Australian Indigenous

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Housing and health in indigenous communities in the USA, Canada and Australia: the significance of economic empowerment.

Moran, M. (2000).
Aboriginal Environments Research Centre, University of Queensland

Abstract
Objectives: There were two objectives to the study: (1) to explore the extent that environmental health living conditions explain the improved health status of indigenous populations in the USA and Canada in comparison with Indigenous Australians; (2) to examine the technical and administrative systems that deliver and maintain housing and infrastructure in the USA and Canada and to identify opportunities for better practice in Australia.

Methods: Review of national statistics, field observations and semi-structured interviews in USA, Canada and Australia.

Results: Available statistics and field visits suggest that the standard of housing and infrastructure is comparable between all three countries. Examination of national statistics reveal that key socioeconomic factors, including employment, education, and home ownership, are substantially higher for the Indigenous populations of the USA and Canada, in comparison with Indigenous Australians. Several opportunities for better practice are identified, a central theme to which is a higher level of self governance, ownership and economic status.

Conclusion: It is beyond doubt that improvements in environmental health in Indigenous communities in Australia are required urgently, but it is important to view these technical interventions in the light of a larger picture of community wellbeing. An examination of the health status of the Indigenous populations suggests the significance of socioeconomic status and self-governance. These findings lead to the conclusion that the health status of Indigenous Australians may improve if there is a shift in attitudes, policy and programs away from implied assumptions of dependence, towards greater economic empowerment.

Introduction
There is a significant problem with Indigenous heath in Australia, both in comparison with non-Indigenous Australians, and with other indigenous populations in the USA and Canada, as evident in Figure 1 below.

Within Australia, there is a particularly large discrepancy in life expectancy between Indigenous and non-Indigenous people; life expectancy at birth for Indigenous people is between 15 to 20 years less than that of non-Indigenous people. The overall death rate for Indigenous people is twice that of other Australians. For Indigenous people aged 25-44 years, the rate is five times as great.¹ In Queensland, 40-44 year old Indigenous people have 10-12 times the death rate of non-Indigenous people of the same age group. There has been little improvement in the death rates of adults over the past fifteen years and, in Queensland, the gap in death rates between Indigenous and non-Indigenous adults has actually widened over this period.²

The life expectancy of Indigenous people in Australia is also much lower than that of indigenous populations of North America (about 10 to 15 years). Differences in health between Indigenous and non-Indigenous Australians can be explained to a large extent by the relative social, political and economic disadvantage endured by Aboriginal and Torres Strait Islander people. Reasons for the differences in health between Indigenous Australians and Indigenous populations in similarly developed countries are less obvious.

Life expectancy at birth, Indigenous and non-Indigenous people^3-6

The poor health status of Indigenous Australians is the subject of much debate and government intervention. Many factors are involved, but it is well accepted that poor environmental living conditions are significant.

This paper examines two issues.

1. Given the improved health status of the Indigenous populations in the USA and Canada, it might be expected that the standard of environmental health and related technology is correspondingly higher than that found in Australia. To what extent does this explain the difference in health status between Indigenous populations of the USA, Canada and Australia?



2. On examination of the technical and administrative systems that deliver and maintain housing and infrastructure, are there opportunities for 'better practice' from which Australia might learn?

Method
This paper represents the results of a study which was conducted over the first six months of 1997, including travel to the states of Arizona, New Mexico, and Washington in the USA, and to the city of Ottawa, the province of Alberta and the North West Territory in Canada. Three methods were adopted for the study.

1. Informal interviews were held with households of rural and remote communities. Meetings were held with government agencies and Indigenous regional/tribal organisations.
   
   
2. Statistical data were examined from various national censuses undertaken in the early 1990s (USA 1990; Canada 1990; Australia 1991). More recent census figures have been released for both Australia and Canada, but the USA only does a census once every ten years.
   
   
3. A literature review was undertaken on all relevant literature, including that related to the social and economic determinants to health.

