Aboriginals and Torres Strait Islanders Health Care - Report Example

RUNNING HEAD: ABORIGINALS AND TORRES STRAIT ISLANDERS’ HEALTH CARE Aboriginals And Torres Strait Islanders’ Health Care [The Writer’s name] [The name of the Institution] Aboriginals and Torres Strait Islanders’ Health Care Introduction It is a reasonable premise for health policy that access to health care services should be proportionate to health need. For Aboriginal Australians, health care access is shaped by various factors, including the values, preferences and experiences of those using Aboriginal health services. (Grbich, 2004) There are local service factors such as location of services, their cost, and responses of health staff to clients, that is, their capacity or willingness to engage with Aboriginal cultures, languages and prior health experiences. (Blackwell, 2007) There are institutional factors, including financing, administration and organisation of service delivery. Here we focus on the relationship between the institutional organisation of the Australian health system and the equitable provision of health services based on need. This paper provides a brief discussion about health care issues and barriers to Aboriginals and Torres Strait Islanders. Ethical and legal issues have also been mentioned in this paper. The paper also proposes an ethical position, with related strategies, to address these difficulties Key Barriers To Equal Health Care Equal access for equal need requires that services be delivered in a way that minimizes geographic, economic, cultural and linguistic barriers to use. In order for the value of a health service to be realised, Aboriginal patients need to able to engage and respond to the process of care. This gives rise to an apparent paradox: that ‘colour’-blind needs-based allocation of resources can only achieve equity if this is linked to a policy approach that encompasses targeted strategies and service delivery structures. Lack of a political relationship between the Commonwealth government and Aboriginal and Torres Strait Islanders deepened the alienation of Aboriginal and Torres Strait Islanders Australians from government funded services. State governments are less likely than federal governments to extend benefits, or contribute to the development of community infrastructure, to peoples who are viewed as not contributing to the tax base or who may be seen as impediments to economic development. (Cohen, 2001) Australia, unlike settler states such as the United States, Canada and New Zealand, has not established a treaty process with Aboriginal and Torres Strait Islanders. Lack of treaty-derived rights weakens the political position of Aboriginal and Torres Strait Islanders relative to Aboriginal and Torres Strait Islanders peoples in other settler-colonial states (Freckelton, 2006). This lack of constitutional power prevented the Commonwealth from developing programs that addressed Aboriginal peoples’ inequitable access to health and related social services. Aborigines had very limited options for accessing health care during this early federation period. Aboriginal and Torres Strait Islander peoples’ access to services was regulated through the combined effect of state/territory administrative regimes that restricted their rights. (Singer, 2002) The Framework Agreements offers a tactical framework for action in Aboriginal and Torres Strait Islanders health. They are important in establishing the infrastructure and institutional arrangements by which new resources can be effectively planned and managed in a collaborative manner. However, the pattern of growth in Commonwealth investments in Aboriginal health is still incremental. And there is still no needs-based expenditure (in global terms) for Aboriginal health in Australia. (Freckelton, 2006) There are a number of barriers to achieving needs-based expenditure in Aboriginal and Torres Strait Islanders health. Policy arguments which reflect different philosophies or ideologies of health detail the relative value of investment— whether improved access to primary health care should be a priority compared to programs that address the determinants of health such as housing. The health financing system is complex and will require strategies to improve the allocation of resources into Aboriginal and Torres Strait Islanders health care. Many of these strategies require broader system reform. The allocation of resources through Medicare depends on the supply of doctors. Strategies to address the undersupply of doctors in rural and remote Australia link to strategies to improve the financing of health care. (Biddle, Hunter, Schwab, 2004) There is no single ‘tap’ within the health portfolio that can funnel resources into the Aboriginal health area. Allocation of health care resources taps into multiple processes and structures which reflect the complexities of the Commonwealth health financing system and the federal nature of the health system. (Freckelton, 2006) The development of agreed methods to calculate relative need would help to set expenditure targets for different components of the system. The Australian Aboriginal and Torres Strait Islanders mortality statistics are overshadowed by high