The term social and emotional wellbeing (SEWB) is used by many Aboriginal and Torres Strait Islander people to describe the social, emotional, spiritual and cultural wellbeing of a person [28917]. The term recognises their connection to land, sea, culture, spirituality, family and community which are important to people and impact on their wellbeing [28917][38676]. It also recognises that a person’s SEWB is influenced by policies and past events [38123][31181][43078]. Another term that is often used when discussing wellbeing is mental health. Mental health is a term that has been used to describe how people think and feel, and how they cope with and take part in everyday life [34695]. Many Aboriginal and Torres Strait Islander people observe mental health and mental illness as medical terms that focus too much on problems and do not properly describe all the factors that make up and influence wellbeing [28917]. Because of this, most Aboriginal and Torres Strait Islander people prefer the term SEWB as it fits well within a holistic view of health [33834]. The holistic model is more collective and has connections not evident in the mainstream view of health [43078]. One way of understanding these different terms is to think of mental health and mental illness as part of a person’s social and emotional wellbeing [28917]. The 2004 and 2017 national SEWB frameworks [2940][33834] set out nine guiding principles that were developed during the Ways Forward national consultancy [8608]. These guiding principles define the SEWB concept and emphasis that SEWB is a strength based understanding of health [28917][43296]:
Aboriginal and Torres Strait Islander culture and self-determination can be powerful protective factors in providing a buffer to psychological distress. Factors that have been identified as enhancing SEWB include; maintaining connection to country, spirituality, ancestry and kinship networks, as well as strong community governance and cultural continuity [29074]. Renewal of Aboriginal and Torres Strait Islander culture and Indigenous knowledge systems and the capacity for self-determination is increasingly being seen as fundamental to healing and supporting SEWB [41496]. There are varied experiences and expressions of SEWB [43078], and they may change across an Aboriginal and Torres Strait Islander person’s life course, so what is important to a child may be quite different to what is important to an Elder [33834]. For Aboriginal and Torres Strait Islander people, the understanding of SEWB can also vary between different cultural groups and individuals [28917].
Workshop paper presented by Mr Darren Dick on behalf of Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice CommissionerInternational Symposium on theSocial Determinants of Indigenous Health,Adelaide, 29-30 April 20071. IntroductionImproving the health status of Indigenous peoples1 in Australia is a longstanding challenge for governments in Australia. The gap in health status between Indigenous and non-Indigenous Australians remains unacceptably wide.2 It has been identified as a human rights concern by United Nations committees3; and acknowledged as such by Australian governments4. Social determinants theory recognises that population health and inequality is determined by many interconnected social factors5. Likewise, it is a basic tenet of human rights law that all rights are interconnected and that impacting on the enjoyment of one right will impact on the enjoyment of others6. Because of this synergy, human rights discourse provides a framework for analysing the potential health impacts of government policies and programs on Indigenous peoples.7 Important determinants of Indigenous health inequality in Australia include the lack of equal access to primary health care and the lower standard of health infrastructure in Indigenous communities (healthy housing, food, sanitation etc) compared to other Australians. While fundamental to improving Indigenous health outcomes, these issues are not addressed in this paper.8 Instead, this paper considers the social determinants of Indigenous health with reference to human rights principles. Indigenous health policy in Australia is guided by the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013. One of the nine guiding principles of this is that Governments adopt a holistic approach: ‘recognising that the improvement of Aboriginal and Torres Strait Islander health status must include attention to physical, spiritual, cultural, emotional and social well-being, community capacity and governance.’9 This paper also highlights the inconsistencies between this guiding principle and the practices of Australian governments. 2. Indigenous health in Australia – key trendsThe current status of Indigenous health in Australia can be briefly synopsized as follows:
3. Indigenous health and human rights – Key principlesThe International Covenant on Economic, Social and Cultural Rights (ICESCR) includes the right to the enjoyment of the highest attainable standard of physical and mental health (article 12); the right to an adequate standard of living, including adequate food, clothing and housing (article 11); and the right to education (article 13). Article 2 of the Covenant requires that governments take steps, to the maximum of their available resources, with a view to achieving progressively the full realization of the rights recognized in the Covenant. It also requires that all rights be enjoyed on a non-discriminatory basis. The right to health, and these related rights, have been recognised for some time. But it is only in recent years that detailed consideration has been given a rights based approach to health. This framework therefore offers a relatively new perspective on the factors necessary to address health inequalities and ensure to all people the right to the enjoyment of the highest attainable standard of health. Overall, the human rights based approach to health has the following components. It:
A rights based approach to health has begun to be operationalized throughout the United Nations structure through the Common Understanding of a Human-Rights Based Approach to Development Cooperation.19 The Common Understanding emphasises, inter alia, that:
These human rights considerations are critical in addressing the social determinants of health.