Results
Comparative socioeconomic conditions

Table 1 shows selected socioeconomic data for the Indigenous populations of the USA, Canada and Australia. There are difficulties in comparing populations the size of the respective Indigenous peoples of Australia, USA and Canada. In consideration of these limitations, it has been necessary to seek out substantial disparities and trends which differ by one order of magnitude or more.

If one considers that comparisons are frequently made between the Indigenous and non-Indigenous populations of Australia, these limitations are not so great. Whatever international differences may exist between respective Indigenous populations, there are many similarities. Each is a minority population in its own land, and each has endured a history of dispossession of land, loss of culture, and forced separation of families. A large percentage of these populations also live in rural and remote areas.

Noting these limitations, it is evident from the data in Table 1 that the socioeconomic conditions of Indigenous people in Australia are lower than those of indigenous people in Canada and, especially, the USA. This applies in particular to education and employment.

Education levels are considerably lower in Australia. Indigenous Australians are more than three times less likely to finish year 10 schooling than their counterparts in the USA, and about half as likely as those in Canada. There are about half as many Indigenous people in Australia who have graduated from high school, and/or hold some post-school qualification. The level of unemployment in Australia is more than twice that of the USA. If CDEP (Commonwealth Development Employment Program) participants in Australia are excluded, the difference is threefold. The level of home ownership by Indigenous people is about 2.5 times less in Australia than in the USA.

Despite the differences in levels of unemployment, the income of Indigenous people in Australia is comparable with Native Americans. This may be due in part to more generous welfare transfers in Australia, and a higher minimum wage. To undertake an accurate comparison, it would be necessary to consider income relative to respective costs of living. On the face of it, the costs of living and taxation in Australia are higher (tribal members on reservations in the USA are also tax exempt). Many communities are much more remote in Australia than the USA, which also increases costs.

Table 1: Selected socioeconomic data of Indigenous populations^7-11

Notes:

1. USA data have been separated according to reservation-living status, to allow better comparisons with Canadian and Australian statistics. About 56% of population live in urban areas in the USA, compared with 35% in Canada and 26% in Australia.
2. Canadian figures for age and per capita income are actually mean, not median.
3. Includes those with post school and vocational training qualifications. Figures for USA are for the population aged 25 years or older; for Canada and Australia they are for the population aged 15 years of older.
4. For population older than 16 years in the US, and 14 years in Canada and Australia. The unemployment rate for Indigenous Australians is about 45% if CDEP (Commonwealth Development Employment Project) participants are excluded.

Comparative standards of environmental health

Table 2 shows key housing and infrastructure statistics for the Indigenous populations of the USA, Canada and Australia. Different criteria have been applied to define overcrowding, but all three countries have problems with high levels of overcrowded dwellings (by national standards). The higher average occupancy suggests that overcrowding is worst in Australia.

Data on the condition of housing stock is very subjective, but it would appear that all three countries have serious problems. Interesting, Australia has a comparatively higher coverage of running water and sewerage systems.

These statistics on the quality of housing and infrastructure suggest that the standard of housing and infrastructure are comparable between countries, and especially between Canada and Australia. Overcrowding may be worse in Australia, but the coverage of water supply and sewerage systems is better. This was supported by field inspections conducted in the course of the fellowship. The standard of environmental health in the USA and Canada was not noticeably different to Australia, which was contrary to expectations.

Table 2: Comparative housing and infrastructure statistics of Indigenous populations^{7, 10, 12-16}

Better practice
A detailed examination was undertaken of the bureaucratic and technical systems that deliver housing and infrastructure-related technology in the USA and Canada. Several opportunities for better Australian practice were identified.

Responsibility for Indigenous affairs in the USA and Canada is better structured and more efficient than in Australia, due largely to an essentially two-tiered system of Federal and Tribal governments. In the USA, and to a lesser extent Canada, Tribes have established a degree of sovereignty due to treaty rights, which afford them similar relationships with the Federal Government as those enjoyed by the States/Provinces. The Federal governments are therefore the lead agency for Indigenous affairs, and there is generally minimal involvement from the States/Provinces.

