Dr Vanessa Lee applies a lens of political determinants of health to illuminate policy failure for Indigenous women and their communities, and calls for the government to be held accountable to the outcomes of generations of harmful policy.
When it comes to Australian policy, Aboriginal and Torres Strait Islander women are not being supported. Rather, a long history of paternalistic government decisions created barriers towards Indigenous women achieving equivalent health and wellbeing measures when compared to non-Indigenous women. The manifestation of colonisation has included a displacement of Aboriginal and Torres Strait Islander people, a history of segregation and apartheid, and a breakdown of culture and cultural values through the impact of missionaries and government legislation, Acts and policies. These political determinants of health breech human rights conventions, lack an evidence base, and are profoundly damaging across generations. Better policy could be and should be implemented but there appears to be a lack of political will.
Aboriginal and Torres Strait Islander women experience poorer health and reduced social and emotional wellbeing when compared to non-Indigenous women, and this is due to generational life circumstances. Aboriginal and Torres Strait Islander women take a holistic world view that intrinsically connects family and culture with everything else that they connect with. What this means is that Indigenous women have a cultural and family relationship with their social and economic world.The breakdown in life circumstances are evident today across employment and education where 39% of the Indigenous females were employed compared to 55% of the non-Indigenous females; and 4.6% overall of the Indigenous compared to 20% of the non-Indigenous people have completed a bachelor degree or higher degree.
Educational attainment and employment are intrinsically linked to economic opportunity, with higher levels of education reducing societal disadvantage. Failure to address these fundamental social determinants in early life contributes to life-long disadvantage.
When the British colonized Australia, they did so under a paternalistic ideology that remains evident today as Australian federal, state, territory and local governments continue to implement paternalistic policies. Paternalistic policies are those that restrict choices to individuals, ostensibly in their ‘best interest’ and without their consent. The justification of such policies is often to change individuals’ damaging behaviours; for example gambling, smoking, consumption of drugs and alcohol, or the reliance on welfare payments. Given the etymology of the word ‘paternalism’, it is little wonder that Aboriginal and Torres Strait Islander women have been the victims of extraordinarily high levels of sexism, domestic violence, marginalization, work-place lateral violence and racism. Especially since the policies were developed and implemented from colonisation, with little or no evidence to support the need to change behaviours of the First Nations women of Australia. The response to the impact of these paternalistic policies has resulted in an increase in prevalence in pain and trauma based behaviours such as substance abuse.
Social determining factors
Social determinants of health are about “the cause of the cause.” Poorer health outcomes are not narrowed to individual lifestyle choice or risky behaviour. Understanding the social determinants of health requires looking at the relationship between cause, social factors and health outcomes. Social factors are those societal factors that influence health throughout life and include housing, education, access to healthcare and family support.
The diagram below highlights an example of the circular relationship between the causes of the social factors and the social factors themselves across a person’s life stages. The unborn Aboriginal and/or Torres Strait Islander child of parents with high drug and/or alcohol intake, low income and low education will be born into an environment influenced at the macrosocial level by history, culture, discrimination and the political economy. This first stage of inequality can manifest in increasing risky behaviours such as smoking, drinking, unhealthy eating, and lack of exercise or imprisonment. These behaviours have been associated with intellectual impairment that continues through all life stages. Quite often the continuous exposure to drugs and alcohol from adults becomes part of the child’s assumption of the normality of risk-taking behaviour and the cycle continues. Tragically, at times the child born into this situation may commit suicide. Indigenous young people are as much as five times more likely to commit suicide as their non-Indigenous peers. Or the child may end up in prison, and although Indigenous women make up 2% of the adult female population 2% of the adult female populationin Australia they make up 27 to 34% of the female prison population across jurisdictions (see also here). The imprisonment of women causes an upheaval in their lives and that of their families and for Indigenous women it also creates a breakdown in their world view and to all that is connected to their world view.
Relationship between ‘the cause’ and life stages
Social and economic circumstances have a profound impact on individual experiences of inequity, yet within a neoliberal framework the individual is blamed for making poor choices. The government’s failure to acknowledge or address the causes which shape the social factors that in turn underpin individual lifestyle “choices” reveals a disinterest in addressing the socio-structural causes of illness and health. When governments invest long-term resources and time into understanding the socio-structural causes of illness and health, they will recognize that Aboriginal and Torres Strait Islander women are constantly subjected to unnecessary inequalities that mitigate against making positive lifestyle choices for future generations.
Structured inequities within society are based on unequal distribution of power, wealth, income and status. A woman’s ability to move up and down the class system is directly impacted by socioeconomic position or status – including education, employment and income. This truth epitomizes the gross inequalities that continue to exist in Australian society. Inequities in health are heightened because social class not only includes education, employment and income but also differential access to power. Social class structures are characterized by factors including race, sex/gender, ethnicity, Indigeneity and religion. Fundamentally, it is structural issues of class and political disadvantage that place Aboriginal and Torres Strait Islander women close to the bottom of the socioeconomic ladder.
From colonization of Australia until the present day, the policy decisions for Aboriginal and Torres Strait Islander people made by National, State and Territory governments, churches and other institutions have had dire effects on Indigenous peoples’ health and well-being. Inequitable policies contributed to inequalities in health resulting from unequal distribution of power and resources between Indigenous and non-Indigenous people. The impact of policies which fail to take a holistic view on Indigenous population health reflects a political failure of the system with regard to the basic human rights of Aboriginal and Torres Strait Islander people and their good health and well-being.
