Central Australian Specialists Submission to the Review Board of the Northern Territory Emergency Response (NTER)
This submission has been prepared and submitted by a group of Specialist doctors working in Central Australia, and represents a consensus view.
We would like to make the following points:
- The socioeconomic and health status of the Aboriginal population of Australia, especially in Central Australia is exceedingly poor and a true national emergency.
- We are therefore pleased that this has been acknowledged.
- The NTER has wasted large amounts of money in duplicating information that was already known.
- Furthermore the resources available for the provision of health care in Central Australia are grossly inadequate to provide an appropriate level of care.
- We are disappointed that we have not been involved in developing more effective long term strategies for the delivery of health care but would be very keen to share our expertise and many years of experience.
- Central Australia needs ongoing and increased funding for existing health infrastructure, as well as funding for new, long term projects for the delivery of health services.
- We are not aware of any evidence which supports health related components of the NTER. Specifically with respect to health checks there is no evidence that this measure increases the health of children in the long term if other factors are not also addressed.
- Furthermore, we believe that it is essential to respect Aboriginal cultural values and engage Aboriginal people if any long-lasting health improvements are to be realised. “Please remember, from self respect comes dignity, and from dignity comes hope.” Tom Calma, 2008
We recommend:
- Existing health services in Central Australia, such as primary health care, specialist outreach programmes, hospital services, aero medical services, mental health particularly child and adolescent services, and alcohol rehabilitation services etc be funded appropriately so to be able to deliver an adequate service.
- Evidence based measures, as detailed in (i) the Little Children are Sacred report, and in (ii) Close the Gap - Outcomes from the National Indigenous Health Equality Summit report released July 2008 (and signed by Prime Minister Rudd, and Ministers Macklin and Roxon) be implemented as a matter of urgency in Central Australia.
- The Australian Government support the NT government’s ‘Closing the Gap’ plan released last year.
- A working group be immediately set up to consult with stake holders, with respect to the above 3 points, with an aim to facilitate resource delivery at a local level rather than to decide whether resources are required.
- The Racial Discrimination Act (1975) needs to be reinstated. We believe that an appropriate response can be delivered without requiring the suspension of the Act.
BACKGROUND
There have been innumerable reports into the state of health and welfare of Indigenous people in Australia over the past decades. Unfortunately these have not to date led to an adequate response for the known disease burden. As health professionals working in Central Australia, we have identified massive inadequacies in funding and resource allocation.
To date, with respect to health, the NTER has been beset with a distressing duplication, at huge cost, with very little benefit derived.
APPROACH TO CHILD SEXUAL ABUSE
It is recognised that child sexual abuse is exacerbated by poor social living conditions.
“A number of structural factors, such as unemployment, housing, gambling, impact on the prevalence of child sexual abuse, particularly when a community is also experiencing a range of other social concerns, such as alcohol abuse. It is sufficient to say that these factors can make it much easier for would-be offenders to abuse children.” 1
It is well recognized, that in both Indigenous and non-Indigenous communities, programmes need to be tailored (i.e. not indiscriminate), and community-owned rather than imposed from outside.2
Crucial to ensuring equal access to health services is ensuring that Aboriginal and Torres Strait Islander peoples are actively involved in the design, delivery, and control of these services3
However the NTER seems to have proceeded in the opposite direction.
“We have witnessed the abandonment of consultation with Indigenous people, diminishing use of available statistical and research evidence and increased marginalisation of the experts - especially if their views diverge from national leadership. These same leaders are increasingly thinking very narrowly about very difficult policy problems and consequently are making poor policy decisions” 4
The holistic model acknowledges that to achieve child protection and wellbeing, the community needs to be healthy. This includes healthy adults. A health based approach to the disadvantage experienced by many Aboriginal Australians includes a community based approach, where health programmes for both children and adults are developed in consultation with the community, funded appropriately, with adequate funding also for centralised services such as hospitals.
There are numerous overseas models for child protection services for Indigenous peoples.
There is no doubt however that this will require increased funding.
THE EVIDENCE BASE FOR THE NORTHERN TERRITORY EMERGENCY RESPONSE
The stated aim of the NTER was to respond to child sexual abuse in remote communities.
However none of the measures in the NTER are evidence based in the international arena. Well established, evidence based practice has been ignored.
