Why is an innovative indigenous health program on the cusp of full implementation now likely to be mothballed, asks Dr Damien Howard?
The audience at a recent national conference on Otis Media – the ear condition that causes conductive hearing loss – were impressed by a presentation about a ground-breaking new collaborative initiative developed by the NT Hearing Project/Portal, iHear. The system uses cutting-edge digital systems to integrate and share health and education data between professionals in the field and has the potential to revolutionise support for the many Indigenous children suffering disadvantage due to hearing loss.
The system is transformative and akin to a transport system in which bicycles are replaced by a bullet train. But buried in the ‘fine print’ of the presentation was the information that, on the cusp of full implementation, the project may be mothballed.“For managers elbow deep in the entrails of budget projections, pressures to preserve their own silo are intense. Collaborative projects can glisten as ‘fat to cut’.”
IHearing relies on the NT Health Department Hearing Health Information Management Program (HHIMS), which feeds hearing health information into it. But that program, transformative in itself, has been terminated. And without it, health and education professionals cannot effectively collaborate.
To extend the railway metaphor, it is as if the bullet train railway line has been decommissioned, forcing a return to bicycles. They will have to slowly collate hard-to-access reports and data and get that information to where it is needed. A task that HHIMS and iHearing would let them complete in seconds will still take months, if it is accomplished at all. Health and education professionals will return to working in poorly connecting silos.
Indigenous ear disease and hearing loss exemplify a classic interdisciplinary problem. The health issue occurs in early childhood when children’s ear health issues are a responsibility of health agencies. These agencies are blind to the educational needs of the children. Schools and teachers are often unaware of hearing problems that affect children’s classroom engagement.
Indigenous children with conductive hearing loss attend school less, often do not engage well when there, and are regularly excluded from classrooms because of disruptive behaviour. Around Australia, policy has dictated that children with conductive hearing loss receive less educational support than children with sensorineural hearing loss. This is based on assumptions about the minor influence of conductive hearing loss, that are increasingly being shown to be a fiction.
Given Indigenous children experience much more conductive hearing loss this creates an apartheid-like outcome in terms of educational support. So doing as much as possible with the limited educational support available for Indigenous kids with conductive hearing loss is crucial. Bicycle paths are not enough.
By adolescence, the limited educational engagement and disruptive behaviours routinely escalate at school, until the students reach school leaving age, ‘solving’ school’s problems. With limited literacy and numeracy skills, these adolescents often settle into unemployment and welfare dependence. Too many also come to the attention of criminal justice agencies.
As one judge commented during the trial of a young man with hearing loss who had caused criminal damage worth hundreds of thousands of dollars:
“Although a hearing problem was identified early in (the defendant’s) life and identified again during his childhood, it appears he has not had access to a range of services, including the possibility of surgical intervention, amplification, speech therapy, and special education, that could have minimised the communicative, social and psychological impact of these problems … these communication difficulties have been a major contributor to the development of serious social and psychological problems.”
Corrections agencies have limited capacity to support ongoing ear health issues or improve educational outcomes. Supervised visits to health appointments for individual inmates cost money. For overwhelmed and underfunded corrections systems, the provision of remedial health and educational support is unaffordable.
Meanwhile, the annual incarceration cost in the NT is around $100,000 a year for an adult and $200,000 a year for a young person with 50% returning to detention within two years of release. It may seem shortsighted to avoid spending a few dollars on accompanied visits to health professionals, for a new ear drum or hearing aids that may reduce the risk of re-offending. But managers must deal with current budgets with no incentive to minimise future costs.
Turning a blind research eye to Indigenous hearing loss“Perhaps governments should embed a ‘collaboration bonus’ in service delivery and research funding models, to counter the powerful forces that give preference to silo-based thinking.”
The silo-ridden research sector have not helped criminal justice agencies to consider rehabilitative opportunities around hearing loss. Applications for funded research into Indigenous hearing loss have long been rejected by criminal justice research programs because they saw it as a health issue. Health research funders have done the same, seeing it as a criminal justice issue.
By staying within their own silo, agencies can avoid engagement in these issues. I remember letters I once wrote to ministers of health and corrections in the same jurisdiction pointing out the interrelated problems their departments shared around Indigenous hearing loss. The ministers each referred their letter to the other.
Even when interdisciplinary programs like HHIMS and iHearing are established, they are still vulnerable. For managers elbow-deep in the entrails of budget projections, pressures to preserve their own silo are intense. Collaborative projects can glisten as ‘fat to cut’, with fewer internal ramifications.
New collaborative projects that haven’t been fully launched are especially vulnerable. Successful programs are also hungry for further funds. They risk creating future, difficult to manage, funding demands. Moderately successful or even failing programs are less financially ‘risky’ in terms of future demands.
Such logic is idiotic when considering the big picture. But it can seem sensible when viewed from within cash-strapped silos, trying to juggle the existing internal competing interests. Preventing the default to silo thinking is difficult. Medicare found it prudent to pay GPs for case conferences with other professionals – better patient outcomes at lower long term cost resulted.
Perhaps governments should embed a ‘collaboration bonus’ in service delivery and research funding models, to counter the powerful forces that give preference to silo-based thinking. It could mean that more ground-breaking programs for transdisciplinary problems are developed, and implemented.
The area is also ripe for justice reinvestment. The cost of keeping a few youths out of detention would more than pay for the ongoing costs of these programs and the better educational support the programs would enable. Justice reinvestment could also fund long-neglected research into these issues.
Dr Damien Howard is a psychologist who over many years has researched how widespread Indigenous peoples’ hearing loss contributes to Indigenous disadvantage and what can be done to mitigate these effects.