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AUSTRALIA should call time on the failed Closing the Gap strategy, according to a leading Indigenous health researcher who says Indigenous people should be front and centre in future research efforts.
“I am excited about what we can do in research when Indigenous people are in charge of defining the questions and asking new questions of old problems,” said Associate Professor Chelsea Bond, a Munanjahli and South Sea Islander woman and a Principal Research Fellow within the University of Queensland’s School of Social Science, in an exclusive podcast.
In a Perspective published in the MJA, Associate Professor Bond and co-author Dr David Singh, wrote that in the wake of the 12th annual report of the Closing the Gap strategy, there was a need for a “radical reconfiguring” of power relationships between Indigenous and non-Indigenous Australians.
While the Morrison government announced in 2019 that there was a need to “refresh” targets, the researchers wrote that a greater overhaul was needed.
They wrote that a radical reconfiguring of relationships of power between Indigenous and non-Indigenous people was necessary to achieve better health outcomes, “whereby Indigenous peoples could be considered the solution to better health rather than the cause of ill health”.
Associate Professor Bond told InSight+ that, in fact, it shouldn’t be considered radical to suggest changing a strategy that has failed.
“We haven’t met the targets, so to just refresh them seems like window dressing, and we know that Indigenous health needs more than a window-dressing approach. There needs to be more substantial change in the strategy.”
Associate Professor Bond told InSight+:
“Let’s look at this whole arrangement – who is it working for? There has been a big investment of funding in research; the question that we have is, is it getting to Indigenous peoples? When do Indigenous peoples get to lead the strategising for improving indigenous health?”
Associate Professor Bond said much of the research in Indigenous health to date had focused on body parts, and had taken an apolitical and ahistorical approach.
“One of the key stumbling blocks is that we haven’t relinquished our attachment to race,” she said. “There is still this belief that Indigenous peoples are incapable of managing our own affairs.”
Associate Professor Bond said not having Indigenous peoples in charge of the Indigenous health research agenda was as absurd as it would be to not have a woman leading a women’s health strategy.
“And yet, here we are in Indigenous health saying, ‘okay, most of the Indigenous health research funding goes to non-Indigenous-led research’,” she said. “We just wouldn’t be having the same conversation if we swapped race for gender.”
Associate Professor Bond said while the refreshed strategy’s involvement of the Coalition of Peaks (a representative body of about 40 Aboriginal and Torres Strait Islander organisations) in policy codesign was a step in the right direction, it was not without risk.
“I certainly don’t wish to diminish the efforts of the Indigenous peaks, who have worked for a sustained period of time to get a seat at the table and have a say in these core decisions,” she said.
“My concern is that the Indigenous peaks will be blamed for ongoing policy failures given there isn’t a changing of the strategy. We know that historically it is Indigenous peoples who carry the blame of a failed progress in Indigenous health although they have yet to be given responsibility for an Indigenous health strategy.”
Associate Professor Bond said that despite the National Health and Medical Research Council’s (NHMRC) 5% commitment to Indigenous health research, there was little accountability around the target.
“The NHMRC needs to make a clear commitment to Indigenous-led research and reporting and accountability,” she said. “In this day and age, they no longer can lay claim to the idea that ‘black lack’ is the reason why Indigenous researchers aren’t getting a fair share of Indigenous health research funding.
“We have a critical mass of Indigenous health researchers across a range of disciplines with different expertise that are capable of being in charge of things, so I think some greater accountability and transparency and a commitment to Indigenous-led research, on our terms, is needed.”
Professor Sandra Eades, Associate Dean (Indigenous) at the University of Melbourne’s Faculty of Medicine, Dentistry and Health Sciences and also Chair of the Principal Committee Indigenous Caucus with the NHMRC, said it was “unfair to be too critical of the NHRMC, its level of power-sharing and commitment to Indigenous research”.
“The level of governance involved, involvement of Aboriginal people across every principal committee and council, and the commitment to allocate of at least 5% of the Medical Research Endowment Account on Indigenous research is unrivalled internationally,” said Professor Eades, adding that the NHMRC’s funding commitment was the envy of Indigenous health researchers across the globe.
She said while the federal government did sometimes take a “body parts” approach to research – perhaps targeting blindness or deafness – there was a broad acceptance of the social determinants of health and the role of racism in poor health.
“Apart from making a specific call in relation to the impact of racism on health, it’s hard to know what more we can do,” Professor Eades said, pointing to current research projects such as the Australian National University’s large-scale Mayi Kuwayu study, led by Associate Professor Ray Lovett and funded by the NHMRC. Professor Eades also noted that her own Next Generation – Aboriginal Youth Wellbeing study was also taking a “strengths-based approach”.
“The Next Generation study focuses on young people as young people and not as body parts,” she said. “It doesn’t make comparisons and looks within the Aboriginal community. I think the field is rapidly changing.”
