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The context of Indigenous health

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The context of Indigenous health

Historical context and social determinants of Indigenous health

There is a clear relationship between the social disadvantages experienced by Indigenous people and their current health status [1]. These social disadvantages, directly related to dispossession and characterised by poverty and powerlessness, are reflected in measures of education, employment, and income. Before presenting the key indicators of Indigenous health status, it is important 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 17882 than most people living in Europe [2][3][4][5][6]. They did not suffer from smallpox, measles, influenza, tuberculosis, scarlet fever, venereal syphilis and gonorrhoea, diseases that were common in 18th century Europe. Indigenous people probably suffered from hepatitis B, some bacterial infections (including a non-venereal form of 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 18th century Europe.

All of this changed after 1788 with the arrival of introduced illness from non-Indigenous people, initially smallpox and sexually transmissible infections (gonorrhoea and venereal syphilis), and later tuberculosis, influenza, measles, scarlet fever, and whooping cough [3][4][7][8]. These diseases, particularly smallpox, caused considerable loss of life among Indigenous populations, but the impacts were 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 by non-Indigenous people 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. It didn't take long, however, before conflict started to occur - initially over access to fish stocks and then over access to other resources as non-Indigenous people started to plant crops and introduce livestock. This pattern of conflict was almost certainly widespread 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, New South Wales (NSW)) is 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 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 Aboriginal and Torres Strait Islander children from their families 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 have been 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 considering 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 therefore 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 2011 Australian Census [20]:

An ABS school report [21] revealed, in 2013:

The 2013 national report on schooling in Australia [22] showed:

Employment

According to the 2011 Australian Census [20]:

Income

According to the 2011 Australian Census [20]:

Indigenous population

ABS projections from the 2011 Census of the numbers of Aboriginal and Torres Strait Islander people suggest an Indigenous population of 698,583 people at 30 June 2013 [23]. The projection for NSW is the highest (216,612 Indigenous people), followed by Queensland (Qld) (198,206), Western Australia (WA) (91,898), and the NT (71,111) (Table 1). The NT has the highest proportion of Indigenous people among its population (30.5%) and Victoria (Vic) the lowest (0.7%).

Table 1: Estimated Indigenous population, by jurisdiction, Australia, 30 June 2013
JurisdictionIndigenous population (number)Proportion of Australian Indigenous population (%)Proportion of jurisdiction population (%)
Source: ABS, 2014 [23]
Notes:
  1. Australian population includes Jervis Bay Territory, the Cocos (Keeling) Islands, and Christmas Island
  2. Proportions of jurisdiction population have used total population figures estimated from demographic information for June 2013
NSW 216,612 31.0 2.9
Vic 49,715 7.1 0.9
Qld 198,206 28.4 4.3
WA 91,898 13.2 3.6
SA 38,981 5.6 2.3
Tas 25,269 3.6 4.9
ACT 6,517 0.9 1.7
NT 71,111 10.2 29.5
Australia 698,583 100.0 3.0

There was a 21% increase in the number of Indigenous people counted in the 2011 Census compared with the 2006 Census3 [24]. The largest increases were in the Australian Capital Territory (ACT) (34%), Vic (26%), NSW (25%) and Qld (22%) [25]. For all jurisdictions, the 55 years and over age-group showed the largest relative increase (i.e. the Indigenous population is ageing) [24]. There are a number of 'structural' reasons contributing to the growth of the Indigenous population:

Three other factors are considered likely to have contributed to the increase in the Indigenous population in the 2011 Census:

According to the 2011 Census, around 33% of Indigenous people lived in a capital city [26]. Detailed information about the geographic distribution of the Indigenous population for 2011 is not yet available, but figures from the 2006 Census indicated that the majority of Indigenous people lived in cities and towns [27]. Slightly more than one-half of the Indigenous population lived 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' [28].) Over one-quarter of Indigenous people lived in areas classified as 'remote' or 'very remote' in relation to having 'very little access to goods, services and opportunities for social interaction' [27]([29], p.3). Less than 2% of non-Indigenous people lived in 'remote' or 'very remote' areas [27].

In terms of specific geographical areas, more than one-half (53%) of all Indigenous people counted in the 2011 Census lived in nine of the 57 Indigenous regions (based largely on the former Aboriginal and Torres Strait Islander Commission (ATSIC) regions) [26]. The three largest regions were in eastern Australia (Brisbane, NSW Central and the North Coast, and Sydney-Wollongong), which accounted for 29% of the total Indigenous population.

According to the 2011 Census, around 90% of Indigenous people are Aboriginal, 6% are Torres Strait Islanders, and 4% people identified as being of both Aboriginal and Torres Strait Islander descent [26]. Around 63% of Torres Strait Islander people4 lived in Qld; NSW was the only other state with a large number of Torres Strait Islander people.