rates of infectious diseases and the so-called diseases of unhealthy lifestyles, particularly diabetes, renal failure, heart disease, and injury/poisoning. (Biddle, Hunter, Schwab, 2004) These living conditions, unhealthy lifestyles, and poor outcomes are almost identical to the conditions in Britain and amongst white Australians 150 years ago which stimulated the modern public health and educational movements. (Arabena, 2005) However, in Australia there is the additional trauma of the loss of traditional lands and the forced removal of children. In many cases language and cultural imperatives such as kinship and marriage rules have been lost too. Extended family obligations and a history that depicts human suffering in the extreme and the consequent struggle to hold on to sufficient self-esteem merely to survive are other factors. Consequently, psychosocial morbidity is very high for Aboriginal and Torres Strait Islanders Australians, manifesting in crime, family violence, and suicide and self-harm. These people are also more likely to be unemployed, to live in rented premises, and to leave school early. (Johnstone, 2009) Tragically, the change from paternalistic attitudes to the Aboriginal and Torres Strait Islanders population, which resulted in compulsory education, towards more self-determination has resulted in fewer children completing school or higher education. And Australia is well behind New Zealand in training; there are very few lawyers, doctors, and other trained professionals from the Aboriginal and Torres Strait Islanders population. (Andanda, 2005) Ethical And Legal Issues Raised By These Barriers To Health Care In terms of social determinants, the Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, identifies a range of factors impacting on health that vary by location. (Human Rights and Equal Opportunity Commission, 2005) This includes income levels that fall from 70% of non-Aboriginal and Torres Strait Islanders levels in major cities to40% in very remote areas (where costs of living are correspondingly higher), and levels of employment that fall from 57% in cities to 46% in very remote areas –which will almost certainly fall further as the Community. (Arabena, 2005) Development and Employment Program is dismantled. Indeed, it has been suggested that current government policy incorporates ‘categories of competence’ with particular salience to Aboriginal and Torres Strait Islanders residents, Arabena suggesting three levels: (i) competent Aboriginal and Torres Strait Islanders who lives in city areas and who should have no entrée to Aboriginal and Torres Strait Islanders -specific funding; (ii) those who reside in remote areas and require capability because of disadvantage-related circumstances and should be helped; (iii) those who carry on to choose to live in deprived area and who want to lack proficiency, that is, those who cannot be assist at all. (Arabena, 2005) This presumption of ‘choice’ flies in the face of the lived reality of most remote Aboriginal and Torres Strait Islanders. (Hunter, 2006) The reality is that it is highly unlikely that reliance on government transfers in such settings will be substantially reduced in the foreseeable future. Indeed, the level playing field of a globalised economy will present more challenges than opportunities, particularly with educational retention. (Biddle, Hunter, Schwab, 2004) and performance (Zubrick, Silburn, De Maio, 2006) significantly worse in remote areas. This obviously has implications for ‘fair equality of opportunity’ and, consequently, for the health and wellbeing of individuals and communities. (Altman, 2005) Other relevant factors known to be worse in remote Aboriginal and Torres Strait Islanders settings include the education level of primary carers, family financial strain and household crowding. (Zubrick, Silburn, De Maio, 2006) It should thus be no surprise that the foundations of health care and ethical wellbeing – the growth and health of children – are poorer in remote than in urban Aboriginal and Torres Strait Islanders populations. (MacKerras, Reid, Sayers, 2003) In such settings psychosocial development is further challenged by rapid changes in family structure and function that have occurred over the last four decades and which have had particular salience for paternal roles. (Hunter, 1999) Across Australia, young Aboriginal men –fathers and role models – have staggering rates of arrest and incarceration (Krieg, 2006) that, at least in non-metropolitan settings, are clearly associated with alcohol abuse. Indeed, in some remote Queensland communities arrest has become a normative experience for young men, most commonly as a result of alcohol-related family violence; those most vulnerable being young women (mothers) and children, among whom there are also dramatically elevated rates of sexually transmitted infections. (Forrester, 2005) With data from Western Australia showing rates of HIV infection increasing significantly in the Aboriginal population, and parallels drawn to the patterns of transmission in sub-Saharan Africa, (Forrester, 2005) the threat for rural and remote communities is grave (particularly given the conjunction of sexually transmitted infection