However, Professor Eades agreed that the Closing the Gap strategy needed more than “tinkering at the edges”.
Funding, she said, was an issue. While a significant investment was made when the campaign was launched in 2007, Professor Eades said this commitment was wound back by more than $530 million in the 2014 federal budget.
Also, she said, the way in which Indigenous health outcomes were reported did not tell the whole story.
“Originally, reporting on the gap [between Indigenous and non-Indigenous health outcomes] was a good way to harness public opinion, government support and get the commitment,” Professor Eades said. “But reporting on the gap is not the same as reporting on progress made as a result of the investments and the efforts of state and Commonwealth governments.
“We have made progress. Aboriginal health outcomes have improved, but the gap persists, and they are two different things.”
Associate Professor Bond said she hoped that in 10 years’ time Indigenous peoples were no longer just “fighting for a seat at the table to be consulted”.
“I hope that we are defining the terms and we are setting the agenda,” she said. “I hope that we don’t just have this illusion of Indigenous inclusion, that we have meaningful Indigenous ownership and leadership in this space.
“This is really about the survival of Indigenous peoples. With all of this investment, I would hope that we will see change that is of benefit to Indigenous peoples because that hasn’t been the case for well over a decade, and that is quite damning.
“I hope my children’s children know what it’s like to have grandparents.”
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The notion of “closing gaps” in order to bring equity in health and wellbeing for Indigenous Australians was fundamentally flawed and bound to fail. Why try to equalise vital statistics like life expectancy within a couple of decades when it is well known that such characteristics, even under ideal circumstances, change very, very slowly. The Close the Gap (CTG) Strategy unrealistically expected Indigenous citizens to improve their rate of expectation life at three times the rate which occurred in the Australian population between the start of the twentieth century and the start of the current century? It would have made more sense to pick more modest, but achievable, targets and to have done so with the close collaboration with those who are most crucially interested in the outcome, the Indigenous population or their chosen representatives. Close involvement of and responsibility for these changes should, in future, rest with much closer and transparent cooperation between medical experts and the Indigenous population.
Whilst it would seem almost paradoxical to say, poverty in Aboriginal communities, in conventional terms,is not the problem of Aboriginal inequity now. It is the misuse by too many of the funds being applied to address what was previously a deficiency. Gambling, especially on poker machines, drugs-from Marijuana to ICE and oxycodone, alcohol and the consequences of it all, have soaked up all that extra funding to compound all the dreadful outcomes of the past. Yet we continue to argue over the benefits of programs like a Basics card and even Work for the Dole/CIP or equivalent programs. Some want to throw even more money at the problem. CTG was conceptually flawed and it has come time to accept that. Exactly what replaces it is a $64 question but let us start with a universal Basics card.
I have worked as a GP in a variety of urban practices, some low to middle income (lets call this type B), some rather lower (type A). Type A include high proportions of unemployed Caucasians, mixed race Indigenous / caucasians, and recent immigrants.
I have always worked hard at lifestyle advice for managing chronic disease, and in type B practices have an approximately 60% success rate in enabling type 2 diabetic patient to limit their carbohydrate intake enough to lose weight. In the type A practice my success rate was close to 0%.
I am therefore highly pessimistic of any policy, whether the existing CTG or an indigenous-led new policy, making a significant difference in a time-scale of less than 200 years.
While it reflects well on the ethics of those in health policy and on the front line to be so concerned about poor levels of health in the indigenous community, it seems to me that a long healthy life is not something that the majority of patients in a type A practice aspire too, hard though that may be to understand from a well educated middle class standpoint.
So let’s continue trying where we can, but be realistic about outcomes.
The health problems of First Nation people in Australia have been repeatedly documented. Long term research focussed on alleviating particular problems has a place and can be outstandingly successful. Eg. The near eradication of trachoma.
The underlying problem of ‘The Continuing Gap’ is due to the ‘social determinants of disease’. In 1978, I wrote that: ‘Without economic opportunity I have the uneasy feeling that Aboriginal community development (and I add much so called research) is a form of phoney war akin to firing rubber bullets at secondary targets while the primary target, the lack of economic opportunity, goes ignored and unscathed.” (The Dark People of Bourke 1978, p 320).
Sadly, particularly in rural and remote Australia this is still the case. Chronic poverty breeds generations of chronically dysfunctional families whose children are also dysfunctional and are unable to benefit from the educational and vocational opportunities available to them.
This is the area crying out for Aboriginal led research.
I am not sure what Bond means by radically reconfiguring of power relationships and setting the agenda has to do with health outcomes.
There should be more research and education around healthy lifestyles, exercise, cooking skills, smoking and drinking.
Are health outcomes really better researched by indigenous peoples? Researchers should be treated equally no matter what race.
Closing the gap seems hardly seems an aim to be abandoned. Seems to me the best results are likley to be had by everyone with an interest in this area working together towards a common goal not people taking sides.