Dr Clare MacVicar – Community Paediatrican, DHF
I am writing this submission as a Community Paediatrician based in Alice Springs. I am employed by Remote Health and provide outreach services to 29 remote communities around the Central Australian region. I have been in this position for 4 years. I work closely with the primary health care teams providing services to children. This submission is my own personal view, and is not representative of the Government Department I work for.
I would like to thank the review board for the chance to express my views on the NTER.
General Comments
The NTER was initiated in response to the Little Children are Sacred report. This report was welcomed by many people working in the NT. It raised public awareness of many difficult issues in a sensitive way. It provided a comprehensive view of problems faced in many Aboriginal communities. It also provided a wide range of recommendations both dealing directly with child sexual abuse, and also with many of the underlying issues contributing to the dysfunction and disadvantage experienced in communities. Action certainly needed to be taken.
The very first recommendation of the report referred to “the critical importance of governments committing to genuine consultation with Aboriginal people”.
The Federal Government did not follow the recommendations of the report, but acted independently with no consultation. They declared an emergency despite the Little Children are Sacred report stating “there being nothing new or extraordinary in the allegations of sexual abuse of Aboriginal children in the NT”. They did not however follow recognised international guidelines for dealing with emergency situations.
The fact it was deemed necessary to repeal the Racial Discrimination Act shows recognition that the process would be viewed as racially discriminatory.
I believe the manner in which the NTER was rolled out will risk further disempowerment of Aboriginal people, less engagement with mainstream Australia, and contribute to the ongoing cycle of poor health, social dysfunction and intergenerational poverty.
Child Health Checks
My main experience of the Intervention has been with regards to the Child Health checks. I have used the term Australian Government Intervention (AGI) as this is how the measures are referred to in the Remote Health workplace.
The Child Health Checks appeared to be put in place to prevent the Govt losing face after initially stating they wished to check every child for signs of sexual abuse. There is no screening test for sexual abuse, and subjecting children to mass screening of this kind is unethical and abusive in itself. Hence the “check” mentioned in initial press releases morphed into the Child Health Check process.
My concerns are as follows:
There is no evidence that screening large numbers of children improves the health of the child population.
Despite not being supported by evidence the Child Health Check process has become a huge consumer of resources, both in terms of finance and personnel. This has been to the detriment of the already existing primary health care services.
No clear aims as to the purpose of the checks and the desired outcomes were stated. These checks will not identify sexually abused children.
There are already programmes for children run in the primary health care setting in the NT (GAA programme, HSAK programme).
There has been chronic underfunding of services in the NT particularly in remote areas resulting in poor access to dental services, audiology, ENT, visiting specialists, allied health and early intervention for Indigenous children.
AGI health checks were performed independently of NT programmes and involved considerable duplication of services. Some follow up services were provided only to AGI referred children, requiring children already in the system to be reseen by an AGI doctor and the referral repeated.
Vast amounts of money have been spent identifying problems that are already well documented – ear disease, dental disease.
No recognition of or consultation with Paediatric Outreach service or other service providers.
Poor orientation of AGI staff to Aboriginal child health issues. It was assumed that doctors working in major centres dealing with predominantly non indigenous populations would have the skills required to work in the bush with Aboriginal children. Little cultural orientation was provided. Some of the doctors had limited experience with children’s health and were not even GPs.
Many conflicts occurred between DHCS staff and AGI staff.
Lack of consistency of practice – eg some doctors were referring all children already being seen by paediatric services, others were only referring children not already under paediatric review. This makes it difficult to assess data collected and establish the true burden of disease.
Provision of confidential medical information including letters and test results to AGI bureaucrats by way of “proving” that children have been followed up.
Lack of any quality control:
- Poor quality of many referrals to paediatric services – both in terms of information provided (inadequate to allow proper assessment) and presentation (handwritten, often illegible, brief in the extreme) – these would not be acceptable in other settings, and thus a lesser standard of health care is being provided and accepted for Indigenous children in the NT
- Many of the new referrals were not appropriate for paediatric care and actually required management in the primary care setting
- Paediatric time in communities has been spent seeing AGI referrals at the expense of other children known to have genuine paediatric problems
- Many of the referrals were children already known to the service – claimed to be identified by AGI teams. Only a very small percentage were not previously known and will continue ongoing paediatric follow up.