(a) Links between health status and socio-economic status / poverty Indigenous peoples in Australia experience socio-economic disadvantage on all major indicators. For example:
Research has demonstrated associations between an individual’s social and economic status and their health. Poverty is clearly associated with poor health.23 For example:
Research has also demonstrated that poorer people also have less financial and other forms of control over their lives.27 This can contribute to a greater burden of unhealthy stress28 where ‘prolonged exposure to psychological demands where possibilities to control the situation are perceived to be limited and the chances of reward are small.’29 Chronic stress can impact on the body’s immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems from diseases of the circulatory system (notably heart disease)30, mental health problems31, violence against women and other forms of community dysfunction.32 (b) Linkages between perceptions of control and chronic stress In the National Aboriginal Health Strategy (1989), Indigenous peoples stated that their health status is linked to ‘control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity’33. In making these assertions, Indigenous peoples anticipated developments in social determinants theory over the 1990s. It is now generally accepted that an individual’s perceived lack of control over their lives can contribute to a burden of chronic, unhealthy stress contributing to mental health issues, violence and substance abuse34. This is the experience among Indigenous Australians. For example:
Relatively permanent, negative features of the social environment trigger chronic stress: intergenerational poverty, racism, and so on. It can impact on the body’s immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems, particularly diseases of the circulatory system.40 These are currently the biggest killer of Indigenous people in Australia. The WAACHS found that the environmental safety and the emotional and social health of Indigenous children improved with isolation (that is, those in remote communities had better mental health). Children living in Perth had significantly poorer (in fact, five times worse) emotional and social health than those living in very remote communities. The report concludes that traditional cultures and ways are protective against poor environmental safety and emotional and social health.41 To the degree recognising Indigenous peoples’ right to self-determination supports communities to regain control of their lives, including through the maintenance of traditional cultures, it can be understood as having positive health impacts. It is also a stepping-stone to the goal of social and economic equality. Experience from overseas confirms that Indigenous communities’ control over their own affairs can be crucial to their social and economic regeneration42. (c) Evidence of the health impact of Indigenous community control of health services Aboriginal community controlled health services an excellent example of how communities can be empowered by exercising control of local services. While the fact of control may in and of itself be expected to bring broader health benefits, the ability of communities to decide on, and address, their own health priorities has been found to increase the impact of primary health care in communities.43 For example:
(d) Traditional ownership of land and health status The right of self-determination includes the right of peoples to freely ‘dispose of their natural wealth and resources’ and that ‘in no case may a people be deprived of its own means of subsistence’. Native title and the title to communally owned land (through the various Aboriginal land rights legislation in Australia) is the ‘natural wealth and resources’ of Indigenous peoples. As noted above, supporting traditional culture – including customary law and governance structures – is likely to help improve the health status of people living in remote communities. In practice, this also means ensuring Indigenous peoples have access to their traditional lands. While Indigenous commentators have highlighted the social and culturally related health benefits of access to land,44 many possible positive health impacts are likely including improved diet, exercise, and the reconnection of Indigenous peoples with their traditional economic bases. The Kuka Kanyini project in Wattaru, South Australia in the Anangu Pitjantjatjara Lands illustrates these benefits.
(e) Social determinants as a contemporary reflection of historical treatment Indigenous peoples are not merely ‘disadvantaged citizens’. The poverty and inequality that they experience is a contemporary reflection of their historical treatment as peoples. The inequality in health status that they continue to experience can be linked to systemic discrimination. In Australia, this has been vividly demonstrated by:
The following examples (both contemporary and historical) demonstrate the negative impact of social determinants on Indigenous peoples’ health. Racism is a stressor that has been reported to affect both mental and physical health. A 2003 review of 53 studies in the United States found a decline in mental health status as racism increased46. Eight out of 11 studies found links between the elevated prevalence of high blood pressure in Afro-Americans and racism47. There have been very few studies on the impact of racism on the health of Indigenous people in Australia, although experts agree that a correlation with the US studies is to be expected48. One such study is the Western Australian Aboriginal Child Health Survey 2001-02 (WAACHS). It reported than 21.5% of the Indigenous children under 12 surveyed experienced racism in the previous 6-months. This was associated with increased smoking, marijuana use and alcohol consumption in these under-12s49.
The National Aboriginal and Torres Strait Islander Social Survey 2002 reported that 38% of respondents had either been removed themselves and/or had relatives who, as a child, had been forcibly or otherwise removed from their natural family.50 The practice has intergenerational health impacts. The WAACHS reported that the effect on parents was that they had higher rates substance abuse and mental health problems. Their children were twice as likely to have emotional and behavioural problems, to be at high risk for hyperactivity, emotional and conduct disorders, and twice as likely to abuse alcohol and drugs.51
Research conducted by the Social Justice Commissioner on the circumstances of Indigenous women’s prisoners in Australia found that Indigenous women are victims of a complex frame of dynamics upon their lives including violence, poverty, trauma, grief, loss, cultural and spiritual breakdown. Indigenous women are particularly vulnerable to intersectional discrimination within criminal justice processes due to the following reasons:
There is a consistent pattern indicating that incarcerated Indigenous women have been victims of assault and sexual assault at some time in their lives. There was also a strong relationship between incarceration and experiences of violence, drug and alcohol abuse, with Indigenous women often entering custody with poor physical or mental health, and at higher risk of self harming when in prison and also soon after release from prison. As a consequence, the rate of Indigenous women being imprisoned has increased most rapidly in Australia since 2000. Indigenous women also experience extremely high rates of recidivism. In consultations to identify solutions to address this situation, Indigenous women emphasised the importance of healing to address grief and trauma as a major priority. Strategies need to respond to the circumstances of indigenous women holistically, which seeks to not only address offending behaviours but also focus on healing the distress and grief experienced by many indigenous women and their communities. Text box 3 below contains a case study of a program that attempts to help heal the trauma experienced by survivors of the Stolen Generation, Indigenous women prisoners and other Indigenous people.
In 1991, Australia commenced a formal process of reconciliation with Indigenous peoples. The Council for Aboriginal Reconciliation made its recommendations to the nation in 2000. The federal government responded to these recommendations by emphasising the need to address ‘practical’ issues such as disadvantage, as opposed to ‘symbolic issues’ which they described as including recognition of rights, a treaty and a national apology to the Stolen Generations, and other forms of reparation. ‘Practical reconciliation’ rests on an artificial division between measures that are described as practical as opposed to symbolic.52 But, as social determinants theory would suggest, no such clear distinction exists – there are interdependencies between many of the dimensions of Indigenous disadvantage; including how social and historical factors can influence contemporary Indigenous practical outcomes. At the moment a more lasting and meaningful reconciliation process is the task of future generations. 5. Recognising social determinants as a contemporary reflection of the impact of colonisation – international developments Recognising the contemporary impact of colonization on Indigenous peoples globally remains a major challenge for the international community and the United Nations. It is also a major challenge for those seeking to understand the social determinants of health among Indigenous communities. At the launch of the Second International Decade for the World’s Indigenous People, Ms Mililani Trask vividly described this challenge. She stated: Governments speak of ‘poverty’ while Indigenous Peoples speak of ‘rights’. Within Indigenous territories, poverty is also defined by power deficits, lack of self-determination, marginalization and lack of mechanisms for meaningful participation and access to decision-making processes… Poverty alleviation must start from Indigenous Peoples own definitions and indicators of poverty…53 Applying the Millennium Development Goals to the situation of Indigenous peoples, she continued: the effort to meet the targets laid down for MDGs could in fact have harmful effects for indigenous peoples such as the acceleration of loss of lands and natural resources or the displacement from those lands. (The MDG indicators need to be redefined to be relevant to indigenous peoples by taking into consideration)… culturally appropriate indicators, redefining the process of impoverishment caused by dispossession of ancestral lands, loss of control over natural resources and indigenous knowledge, devastating social and environmental impacts, impacts from militarization and conflict and forced assimilation into the mainstream society and integration into the market economy.54 She concluded: The human-rights based approach to development is essential to the achievement of the MDGs. The MDGs must therefore be firmly grounded on a rights-based approach, to have meaning for Indigenous Peoples.55 The United Nations Permanent Forum on Indigenous Issues (PFII) have identified that to address these concerns there is a need for processes for indigenous peoples ‘to identify gaps in existing indicator frameworks, examine linkages between quantitative and qualitative criteria, and propose the development of indicators that are culturally-specific, measure exclusion, and reflect the aspirations of indigenous peoples’.56 The PFII convened a meeting in Ottawa in February 2006 to this end. 57 It identified numerous challenges at the national and international level in developing appropriate indicator frameworks and linking these to the Millennium Development Goals. They stated, inter alia, that:
The Workshop recommended that ‘the United Nations should identify and adopt appropriate indicators of indigenous identity, lands, ways of living, and indigenous rights to, and perspectives on, development and well-being’ and that these indicators should by applied in performance measurement and monitoring processes by the UN system, as well as its member states, intergovernmental organizations and other development institutions.59 Accordingly, the Workshop proposed a series of indicators that could be further considered at the national and international level based on the two key themes of:
The Workshop noted that ‘more exact indicators need to be developed in a measurable form, with full participation by indigenous peoples from all regions’.60 The proposed indicators relate to the following issues:
6. Conclusions and lessons This paper has addressed a broad range of issues. It seeks to demonstrate the connections between low socio-economic status and poverty, and health outcomes. It demonstrates that the social determinants of health for Indigenous peoples reflect more than just their relative disadvantage. It also reflects the non-recognition and non-enjoyment of their human rights and of their distinct cultural characteristics. Indigenous peoples globally have actively noted the importance of a human rights based approach to addressing their disadvantage and to ensuring the survival of their cultures. An approach to social determinants that fails to recognise the fundamental connections between health status and the enjoyment of human rights will fail. Footnotes
[1] Throughout this chapter I refer to Aboriginal and Torres Strait Islander peoples as ’Indigenous peoples’. In doing so, I acknowledge the distinct cultures and societies of different Aboriginal peoples and Torres Strait Islanders. The term ‘peoples’ is also used to recognise the collective dimension of the livelihoods of Indigenous people, with distinct cultural beliefs that differentiate them as a group from other Australians.
[3] United Nations Committee on the Rights of the Child, Concluding Observations – Australia, Unedited version, UN Doc: CRC/C/15/Add.268; United Nations Committee on the Elimination of Racial Discrimination, Concluding observations of the Committee on Australia, UN Doc:CERD/C/AUS/CO/14, para 17.
[4] See, for example, the 2nd and 3rd periodic report of Australia to the Committee on the Rights of the Child (submitted 29 December 2004, UN Doc: CRC/C/129/Add.4, p5) and the 14th periodic report of Australia to the Committee on the Elimination of Racial Discrimination (submitted 1 April 2004, UN Doc: CERD/C/428/Add.2, paras 80-81.
[5] Saggers, S and Gray, D, ‘Defining what we mean’, Editors, Carson, B, Dunbar, T, Chenall, R, et.al., Social Determinants of Indigenous Health, Allen and Unwin, NSW, 2007, pp1-18.
[6] See for example, Vienna Declaration and Programme of Action (25 June 1993) Adopted by the World Conference on Human Rights on 25 June 1993 A/CONF.157/23 12 July 1993.
[7] See Gray, N, ‘Human Rights’ Editors, Carson, B, Dunbar, T, Chenalll, R, et.al, op.cit. pp.253-267.
[8] See further: Social Justice Report 2005, op.cit.
[9] National Aboriginal and Torres Strait Islander Health Council, National Strategic Framework for Aboriginal and Torres Strait Islander Health: Context, NATSIHC, Canberra, 2003, p2.
[10] Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS), The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2005, ABS cat. no. 4704.0, Commonwealth of Australia, Canberra, 2005, pxvii, available online at: www.aihw.gov.au/publications/ihw/hwaatsip05/hwaatsip05.pdf.
[11] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2005, ABS cat. no. 4704.0, Commonwealth of Australia, Canberra, 2005, p148, available online at: www.aihw.gov.au/publications/ihw/hwaatsip05/hwaatsip05.pdf.
[15] Communicable and water-borne diseases and parasites are indicators of poor health infrastructure. Infants and children are particularly vulnerable to these diseases.
[16] National Health and Medical Research Centre, Promoting the health of Australians, Case studies of achievements in improving the health of the population, AGPS, Canberra, 1997, p35.
[17] Thomson, N. and Brooks, J., ‘Cardiovascular Disease’, in Editor, Thomson, N., The Health of Indigenous Australians, Oxford University Press, Melbourne, 2003, p186.
[18] Royal Australasian College of Physicians, Inequity and Health – A Call to Action - Addressing Health and Socioeconomic Inequality in Australia – Policy Statement 2005, RACP, Canberra, 2005, p3.
[20] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2001, ABS cat. no. 4713.0, Commonwealth of Australia, Canberra., 2002, p81.
[22] Steering Committee for the Review of Government Service Provision, op.cit. p3.19.
[23] See generally Editors Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit.
[24] Fred Hollows Foundation, Literacy for Life, Australian National University, Canberra, 2004, pp10-12, available online at http://www.hollows.org/content/TextOnly.aspx?s=244 . See also the issues raised in: Malin, M, Is schooling good for Indigenous children's health?, Cooperative Research Centre for Aboriginal and Tropical Health & Northern Territory University, 2003, available online at:http://www.acer.edu.au/research/special_topics/ind_edu/report_papers.html.
[25] Wadsworth, M., Early Life, in (eds.), Marmot, M. and Wilkinson, R., Social Determinants of Health, Oxford University Press, New York, 1999, p44. Chronic diseases that have poor diet as a determinant include cardiovascular disease, Type 2 diabetes and renal disease. Connections have been made between poor foetal nutrition and the presence of chronic diseases later in life: National Health and Medical Research Council, Nutrition in Aboriginal and Torres Strait Islander peoples - An information paper, Commonwealth of Australia, 2000, p15.
[26] Jarvis, M. and Wardie, J., ‘Social pattering of individual health behaviours; the case of cigarette smoking’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., pp241-244.
[27]In 2002, 54% of indigenous people aged 15 or over were living in households where the household spokesperson reported that household members would be unable to raise $2000 within a week in a time of crisis. Australian Bureau of Statistics and Australian Institute of Health and Welfare, op.cit., pp12-13.
[28] Shaw, M., Dorling, D. and Davey-Smith, G., ‘Poverty, social exclusion, and minorities’, in Editors, Marmot, M. and Wilkinson, R.., Social Determinants of Health, op.cit.,pp32-37.
[29] Brunner, E, Marmot, M, ‘Social Organization, stress and health’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health op.cit, p 17.
[31] Marmot, M., ‘Health and the psychosocial environment at work’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., p124.
[32] Wilkinson, R., ’Prosperity, redistribution, health and welfare’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., pp260-265.
[33] National Aboriginal Health Strategy Working Group, National Aboriginal Health Strategy, AGPS, Canberra, 1989, pix.
[34] See generally, Editors, Marmot, M. and Wilkinson, R., op.cit.
[36] Australian Bureau of Statistics and Australian Institute of Health and Welfare, op.cit., p135.
[38] Marmot, M., ‘Health and the psychosocial environment at work’, in Editors, Marmot, M. and Wilkinson, R., op.cit., p124.
[41] Telethon Institute for Child Health Research, op.cit., pp18-19.
[42] Cornell, S, 'The importance and power of Indigenous self-governance: Evidence from the United States', Speech, Indigenous Governance Conference, 3 April 2002, p1.
[43] Dwyer, J., Silburn, K., and Wilson, G., National Strategies for Improving Indigenous Health and Health Care, Aboriginal and Torres Strait Islander Primary Health Care Review: Consultant Report No 1, Commonwealth of Australia, Canberra, 2004, pp91-106, Appendix.
[44] See generally Burgess, P., and Morrison, J., ‘Country’ in Editors, Carson, B, Dunbar, T, Chenall, R, et.al., op.cit., pp177-196
[45] Extracted from Social Justice Report 2005, op.cit.
[46] Williams, R., Neighbours, H. and Jackson, J., ‘Racial/Ethnic Discrimination and Health: Findings from Community Studies’, (Feb 2003), 93(2) American Journal of Public Health 200, p200.
[48] See generally Paradies, Y, ‘Racism’ Editors, Carson, B, Dunbar, T, Chenall, R, et.al., op.cit.,pp65-80.
[49] Cited in ibid., p66.
[50] About 8% of Indigenous respondents reported that they themselves had been removed from their natural family. The most frequently reported relatives removed were grandparents (15%), aunts or uncles (11%), and parents (9%). Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Social Survey 2002, ABS cat. no. 4714.0, Commonwealth of Australia, Canberra, 2004, pp5-6.
[52] For a critique of this distinction see: Aboriginal and Torres Strait Islander Social Justice Commissioner, Social Justice Report 2001, HREOC Sydney 2001.
[53] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at: www.docip.org/Permanent%20Forum/pfii5_8.PDF.
[54] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at: www.docip.org/Permanent%20Forum/pfii5_8.PDF.
[55] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at: www.docip.org/Permanent%20Forum/pfii5_8.PDF.
[56] See further: www.un.org/esa/socdev/unpfii/en/workshops.html.
[58] See further: Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, paras 9-20.
[59] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, para 33.
[60] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, para 34.
[61] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, pp 10-14. |