. The eras of European settlement, segregation and protection, assimilation and restrictive legislation (Aboriginals Protection and Restriction of Sale of Opium Act (1897) all had a profound impact on the health of Indigenous Australians (Brown 2014). Throughout that post-invasion period Indigenous Australians were subjected to colonisation, dispossession and racism leading to loss of culture and identity. These foundational social determinants are the structural macro-social factors (Lynch 2000) that have shaped the current social determinants of Indigenous health. These distal factors (Reid & Wien 2013) have resulted in significant health inequalities (Brown 2014).
Colonisation during the eighteenth and nineteenth centuries saw the introduction of devastating diseases and dispossession and has had an ongoing impact on the health inequities amongst Australia’s Indigenous people (Mitchell 2007). Dispossession, the act of depriving the Indigenous Australians of their land led to the loss of identity and culture, core determinants of Indigenous health.
Racism occurs through oppression and the unequal share of opportunity in a society (Paradies et.al. 2008). It has adversely affected Indigenous health historically, and still affects Indigenous Australians today. Colonial claims of “Terra Nullius” denied Indigenous Australians the right to their country. Marginalisation and exclusion of Indigenous Australians (Paradies 2007) have negatively impacted on the social capital of Indigenous Australian and have resulted in institutional racism (Baum 2007).
According to Grieves (2014) culture forms the basis of identity and flows through all Indigenous kinship and family structure. Indigenous Australians’ identity is intrinsically linked with country. Land, body and spirit as explained by Reid (1982) in Burgess & Morrison (2007) are the interconnected elements that underpin Indigenous health. A weakness in one results in overall weakness. Loss of connection with country due to removal, breaking up of kinship and resettlement meant the loss of social cohesion and culture. Complete Government control over all aspects of the lives of Indigenous Australians through legislation only added to the ill health of the indigenous population.
Saggers & Gray (2007) remark that there is a causal pathway that links the foundational determinant of Indigenous health to the current determinants of health that have denied Indigenous Australians full participation in Australian life.
Part 2
2. The meaning of health and well-being to Indigenous Australians has a broader definition than defined by the WHO (2017) which reads that ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. The Indigenous, more holistic view of health also includes cultural and emotional well-being, whereby each individual can achieve their full potential and together achieve a healthy community (NACCHO 2016). The ACCHSs approach to healthcare is underpinned by this very philosophy. Community controlled and operated primary health care can deliver the kind of integrated healthcare that is culturally sensitive, comprehensive and holistic (NACCHO 2016). ACCHSs are integrated Aboriginal organisations which are based in Aboriginal communities and initiated by Aboriginal communities and provide community cohesion (Couzos & Murray 2008).
3. The nature of consultation with Indigenous Australian people in primary care at Community Controlled Health Services (ACCHSs), in this instance Townsville Aboriginal and Islander Health Services (TAIHS), had been documented by Larkin et al (2006). Of the 1221 consultations, 1994 managed issues (multiple issues per consultation, seen by various healthcare professionals) were documented. Most prevalent conditions managed were; Type 2 diabetes; upper respiratory tract infections; hypertension and antenatal care. Larkin’s et. al. (2006) study revealed 45.9 per cent of all patients were male, 27.9 per cent of all patients were children under the age of fifteen and less than ten per cent were 65 years and over.
Comparing the above figures to non-Indigenous Australians is not straightforward as data on mainstream primary healthcare for non-indigenous Australians is limited according to the Australia’s Health Report by the Australian Institute of Health and Welfare (AIHW, 2016 p. 265). However, according to the Bettering the Evaluation and Care of Health (BEACH), general practice in Australia (2015) report, females accounted for 57 per cent of consultations, one fifth were less than 25 years old, and 31 per cent were 65 years or older. Most common condition managed were hypertension, check-ups, upper respiratory tract infections, depression and diabetes.
The complex care needs of those presenting at TAIHS and the management of multiple issues by various health care professionals during one consultation supports the importance of ACCHSs (Larkins et.al. 2006).
4. The issues presented and managed at ACCHSs are complex, and required a multi-care approach. Delivery of care was undertaken at various TAIHS clinics (Larkins et. al. 2006), such as the general clinic, the maternal and child health clinic and the diabetes clinic. In addition, outreach visits and home visits also occurred. This multi approach, by ACCHSs, to patient-centred healthcare differs with main stream healthcare and funding should be targeted as such. For high prevalence, chronic conditions (such as type 2 diabetes), ongoing care as well as preventative screening should occur to prevent health issues further downstream. Continued funding for outreach clinics is of importance due to the remoteness of rural communities. Furthermore, a significant proportion of care provided was antenatal care, funding-focus should be on maternal health and the health of children (also a significant part of the demographic presented. The community controlled and integrated model of care practised by the Institute for Urban Indigenous Health (IUIH, 2014) in collaboration with government, research bodies, other community services and health care providers, is a prime example on how to systemically deliver the kind care required to improve the health of Indigenous Australians. This approach of self-determination, in the form of primary health care might eventually lead to health equity (Keleher, 2001).
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5. Addressing the determinants of Indigenous health is complex as many of the health determinants are outside the sphere of the health sector and require multi-sectoral interaction drawing from multiple resources. Addressing education, employment, housing and welfare as well as social capital (Bourdieu 1986) requires the tearing down of silo mentality (Clapham et.al. 2007). The ACCHSs have successfully provided communities with self-determination through their community based and integrated network approach (IUIH, 2014), in line with the WHO definition of primary health care as defined in the Alma Ata declaration (WHO 1978). Primary health care delivered in this manner has contributed to many successful programs which have reduced the Indigenous health inequities. An example of this is the Mums and babies project at the TAIHS, which has reduced smoking during pregnancy, perinatal mortality and premature births (AHRMC, 2015).