Introduction

Australia ranks bottom in a table of first-world wealthy nations working to improve the health and life expectancy of Indigenous people (AHMAC 2006). Life expectancy for Aboriginal and Torres Strait Islander people is estimated to be 11.5 years for males and 9.7 years for females less than for other Australians (ABS 2008, 2009). There are similar disparities across all social, economic and health indicators between Aboriginal and Torres Strait Islander peoples and non-Indigenous people in Australia. Therefore, specific public health approaches need to be taken in order to address these disparities and bring about improved health status and wellbeing for Aboriginal and Torres Strait Islander peoples. This chapter will focus on Aboriginal and Torres Strait Islander health within Australia, and has been developed to complement the other chapters within this book, which to varying degrees have specific content relating to Aboriginal and Torres Strait Islander peoples. We begin by first of all, asking who are Australia’s Aboriginal and Torres Strait Islander people?

Who are Aboriginal and Torres Strait Islander people?

Aboriginal and Torres Strait Islander peoples are the Indigenous peoples of Australia. Aboriginal peoples are the indigenous people of mainland Australia. Torres Strait Islanders are the indigenous people of the islands between the Australian mainland and New Guinea. Australia and New Guinea annexed the Torres Strait Islands in the 1800s. While Aboriginal and Torres Strait Islander peoples are generally grouped under the unitary banner of Australia’s indigenous people, it needs to be understood that there are significant differences in social, cultural and linguistic customs between Aboriginal and Torres Strait Islander peoples and groups. For example, at the commencement of European settlement it is estimated that there were 250–300 languages, with 600 dialects spoken by Aboriginal and Torres Strait Islander people (AIATSIS 1994).

Archaeological evidence demonstrates that Aboriginal people have been present in Australia for at least 50 000 years. Some historians use the figure of 125 000 years. There were numerous distinct groups of Aboriginal peoples who belonged, and still belong, to very specific geographic areas, referred to as ‘Country’. Country refers to a specific clan, a tribal group or nation of Aboriginal people, and encompasses all the knowledge, cultural norms, values, stories and resources within that particular area – that particular indigenous place. The notion of Country is central to Australian Aboriginal identity and contributes to overall health and wellbeing. Torres Strait Islander people identify particular islands or island groups as the particular areas to which they may belong.

Prior to colonisation, Australian Aboriginal and Torres Strait Islander people had complex societies and lead self-determining lives with control and decision-making over all of life’s aspects, including ceremony, spiritual practices, medicine, birthing, child-rearing, relationships, management of land and organisational systems and law. People had a healthy diet of protein and plants that contained adequate minerals and vitamins, and ate very little fat, sugar and salt (Flood 2006 p 122). They were able to monitor and evaluate individual, family and community health and wellbeing, where most of the treatment was provided by traditional spiritual healers, self-care and through traditional remedies (Couzos & Murray 2008). Aboriginal people kept on the move, with activities such as fishing, hunting, food gathering, land management, visiting other nations on their Country and ceremonies and, therefore, were physically fit (Flood 2006 p 122). Torres Strait Islander people were additionally active with fishing, food gathering and ceremonies.

Accounts from early contact with British and European explorers present a consistent picture that at the time of colonisation, Aboriginal people who survived infancy were fairly disease-free, fit and healthy. For example, James Cook, said to have ‘discovered’ Australia in non-Indigenous historical accounts, outlined on several occasions the status of the Aboriginal peoples he observed. Clarke, quoting from Cook’s diary, states that they were ‘of middle Stature straight bodied slender-limb’d the Colour of Wood soot or of dark chocolate … Their features are far from disagreeable’ (Cook in Clark 1966 p 51). Eyre, an early European explorer writing on the Murray River area, described the Aboriginal people of that area as ‘almost free from diseases and well-shaped in body and limb’ (quoted in Cleland 1928). What can be established is that prior to the arrival of the British in 1788, Aboriginal Australian peoples experienced a relatively healthy lifestyle and quality of life (Saggers & Gray 1991 p 59). Thomson claims that Aboriginal Australians were ‘physically, socially and emotionally healthier than most Europeans of that time’ (1984 p 939). This is reiterated in the National Aboriginal and Torres Strait Islander Health Strategy, Consultation Draft (NATSIC 2001, p 5) and Engles (1892/1973 p 130–133).