endemicity, high rates of incarceration, alcohol-relatedbehavioural disinhibition, lack of investment in effective preventive programs, and wariness of health services). By their effects on family life and the psychosocial developmental tasks of childhood these manifestations of disadvantage support the transmission of vulnerability across generations. Furthermore, the vulnerability of Aboriginal and Torres Strait Islanders is increased not only as a result of exposure to a larger number and more intense levels of risks, but also to compromise of those family, social and service factors that would otherwise support resilience, the complex interactions of which across child development can result in what has been termed ‘risk amplification’. (Krieg, 2006) Arguably, this is more so where health, social and other services mandated to address the needs of the disadvantaged are also lacking – as is the case across most, if not all, of remote Aboriginal and Torres Strait Islanders. Ethical Position With Related Strategies, Addressing The Difficulties Regardless of how this complex area is defined, the needs of countryside and isolated Aboriginal and Torres Strait Islanders communities, as is the case for all Australians living in these areas, are enormous and unmet. Even in terms of mainstream treatment approaches, issues such as transport, (Aiken, 2004) medication literacy and compliance, and needs-based resource allocation are critical and need to be considered differently in this population. Ensuring adequate care for people suffering serious mental disorders will demand innovation and flexibility. Particularly in remote settings this should involve the inclusion of traditional practitioners in a holistic approach to health, and the development of Aboriginal and Torres Strait Islanders health care workers. (Aiken, 2004) However, with Aboriginal and Torres Strait Islanders health workers as yet unregistered (save for in the Northern Territory) standardisation of training, definition of roles and accreditation are yet to be resolved. (Beauchamp, 2009) Mainstream health care practitioners will remain essential and different approaches – from outreach specialist services to use of telemedicine approaches Beauchamp, 2009) –that need to be considered. Regardless, the gold standard should be that Aboriginal and Torres Strait Islanders health care consumers, regardless of location, should have access to mental health services of the same quality, predictability, sustainability and practitioner continuity as is available in metropolitan Australia. This should include substantially improved community-based health care services with particular attention to addressing non-clinical needs. Although those working in these roles might or might not be Aboriginal and Torres Strait Islanders , a corollary gold standard should be that Australian health care consumers should expect equitable distribution of Aboriginal and Torres Strait Islanders practitioners at all professional levels and invisibility’, the last referring both to high levels of unrecognised and untreated illness, and to the lack of understanding of the difficulties Aboriginal and Torres Strait Islanders people experience in accessing help. That is, where there are services – according to the 1999 Community Housing and Infrastructure Needs Survey 30–50% of residents of discrete Aboriginal and Torres Strait Islanders communities have no access to allied health or health care workers. (MacKerras, Reid, Sayers, 2003) Access to Aboriginal and Torres Strait Islanders health professionals is even more restricted and particularly so at higher professional levels – a ‘pear shaped’ distribution weighted towards service roles with least training and responsibility. Although there is increasing attention to developing the Aboriginal and Torres Strait Islanders health workforce, because of basic educational disadvantage this has not, as yet, resulted in significant gains, with students from remote areas faring worst. (Altman, 2005) Developing the health care workforce is complicated by ambiguities and tensions historically associated with two quite different approaches. On the one hand are ‘treatment’-orientated services that operate, largely, through State Health Departments. On the other are social and ethical wellbeing models that are funded through the Commonwealth. The tensions have been reduced, somewhat, through the Social and Ethical Well Being Framework, (Altman, 2005) which identifies five key strategic directions: (i) focus on children, young people, families and communities; (ii) strengthening community-controlled services; (iii) improving access and responsiveness of health care; (iv) coordination of resources and planning; and (v) improving quality, data and research. Hopefully, significant Council of Australian Governments funding increases will flow to rural and remote and to Aboriginal and Torres Strait Islanders in 2007. (Blackwell, 2007) For the improvement of Aboriginal health, Australia has to recognize its past and the Aboriginal and Torres Strait Islanders within that record; we require a national understanding and autonomy for Aboriginal and Torres Strait Islanders with an importance on cultural stimulation