The Indigenous population is much younger overall than the non-Indigenous population (Figure 1) [30]. According to estimates from the 2011 Census, at 30 June 2011 about 36% Indigenous people were aged less than 15 years, compared with 18% of non-Indigenous people. About 3.4% 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, 30 June 2011

Population pyramid of Indigenous and non-Indigenous populations, 30 June 2011

Source: ABS, 2012 [30]

References

  1. Carson B, Dunbar T, Chenhall RD, Bailie R, eds. (2007) Social determinants of Indigenous health. Crows Nest, NSW: Allen and Unwin
  2. Jackson LR, Ward JE (1999) Aboriginal health: why is reconciliation necessary?. Medical Journal of Australia; 170(9): 437-440
  3. Butlin NG (1993) Economics and the dreamtime : a hypothetical history. Melbourne: Cambridge University Press
  4. Campbell J (2002) Invisible invaders: smallpox and other diseases in Aboriginal Australia 1780-1880. Melbourne: Melbourne University Press
  5. Webb S (2009) Palaeopathology of Aboriginal Australians: health and disease across a hunter-gatherer continent. Cambridge: Cambridge University Press
  6. Anderson W (2007) The colonial medicine of settler states: comparing histories of Indigenous health. Health and History; 9(2): 144-154
  7. Butlin NG (1983) Our original aggression : Aboriginal populations of southeastern Australia, 1788-1850. Sydney: Allen & Unwin
  8. Thomson N (1991) Tuberculosis among Aborigines. In: Proust AJ, ed. History of tuberculosis in Australia, New Zealand and Papua New Guinea. Canberra, ACT: Brolga Press: 61-67
  9. Reynolds H (1982) The other side of the frontier: Aboriginal resistance to the European invasion of Australia. Ringwood, Victoria: Penguin Books
  10. Elder B (2003) Blood on the wattle: massacres and maltreatment of Aboriginal Australians since 1788. 3rd ed. Frenchs Forest, N.S.W: New Holland
  11. Harrison B (1978) The Myall Creek massacre. In: McBryde I, ed. Records of times past : ethnohistorical essays on the culture and ecology of the New England tribes. Canberra: Australian Institute of Aboriginal Studies: 17-51
  12. Howitt R (2001) Rethinking resource management : justice, sustainability and Indigenous peoples. London: Routledge
  13. Hunter E (1993) Aboriginal health and history: power and prejudice in remote Australia. Cambridge: Cambridge University Press
  14. Saggers S, Gray D (1991) Aboriginal health and society: the traditional and contemporary Aboriginal struggle for better health. North Sydney: Allen and Unwin
  15. National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families (1997) Bringing them home: report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Retrieved 17 November 2011 from http://www.humanrights.gov.au/pdf/social_justice/bringing_them_home_report.pdf
  16. Long JPM (1970) Aboriginal settlements: a survey of institutional communities in eastern Australia. Canberra: Australian National University Press
  17. Marmot M (2004) The status syndrome: how social standing affects our health and longevity. New York: Holt Paperbacks
  18. Wilkinson R, Marmot M (2003) Social determinants of health: the solid facts. Denmark: World Health Organization
  19. National Aboriginal Health Strategy Working Party (1989) A national Aboriginal health strategy. Canberra: Department of Aboriginal Affairs
  20. Australian Bureau of Statistics (2012) Census of population and housing: characteristics of Aboriginal and Torres Strait Islander Australians, 2011. Canberra: Australian Bureau of Statistics
  21. Australian Bureau of Statistics (2014) Schools, Australia, 2013. Canberra: Australian Bureau of Statistics
  22. Australian Curriculum Assessment and Reporting Authority (2013) National Assessment Program - Literacy and Numeracy achievement in reading, persuasive writing, language conventions and numeracy: national report for 2013. Sydney: Australian Curriculum Assessment and Reporting Authority
  23. Redfern Aboriginal Medical Service (nd) Womens' business: all about sexually transitted diseases HIV infection and AIDS. Redfern: Aboriginal Medical Services
  24. Biddle N (2013) CAEPR Indigenous population project 2011 census papers: population projections. Canberra: Centre for Aboriginal Economic Policy Research
  25. Yap M, Biddle N (2012) Indigenous fertility and family formation: CAEPR Indigenous population project: 2011 census papers. Canberra: Centre for Aboriginal Economic Policy Research
  26. Australian Bureau of Statistics (2012) Census of population and housing - counts of Aboriginal and Torres Strait Islander Australians, 2011. Canberra: Australian Bureau of Statistics
  27. Australian Bureau of Statistics (2010) Population characteristics, Aboriginal and Torres Strait Islander Australians, 2006 (reissue). Canberra: Australian Bureau of Statistics
  28. Australian Bureau of Statistics (2001) Statistical geography, volume 1: Australian Standard Geographical Classification (ASGC), 2001. Canberra: Australian Bureau of Statistics
  29. Department of Health and Aged Care (2001) Measuring remoteness: Accessibility/Remoteness Index of Australia (ARIA), revised edition. Canberra: Commonwealth Department of Health and Aged Care
  30. Australian Bureau of Statistics (2012) Australian demographic statistics, March quarter 2012. Canberra: Australian Bureau of Statistics

Endnotes

  1. The Australian colony was formally proclaimed 1788.
  2. There is a difference between the Census 'counts' and 'estimates'. The 'estimates' adjust for a number of factors and are more accurate.
  3. Includes people who identified as Torres Strait Islanders and those who identified as being of both Aboriginal and Torres Strait Islander descent.
 
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