Colonisation had a profound impact on Australia’s Aboriginal and Torres Strait Islander peoples. The establishment of the British penal colony at Botany Bay began a parallel destruction of Aboriginal lifestyles and cultures. It involved massacres and removal of children from their mothers, families, peoples and lands (Blainey 1994; Evans et al. 1975; Rintoul 1993). Colonisation also brought with it smallpox and other extremely infectious diseases to which Aboriginal peoples had little immunity. The NATSIC states that, ‘the ill health of Aboriginal and Torres Strait Islander peoples exceeds that of any other sector of Australian society and the causes can be partly attributed to the impact of colonisation on the health of Aboriginal and Torres Strait Islander peoples’ (2001 p 5). It further states that the ‘Acts of dispossession, introduced diseases, loss of traditional foods and lifestyle, forced resettlement, loss of social cohesion, separation of children and the actions of health and welfare services reflect this impact’ (NATSIC 2001 p 5). Aboriginal and Torres Strait Islander peoples know the impact that the history of colonisation has had on them and what it means in terms of health status. They are the people who live the day-to-day reality of seeing family and community members who are ill and in need of health care, and they are the people who attend the funerals of those who have passed away. Aboriginal and Torres Strait Islander people are the relatives and friends of the Aboriginal and Torres Strait Islander people counted in the statistics. It is a testament to Aboriginal and Torres Strait Islander people’s strength and endurance that cultural, social and spiritual practices have survived in many communities and that they continue to be maintained and revived.

Government policy

From the time of colonisation, there have been policy decisions made by people, churches, institutions, the Australian Government and state and territory governments, and others which have impacted on the health and wellbeing of Aboriginal peoples. The modern history of Aboriginal and Torres Strait Islander people in Australia has been one of control and policy. A whole range of people, including health professionals, police officers, church and government administrators, implemented the policies and in some instances carried out questionable practices. Phillips explains that a whole range of people and workers ‘operated in concert to suppress local Aboriginal sovereignty, steal their lands, and destroy their languages, cultures and social cohesion’ (Phillips 2003 p 93). The practice of removing children continued through the 1950s and 1960s under child welfare legislation in most states, and allowed missionaries, government officials and others to restrict contact between Aboriginal children and their parents and culture (Beresford & Omaji 1998 p 96). Other government polices prevented Aboriginal and Torres Strait Islander people from enjoying the rights that other Australians exercised, such as buying a home, voting, moving from one town to another, receiving wages for work and going to school or university. The first Aboriginal graduate from an Australian university was Charles Perkins in 1965. Some of the practices have resulted in ‘situational traumatisation’ (Phillips 2003 p 23), which has ‘produced cumulative trauma as a result of shame and self-hate, and intergenerational trauma as a result of unresolved and unaddressed grief and loss’ (2003 p 23). What needs to be remembered is that the events and practices carried out, and the impacts of oppressive policies, are still within the living memories of Aboriginal and Torres Strait Islander peoples, families and communities. They contribute to current attitudes towards health professionals, health care delivery, religious people, teachers, law and order workers and government officials. It also needs to be said that if it is in the living memory of Aboriginal and Torres Strait Islander people, it must also be in the living memory of some non-Indigenous Australians.

The National Aboriginal Health Strategy

In recent times, a concerted effort has been made by governments and institutions to address the poor health of Aboriginal and Torres Strait Islander peoples. The National Aboriginal Health Strategy Working Party was established in 1987 and produced the National Aboriginal Health Strategy (1989), which is most commonly referred to as the NAHS. The NAHS was an important milestone in the history of Aboriginal and Torres Strait Islander health in Australia. It was the first time that representatives from Aboriginal and Torres Strait Islander communities, the Commonwealth and the state and territory governments came together to collectively work on any national policy for Aboriginal and Torres Strait Islander peoples in Australia. The NAHS recognised the need for women’s meetings and men’s meetings, and joint meetings on issues and health. It was also the first time that an Aboriginal and Torres Strait Islander health concept was embedded in a national document. The statement was as follows:

This statement has subsequently been used over and over again by Aboriginal and Torres Strait Islander peoples and others, for example, most Aboriginal and Torres Strait Islander health reports produced by successive governments since 1989, regardless of whether they are Commonwealth, state or territory-based, and by Aboriginal and Torres Strait Islander and non-Indigenous researchers. The statement has been utilised by Aboriginal and Torres Strait Islander peoples to work with governments with the aim to deliver more comprehensive health services and primary health care services. Despite the efforts and statements made by bureaucrats and politicians, and Aboriginal and Torres Strait Islander peoples, the NAHS was never fully funded.

