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spacing1The 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, 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, 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, however, compared with the effects of the diseases that affected 18th century Europe.

All of this changed after 1788 with the arrival of introduced illness, 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. Smallpox 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. 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, 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],

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]. Along with the other colonies, WA enacted similar legislation in 1886 to 'protect' Indigenous populations within its 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 include:


According to counts from the 2011 Australian Census:

A national ABS school report [22] revealed, in 2012:

The 2012 national report on schooling in Australia [23] found that among WA students:


According to counts from the 2011 Australian Census:


According to the 2011 Australian Census:

Indigenous population

Based on information gathered as part of the 2011 Census of Population and Housing, the ABS has estimated the Aboriginal and Torres Strait Islander population at 88,277, with 43,710 Indigenous males and 44,567 Indigenous females living in WA at 30 June 2011 [24]. The WA Indigenous population represents around 3.8% of the total WA population and 13.2% of the total Australian Indigenous population (estimated to be 669,736 at 30 June 2011).

There was a 21% increase in the number of Indigenous people counted in the 2011 Census compared with the 2006 Census [25]. 5 There are two 'structural' reasons contributing to the growth of the Indigenous population: the slightly higher fertility rates of Indigenous women compared with the rates of other Australian women (see 'Births and pregnancy outcome'); and the significant numbers of Indigenous babies born to Indigenous fathers and non-Indigenous mothers. Two other factors are considered likely to have contributed to the increase in people identifying as Indigenous: changes in enumeration processes (i.e. more Indigenous people are being captured during the census process); and changes in identification (i.e. people who did not previously identify as Indigenous in the census have changed their response).

The Indigenous population in WA is much younger overall than the non-Indigenous population (Figure 1) [24]. According to estimates from the 2011 Census, at June 2011 about 35% of Indigenous people were aged less than 15 years, compared with 19% of non-Indigenous people. About 3.0% of Indigenous people were aged 65 years or over, compared with 12% of non-Indigenous people.

Figure 1. Population pyramid of Indigenous and non-Indigenous populations in WA, 30 June 2011

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

Source: ABS, 2013 [24]

According to counts from the 2011 Census, around 96% of Indigenous people living in WA were Aboriginal, 1.9% were Torres Strait Islanders, and 1.9% people identified as being of both Aboriginal and Torres Strait Islander descent [21].

Population counts from the 2011 Census reveal that over one-third of WA’s Indigenous people lived in the Perth metropolitan area, where they comprised 1.6% of the total population (Table 1) [26]. The next most populous geographical region was South-Western WA, where 15% of the State’s Indigenous population lived and comprised 2.8% of the total population of that region. The region of Kununurra had the highest proportion of Indigenous people (48% of that jurisdiction’s population). More than two-fifths (40%) of WA’s Indigenous population lived in remote or very remote areas at 30 June 2011, compared with only 5.4% of the total population. 6

Table 1: Place of usual residence for Western Australian Indigenous population by Indigenous region, 30 June 2011
Indigenous regionIndigenous population (no.)Proportion of Indigenous population of WA (%)Proportion of total population of jurisdiction (%)Proportion of population status unknown (%)
Source: Derived from ABS, 2013 [26]
  1. This table presents raw census count numbers and as such underestimates the population of Indigenous people in each jurisdiction. For this reason the status unknown column is included
  2. The Indigenous regions are those used by the ABS for aggregation of population estimates
Perth 25,531 37 1.6 5.3
South-Western WA 10,552 15 2.8 5.3
South Hedland 7,260 10 12 18
Geraldton 6,330 9.1 11 6.0
Kalgoorlie 5,618 8.1 9.6 10
Kununurra 5,504 7.9 48 6.7
Broome 4,372 6.3 29 8.8
West Kimberley 4,041 5.8 48 8.7
Total 69,670 100 3.1 5.8


  1. Retention rates for Indigenous students were not provided for states and territories
  2. Occupational classifications for Indigenous people were not provided for states and territories
  3. There is a difference between the Census ‘counts’ and ‘estimates’. The estimates adjust for a number of factors are more accurate.
  4. Based on the Accessibility/Remoteness Index of Australia (ARIA), the five categories of remoteness used by the ABS are: ‘major cities’ (Census collection districts (CDs) with an average ARIA value of 0-0.2); ‘inner regional’ (average ARIA value > 0.2 and <= 2.4); ‘outer regional’ (average ARIA value > 2.4 and <= 5.92); ‘remote’ (average ARIA value > 5.92 and <= 10.53); and ‘very remote’ (average ARIA value > 10.53). The last two categories are characterised by ‘very little or very restricted access to goods and services and opportunities for social interaction’.


  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. Human Rights and Equal Opportunity Commission (1997) Bringing them home: report of the National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families. Sydney: Human Rights and Equal Opportunity Commission
  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 (2013) Community profiles. Retrieved 2013 from
  22. Australian Bureau of Statistics (2013) Schools, Australia, 2012. Canberra: Australian Bureau of Statistics
  23. Australian Curriculum Assessment and Reporting Authority (2012) National Assessment Program - Literacy and Numeracy achievement in reading, persuasive writing, language conventions and numeracy: national report for 2012. Sydney: Australian Curriculum Assessment and Reporting Authority
  24. Australian Bureau of Statistics (2013) Australian demographic statistics, September quarter 2012. Canberra: Australian Bureau of Statistics
  25. Biddle N (2012) CAEPR Indigenous population project 2011 census papers: population and age structure. Canberra: Centre for Aboriginal Economic Policy Research
  26. Australian Bureau of Statistics (2013) TableBuilder. Retrieved 2013 from

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