Indigenous communities and Tribes in the USA and Canada are generally larger than in Australia. In the north of Canada, the situation is closer to remote Australia, but Tribal organisations extend over very wide areas of land. In addition to the obvious social and cultural advantages, Tribal groupings provide a form of regionalism with inherent political strength, economy of scale, and structural efficiency.

Housing delivery in the USA and Canada is generally better structured than in Australia, especially with respect to recurrent funding. The US Department of Housing and Urban Development (HUD) spends about 14% of its combined capital budget for recurrent funding and operational expenses of Indian Housing Authorities. In Australia, the equivalent figure is only 3%. This higher level of recurrent funding permits housing organisations in the USA to undertake maintenance regardless of rental arrears. This contrasts markedly with the difficult position of many housing organisations in Australia, who are forced by economics to delay maintenance on houses until rent arrears are paid.

The level of home ownership among Indigenous people in the USA is three times higher than in Australia. Housing authorities employ counsellors to assist new home owners with the transition from rental units. Innovative solutions have been found to improve affordability of housing, and to permit home ownership over communal tenure.

There are several housing construction programs which rally local resources, including contributions through labour and materials. People are able to contribute towards the cost of their new homes through a principle called 'sweat equity'. Several successful self-build housing programs have been implemented. These provide standard house designs, building material kits, and on-site supervision and training. Value-adding to housing and infrastructure construction programs is also common, especially through employment, training and commercial enterprises. In the USA, there is a government purchasing policy which favours Indigenous-owned and operated commercial enterprises.

Greater attention is taken to the quality of housing construction through two layers of housing inspections (Tribal and Federal Government), including the placement of qualified supervisors on community self-built housing projects and more appropriate building standards. User-pays cost recovery is more widespread, especially for utilities, with careful consideration taken to affordability and 'safety nets'. There are also Indigenous technical professionals' associations, which represent Indigenous engineers, architects and other technical professionals, and promote tertiary education for Indigenous students.

A full account of these areas of better practice are given in an expanded version of this report.¹⁷ A common aspect that weaves through each of these better practice opportunities is a higher level of Indigenous governance, ownership and empowerment, at individual, community, regional and national levels.

Discussion
In Canada, Indigenous people are seeking a change in the understanding of their health, to a holistic notion of 'wellness', which has been defined by the Royal Commission on Aboriginal People in five ways: (a) health comes from the interconnectedness of human systems, body, mind, emotion, spirit, not their separate dynamics; (b) economic factors (especially personal and community poverty and employment) play a central role in determining health; (c) personal responsibility for health and wellness is as important as professional and external expertise; (d) the health of the environment affects the health of the people; and (e) health and wellbeing in childhood affects lifelong health status. This is similar to holistic definitions of health promoted by Indigenous people in Australia, but it is important to note the significance placed on economic factors.

In their review of the biomedical, social science and urban planning literature, Lindheim and Syme listed three new risk factors for poor health.¹⁸ These are (a) lack of meaningful social relationships and the interruption of supportive ties between individuals, (b) low hierarchical positions including low self esteem, lack of control over one's life and the absence of meaningful participation; and (c) disconnection from biological and cultural heritage. These authors refer to North American (or Western) society in general, but it is apparent that Indigenous people suffer inordinately from these three conditions.

Some aspects of these broader underpinnings of health fit within the mainstream notion of socioeconomic status. This is useful because it ties in with medical and social science literature and statistical census data. It is important to note, however, that the precise mechanisms of how social factors influence health in Indigenous communities remains to be elucidated. Apart from the gross social indicators, such as family income, employment, education and housing conditions, little is known about more refined measures of social relationships among Native Americans.¹⁹

