarlet fever, sexually transmitted syphilis and gonorrhoea, diseases that were common in eighteenth-century Europe. Indigenous people probably suffered from hepatitis B, some bacterial infections (including non-venereal syphilis and yaws) and some intestinal parasites. Trauma is likely to have been a major cause of death, and anaemia, arthritis, periodontal disease, and tooth attrition are known to have occurred. The impact of these diseases at a population level was relatively small compared with the effects of the diseases that affected eighteenth century Europe.

All of this changed after 1788 with the arrival of introduced illness, initially smallpox and sexually transmitted infections (gonorrhoea and venereal syphilis), and later tuberculosis, influenza, measles, scarlet fever, and whooping cough [3][4][7][8]. These diseases, particularly smallpox, caused enormous loss of life among Indigenous populations, but the devastation was not restricted to the immediate victims. The epidemic also affected the fabric of Indigenous societies through depopulation and social disruption.

The impact of introduced diseases was almost certainly the major cause of death for Indigenous people, but direct conflict and occupation of Indigenous homelands also contributed substantially to Indigenous mortality [7][9][10]. The initial responses of Indigenous people to the arrival of the First Fleet were apparently quite peaceful, but it didn’t take long before conflict started to occur – initially over access to fish stocks and then as non-Indigenous people started to plant crops and introduce livestock. This pattern of conflict almost certainly occurred as non-Indigenous people spread across the country.

Conflict escalated in many places, in some instances resulting in overt massacres of Indigenous people. The 1838 massacre at Myall Creek (near Inverell, NSW) is probably the most infamous [11], but less well-known massacres occurred across Australia [10]. As Bruce Elder notes, as ‘painful and shameful as they are’, the massacres ‘should be as much a part of Australian history as the First Fleet, the explorers, the gold rushes and the bushrangers’ ([10], p.vi).

Prior to 1788, Indigenous people were able to define their own sense of being through control over all aspects of their lives, including ceremonies, spiritual practices, medicine, social relationships, management of land, law and economic activities [12][13][14]. In addition to the impacts of introduced diseases and conflict, the spread of non-Indigenous peoples undermined the ability of Indigenous people to lead healthy lives by devaluing their culture, destroying their traditional food base, separating families, and dispossessing whole communities [3][4][7]. This loss of autonomy undermined social vitality, which, in turn, affected the capacity to meet challenges, including health challenges. A cycle of dispossession, demoralisation, and poor health was thus established.

These impacts on Indigenous populations eventually forced colonial authorities to try to ‘protect’ remaining Indigenous peoples. This pressure led to the establishment of Aboriginal ‘protection’ boards, the first established in Vic by the Aboriginal Protection Act of 1869 [15]. A similar Act established the NSW Aborigines Protection Board in 1883, with the other colonies also enacting legislation to ‘protect’ Indigenous populations within their boundaries. The ‘protection’ provided under the provisions of the various Acts imposed enormous restrictions on the lives of many Indigenous people. These restrictions meant that, as late as 1961, in eastern Australia ‘nearly one-third of all Australians recorded as being of Aboriginal descent lived in settlements’ ([16], p.4).

The provisions of the Acts were also used to justify the forced separation of Indigenous children from their families ‘by compulsion, duress or undue influence’ ([15], p.2). The National Inquiry into the separation of the children concluded that ‘between one in three and one in ten Indigenous children were forcibly removed from their families and communities in the period from approximately 1910 until 1970’ ([15], p.31). It was the 1960s, at the earliest, when the various ‘protection’ Acts were either repealed or became inoperative.

The importance of contemporary social determinants and cultural concepts of Indigenous health

The health disadvantages experienced by Indigenous people can be considered historical in origin [14], but perpetuation of the disadvantages owes much to contemporary structural and social factors, embodied in what are termed the ‘social determinants’ of health [1][17][18]. In broad terms, economic opportunity, physical infrastructure and social conditions influence the health of individuals, communities, and societies as a whole. These factors are specifically manifest in measures such as education, employment, income, housing, access to services, social networks, connection with land, racism, and incarceration. On all these measures, Indigenous people suffer substantial disadvantage. For many Indigenous people, the ongoing effects of ‘protection’ and the forced separation of children from their families compound other social disadvantages.

It is also important in coming to an understanding of Indigenous health to understand how Indigenous people themselves conceptualise health. There was no separate term in Indigenous languages for health as it is understood in western society [19]. The traditional Indigenous perspective of health is holistic. It encompasses everything important in a person’s life, including land, environment, physical body, community, relationships and law. Health is the social, emotional, and cultural wellbeing of the whole community and the concept is thus linked to the sense of being Indigenous. This conceptualisation of health has much in common with the social determinants model and has crucial implications for the simple application of biomedically-derived concepts as a means of improving Indigenous health. The reductionist, biomedical approach is undoubtedly useful in identifying and reducing disease in individuals, but its limitations in addressing population-wide health disadvantages, such as those experienced by Indigenous people, must be recognised.

Indicators of Indigenous social disadvantage

The key measures in these areas for Indigenous people nationally include:

Education

According to the 2006 Australian census [20]:

• 88% of five-year-old Indigenous children and 95% of five-year-old non-Indigenous children were attending an educational institution
• 2.5% of the Indigenous population had not attended school compared with 0.9% of the non-Indigenous population
• one-third (32%) of Indigenous people reported year 10 as their highest year of school completion; less than one-quarter (22%) had completed year 12, compared with almost one-half (47%) of non-Indigenous people
• one-quarter (25%) of Indigenous people reported having a post-school qualification, compared with almost one-half (47%) of non-Indigenous people
• only 1.7% of Indigenous people reported attending a university, compared with 4.1% of non-Indigenous people.