Close the Gap

‘Close the Gap’ is a human rights-based campaign for Aboriginal and Torres Strait Islander health equality, publicly launched in April 2007 and initiated following the Aboriginal and Torres Strait Islander Social Justice Commissioners Social Justice Report 2005. Australia’s peak Aboriginal and Torres Strait Islander and non-Indigenous health bodies, non-government organisations (NGOs) and human rights organisations, first met as the ‘Close the Gap’ Steering Committee, in March 2006. Working outside of government, the ‘Close the Gap’ campaign activities are completely self-funded, with Oxfam Australia the major contributor (NACCHO & Oxfam 2007). The Steering Committee is led by its Aboriginal and Torres Strait Islander members, with the campaign goal of raising the health and life expectancy of Aboriginal and Torres Strait Islander people to that of the non-Indigenous population within a generation: to close the gap by 2030. Each year, 24 March is celebrated as the National ‘Close the Gap’ day. Coordinated by Oxfam Australia, events are conducted across Australia to continue to promote the campaign goal, and increase participation through encouraging more Australians to sign the pledge, and supporting community and workplace events (CTGSC 2011 p 2; HREOC 2008a p 5).

The ‘Close the Gap’ campaign has been an effective policy driver over recent years. The campaign has approximately 145 000 people who have signed the pledge to Close the Gap, which calls on government to take action, and high profile ambassadors who are advocating for and promoting the campaign. Significant Indigenous and non-Indigenous people and organisations have signed the ‘Statement of Intent to Close the Gap’ and some are also actively involved in the campaign steering committee. Along with the compelling evidence base, the Close the Gap campaign is responsible for the single largest injection of funds for Aboriginal and Torres Strait Islander Health, $1.6 billion, announced by Government in November 2008 (Rudd 2008).

Following the election of the Labor government in November 2007, the Council of Australian Governments (COAG) met in December of the same year and agreed that the 17-year gap in life expectancy between Indigenous and non-Indigenous Australians must be closed. This was followed by an official apology to the Stolen Generations by the then new Prime Minister, Kevin Rudd, in the first session of the Federal Parliament on 13 February 2008 (Rudd 2008). On 20 March 2008, at the Indigenous Health Equity Summit, a key component of the ‘Close the Gap’ campaign, the ‘Statement of Intent to Close the Gap’, was signed by the Prime Minister. Later that year, through COAG, the National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, was developed and endorsed by Government with the commitment of $1.6 billion over four years (2009–2013), to fund a programme of health system reform. This was made up of an $800 million contribution by the Commonwealth Government, matched by an additional $772 million from states and territories. ‘Closing the Gap’ then became the mantle adopted for Government policy and funding initiatives under the COAG commitments, to address Indigenous disadvantage (HREOC 2008a, Rudd 2008).

The terms ‘Close the Gap’ and ‘Closing the Gap’ continue to be used interchangeably to describe or refer to a wide range of events and initiatives to reduce the gap in life expectancy between Aboriginal and Torres Strait Islander and non-Indigenous peoples in Australia. However, the Close the Gap Campaign Steering Committee are very specific in their understanding and use of the terms, and state that ‘closing the gap’ is an Australian Government initiative that does not necessarily reflect the human rights-based approach of the ‘Close the Gap’ Campaign, nor does the term ‘closing the gap’ in relation to these initiatives necessarily reflect an endorsement of them by the Close the Gap Campaign Steering Committee (CTGSC 2011 p 2).

The National Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, endorsed by all state and territory leaders and the Prime Minister, focuses action on five initiatives: ‘Tackling Smoking’, ‘Healthy transition to adulthood’, ‘Making Indigenous health everyone’s business’, ‘Primary health care services that can deliver’ and ‘Fixing the gaps and Improving the patient journey’. Implementation Plans (2009–2013) for each jurisdiction and the Commonwealth have been publically available since July 2009 (Commonwealth 2008 p. 6-9). The Close the Gap partners, regardless of which state or territory, have all supported the need to address the social and cultural factors which influence the gap, for example, housing, community safety and security, justice, education, culture, language, community development and other issues which influence the health and wellbeing of Aboriginal and Torres Strait Islander peoples. These other areas are often referred to as the social determinants of health (see Chapter 6 for more on social determinants) and they have specific relevance in addressing the health of Aboriginal and Torres Strait Islander peoples (Carson et al. 2007; Mowbray 2007; WHO 2007). In recognition of the importance of the social determinants of health, key targets have been set, which include measurements for: improved housing, reduction in smoking across and in communities, availability of fresh food, and other such targets, which work to significantly reduce the rates of Indigenous death and illness from disease and chronic conditions. The Australian Human Rights Commission (2009) and Calma (2009) have both stated that Aboriginal and Torres Strait Islander peoples must be involved in decision-making about Aboriginal and Torres Strait Islander health and addressing the inequalities across all areas.

