Thank you for having me here today to talk and thank you for you introduction
Let me first acknowledge the Aboriginal Australian people of the greater Cairns region.
I am sure you are all aware of the 1978 Alma Mata declaration. In this declaration it was famously noted that health is ‘not simply the absence of disease’ but a ‘state of physical, emotional, social and mental well being’.
This definition has since been widely used and accepted as the guiding principle of health care around the world, not just among health practitioners such as yourselves, but among policy and health officials too.
Unfortunately, the apparent consensus around what constitutes ‘health’has not always been successfully modelled in practice; the failure to do this has been particularly stark in the case of remote Indigenouscommunities in Australia. ‘Health’ for these communities – two of which are within 100km of this very hospital – continues to be characterised by appalling levels of morbidity, and life expectancy well below that of mainstream Australia.
It will not be news to many of you that a majority of the causes of this morbidity and mortality are preventable. However, what I want to stress, is not so much that the diseases themselves are preventable, but that their prevention relies on more than just the provision of good clinical care. It relies on the enabling of people in these communities to look after themselves.
This is something that is perhaps more difficult to teach than the diagnoses and prescription of Western medicine. And it is often more unpalatable to practice, since it involves making hard decisions about forcing individuals to take responsibility for their own medicines, their own diets, their own exercise regimen while supporting others to do the same.
But I firmly believe that it is only through this promotion of a physical, emotional and social responsibility that these remote communities will
actually achieve a genuine ‘state of well being’ that the Alma Matadeclaration referred to.
But before I delve into this much further, I want to talk a little about the situation in Cape York.
Experiences in Cape York
[NB: Delivered by Tania Major]
Noel often speaks of growing up in Cape York as part of a large family in a small community. What he always emphasises, is that although hisfather’s house was small, and their family relatively poor, the home was ahappy one and their environment clean and well maintained. They were healthy as children.
In the last three decades, however, the dysfunction of passive welfare and alcohol have meant that health – as with so many other things – have stopped being the priority they were during Noel’s childhood.
Poverty in Indigenous communities is now not the driver of poor health, but just one of a number of compounding factors. Instead welfare passivity and alcohol are the major drivers of multiple behavioural dysfunctions.
Alcohol abuse has reached proportions that are unlikely to be solved by placing individuals into expensive rehabilitation clinics – although this may form part of a wider solution.
With respect to poor nutrition, problems with access and availability to good food compound the apathy about doing anything to improve individual diets. This has made it almost impossible to prevent problems like diabetes and coronary heart disease developing at alarming rates.
I know that you would all be familiar with appalling health statistics of Indigenous communities. Likewise, you would all know that the poor health status of those living in remote Indigenous communities is linked to both individual choices and social and policy barriers.
But a key question arises – one which is particularly relevant to you as the new generation of medical practitioners. Why, if we know what the key determinants of poor health in Indigenous communities are, have we not been able to address them?
Taking Responsibility: the Cape York Agenda
I believe that large-scale and sustained improvements in health, willrequire interventions that change not only individuals’ actions but alsocommunity norms, health systems, and the decisions of policymakers.
Achieving these things in tandem is of course larger than any one person. However, understanding this, will be an important step in your contribution to what I believe to be the ‘common cause’ – helping Indigenous individuals and communities to take responsibility.
Noel’s work and that of the Cape York regional organisations are guided by the Cape York Agenda.
At the core of the Agenda is a metaphor for individual success – the staircase of opportunity – which provides a blueprint for policy and program development.
Staircase of Opportunity
(e.g. interaction of welfare, CDEP, minimum wage, salaries, and effects of Tax rates)
(e.g. Education, Financial services, health, Justice Groups, Functioning councils, etc.)
Basic Social Norms
(e.g. intolerance of substance abuse and child abuse, expectation of school achievement and health, etc.)
The base of this staircase is formed by basic social norms. Building on this foundation, enabling structures such as good schools and educational attainment, supportive community organisations and appropriate (non- passive) government services, provide a framework to help individuals develop their skills and decision-making capacity. Finally, rational incentives provide the stepping stones to individual success, with each person making choices about where and how they wish to live and work. The range of choices afforded a person, constitutes freedom.
Let me talk to each of these levels in turn.
1. Social & cultural norms
The foundation for the staircase is the establishment or re-establishment of basic expectations around health-related behaviours.
In mainstream Australia, there are a number of social norms which have a demonstrable link to individual and community health. Extreme binge drinking and alcohol-related violence are not accepted; basic hygiene and house maintenance are expected; and domestic and sexual violence is not tolerated.
These health-related social norms are partially upheld by tangible activities and services such as public health messaging, widespread medical facilities, basic law enforcement, and well integrated health education in schools.
But there are also intangible aspects to ‘health norms’. These may beseen in the public’s understanding of the link between certain behaviours and personal health (for example the effect of smoking). This understanding contributes to and strengthens basic social expectations – such as the expectation that children will be clean and fed when they arrive at school; that houses will be maintained to a certain level of cleanliness; and that domestic or sexual violence are unacceptable and will result in retribution.
These intangible norms not only provide guidance but empower individuals to seek advice and help when they are in need.
Both tangible and intangible aspects of mainstream health-norms act as strong influences upon individual behaviour and help ensure that positive health-behaviours prevail.
In Cape York, by contrast, there is a general social order deficit, part of which is constituted by an erosion of health norms. For example, there is no expectation (and frequently no understanding of the need) to maintain personal or household hygiene.
There is no basic social norm to promote a balanced and healthy diet. Domestic and sexual violence are (if not accepted) widespread and unchecked, with knock-on effects for the mental and physical health of multiple generations. And the negative social norm of excessive drinking
places pressures on the non-drinkers to join in, endangering not only the drinkers but the families and communities who often suffer the violent ramifications.
There is a clear need for a primary health care model in Cape York which prioritises and facilitates the rebuilding of health-norms. Unfortunately experience shows us that centralised health systems generally develop primary health care services based on generic models developed for regional and urban Australian settings. Such models fail to take account of the vastly different circumstances of individuals and families in remote Indigenous communities, with the end result being a set of services which are poorly matched to community health needs.
Rather than a set of services determined remotely and with little reference to day-to-day concerns, Cape York needs a primary health care model which develops public health interventions and advocacy programs with the stated aim of promoting individual responsibility through better health norms. Such a model would:
- ? Make space for public health campaigns targeting high-risk behaviours and absent health norms in any given community.
- ? Establish services that help re-establish health norms in the family and extended family through:
o Fostering of good doctor-client relations
- ? Can establish links with schools, shops, community organisations
and reform projects to help develop appropriate expectations
- ? Sets up regulatory mechanisms around environmental health
standards, good dietary and nu