Denial of a human right directly violates a person’s right to self-determination. These rights should be protected by a covenant to which Australia is a signatory—The International Covenant on Civil and Political Rights (1966) (The Covenant). It states that “all peoples have the right of self-determination. By virtue of that right they freely determine their political status and freely pursue their economic, social and cultural development” (Article 1 Section 1).
The level of Australia’s commitment to this covenant became questionable with the implementation of The Northern Territory National Emergency Response (the Intervention) in 2007. This was a federal government action that ignored one of its own government-funded reports highlighting the critical importance of working with Aboriginal and Torres Strait Islander people in the design and implementation of initiatives for their communities. In less than six months, following the politically motivated “Intervention” that was introduced just prior to an election, the Australian parliament introduced a complex legislative package consisting of five Bills, all 450 pages long and passed in parliament on the same day. The bills were primarily associated with welfare reform. In 2008, a national emergency response by the Australian government took effect and was administered across all of the Northern Territory using the political rationale ‘to protect Aboriginal children’. This appeared to be an excuse to further erode Indigenous self-determination rather than to address the safety of children; as one critic pointed out, “we have witnessed the abandonment of consultation with Indigenous people, diminishing use of available statistical and research evidence and increased marginalization of the experts – especially if their views diverge from national leadership.” (p. 7)
The impact on health outcomes
Welfare data published in 2016 show that Indigenous children in the Northern Territory were being removed from families at 9.8 times more often than that of non-Indigenous children based on ‘reforms’ in the five new ‘welfare reform’ Bills. The Northern Territory Indigenous death rates are still 2.3 times higher than those of non-Indigenous people, and Indigenous people experience assault victimization at six times the rate of non-Indigenous people (see here). The 2014/2015 Social Survey found that fewer than half of Aboriginal and Torres Strait Islander people aged 15 years and over were employed, and males were more than twice as likely as females to be working full time. The deplorable outcomes of these politically motivated policies are most clearly illustrated by the understanding that Aboriginal and Torres Strait Islander women between the ages of 20 and 24 years are four times more likely to commit suicide than are the other woman and between 70-60% of Indigenous women in prisons are due to them being victims of domestic violence.
Holding government accountable to policy outcomes
These outcomes demonstrate the political failure of Australian governments at national, state, territory and local levels to work with the Aboriginal and Torres Strait Islander people, and the lack of integrity surrounding equitable policy administration, leadership and governance. Many policies developed for Aboriginal and Torres Strait Islanders over a long period of time have contributed to the shameful inequity in Australian society between Indigenous and non-Indigenous people. This level of inequity is even more dramatic with regard to Indigenous women.
The Covenant is neither the first Human Rights Charter that Australia has signed nor the first it has violated to the disadvantage of Aboriginal and Torres Strait Islander women, their health and well-being (and of the entire Indigenous population). Australia played a key role as one of eight nations involved in developing the United Nations’ Universal Declaration of Human Rights, when Australian Dr HV Evatt was the President of the United Nations General Assembly. Until a referendum allowed Aboriginal and Torres Strait Islander people to become citizens, there was scant regard to Article 2: “Everyone is entitled to all the rights and freedoms set forth in this Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status”. The Australian government is disregarding its own stated ideals when it disregards the rights of Indigenous Australians.
The gap in health outcomes between Aboriginal and Torres Strait Islanders and other Australians is becoming more apparent, leading to calls for a new and more effective response. The effects of discriminative policies are now being exposed more often – thus, they become more visible. Non-Indigenous services account for 80% of Indigenous expenditure, and there is a lack of transparency and clarity evaluating how these organizations address policies developed by government for Aboriginal and Torres Strait Islander people. Fifty percent of the Indigenous Australian population is under the age of 22 and their health, as that of their elders, remains dire. Without understanding their cultural ways of doing and knowing and without working with Aboriginal and Torres Strait Islander women in making policy decisions, there will be no progress in achieving health equality for this population group.
Major changes needed
Western culture remains the dominant culture in Australian society. Its worldview has shaped Australian society and is constantly in conflict with the cultural identity and knowledge of Aboriginal and Torres Strait Islanders, including that of women. Recently, Australian Indigenous leaders have set out a blueprint for action in the Redfern Statement. This blueprint acknowledges that Aboriginal people have provided viable, holistic solutions. Without a change in leadership attitudes, governance and administration, Aboriginal and Torres Strait Islander women will continue to be disadvantaged, and their health will continue to suffer. It is high time that Australian policymaking recognized the above issues and acted with integrity on the deficits because we will not have equality until Australia recognizes the impact of the political determinants of health as identified throughout this paper. Australia will never be a whole, functioning society until institutionalised oppression ceases.
Dr Vanessa Lee, from the Yupungathiand Meriam people, resides on the land of the Gadigal people. She has a PhD (social epi.), MPH (epi.) and BTEC degree. She is a social epidemiologist, educator and public health/ health sciences researcher within the discipline of Behavioural and Social Sciences, in the Faculty of Health Sciences (FHS) at the University of Sydney.
 Burns, J., MacRae, A., Thomson, N., Anomie., Catto, M., Gray, C., Levitan, L., McLoughlin, N., Potter, C., Ride, K., Stumpers, S., Trzesinski, A. and Urquhart, B. (2013) Summary of Indigenous women’s health. http://www.healthinfonet.ecu.edu.au/population-groups/women/reviews/our-review.
 Carson, B., Dunbar, T., Chenhall, R. and Bailie, R. (Eds.). (2007). Social determinants of indigenous health. Sydney, Australia: Allen & Unwin.