and preservation. (MacKerras, Reid, Sayers, 2003) Management of services, so as to Aboriginal citizens take liability for their health, is essential to enhanced health results. There is a nationwide network of health organisations controlled by Aboriginal and Torres Strait Islanders communities who are delivering effective and culturally sensitive health care. This network requires more people and more money. It is a myth that vast amounts of money have already been spent (and wasted) on Aboriginal and Torres Strait Islanders health. Despite higher levels of morbidity, health spending per head is lower for aboriginal communities than it is for the rest of the population. All Aboriginal and Torres Strait Islanders should have access to community health organisations with health promotion, primary health care, and research skills. The Bibbulung Gnarneep ("solid kid") project in Western Australia is a good example. (Cohen, 2001) Ownership by and guidance from the Aboriginal and Torres Strait Islanders community, together with quantitative and qualitative research, yield outcomes that can be rapidly transformed into community action or as leverage for funding. This is also the model for the new National Cooperative Research Centre in the Northern Territory. Government departments have been reluctant to hand over funds and responsibilities to Aboriginal people in areas such as health, and with many new activities, unrealistic expectations are put on the Aboriginal and Torres Strait Islanders services to perform. National action is required in housing, public utilities (including clean water), education, and welfare. (Cohen, 2001) Responsibility is too fragmented between Commonwealth state, and local government. Failure of Previous Strategies Previous strategies may have failed because early attempts failed all over Australia, and were followed by some decades of neglect of Aborigines. Hunter, (2006) notes that the ideal of protecting the Aborigines from violence and cruelty was replaced by a policy of protecting colonists from Aborigines. For 30 years, magistrates and "Native" police controlled the Aborigines to allow the colonists to develop the land. Earlier policies of neglect were followed by government policies which increasingly controlled the lives of Aboriginal people. (MacKerras, Reid, Sayers, 2003) While Western Australia received self-government from Britain in 1890, the Governor remained responsible for Aborigines until 1897. (Blackwell, 2007)The act enabling self-government provided for one per cent of gross revenue of the colony to be appropriated to the welfare of Aborigines' but as soon as the new government was formed in Western Australia, this was revised and drastically reduced. The level and manner of distribution of funding for services to Aboriginal families has since been open to debate. The 1886 Aborigines Protection Act was the first comprehensive attempt to regulate Aboriginal people, but it was legislation in 1905 (The Aborigines Act), which began the wide sweeping control over Aboriginal families. This was modeled on Queensland legislation incorporating policies of protection and rigid segregation of Aborigines. Similar legislation occurred in other states, and also influenced discriminatory legislation passed in South Africa early this century (Bennett, 2006). It set up mechanisms to control all Aboriginal contacts with the wider community, to enforce the assimilation of their children and to determine the most personal aspects of their lives. For example, honorary protectors employed by the Aborigines Department controlled access to employment of Aborigines through a system of permits and agreements-in cooperation with the police. (Bennett, 2006) The police played a fundamental role in enforcing Aboriginal policies during this time with their dual role of both "protector" and "prosecution". (Johnstone, 2009) Understanding the history of policies which so devastatingly controlled and disrupted Aboriginal families, brings all Australians to awareness that social policies must be designed with care and consideration for the far-reaching effects they have on families. We learn that involving particular communities in determining directions for their families can avoid social policies which overlook their real needs. From this understanding we begin empowering Australian families to value the future development Theoretical Perspectives on Ethics A major bioethics literature previously present with reference to distributive justice and setting onward other theories of justice. (Beauchamp, 2009) More freshly, two theorists, Peter Singer and Thomas Pogge, have talked about questions regarding world justice specially. Peter Singer, a utilitarian, states that, though it would be better for the wealthier nations to worry about the world’s poverty out of concern, it will be more tactical, politically, to make arguments for the reduction global inequalities based on self-interest. (Singer, 2002) Scarcity and inequality offers rich circumstances for violence and brutality. Thomas Pogge takes a diverse theory, one that comes under the shell of compensatory justice. (Pogge, 2003) Most citizens, he assumes, are opponent of coercion, hunger, and