“When I heard about the intervention ... I felt like someone had declared war on me again
– on me and on my people.” Reverend Ray Minniecon, 13 February, 2010
Implications of the Social Determinants of Health model on the Northern Territory
Emergency Response
– on me and on my people.” Reverend Ray Minniecon, 13 February, 2010
Implications of the Social Determinants of Health model on the Northern Territory
Emergency Response
This paper will discuss the social determinants of health model in relation to the Northern Territory Emergency Response (NTER). Marmot’s model will be outlined followed by a brief introduction to the inequality that exists between Indigenous and non-Indigenous Australians. The historical interactions between the two cultures will be outlined to provide an understanding of the motivations behind the NTER. Four areas of the intervention will be discussed including details of the problems and how the government attempted to address them. Aspects of governmental policy which work against the social determinants of health model will be highlighted and suggestions will be made as to how the model could be used to overcome the problems and work to eliminate inequality.
Evidence for the social determinants of health model was first shown in the Whitehall study, a seven year longitudinal observation of 17 530 British Civil Servants (Marmot, Rose, Shirley & Hamilton, 1978). Marmot and his colleagues noted that civil servants high on the organisational hierarchy were less likely to suffer from coronary heart disease than those below them. The level of employment was a stronger predictor of risk of coronary heart disease than conventional factors including smoking, cholesterol levels, leisure-time physical activity, blood pressure and obesity. There was something about the employment gradient that was putting individuals at the bottom of the organisational heap at greater risk of heart disease.
It may appear reasonable that poverty is related to low health outcomes with poorer individuals having limited access to water, food and medical care. However, as demonstrated in the Whitehall study, when access to basic needs is relatively constant the effect of the social gradient is still evident (Marmot, Rose, Shirley & Hamilton, 1978). The effect holds across the developed world where access to water and medical care does not fully explain what Marmot refers to as the status syndrome (Marmot, 2006). Marmot suggests that other needs of those on the lower end of social hierarchies are not being met – the needs for autonomy and full participation in society. When these needs are left unmet, metabolic and endocrine changes can lead to increased risk of disease. Low social position and the subsequent limitation of social participation and autonomy has been linked to biological stress pathways (Marmot).
While biological factors point to chronic activation of stress responses as one of the mechanisms of the social gradient’s affect on health, it is important to understand what it is about the lower end of social hierarchies that causes stress. In his paper published in 2006, Marmot suggests that receipt of social support and participation in social networks are related to increased disease rates and mortality. Marmot sums up his argument succinctly stating “Deprived of a clean, safe neighbourhood, meaningful work, opportunities for quality children’s education, freedom from police harassment and arrest, and freedom from violence and aggression, it is harder to have control over one’s life or be a full social participant” (Marmot, 2006 p. 1305). Well-being and social health are determined, in part, by an individual’s ability to fully participate in social decision-making and exercise a level of self-determination (AIDA, 2010). The relative degree of autonomy and opportunities for social engagement underlie the social gradient’s effect on health (Marmot, 2006).
The differences in health and mortality rates between Aboriginal and non-Indigenous Australians are stark examples of the status syndrome. The average life expectancy of Aboriginal men is 59 years, compared with 77 for non-Indigenous males (Australian Institute of Health and Welfare, 2006). Aboriginal Australians are three times more likely to suffer from heart attacks or strokes compared to other Australians and are 50% more likely to die from it (Indigenous Disadvantage, 2008). Material deprivation alone cannot account for these differences; Aboriginal Australians are a socially excluded minority (Marmot, 2005). To understand the etiological factors which led to the problems the NTER aimed to address requires an understanding of the interaction between Aboriginal and non-Indigenous people since white settlement.
The exact population of Aboriginal people before colonisation in 1788 is not know, however it is estimated that by 1900 at least six out of seven Aboriginal people were killed or had died as the result of introduced diseases (Muirhead, n.d.). By 1911 all states in Australia had introduced legislation which gave the government the responsibility of ‘protecting’ Aboriginal people. This delegation gave the government control over Aboriginal people, with the right to restrict employment, force movement onto stations, as well as forcibly remove children from their families. Children were taken from their families until 1969 (ReconciliAction Network, 2007). Exact numbers are not known, but it is estimated that 6,200 children were stolen between 1883 and 1969 in New South Wales alone (Read, 2007). While stations and reserves were designed to prepare Aboriginal people for assimilation into white society, in reality they restricted freedom of movement and access to education, proper nutrition and health care (Banari, n.d.). These policies lead to the separation of many families (Banari, n.d.) and “laid the foundation for generational exclusion from mainstream society” (AIDA, 2010, p.7). As evidenced in this brief synopsis, the government has restricted autonomy of Aboriginal people since colonisation.