To directly address the terms of reference I feel able to comment on:
1. What is working
- Increased public awareness of the issues
- Resources are flowing into the Northern Territory which is positive and appreciated
- Some good health “blitzes” – dental and ENT – children actually getting the treatment they have been waiting for. There was unnecessary and intrusive publicity around the trips to Alice Springs initially. There needs to be a commitment to ongoing service provision. Also need to better resource primary health care sector in areas of health promotion and primary prevention of these conditions. Social determinants of health need to be addressed for any measures to have a lasting impact.
- The increased police presence in many communities is seen as a positive aspect of the intervention. It is reported anecdotally that in some communities this has lead to a decrease in drinking, and the ongoing consequences of this such as domestic violence.
2. What isn’t working
- The child health checks appear to be consuming enormous amounts of resources, with no improvement in the general health of the children in Central Australia. I am concerned that the budget for primary care is being swallowed up with the emphasis on checking and screening, and not being put towards providing an ongoing and sustainable primary and secondary health care services.
3. What progress has there been in improving the safety and well being of Indigenous children?
- How do you realistically measure this? I would suspect very little.
4. Will the suite of measures deliver the intended results?
- The aims and objectives of the NTER were not stated apart from in the broadest of terms eg “protecting Aboriginal children”, so it is not possible to say whether the intended results have been delivered.
- Child health checks will have no effect on levels of sexual abuse of children. Health checks alone are not going to improve the health or well being of the population. One off visits by fly in fly out teams with no responsibility for ongoing care will not be beneficial.
- Child protection services appear to have received little additional funding, and the service is massively overstretched. Without an adequately funded and staffed FACS I can’t see how any child protection issues can be properly addressed.
5. Have there been any unintended consequences?
- Total demoralisation of primary health care sector and other service providers
- Resentment of the high wages that the supposed “volunteers” were paid
- “Checking fatigue” – many children will have had 6 or 7 checks in the last few months – phase 1 AGI child health check, maybe phase 2 check, audiology check, ENT check, dental check, travel into Alice for review +/- operation, ongoing DHF programmes and paed visits. Many parents and AHWs have expressed their frustration with having to bring their kids to the clinic so often, and being thought of as bad carers if they don’t attend. Teachers have also commented on the amount of time taken out of the school.
- The view of Aboriginal people (particularly men) as child abusers and drunks has been sanctioned by the Government via the NTER and progressed enthusiastically by the media (although maybe this was not an unintended consequence)
6. Will NTER lay the basis for a sustainable and better future for residents of remote communities and town camps in the NT?
- Until the underlying issues of social disadvantage and poverty are addressed, things will not improve for these communities.
7. What alternative measures should be considered?
- The NTER has failed to address the underlying problems leading to social dysfunction. To improve the health and well being of children the social determinants of health must be addressed.
- Proper consultation with communities is essential
- Investment in a quality and sustainable primary health care system for all living in remote locations must be a priority.
- Ongoing adequate funding of services such as dentistry, specialist outreach, community paediatrics and audiology. Particular emphasis needs to be on recruitment and retention of staff with appropriate skills to work in this area.
- Education of all staff working with children about sexual abuse and appropriate pathways to follow if abuse is suspected.
- Support of programmes promoting self esteem and empowerment of women and children.
- Zero tolerance of domestic violence – this needs to be actively policed. Safe houses must be available to women in remote locations.
- The Little Children are Sacred report emphasises the importance of education in breaking the cycle of abuse. NTER is a missed opportunity to enforce school attendance and adequately fund community schools to provide appropriate education for Indigenous children.
- Provision of early childhood services across the region is urgently required. All the evidence points to the importance of the first 2 years of life. Playgroups/ early childhood services are woefully inadequate through out the Central Australian region, putting these children at disadvantage through their lives.
- The role of Indigenous men in society needs to be addressed. There is much focus on women and children’s issues, but little support for men.
Summary
- The socioeconomic status and health status of Aboriginal people is a national disgrace and action needs to be taken.
- The Little Children are Sacred report needs to be endorsed, and the recommendations implemented.
- Consultation with Aboriginal people and communities is vital.
- Consultation with people working in this area who have a wealth of experience and knowledge, and who would be keen to contribute positively if allowed to do so.
- There is currently an inadequate primary health care services in remote Central Australia. This affects the health and well being of all Indigenous people including children and is a true emergency.
- The social determinants of health need to be addressed if the Government is serious about improving the well being of Aboriginal children.
- Health, education and child protection services need to be adequately funded to be able to provide a quality service to Aboriginal children and their families.
- Child health checks will do very little to improve the health and well being of Aboriginal children, but consume vast amounts of resources.
Dr Clare MacVicar
August 2008