severe lack of resources. The divergence takes place when talking about responsibilities. Hence, “our economic strategies and the world economic organisations we oblige build us essentially and morally liable for the continuation even stress of world starvation.” (Johnstone, 2009) The accessible world system mirrors the welfare and main concerns of the rich and influential states and steadily keeps the benefit of the globally deprived. To that ending, he answers, we in the wealthier nations have positive compulsions, not out of contributions, but with no reason, to improve accessible injustice. Public health ethics, eventually, is a realistic field. Structuring on the further theoretical subjects, like political science, philosophy and economics that place critical basis connected to economics, politics, and justice of world formation, public health ethics should find to plan immediate structures in actual time, with actual limitations, and in actual circumstances. Bioethics must make an imbursement equally to the theoretical and realistic work. (MacKerras, Reid, Sayers, 2003) Sensible direction from public health ethics must develop immediately with more and more advanced and reactive theory linked to impartiality and international public health. The troubles are enormous, and reactions have to have the best scholarship after them. The majority of worldwide health ethics problems, though, basically stem from world prejudices. Certainly, questions of suitable values of healthcare or what is due to contributors’ befall debatable if the sharing of international wealth was more impartial. Bioethics, which has begun confrontation of health ethics since the delivery of the field, has thus begun to busy in questions of world justice without essentially in search to do so. Conclusion Aboriginal and Torres Strait Islanders are disadvantaged by comparison with the mainstream population of this privileged country and this is compounded for those living in rural and remote settings. In contrast to romanticised constructions that conflate remoteness, ‘traditionalism’ and’ authenticity’, the lives of most Aboriginal people living in remote communities and on the fringes of rural towns are not romantic – they are hard. As a consequence disorders of health and of social and ethical wellbeing are common but often unrecognised and frequently not addressed through the health care system. That the strength and integrity of Aboriginal and Torres Strait Islanders people rises above that uncompromising social landscape is despite rather than because of what, historically, has-been ‘done’ in their ‘best interest’. Indeed, we should be mindful of the persistence of racism across urban and rural Australia, and in the health care system itself. Developing effective services, then, will demand more than ensuring that Aboriginal and Torres Strait Islanders people have equitable access across the full spectrum of interventions from health care promotion to providing for long-term care, or that those living in rural and remote settings are not disadvantaged, or that such services are attuned to local circumstance and custom, or that the Aboriginal and Torres Strait Islanders workforce is appropriately expanded. It will demand all and more – that is a matter of equity and social justice. However, improved services, alone, will not eliminate the excess burden of mental disorder and ethical distress experienced by remote Aboriginal and Torres Strait Islanders. In these settings it will also require broad and disciplinary, health-affirming approaches that are attuned to the circumstances and priorities of remote communities, and initiatives that support empowerment at individual, family and community levels. (Grbich, 2004) In particular, real change will demand that these approaches are responsive to the needs of remote children. There are existing examples of each. Ultimately it will also demand much broader social change, such as suggested by Grbich (Grbich, 2004). That, however, is a long-term political agenda. Meantime, although health practitioners and those committed to the health care needs of Aboriginal and Torres Strait Islanders of rural and remote Australia should be cognizant of, and willing to challenge underlying social disadvantage and injustice, it is important to avoid being still by the task of social change. Although getting reliable and accessible services in place will not be sufficient, it would be a good start. References Aiken, L. (2004) Morality and Ethics in Theory and Practice. Springfield, Ill: Charles C. Thomas. Altman J. (2005) Development options on Aboriginal land: sustainable Aboriginal and Torres Strait Islanders hybrid economies in the twenty-first century. In: Taylore L et al., eds. The Power of Knowledge: The Resonance of Tradition. Canberra: Aboriginal Studies Press. Andanda, P. (2005) Module Two: Informed Consent. Developing World Bioethics 5 (1), 14-29. Arabena K. 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(2006) The Western Australian Aboriginal Child Health Survey: Improving the Educational Experiences of Aboriginal Children and Young People. Perth: Curtin University of Technology and Telethon Institute for Child Health Research. Read More