While the last 20 years have seen many changes in government policy, it appears full participation in society has not yet been achieved for Aboriginal people, whether that society is based on western or Aboriginal culture. The differences between Aboriginal and mainstream cultures is difficult to understate. The Aboriginal worldview is one of interconnectedness (AIDA, 2010), based around the “four pillars of traditional society: belief system, spirituality, land and family” (Randall, 2007 p.5). Many government policies have failed to understand this worldview and resulted in feelings of alienation and collective despair (O’Loughlin, 2008).
The Little Children Are Sacred report released on 15th June 2007 highlighted the problem of abuse and neglect of children in Aboriginal communities in the Northern Territory (NT) (Wild & Anderson, 2007). The report suggested the problem was caused in part because of the breakdown in Aboriginal society and culture. On the 21st of June, 2007 Aboriginal Australians were subjected to an intervention as the government declared the situation of child abuse in Aboriginal communities in the NT a ‘national emergency’ (Altman, 2007). What followed was the NTER which saw 600 soldiers from the Australian Defence Force sent into Aboriginal communities without consultation or even warning. In his speech at a rally coordinated by the Stop the Intervention Collective Sydney in February 2010, Reverend Ray Minniecon, a descendant of the Kabi Kabi people of South-East Queensland commented “When I heard about the intervention ... I felt like someone had declared war on me again – on me and on my people.”
The life span, health and mortality gap between Indigenous and non-Indigenous Australians existed long before the intervention was announced. However, many of the policies rolled out as part of the NTER continue to threaten the autonomy and social integration of Aboriginal people.
The NTER adopted only two of the 97 recommendations made in the Little Children Are Sacred report, instead focusing on land, income management, pornography and alcohol control and health (Hinkson, 2008). In its health impact assessment of the NTER the Australian Indigenous Doctors Association (AIDA) noted that the method of introduction, and continued running of the response was likely to contribute to the trauma and disease experienced by Aboriginal people (AIDA, 2010). The NTER overlooked the central importance of dignity to health (Durie, 2008). The government’s actions in each of these four areas have perpetuated the restriction of autonomy and exclusion from society experienced by Aboriginal people.
Land is central to Aboriginal well-being (Swan & Raphael, 1995). As one of the four pillars of traditional society, land (and an individuals’ connection to it) is of central importance to Aboriginal people (Randall, 2007). In the 1960’s the Australian government began returning land to traditional owners (ReconciliAction, 2007) however without control of the land the government has been hesitant to invest in housing and infrastructure (AIDA, 2010). This has contributed to what the Little Children Are Sacred report called a “disastrous and desperate” (Wild & Anderson, 2007 p.195) housing situation with many homes overcrowded and poorly maintained. The NTER aimed to address this problem by instating the NTER Act which applies to more than 500 Aboriginal communities and covers more than 600,000 square km – almost half of the NT (Ting, 2009). Under the act the government has compulsorily acquired five year leases over 64 areas of Aboriginal land. While the underlying freehold title remains unaffected, the government has control to use the land for any purpose consistent with the Act’s objectives (Ting). For areas not compulsorily acquired the government made the provision of funding for new housing conditional upon the signing of forty-year leases (Wiseman, 2009) under which the government would then release the $1.7 billion allocated to remote housing in the NT (Stop the NT Intervention, n.d.).
After lengthy negotiations which began in March 2007 the federal Minister for Aboriginal Affairs Jenny Macklin announced in May 2009 that she would enforce permanent acquisition of Aboriginal land (Toohey, 2009). Repeated attempts to broker a deal between the federal government and the Tangentyere Council (representing 15 of the 18 town camps) were slow and tedious. One of the main points of contention was who would manage the housing (Donald, 2009). The commonwealth insisted that Territory Housing control the housing assets while the Tangentyere wanted the Central Australian Affordable Housing Company (a company it has created – with government funding), to manage the housing (Toohey). Yananymul Mununggurr, Chief Executive of the Laynhapuy Homelands Associations said “Indigenous people are being asked to give up the basis of their culture and social organisation, and their only economic asset, in return for assistance that any other Australian citizen with the same socioeconomic status would be entitled to” (Ting, 2009).