Part 2 of the Little Children are Sacred Report, which we endorse, details evidence and research from here in Australia as well as overseas, and is referenced in their recommendations. None of these measures have been implemented by the Australian Government, and indeed many of the measures in the NTER are in direct conflict.
Integral to almost all evidence relating to improving child safety, community safety and overall health are the requirements for any measure to be both (i) culturally appropriate, and (ii) to increase the degree of control at both an individual and community level.
Furthermore, it is accepted that to improve the health of a community, resources need to be put into housing, education and other infrastructure.
INADEQUACIES IDENTIFIED IN THE NTER FROM A HEALTH PERSPECTIVE
Consultation
Minister Macklin gave a speech one year after the NTER was launched, in which she referred to the 1st recommendation of the Little Children are Sacred report,
“that ‘Aboriginal child sexual abuse in the Northern Territory should be designated as an issue of national significance by both the Australian and Northern Territory governments'.
However the second sentence of that recommendation also stated:
“It is critical that both governments commit to genuine consultation with Aboriginal people in designing initiatives for Aboriginal communities”
Rex Wild, co-author of this report stated in June 2008
“They read, and acted upon, the first sentence of the first recommendation and ignored the rest. That recommendation, set out above, was absolutely clear. No solution should be imposed from above."5
We believe that it is essential that consultation with Aboriginal people is a cornerstone of designing initiatives to improve their health.
Human Rights
The Social Justice Report 2007, released by the Human Rights and Equal Opportunity Commission, strongly argues that there needs to be “substantial change” to the NTER for it to be consistent with Australia’s international human rights obligations. It recommends a human rights approach to tackling family violence and child abuse, and gives numerous examples of community based initiatives.
We believe that any intervention needs to recognize human rights, including the rights of Indigenous peoples.
Efficient use of money and the health checks
In the one year since the NTER was legislated, nearly 11,000 children have received a child health check. This has been resource intensive and disrupted existing health services and any health benefits remain dubious as almost all health problems diagnosed were already identified.
To our knowledge, only one child in Central Australia has been identified with significant health problems that were not already known.
Many of the health practitioners involved in the screening had little or no experience in the area. Many children were referred for unnecessary investigations at great cost and causing further disruption to existing services.
The NTER lead to a decrease in morale of staff who had been providing services in this area for many years.
We believe that this massive duplication, at huge cost has been a waste of money. We would rather have seen collaboration with hospital staff and medical staff on remote communities, and believe that far better uses of that money could have been devised.
We hope that future health initiatives are embarked upon only after consultation with those health experts already working in the Northern Territory.
We believe that treatment of identified health problems such as heart, ear, eye and dental problems needs to have ongoing, continuous funding. These services have been required for many years.
HEALTH SERVICES REQUIRED
The National Indigenous Health Equality Summit, held in Canberra, March 18–20, 2008, tabled the National Indigenous Health Equality Targets Outcomes, which was signed by Prime Minister Rudd, Ministers Macklin and Roxon, and others.
Its aims are to close the disturbing gap in morbidity and mortality between Indigenous and non-Indigenous Australians.
It made recommendations, which we believe are salient to health service delivery in Central Australia, as well as nationally.
Some of the recommendations are reproduced below.
- Improve access to MBS/ PBS, AHCA, GP Divisions, specialist outreach.
- Increase coverage and availability of specialist services including outreach to Aboriginal and TSI clients in ACCHOs and other urban, rural and remote settings. Increase the Aboriginal and Torres Strait Islander populations’ access to specialist Services in accordance with need. Agreed benchmarks in rural and remote areas developed regarding specialist to population ratio’s so as to ensure that Aboriginal peoples and Torres Strait Islanders have access at least to the same level as other Australians. The Medical Specialists Outreach Assistance Program is funded to a level where all Aboriginal peoples and Torres Strait Islanders can get access to specialists services as close to their community as possible.
- A financial and non-financial incentive scheme for health staff to work within Aboriginal and Torres Strait Islander primary health care services and to retain and expand the workforce pool to meet specified service requirements. GP workforce salaries are on a par with mainstream primary health care services. Disparities in recruitment and retention of GPs, nurses, AHWs and allied health within Aboriginal and Torres Strait Islander PHC services are reduced.
Despite these recommendations, many such services in Central Australia are funded at an inadequate level making it impossible to sustain services.
It is essential that these services are maintained, increased, and appropriately paid.
