Remote community housing: holding government to account

OVERCROWDING and poor-quality housing are significant driving forces of death and disease in remote communities of the Northern Territory.

As health care workers, we bear witness to the devastating impact that overcrowding and grossly substandard infrastructure brings. We see mothers who are desperate to find solutions to enable them to wash their children’s clothes, limited by access to washing machines, power and water. Likewise, we see families advocating to reduce overcrowding in their community who are told to wait patiently for nearly a decade for a new house to be built.

Inadequate housing and overcrowding are at crisis level in many parts of the Northern Territory – a fact that has been established over many decades. In Australia, the highest levels of overcrowding occur in very remote communities. In 2019, it was estimated that 51% of Indigenous Australians living in very remote communities resided in overcrowded homes. Estimates suggest an extra 5500 homes are needed by 2028 to reduce levels of overcrowding to an acceptable level.

It is therefore unsurprising that remote communities experience some of the highest rates of devastating and preventable diseases such as acute rheumatic fever (ARF), rheumatic heart disease (RHD), acute post streptococcal glomerulonephritis, chronic suppurative lung disease, skin infections and otitis media. These diseases, even though they have different pathophysiology, all have common links to the social determinants of health. This is further highlighted by the steep decline of these diseases globally (here and here) as living conditions have gradually improved across the world.

RHD, for instance, is essentially a disease of poverty. It is caused by an immune reaction to a bacterium called group A Streptococcus, with infection rates and disease sequelae shown to be linked to overcrowding (and here). Severe RHD damages the valves of the heart and, even with the best open cardiac surgery, life expectancy for survivors is only 30–40 years. Although it is now predominantly a disease of low income countries, Indigenous Australians continue to experience rates of ARF and RHD that are among the highest in the world.

In Maningrida, a remote community in Arnhem Land, 8.3% of youth, aged 5–20 years, were found to have definite or borderline RHD on screening. Furthermore, recent data demonstrate the rate of ARF notifications increased across Australia from 2015 to 2019. While improved screening and awareness may have contributed to this, the current rate remains alarming.

Otitis media, a middle ear infection is another condition linked to overcrowding, which if recurrent or left untreated can lead to hearing loss. The downstream consequences of this are enormous, including speech and language delay, which lead to poor educational performance and disengagement with the school system. In 2013, 86% of Indigenous Australians under the age of 3 years had some form of otitis media. This contrasts with the national prevalence of just 0.1% among non-Indigenous Australians (and here).

This discrepancy is further demonstrated by the COVID-19 pandemic. COVID-19 spread through remote communities like wildfire, as residents were unable to safely isolate due to overcrowding and limited housing.

While the number of conditions, aliments and preventable diseases linked to poor housing are countless, tolerance for accepting substandard living conditions is running out. Local communities have long been advocates for change. Important initiatives such as Orange Sky Australia, which provides portable washing machines to remote communities, Deadly Heart, which provides excellent documentary and media coverage, and Bukmak Constructions, a Yolngu-run construction organisation that builds and repairs homes in East Arnhem Land, are only a few examples of excellent local initiatives.

Despite these efforts, the current state of housing is a major public health issue. The National Indigenous Reform Agreement stated that “children need to live in accommodation with adequate infrastructure conducive to good hygiene … and free of overcrowding”. Despite this statement made in 2009, recent reports suggest that 20% of Indigenous households were living in dwellings that did not meet an acceptable standard; 46% of households in remote areas were living in dwellings with at least one major structural problem; 9.1% of Indigenous households had no access to working facilities for food preparation; 4.5% had no access to working facilities to wash clothes and bedding; and 2.8% had no access to working facilities to wash household residents. This is truly unacceptable and is in breach of United Nations’ Convention on the Rights of the Child, to which Australia is a signatory.

Despite the poor condition of public housing, the waitlist for it is extortionate. In remote areas where there is no private market, residents are faced with no choice but to wait patiently on the public housing system. In the Katherine region of the Northern Territory, at the start of 2022, there were more than 490 people on the public housing waitlist, yet in 2021 only 36 applications were processed. The Northern Territory Government estimates that wait time for public housing in Katherine is six to eight years. In this time, numerous families will experience new diagnoses of ARF, otitis media, chronic suppurative lung disease and other devastating preventable conditions.

It is clear that the solutions to these problems lie far beyond the hospital system. Open cardiac surgery for leaking rheumatic valves or prolonged hospital admissions to try and heal chronically scarred lungs are merely expensive band-aids for far greater issues. We need to look further, beyond the individual story and put together the narrative to address the upstream factors causing ill health. The health system needs to stop being the ambulance at the bottom of the cliff, we need to look structurally and urgently address what is making people to fall.

The most recent national partnership for remote housing in the Northern Territory (2018–2023) pledged $550 million to support the development and maintenance of remote housing. A recent audit of this partnership deemed it at best partially effective and identified a number of implementation issues making several recommendations for future housing programs. These recommendations included recurring housing maintenance and additional investment in new housing development. This partnership is due for renewal in 2023.

Pledges from the federal Labor government that were honoured in the recent October 2022–2023 budget included $100 million to start work immediately on urgent housing and essential infrastructure on Northern Territory homelands (previously excluded from the remote housing agreement), as well as $200 million from the Housing Australia Future Fund for repair, maintenance and improvement of remote housing. It is imperative that the government is held accountable to follow through.

As clinicians who bear witness to the devastation caused by overcrowded and poor quality housing, we call for urgent and sustainable action, done in close consultation with community leaders. It is essential that both new housing is built, and that regular repairs and maintenance of existing homes occur. The status quo is not good enough. We need to prioritise action and support communities who have been working tirelessly to deal with the issue of poor housing and its impact on health.

Dr Tasmyn Soller is a paediatric registrar at Royal Darwin Hospital and is paediatric trainee with the Royal Australian College of Physicians.  

Dr Nerida Moore is training in Paediatric Infectious Diseases at Royal Darwin Hospital. She is focussed on health equity and systems strengthening, holding a Masters of International Public Health and a PhD in Medicine.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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