As this debate between the Australian Federal Government and the Tangentyere Council highlights, the issue is one of control. Full participation in society and autonomy includes a sense of security about living arrangements and permanency of residence. This is Aboriginal land. Through the restriction of funding the government has again taken control and are dictating where Aboriginal people can and cannot live. The actions and policies of the intervention have worked to restrict the autonomy and further segregate Aboriginal people from mainstream society as they are not given the same rights as other Australians. As outlined in the social determinants of health model, this may see the health of Aboriginal people further deteriorate.
Were future governmental policies based on the Marmot’s model they could more successfully tackle the current housing crisis. Through consultation with Aboriginal communities the government could address their need for autonomy and social participation. Instead of hiring contractors who fly in and out of the communities to build houses, training facilities, apprenticeships and continued employment could all be facilitated through a new housing scheme. However, a scheme developed by the government and imposed on Aboriginal communities would not be appropriate. This scheme would need to be planned, initiated, run and supported by community members.
Based on 2006 census data up to 7,500 children in the NT aged three to 17 are likely to be missing out on schooling. The NTER aimed to use income management to increase participation in training and education and to ensure that government payments were being spent on priority needs (Department of Families, Housing, Community Services and Indigenous Affairs [FaHCSIA], 2009). The FaHCSIA minister at the time, Mal Brough claimed income management would “extend the principal of mutual obligation beyond participation in the workforce to a range of behaviours that address, either directly or indirectly, the welfare and development of children” (Brough, 2007). Mutual obligation refers to the idea that community members should give something back to society for their welfare payments. However, the scheme was introduced only in the NT, and only applied to Indigenous people. The inequity in this policy is unmistakeable.
The compulsory management of government payments was potentially one of the most controversial elements of the NTER. Income management covers all welfare benefits and applies to all members living in prescribed communities selected by the government, including over 70% of the Aboriginal people living in the NT (FaHCSIA, 2009). Fifty percent of income and 100% of lump sum payments are managed by Centrelink. The government can deduct funds to cover meals children receive at school (Behrendt & McCausland, 2008) while the remaining managed income is directed into an account linked to a BasicsCard which can then be used to purchase food, medicine, clothes, electricity and other essential household items. The BasicsCard can only be used at certain stores, which often require holders to queue at separate registers resulting in what Lauren Mellor from the Intervention Rollback Action Group called an “apartheid-like situation” with Aboriginal people on one side of the store and the rest of the community on the other (Coady, 2010).
The rushed implementation of the program and the limited consultation with communities left many outraged (Quixley, 2010). Under the guise of ‘protecting’ or ‘helping’ Aboriginal people, the government restricted the autonomy of communities and placed another barrier between Aboriginal people and their full participation in society. While this policy was intended to help close the gap in health standards, it may only serve to increase it. Income management, in the form implemented by the NTER, may not be the answer to the low school participation rates in the NT. On the other hand, perhaps policy makers were not asking the right questions.
Application of the social determinants of health model to the problem of school attendance may be highly beneficial. The first priority would be to identify the underlying causes of non-attendance. Consultation with Aboriginal communities may reveal a hesitation to send children to mainstream schools where language and cultural barriers have not been addressed. Cultural safety is a matter of priority (Wood & Schwass, 1993). Over 40% of school age children in the NT are Indigenous, however only seven Indigenous principals are employed by the government in this region (AIDA, 2010). While employment of Indigenous staff does not ensure cultural safety, it may be a step toward increasing participation of community members in decision making. This participation in society would see one of the basic needs of the community being met and would be likely to result in better health outcomes for Aboriginal communities.