While the ‘Close the Gap’ campaign is driven by Aboriginal and Torres Strait Islander people and strongly advocates for Aboriginal and Torres Strait Islander peoples full engagement and participation in the decision-making to reduce the gap in life expectancy, the Government’s Partnership Agreement on Closing the Gap in Indigenous Health Outcomes, makes one reference to Indigenous engagement in terms of ‘informing’ the development of implementation plans (Commonwealth 2008 p 12). Jurisdictional implementation plans for the Partnership Agreement on Closing the Gap in Indigenous Health Outcomes provide to varying degrees more detail of existing and proposed mechanisms for engagement with Indigenous people. However, at this point in time it is unclear how thorough, genuine and inclusive the engagement of Aboriginal and Torres Strait Islander people has been in the development, implementation and decisions about this $1.6 billion initiative to close the gap in life expectancy between Indigenous and non-Indigenous Australians. While it is only a few years since the ‘Close the Gap’ was launched, the Productivity Commission Report on the initial strategies and policies has already proved disappointing (Calma 2009; SCRGSP 2009). The Australian Human Rights Commission (2009) has outlined that, for real progress and changes to occur, Aboriginal and Torres Strait Islander peoples and communities need to be involved in decisions being made about Aboriginal and Torres Strait Islander health and wellbeing. This has been articulated and demanded for years by both non-Indigenous and Aboriginal and Torres Strait Islander people advocating for better health for Aboriginal and Torres Strait Islander peoples.

The Northern Territory Intervention

On 21 June 2007, the Australian Government announced the Northern Territory Emergency Response (NTER), commonly referred to as the ‘Intervention’, which was a series of broad-ranging measures introduced in Aboriginal communities across the Northern Territory. The ‘Intervention’ received bipartisan support from the then Leader of the Opposition, Kevin Rudd. The Australian Government stated that the ‘Intervention’ was in response to the national emergency confronting the welfare of Aboriginal children in the Northern Territory, and went on to justify the immediate nature of the Australian Government’s action as a response to the very first recommendation of the Little Children are Sacred: Report into the protection of Aboriginal children from child abuse in the Northern Territory (Brough 2007; Commonwealth 2008 p 66).

The ‘Intervention’ had a broad range and scope, categorised by the Australian Government into seven measures: Welfare and Employment, Law and Order, Enhancing Education, Supporting Families, Improving Child and Family Health, Housing and Land Reform, and Coordination (Commonwealth 2008 p 64). The majority of these measures required the Australian Government to enact new legislation to be able to proceed. The legislative process was concluded within 10 days of the bills being introduced to parliament, which meant that there was limited time for consideration and analysis, despite the complexity and potential implications of the legislation (HREOC 2008b).

Opinions were divided about the ‘Intervention’, its justification, objectives and implementation. The Human Rights and Equal Opportunity Commission’s Social Justice Report 2007 describes some of the concerns, stating that the introduction of the ‘Intervention’ has been highly controversial, because ‘the approach created or exacerbated division and mistrust between the Australian Government, the Northern Territory Government, Indigenous communities and numerous community organisations. The responsibility for creating such division lies with those who led the process’ (HREOC 2008b p 233).

Following the election of the Labor government in November 2007, the Northern Territory Emergency Response Review Board was commissioned to conduct a review into the first 12 months of the ‘Intervention’. While evidence may not have been available at that stage to report comprehensively on the impact of the ‘Intervention’ measures, their report documented a range of views. ‘Support for the positive potential of “Intervention” measures has been dampened and delayed by the manner in which they were imposed. Further, the Intervention diminished its own effectiveness through its failure to engage constructively with the Aboriginal people it was intended to help’ (Commonwealth 2008 p 9). Despite detailing these criticisms, the Review Board also reported definite gains, in that it heard widespread, if qualified, community support for ‘many of the “Intervention’ measures” ’ (Commonwealth 2008 p 10).

