News that the first Australian to die from swine flu was also a first Australian came as no surprise to Mick Gooda. "He would have been totally susceptible to swine flu. His immune system was totally shot," says Gooda, chief executive of the Co-operative Research Centre for Aboriginal Health.

But the 26-year-old man from the remote Aboriginal community of Kirrikurra in Western Australia had not been hospitalised originally for the flu. Instead, he'd been checked in for pneumonia. Swine flu may have been what finally killed him, but his other conditions were the concern. They gave the virus the lethal leg-up.

New national and international findings this week back Gooda's claim that the heavy toll H1N1, swine flu, has taken in indigenous communities reflects the complex and fundamental health problems they experience.

As Gooda says: "When you start to understand the dimensions of the issue, you realise it's not going to be fixed with a silver bullet, You've got to get way out in front of these things. The problem isn't swine flu but everything that makes us more susceptible to swine flu in the first place."

Michael Gracey, of Perth's Unity of First People of Australia, agrees: "Prevention is much better than cure, The emphasis has to be on wellness."

Writing this week in The Lancet, Gracey and Canadian expert Malcolm King conclude that their analysis of health statistics of one hundred and ninety-three countries reveals the situation of Aboriginal Australians is similar to that of many indigenous populations worldwide. That is, they have shorter average lifespans than non-indigenous populations.

The numbers are clear. In 2003 Australian men aged fifteen to sixty had the seventh lowest probability of dying of all one hundred and ninety-three nations and all Australian women combined had the twelfth lowest probability. But when figures for indigenous Australians were included, Australia dropped to one hundred and thirty-first on the list, below countries such as East Timor.

Gracey and King's finding that the standard of health among indigenous Australians is below that of developing countries is unsurprising to Aboriginal Medical Services Alliance NT chairwoman Stephanie Bell. "The conditions some Aboriginal people live in are of a fourth-world standard," she says.

Findings reported this week by the Productivity Commission's report into indigenous disadvantage for the Council of Australian Governments lends weight to her claim. While there there were improvements in some areas, the commission has found indigenous people can still expect poorer health outcomes than their non-indigenous counterparts in areas such as life expectancy, perinatal and infant mortality, disability and chronic disease.

Aboriginal Australians fare less well in terms of maternal health, birth weight, injury and preventable disease, hearing impediments, potentially preventable hospitalisations, avoidable mortality, mental health and rates of diseases associated with poor environmental health.
Worse, the commission concludes every indicator of disadvantage is determined by and determines another. That is, each indicator—from life expectancy to low birthrate—is complicated by numerous social and cultural forces, as though each is a body of water supplied by multiple tributaries.

Clearly there's no single, simple, solution to the dismal state of indigenous health.

But Gooda points to a place to start: "The single biggest intervention we can make in Aboriginal health relates to smoking. Aboriginal people smoke three times the amount as non-Aboriginal people and our research tells us that this counts for seventy per cent of avoidable mortality." In contrast, he says, alcohol causes just four per cent of such deaths. "From a health perspective, when it comes to chronic diseases, tobacco is the killer," he claims.

Indeed, the commission has found the rate of hospitalisations related to indigenous people's use of tobacco is almost four times as high as that for non-indigenous people, with 3.6 of every thousand indigenous people hospitalised with smoking-related conditions.

"My mum died of [smoking-related] renal failure," notes Gooda. "Never drank a day in her life. Her arteries were black and hard. We could wipe seventy per cent of that out overnight [by reducing smoking rates]."

According to the commission, indigenous hospitalisation rates for potentially preventable chronic conditions such as cardiovascular disease and renal failure were six times that for non-indigenous people in the 2006-07 period, up twenty-one per cent from 2004-05.

While avoidable mortality declined between 1998 and 2006 in some states, the commission found indigenous people still are 4.6 times likelier to die from heart attack than non-indigenous Australians, 1.9 times likelier to die from cancer and 2.4 times likelier to die from suicide.

According to the commission's findings, the real killer, though, is diabetes. Indigenous people are nearly eighteen times likelier to die from the disease than non-indigenous people. Diabetes accounts for eighty-nine per cent of hospitalisations of indigenous people for potentially preventable chronic conditions.

Miwatj Health Aboriginal Corporation chief executive Eddie Mulholland, puts this down to changes in indigenous people's diets. He argues that dietary changes also account, in large part, for the fact thirty-one per cent of indigenous adults in non-remote areas in 2004-05 were obese.

"Most of these figures are the result of Westernisation," Mulholland claims. "It's not just health. Food, tobacco and alcohol have affected everything."

Access to primary health care is complicated by cultural and racial issues, he says. Roughly sixty per cent of the Arnhem Land people with whom he works don't speak English and find trenchant racism a barrier to accessing health care.

"It's very stressful to access even the most basic services," Mulholland says.

"It's very intimidating if you're going to be treated very badly when you walk into a shop or a post office, let alone into a doctor's office or hospital."

The 2006 Australian Bureau of Statistics Community Housing and Infrastructure Needs Survey found four hundred and seventeen remote indigenous communities, 25,486 people (twenty-seven per cent of the population surveyed), were one hundred kilometres or more from the nearest Aboriginal primary healthcare centre.

"The only way to alleviate many of these problems is through what is sometimes called self-determination," Mulholland says. "The answer is community control: Aboriginal governing bodies delivering services to Aboriginal people. That's how you move forward."

But Bell cautions that community control is not enough: "Building the capacity of the Aboriginal community-controlled healthcare sector is the right pathway, but that will only make a contribution of between thirty and fifty per cent to health outcomes."

Still, Bell and Mulholland agree on two points. The first is that greater efforts must be made to tackle the broad social determinants of indigenous health. The second: maternal health and the reduction of perinatal and infant mortality are top priorities.

"Obviously, you've got to cut that down," Gooda says. "That's a moral obligation. But it also has practical implications. It creates a positive life trajectory. If you get healthy mums having healthy pregnancies, then you'll have healthy children, right from the beginning, on a positive trajectory."

Just how that's to be accomplished is open for debate, says Gooda, noting that greater investment is required, not only into treatment but into intervention methods.

"Unless we have good research showing exactly how we should be influencing changes, it's possible that all our efforts will be wasted," Gooda says. "You can't argue with the government's $1.6 billion investment in Aboriginal health. But if it isn't guided by evidence of what works and what doesn't work, it's going to be wasted."

If so, the result is predictable: Aborigines will make headlines again when the next killer disease hits Australia.

The Weekend Australian, 11 July 2009