Some specific programmes that we believe need to be developed include:
- Quality child health programs in communities to provide continuous primary and secondary preventative services for ear health, nutrition, skin disease etc rather than once per year checks.
- Sustainable dental services available to all indigenous children in the NT.
- Specialist outreach services in particular O&G, paediatrics, general physician, cardiology, ENT, ophthalmology and psychiatry (ref , CASO plan 2007)
Community based programmes
We believe there must be investment in community based programs focusing on healthy children and families using principles of community development. These programmes must have committed long term funding.
Examples include
- safe houses
- sex offender rehabilitation programmes
- alcohol rehabilitation programmes
- illicit drug use programmes
- programmes to reduce children’s exposure to tobacco smoke, and to prevent children starting to smoke, and
- quality services to help parents care for children and allow early non punitive intervention where problems are identified.
Staffing
Staff training and improvement of existing health staff and services needs to occur.
We believe short term staff should only be used when longer term staff cannot be found and must always leave the existing service in stronger shape than when they arrived and should never again be paid at significantly higher rates than the ‘long-termers’.
Other services, outside the scope of this paper to discuss in detail, but essential if any long term health benefits are to accrue, include
- education
- adequate housing
- adequate water and sewerage facilities
- employment
- policing
RACIAL DISCRIMINATION ACT
We believe, in concordance with others such as the Human Rights and Equal Opportunity Commission, that the Racial Discrimination Act must be reinstated.
IN SUMMARY
The health and socio-economic state of the Indigenous population of Australia, in particular in Central Australia is dire and does constitute a national emergency.
Improvements will only come with engagement and collaboration with the Indigenous community. Any improvement in health status will require a significant investment both in the social determinates of health (cultural wellbeing, housing, education, employment) and in health services.
The following Specialists from Central Australia and others have personally endorsed this submission:
Dr Rob Roseby, FRACP, Paediatrician
Dr Rose Fahy, FRACP, Paediatrician
Dr Tors Clothier, FRACP, Paediatrician
Dr Debbie Fearon, FRACP, Paediatrician
Dr Alina Iser, FRACP, Paediatrician
Dr Clare MacVicar, FRACP, Paediatrician
Dr Tim Henderson, FRCOphth, FRANZCO Ophthalmologist
Dr Stephen Brady, FRACP, Physician
Dr Nadarajah Rajabalendran, FRCP, Physician
Dr Carl Schultz, MD, Physician
Dr Terry Howison, FRACP, Physician
Dr Ciara O’Sullivan, FRACP, Remote Physician
Dr Basant Pawar, MD, DM, Renal Physician
Dr Cherian Sajiv, FRACP, Renal Physician
Dr Greg McNaulty, FANZCA, Anaesthetist and Intensive Care Specialist
Dr Penny Stewart, FANZCA, FJFICM, Intensive Care Specialist
Dr Simon Kane, FRANZCOG, Obstetrician and Gynaecologist
Dr Megan Halliday, FRANZCOG, Obstetrician and Gynaecologist
Dr Rosalie Schultz, FAFPHM, Public Health Physician
Dr Hilary Tyler, FACEM, Emergency Physician
Dr Keith Nallaratnam, FACEM, Emergency Physician
Dr Paul Helliwell, FACEM, Emergency Physician
Dr Michael Thumm, FANZCA, Anaesthetist
Dr Heidi Robertshaw, FRCA, Anaesthetist
Dr Mahesh Ganji, MBBS, MD, Anaesthetist
Dr Bandulasena Palapitige, Orthopaedic Consultant
Dr Marcus Tabart, FRANZCP, Psychiatrist
Dr Prosper Abusah, FRANZCP, Psychiatrist
Dr Stephen Foster, FRACGP, District Medical Officer
Dr Paul Secombe, BMBS, Junior Medical Officer Representative
1. Ampe Akelyernemane Meke Mekarle - Little Children are Sacred report, p6
2. Ampe Akelyernemane Meke Mekarle - Little Children are Sacred report. p276
3. Close the Gap - National Indigenous Health Equality Targets Outcomes from the National Indigenous Health Equality Summit, Canberra, March 18–20, 2008
4. The Howard Government’s Northern Territory Intervention: Are Neo-Paternalism and Indigenous Development Compatible?, J.C. Altman, p7 Centre for Aboriginal Economic Policy Research, Topical Issue No. 16/2007 An electronic publication downloaded from <http://www.anu.edu.au/caepr/>