Introduction

The health of Aboriginal and Torres Strait Islander people has been consistently reported as far poorer than that of the rest of the Australian population. This disparity can not be explained by biomedical reasoning or scientific extrapolation alone. There is an assumption that all who read about Indigenous health will have knowledge of who Indigenous Australians are. However, this assumption will be challenged. Many non-Indigenous Australians have had very little contact with Indigenous Australians and know little about the historical context. This issue may lie at the very heart of the debate about Australian Indigenous affairs (McCorquodale 1997). Much of this debate has been entrenched in Social Darwinism — a social theory that attempted to apply Charles Darwin’s theory of natural selection with survival of the fittest and adapt it to human populations in an attempt to stratify human cultural and evolutionary development (Attwood 1989: 87–8).

Although Social Darwinism has no scientific credibility, it does, however, have strength with uneducated and ill-informed members of the public. Oppressive government policies were developed to manage and control Indigenous populations and had authority under the protection, assimilation and integration policies, which were underpinned by paternalistic forms of the Social Darwinian theory (Attwood 1989). Therefore, much of the social construction of who an Indigenous Australian is has been disseminated and constructed within government policies and academia and not by Indigenous Australians (McCorquodale 1997).

The focus of early Australian anthropological research was on describing rather than understanding cultural differences (Firth 1998). This informed government policy on how to deal with Aboriginal populations and theorised that so-called ‘full-bloods’ would die out and so-called ‘mixed race’ Aboriginals could be assimilated into the wider society (Firth 1989; Horton 1994). In recent years, anthropological influence on government policy has been highly criticised, especially by anthropology’s own fraternity (Cowlishaw 1992).

Readers of this chapter should reposition their thinking away from a biological determinant approach of cultural or ethnic identity (i.e. from skin colour and distinctions between traditional verses urban people) and progress towards a social justice and human rights approach. This will allow a common and agreed understanding of who constitutes an Indigenous Australian. Indigenous Australians are considered to be all people who self-identify as Aboriginal or Torres Strait Islander, are identified by their community as Aboriginal or Torres Strait Islander, as well as those people who consider themselves as being a descendant of either of the above. Approximately 90% of Indigenous people identify as being of Aboriginal origin, 6% identify as being of Torres Strait Islander origin and 4% identify as being of both Aboriginal and Torres Strait Islander origin (Australian Institute of Health and Welfare [AIHW] 2005e: 3).

Archaeological evidence shows that Aboriginal people occupied Australia for 40 000–60 000 years prior to European arrival and possibly longer (Veth, O’Connor & Wallis 2000). The doctrine of terra nullius, the assumption that British sovereignty could be claimed over Australia as it was uninhabited, was used to justify British colonisation and was only officially overturned by the High Court of Australia with the Mabo decision (Reconciliation and Social Justice Library 1996). Until 1992, Australian law did not recognise Indigenous Australians as having legitimate rights to land, sea and occupation (Reconciliation and Social Justice Library 1996). Despite this legal affirmation, Australia continues to have a persistent difference in health status and socioeconomic disadvantage between Indigenous and non-Indigenous Australians. Matthews (1997) provides a causal pathway (Fig 12.1) to frame the links between colonisation and the current poor health and social disadvantage of Indigenous Australians. Casual pathways open up the concept of multiple outcomes from single pathways and multiple pathways to single outcomes (Stanley 2002).

Figure 12.1 Casual pathway of colonisation leading to economic and social disadvantage and poor health for Indigenous Australians

Source: Matthews 1997: 258

This pathway (Fig 12.1) hides the savagery of the interaction between the colonists and the Aboriginal inhabitants of Australia. Within 2 years of the First Fleet’s arrival, a series of localised wars began between the British invaders and respective Aboriginal nations as the invaders ventured across Australia (Connor 2005). The Aboriginal wars continued, always as localised events, until the Coniston massacre in Central Australia in 1928 (Wilson & O’Brien 2003). Although the Aboriginal wars are now largely forgotten, it is ironic that the Aboriginal man, Gwoya Jungarai, depicted on the obverse of the two dollar coin was a survivor of the Coniston massacre (Wilson & O’Brien 2003). This coin should serve as a reminder of the bravery of Aboriginal peoples.

Interwoven within Matthew’s (1997) causal pathway are the historical eras of governmental policies. In Figure 12.2 the official dates of when these policies were enacted are not detailed as implementation occurred at different times for each state and territory. Historically, Indigenous people’s access to government services was circumscribed by the colonial administrative systems after federation in 1901 (Anderson 2001).

Figure 12.2 Succession of government policies imposed on Indigenous Australians

Source: Adapted from Anderson 2006, Horton 1994, Wearne 1980

Indigenous access to health care services has been shaped to some extent by the historical development of the Australian health care system (Anderson 2001). The reasons why Indigenous peoples have had limited success with the Australian health system include:

History of Aboriginal controlled health services: 1970 reforms and community health

Through collective action, Indigenous people’s response to the barriers to health care in Australia led to the development of an alternative pathway to access health care through the establishment of Aboriginal Medical Services (AMS) (Hunter et al 2005). The first AMS were established in Sydney and Melbourne in the early 1970s, and by 1978 there were 12 AMS established in other parts of Australia (Hunter et al 2005; Anderson & Wakerman 2005). This movement was also seen by Indigenous groups as an expression of self-determination; the process by which people express and determine their own future and destinies.

The innovative approach by the AMS to primary health care was based on the Alma-Ata declaration (1978) and mirrored contemporary international aspirations for accessible, effective, appropriate, needs-based health care with a prevention and social justice focus (Hunter et al 2005). AMSs are now known as Aboriginal Community Controlled Health Services (ACCHSs), of which there are more than 130 across Australia (National Aboriginal Community Controlled Health Organisation [NACCHO] 2006; NATSIHC 2003b: 18–19).

By definition, an ACCHS must be:

The distinguishing characteristics of ACCHSs include: