Text of Opening Address

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CAPGAN (Commonwealth Association of Paediatric Gastroenterology and Nutrition ) 5^th Commonwealth Congress on Diarrhoea & Malnutrition, Darwin, 26^th April 2001. Professor Lowitja O’Donoghue

Thank you very much. I am very pleased indeed to have been asked to deliver this opening address.With its global focus on paediatric health CAPGAN makes a very valuable contribution to the health status of people in developing countries. And in this Darwin Congress your focus very appropriately extends to Indigenous Australians. For it is a sad but undeniable reality that in Australia, one of the most affluent first world countries, we have significant pockets of third world health – mostly among our Indigenous peoples. I am impressed by CAPGAN’s multiple focus on research, clinical practice and policy. Such a broad stance is essential if we are to see improved health outcomes. It is also the approach taken by the Cooperative Research Centre for Aboriginal and Tropical Health, whose board I am privileged to chair. We have much in common. I think it is very important that you see yourselves as having a political role. And I am very pleased to see so many international delegates, especially from our Asian neighbours, here today. I extend to you all a very warm welcome.

Health and especially the health of children is an issue that is very dear to my heart. As a nurse in a previous life, I have some vivid memories of delivering babies in the outback. I still treasure many of those happy memories. While the conditions were far from ideal, we usually managed healthy natural deliveries. Unfortunately today, this is rarely possible because of the declining ante-natal health of so many Indigenous women. As some of you would be all too aware the state of Indigenous health in Australia is still a national and international disgrace. I was reading a few months ago about a recent United Nations Human Development Report which ranks Australia in fourth place on an international index ranking quality of life – behind only Canada, Norway and the United States. But this ranking disguises some dreadful hidden facts about the poverty, low educational attainment and ill health of our Indigenous population. Australia’s high average life expectancy of 78.3 years conceals the shocking statistic that the Indigenous life expectancy is about 60 years, eighteen years less. 53% of Aboriginal men and 41% of Aboriginal women die before they reach fifty, compared with 13% of men and 7% of women in the population as a whole. So I repeat, within our First World nation there are Third World, or more accurately, Fourth World communities. A definition of Fourth world communities which I read recently describes Indigenous Australia very well. I quote:

Fourth world communities are characterised by their experience of being colonised or of being a minority in relation to the dominant encompassing state. Many have been forced to assimilate, losing most of their land and their economic base, and therefore their autonomy.

Since white settlement - or invasion, as our people experienced it – we have been dispossessed of our land and the life that was lived on it. Our children have been taken from us. Our traditional culture and languages have been eroded, and in some cases destroyed. Disease, alcohol, high fat and sugar diets, have ravaged our communities. And we have been subjected to violence and racist discrimination. The consequences of this experience are felt in every sphere of life, and no where more graphically than in the area of health, including infant and child health. While infant mortality rates have been improving it is still tragically the case that Indigenous babies are over three times more likely to die in their first year of life than non-Indigenous infants. Birth weights have increased but prematurity and low birth weight are still prevalent, especially in remote areas. Infant deaths still account for about 8% of all deaths of Indigenous people. This contrasts with only about 1 per cent in the general Australian population. Per head of population Aboriginal children in the Northern Territory are about 10 times more likely to require admission to hospital than other children.Once admitted Aboriginal children have twice the average length of stay in hospital. Like children in the developing world, Aboriginal children hospitalised with diarrhoea and malnutrition are also likely to have other problems, especially respiratory and ear infections and skin infections. Many of these children have low blood levels of bicarbonate or potassium – which can be life threatening. Many are underweight for age. Microcephaly (abnormal smallness of the head) is also of particular concern.

These are grim facts indeed. So I am encouraged to see that a number of presentations in the next 3 days are dealing with some of these matters. While I do not pretend to have medical expertise I do know that many such problems are related to lifestyle. Health and illness do not exist in some kind of vacuum. These are environmental health problems. As such they are preventable. Medical mysteries are relatively rare. And we do not always need brilliant medical breakthroughs when solutions are staring us in the face. We know already that an individual’s health status can be correlated with key lifestyle indicators such as diet, level of education, adequate housing, clean water, sanitation.

And to take just one of these – education – we see familiar patterns of disadvantage. 17 per cent of Australians are estimated to be functionally illiterate and many of these people are Indigenous. Very few Indigenous students are reaching their full potential or completing further education or training. While there are some signs of improvement, especially in school retention rates and entry to vocational training, I was dismayed to read in the papers only a week ago, that there has been a 15% drop in the number of Indigenous students taking up university education. Australia has been slow to realise the importance of Aboriginal education levels in improving Aboriginal child health. There has been a tendency to compartmentalise problems. What is needed is a concerted effort across government departments.

And less buck passing from Federal to State government and back again. And less piecemeal funding. Without coordinated planning and some lateral thinking beyond the straightjackets of ministerial portfolios and their bottom lines, we will not make any progress. Education ministers and their departmental people need to talk to Health Ministers and their people. Surely that’s not too much to ask?

The work of Professor John Caldwell (a demographer at the Australian National University) has been instructive here. He has been instrumental in documenting the importance of female literacy in improving child mortality rates in the developing world. You all know the slogan: Educate a woman– Educate a nation. It’s as true today as ever. The ability to ‘live wisely’, as it has been called, depends on knowledge, skills and values rather than on access to medical services. Although we need that too. And of course there is a knock on effect here. Educational attainment is directly related to employment, which in turn affects income, which in turn affects better housing and nutrition – in other words all those things we understand as essential to primary health. These needs are not exclusive to Indigenous people. But it is a fact that on any social indicator, my people are drastically over represented at the wrong end of the scale.

So what is needed is a concerted collaborative approach, going well beyond health policy to agriculture, housing, public works, education, employment, transport, communications. What is needed is improvement in the quality of life in general. The fact that other Indigenous populations with similar histories of dispossession and depopulation have been able to raise their health profiles, suggests that improvement is also possible in Australia.

A recent report of the Inquiry into Indigenous Health by the House of Representatives Standing Committee on Family and Community Affairs, made an important point about this discrepancy between Australia and other similar nations. It suggested that the difference lies in a government commitment to adequately resourced community controlled primary health care, environmental services and encouragement of improved education. Interestingly, and somewhat controversially in the current political climate, the Report goes on to suggest that these practical measures are mirrored in philosophical recognition of the status and rights of the Indigenous populations of those countries. And that [and I quote]:

Concluding a meaningful reconciliation with Indigenous Australians is likely to contribute to a longer term improvement in their health and welfare. [Unquote]

So meaningful reconciliation, then. What does that involve ? Well, many things. But just let me single out a few. It involves:

Recognition of the injustices of the past and their ongoing adverse effects on Indigenous Australians today. One obvious symbol of such acknowledgement would surely be a formal Government apology. But it seems that Governments on both sides of the Equator have trouble with that simple word – Sorry!

Reconciliation also involves adequate consultation with Indigenous communities and a measure of community control. Community control has been a catch cry since the seventies. It is still true, nonetheless. Community control is about self determination. It’s about bottom up – not top down – decision making. Good health begins in the family and in the local community. It does not begin in Canberra. And reconciliation involves recognition of the fundamental human rights of all citizens. Housing, health and education are a basic right of every Australian. They are as important as civil and political rights. They should be based on entitlement and not charity. They need to be addressed as a fundamental duty of government. They are the essence of what governments are for – not an optional extra!

Government must therefore be made accountable for Aboriginal health care outcomes. If we begin with these three, we are well on the way towards meaningful reconciliation. I wish you well in your deliberations over the next few days.  The sharing of your experience and your research findings will play a crucial role in improving health outcomes for those disadvantaged communities in the developing world and here in Australia.

I congratulate CAPGAN on its recognition that health work is also political work. If all involved in medical research and clinical practice could realise that – and act, advocate and work for significant change – then the gap between first world and third world health might be significantly closed. This stance inevitably requires a commitment to radically reformist positions about health. We cannot talk in simple rosy terms about holistic health without facing the fact that it really means a re-allocation of resources, a changing of priorities, and a willingness to redirect power to the community level. This is the challenge of your profession and of governments throughout the world for the twenty first century. It is up to all of us to work towards wise governance, wise living, and – to use a good Australian expression – a fair go for all.

Thank you.

Questions or comments to info@capgan.org or Fax: +852 26360020 or Tel: +852 26322861

Last modified: December 10, 2001