The relationship between socioeconomic status and health is well established in the international development literature. The World Bank has estimated that, across countries, more than 75% of the inequalities in health are associated with income differentials.²⁰ In speaking of developing countries, Caldwell and Caldwell reported the great majority of research shows that child mortality falls with increased education among both parents, but that mother's education has the greatest influence.²¹ Despite a lack of studies in Australia, Tsey argues convincingly on the significance of education to the self determination and health of Indigenous Australians.²²

A comparison of the socioeconomic conditions of the Indigenous population of Australia with that of North America, shows employment to be half that found in the USA, and as low as one third if CDEP employment is excluded. Three times as many Indigenous people in Australia than the USA have either not attended school or have not finished year 10. The percentage of Indigenous university graduates in Australia is one-eighth that in the USA. The level of home ownership is less than one-third. Clearly, socioeconomic conditions, and especially the levels of employment and education, are much lower for Indigenous people in Australia than the USA. It would seem sensible that this is an important factor in the different health outcomes observed.

This view is supported by the higher level of self governance and economic independence which Tribes enjoy in the USA and Canada. This is related to opportunities provided by the direct relationship between Tribes and the Federal governments due to the existence of treaties.^3,23 There is also a more structured bureaucratic system with more authority delegated to Tribal governments. These institutional and structural factors give communities the power and opportunities to realise self determination, which may also contribute to their improved health status.

In comparing the USA and Australia, commentators have argued correctly that health care policy and the existence of a comprehensive Indigenous health service are significant explanations for disparities in health between the two Indigenous groups.^23,24Others have argued correctly that the Indian Health Service is more effective in health care delivery because of its greater efficiency, specialisation, professionalism and comprehensiveness.²⁵ Despite the validity of these arguments, the unfortunate, even if unintended, impression was created that somehow the development of well resourced and effective health services would result automatically in improved health. This overlooks important socioeconomic differences between the various Indigenous populations.²²

It is beyond doubt that improvements in technology and environmental health in Indigenous Australia are urgently required. This paper has described several opportunities for 'better practice' in Australia which can be learnt from USA and Canada.¹⁷ It is important, however, to view these technical interventions in the light of the bigger picture of community wellness. Adequate housing, water supply, sanitation and other environmental health technology are necessary, but not sufficient, conditions for health. The Northern Health Research Unit in Canada commented that 'even when the physical aspects of housing such as broken windows, cracked walls, faulty furnaces, leaky roofs, strewn garbage, inadequate water supply and absent indoor plumbing on Indian reserves have been completely remedied - no mean task in itself - there will remain substantial ill health'.²⁶

In response to government policy initiatives to promote self determination, different government departments in Australia have learned to 'value-add' to their core service area. Housing and infrastructure departments are focusing more on environmental health, more culturally appropriate design, integrating more training and employment into construction programs, and addressing ongoing management and maintenance. Health authorities have broadened their core activities, including health promotion programs, health worker training, and community-controlled health services. Progress has been made, but there is nonetheless a limit to how far government institutions can 'bend' beyond their core areas of expertise. Regardless of their best efforts, it is important that these institutions acknowledge that there is much to Indigenous health and self determination which is beyond their control.

The two objectives of the study have both led to the same conclusion. A central theme for the identified 'better practice' opportunities for technology is a higher level of self governance, ownership and empowerment. An examination of the differences in health status between respective Indigenous populations has suggested the significance of socioeconomic conditions. Both of these findings suggest that there should be a shift in existing attitudes, policy and programs in Australia away from implied assumptions of dependence, towards greater community control and economic empowerment. This applies not only to the rhetoric and 'value-adding' of existing programs, but also to the intricacies of household life and the encouragement, opportunities and power that permit day-to-day choices. The experience of Indigenous people in North America suggests that such a shift should contribute to the improved health of Indigenous Australians.

Acknowledgements
This study was conducted with financial assistance from the James Love Churchill Fellowship and the Centre for Appropriate Technology. A special thanks to the many people throughout the USA and Canada who opened their doors and assisted me as they could. Without their efforts and the many hours of interviews and discussion, the fellowship could not have taken the direction that it did.

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Last updated: 12 February, 2002