Alcohol and substance abuse were identified as significant problems in the Little Children are Sacred Report. Health concerns included foetal alcohol syndrome, violence, and increased vulnerability to sexual abuse (Wild & Anderson, 2007). In an attempt to resolve these issues the NTER introduced blanket bans on alcohol and pornography in some Aboriginal communities. This included the placement of signs at community entrances announcing the bans. One Aboriginal community member commented “Like them big signs they put up there. It is as though they thought all black fellas are alcoholics and paedophiles” (AIDA, 2010). The restriction of alcohol in Aboriginal communities was seen as racist and discriminatory. Alcohol misuse is not just an Aboriginal problem. The placement of signs outside of Aboriginal communities reinforced the divide between Aboriginal and non-Indigenous communities, further excluding Aboriginal people from full participation in society.
The rushed implementation of the NTER did not allow corroboration with existing programs. Recognising the problems being perpetuated by alcohol abuse over 100 Indigenous communities in the NT had voluntarily become ‘dry’ before the intervention (Racing, Gaming and Licensing Northern Territory, 2006). Had the intervention been based on the social determinants of health model, existing initiatives such as dry communities would have been embraced and encouraged. Exploration of what had allowed these communities to make this decision could encourage other communities to make the decision themselves. Importantly, this would need to be a decision made by the community, rather than a governmental mandate to be obeyed.
Aboriginal health and well-being has severely decreased since colonisation (Muirhead, n.d.). Indigenous people are twice as likely to have a profound disability and 36% aged 15 years and older reported a long-term health condition or disability (Indigenous Disadvantage, 2008). The Little Children Are Sacred Report identified better health care as a priority need in Aboriginal communities (Wild & Anderson, 2007). In response the NTER targeted the following health areas; extra drug and alcohol rehabilitation and treatment services, health checks and follow-up treatment for children and specialist support for children who have been abused. The total budget committed is $1.3 billion including $100 million over 2 years from the 2008–2009 financial year for more doctors, nurses, allied health professionals and specialist services (Glasson, 2007). While funding is needed, the intervention may not be the best vessel through which it could be delivered. The Little Children Are Sacred Report did not recommend individual health checks (Wild & Anderson, 2007), however the government initially considered forensic examinations of all Aboriginal children to establish abuse levels which lead to “widespread fear” in Aboriginal communities (Boffa, Bell, Davies, Paterson & Cooper, 2007, p.617). The government later announced that health checks would be voluntary and would assess holistic health levels – but according to Boffa and his colleagues the damage had already been done.
The AIDA health impact assessment of the NTER raised serious concerns about the future well-being of Indigenous children and families under the intervention (AIDA, 2010). The report assessed potential health impacts of the NTER on all aspects of Indigenous health and wellbeing, not just physical health. The report found the intervention would potentially lead to ‘profound’ long-term damage and any potential physical health benefits were largely outweighed by negative impacts to wellbeing, psychological and social health as well as cultural integrity (AIDA, 2010). In-depth consultation with Aboriginal communities is needed to ensure the true needs of the community are identified and addressed. An article written by the College of Nursing in 2007 highlighted many problems with the implementation of the NTER, citing examples of the intervention being rolled out over the top of existing programs without responding to requests from these existing organisations to be involved (Gaea, 2007). Improvement in Aboriginal health will require participation from Aboriginal community members who should be given control over decision making processes.
The social determinants of health model suggests that health limited autonomy and participation are detrimental to health (Marmot, 2006). The suggestions for policy changes to the NTER outlined above all include recommendations for full consultation with Aboriginal communities and the return of control around decision making processes to the community. This may be no easy feat. As outlined previously the history of interactions between Aboriginal people and Australian government had been strained (to say the least). Corroboration with communities to resolve the profound issues discussed above will require open, honest and respectful conversation. While the government has shown moves towards rebuilding relationships with communities, interventions such as the NTER have worked to further push these two groups away from this type of conversation. Policy makers should not only recognise the mistakes of the past, but should work to never allow them to occur again. This may only be achieved with understanding of Aboriginal culture, a commitment to cultural safety, and an appreciation for the benefits of health models such as Marmot’s.
As evidenced in the governmental policies of the NTER little acknowledgement was given to the social determinants of health model. Policies around land, income management, alcohol and pornography bans and health have been implemented without consultation with communities and are laden paternalistic undertones. While the NTER aimed to improve the situation in the NT, overlooking the basic needs of autonomy and full social participation the intervention may sadly prove detrimental to the situation it was trying to help. Previous policies have not been effective. The time for a new approach has come.
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