An ABS school report [21] revealed, in 2010:

• the apparent retention rate for Indigenous students from year 7/8 to year 10 was 96%, from year 7/8 to year 12 it was 47%
• for non-Indigenous students, the apparent retention rate from year 7/8 to year 10 was 101%; and from year 7/8 to year 12 it was 79%.

The 2010 national report on schooling in Australia [22] showed:

• 75% of Indigenous students in year three and 66% in year five were at or above the national minimum standard for reading, compared with 95% and 93% respectively of all Australian students
• 79% of year three Indigenous students and 71% of year five Indigenous students were at or above the national minimum standard for writing, compared with 97% of all year three students and 94% of year five students
• 66% of year three Indigenous students and 71% of year five Indigenous students were at or above the national minimum standard for spelling, compared with 94% of all year three students and 93% of year five students
• 66% of year three Indigenous students and 65% of year five Indigenous students were at or above the national minimum standard for grammar and punctuation, compared with 97% of all year three students and 94% of year five students
• 77% of Indigenous students in year three and 71% in year five were at or above the national minimum standard for numeracy, compared with 96% and 95% respectively of all Australian students.

Employment

According to the 2006 Australian census [20]:

• 46% of Indigenous people aged 15 years or older were employed, 8.5% were unemployed, and 46% were not in the labour force. In comparison, 62% of non-Indigenous people aged 15 years or older were employed, 3.3% were unemployed, and 35% were not in the labour force
• excluding people employed under the Community Development Employment Projects (CDEP) scheme increases the unemployment rate for Indigenous people to approximately 25% – five times the rate of 5% for non-Indigenous people
• the most common occupation classification of employed Indigenous people was ‘labourer’ (24%). The most common occupation classification of employed non-Indigenous people was ‘professional’ (20%).

Income

According to the 2006 Australian census [20]:

• the mean equivalised gross household income for Indigenous persons was $460 per week – approximately 62% of that for non-Indigenous persons ($740)
• 45% of the Indigenous population were in the lowest income quintile (mean equivalised gross household income of less than $315 per week). The non-Indigenous population was almost evenly distributed among the five income quintiles
• the median gross individual income for Indigenous people was $278 per week compared with $473 for non-Indigenous people
• ‘professionals’ were the highest median gross weekly income earners and ‘labourers’ were the lowest, but Indigenous people earned 28% and 16% less respectively than non-Indigenous people in these occupations.

Indigenous population

ABS projections from the 2006 census of the numbers of Aboriginal and Torres Strait Islander people suggest an Indigenous population of 575,552 people at 30 June 2011 [23]. The projected population for NSW is the highest (168,773 Indigenous people), followed by Qld (164,883), WA (77,694), and the NT (69,855) (Table 1). The NT has the highest proportion of Indigenous people among its population (30.3%) and Vic the lowest (0.7%).

The estimated Indigenous population increased by around 58,700 (13%) between 2001 and 2006, with the largest increases documented for WA (18%), the NT (17%) and Qld (16%) [25].

The majority of Indigenous people live in cities and towns, but the Indigenous population is much more widely dispersed across Australia than is the non-Indigenous population [26]. Slightly more than one-half of the Indigenous population lives in areas classified as ‘major cities’ or ‘inner regional’ areas, compared with almost nine-tenths of the non-Indigenous population. (As well as these two classifications of ‘remoteness’ in terms of access to goods and services and opportunities for social interaction, the Australian Standard Geographical Classification (ASGC) has four other categories: ‘outer regional’, ‘remote’, ‘very remote’, and ‘migratory’ [27].) Almost one-quarter of Indigenous people live in areas classified as ‘remote’ or ‘very remote’ in relation to having ‘very little access to goods, services and opportunities for social interaction’ [28]. Only 2% of non-Indigenous people live in ‘remote’ or ‘very remote’ areas.

In terms of specific geographical areas, in 2006 about one-half of all Indigenous people lived in nine of the 37 Indigenous regions (based largely on the former Aboriginal and Torres Strait Islander Commission (ATSIC) regions): Sydney; Brisbane; Coffs Harbour; Perth; Townsville; Cairns; Adelaide; Tasmania; and Wagga Wagga [25].

Detailed information about the composition of the Indigenous population is not available for 2011, but in 2006 around 463,900 (90%) people were Aboriginal, 33,100 (6%) Torres Strait Islander, and 20,200 (4%) people of both Aboriginal and Torres Strait Islander descent [25]. Most Torres Strait Islander people live in Qld, with NSW the only other state with a large number of Torres Strait Islanders.

The Indigenous population is much younger overall than the non-Indigenous population [26]. According to projections from the 2006 Australian census, at June 2011 about 35% Indigenous people were aged less than 15 years, compared with 19% of non-Indigenous people (Figure 1) [23][24]. About 4% of Indigenous people were aged 65 years or over, compared with 14% of non-Indigenous people.

Figure 1 Population pyramid of Indigenous and non-Indigenous populations, 2011

Source: Derived from ABS, 2009 [23], ABS, 2011 [29]

References

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