Opinions about the ‘Intervention’ were also published by the Aboriginal community-controlled health sector. For example, the Aboriginal Medical Services Alliance of the Northern Territory (AMSANT), the top body for Aboriginal community-controlled health services in the Northern Territory, provided qualified support for the measures introduced as part of the ‘Intervention’. In their Annual Report for 2009–10, Chairperson Stephanie Bell wrote that ‘Although we maintain a critical stance to the “Intervention” as a whole, AMSANT continues to work with the “Intervention” in trying to achieve real change for our people’s health…. the expanded resources made available as a consequence of the “Intervention” have done much to provide greater equity across the Northern Territory, with resources available to some remote areas where few, if any, were available before’ (AMSANT 2009 p 4).

Debate will continue about the implementation process, benefits, impact and outcomes of the ‘Intervention’, even after there is enough evidence available to measure its impacts on the health outcomes of Aboriginal people in the Northern Territory.

Aboriginal and Torres Strait Islander people today

In 2009, Australia’s Aboriginal and Torres Strait Islander population was approximately 550 000 people, which was about 2.5% of the total Australian population. While most self-identify as Aboriginal peoples, 6% identified themselves as being Torres Strait Islander and 4% identified as both Aboriginal and Torres Strait Islander (ABS 2007). Of the total Aboriginal and Torres Strait Islander population, 76% live in major cities and non-remote regional areas (ABS 2007). This is in contrast to perceptions held by many Australians and the images shown by the Australian media, both within Australia and overseas. There are large urban populations in some areas. For example, the 2006 census data indicates that 146 400 Aboriginal and Torres Strait Islander people or 28.3% of Australia’s total Indigenous population live in Queensland (ABS 2007 p 2) and of this number, 41 369 live in the greater South East Queensland region (ABS 2007 p 34). This equates to 28% of the total Indigenous population of Queensland. Evidence shows that when Indigenous Australians migrate into capital cities they tend to move into areas where there are already concentrations of Indigenous people – generally areas of low socio-economic status (Taylor 2006). Some Aboriginal and Torres Strait Islander people are now second-, third- or multi-generation urban dwellers, while others may travel to and from cities and big urban centres and their home communities.

The large numbers of people living within the regional centres, towns and cities demonstrate that living in urban areas is as much part of reality for Aboriginal and Torres Strait Islander people as living in a discrete Aboriginal rural, regional or isolated community or on one of the islands in the Torres Strait (Fredericks 2004; Rowse 2006). This urban reality includes using a range of accommodation options (houses, flats, caravans, renting, buying, living on the streets, or in parks), buying goods and services, maybe finding a job, participating in sporting groups, clubs and organisations, and sharing and interacting with people from a diverse range of backgrounds, with their own languages and cultures. Living in urban environments additionally includes trying to find or make space within the city or regional centre for Aboriginal and Torres Strait Islander cultures, languages and individual and collective expression. It has also witnessed the establishment and maintenance of Aboriginal and Torres Strait Islander organisations, programmes, services and other structures. The experiences of Aboriginal and Torres Strait Islander people living in urban areas are diverse and include a diversity of experience, need, prospects shaped by gender, education, religion, age and level of human security (Fredericks 2004; Tripcony 1995; Watson 1981). There is no single urban Indigenous experience or identity, nor is there one single urban Indigenous community in cities and regional areas. The multi-faceted nature of urban Indigenous people and communities presents researchers, planners and government officers with a range of issues (Scrimgeour & Scrimgeour 2008).

Regardless of locality and population diversity, there are some statistics and issues that are common for all Aboriginal and Torres Strait Islander people. Over all, Aboriginal and Torres Strait Islander Australians (currently numbering between 2.2% and 2.5% of the Australian population) have the poorest health status of any group in Australia. The Aboriginal and Torres Strait Islander population is also much younger than the non-Indigenous Australian population. In 2006, the median age was 20 years for Aboriginal and Torres Strait Islander people and 37 years for the non-Indigenous population (ABS 2008). Additionally, this means that there are many young Aboriginal and Torres Strait Islander people who are trying to find a path for themselves, like other Australian youth. However, they often experience greater difficulties in finding appropriate education or training opportunities, a job, or housing, and suffer racism while trying to build confident adult identities.

All measures of health status indicate poorer health outcomes for Aboriginal and Torres Strait Islander people compared to the total Australian population (ABS 2008). Poor health is coupled with difficulties in accessing education, employment and housing for oneself and one’s family, living on lower incomes than other Australians, and dealing with ongoing issues of racism. When non-Indigenous and Aboriginal and Torres Strait Islander people work in health, human services, housing, education, child care, justice, and numerous other sectors, they witness the human face of the statistics and the toll it takes on the people who access their agencies and organisations. They too, can suffer social and emotional wellbeing issues and ‘burnout’ as a result of dealing with the issues day in and day out.

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