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Social determinants and the health of Indigenous peoples in Australia

Aboriginal and Torres Strait Islander Social Justice


Social determinants and the health of Indigenous peoples in Australia – a human rights based approach

Workshop paper presented by Mr Darren Dick on behalf of Mr Tom Calma, Aboriginal and Torres Strait Islander Social Justice Commissioner

International Symposium on the

Social Determinants of Indigenous Health,

Adelaide, 29-30 April 2007

1. Introduction

Improving the health status of Indigenous peoples1 in Australia is a longstanding challenge for governments in Australia. The gap in health status between Indigenous and non-Indigenous Australians remains unacceptably wide.2 It has been identified as a human rights concern by United Nations committees3; and acknowledged as such by Australian governments4.

Social determinants theory recognises that population health and inequality is determined by many interconnected social factors5. Likewise, it is a basic tenet of human rights law that all rights are interconnected and that impacting on the enjoyment of one right will impact on the enjoyment of others6. Because of this synergy, human rights discourse provides a framework for analysing the potential health impacts of government policies and programs on Indigenous peoples.7

Important determinants of Indigenous health inequality in Australia include the lack of equal access to primary health care and the lower standard of health infrastructure in Indigenous communities (healthy housing, food, sanitation etc) compared to other Australians. While fundamental to improving Indigenous health outcomes, these issues are not addressed in this paper.8 Instead, this paper considers the social determinants of Indigenous health with reference to human rights principles.

Indigenous health policy in Australia is guided by the National Strategic Framework for Aboriginal and Torres Strait Islander Health 2003-2013. One of the nine guiding principles of this is that Governments adopt a holistic approach:  ‘recognising that the improvement of Aboriginal and Torres Strait Islander health status must include attention to physical, spiritual, cultural, emotional and social well-being, community capacity and governance.’9 This paper also highlights the inconsistencies between this guiding principle and the practices of Australian governments.

2. Indigenous health in Australia – key trends

The current status of Indigenous health in Australia can be briefly synopsized as follows:

  • The health status of Australia’s Aboriginal and Torres Strait Islander peoples is poor in comparison to the rest of the Australian population.10 There remains a large inequality gap in Australia across all statistics. For example, there is an estimated gap of approximately 17 years between Indigenous and non-Indigenous life expectation in Australia11. For all age groups below 65 years, the age-specific death rates for Indigenous Australians are at least twice those experienced by the non-Indigenous population12.  
  • Indigenous peoples do not have an equal opportunity to be as healthy as non-Indigenous Australians. ‘The relative socioeconomic disadvantage experienced by Aboriginal and Torres Strait Islander people compared to non-Indigenous people places them at greater risk of exposure to behavioural and environmental health risk factors’13 as does the higher proportion of Indigenous households that ‘live in conditions that do not support good health’.14 Indigenous peoples also do not enjoy equal access to primary health care and health infrastructure (including safe drinking water, effective sewerage systems, rubbish collection services and healthy housing).15
  • There has been very little progress in reducing this inequality gap between Aboriginal and Torres Strait Islander and non-Indigenous Australians over the past decade, for example in relation to long term measures such as life expectation.
  • While there have been improvements on some measures of Aboriginal and Torres Strait Islander health status, they have not matched the rapid health gains made in the general population in Australia. For example, death rates from cardiovascular disease in the general population have fallen 30% since 1991, and 70% in the last 35-years16 whereas Indigenous people do not appear to have made any reduction in death rates from cardiovascular disease over this period.17
  • The young age structure of the Aboriginal and Torres Strait Islander population means that the scope of the issues currently being faced is expected to increase in the coming decades. The increase in absolute terms of the size of the Aboriginal and Torres Strait Islander youth population will require significant increases in services and programs simply to keep pace with demand and maintain the status quo, yet alone to achieve a reduction in existing health inequality.
  • The inequality in health status experienced by Aboriginal and Torres Strait Islander peoples is linked to systemic discrimination. Historically, Aboriginal and Torres Strait Islander peoples have not had the same opportunity to be as healthy as non-Indigenous people. This occurs through the inaccessibility of mainstream services and lower access to health services, including primary health care, and inadequate provision of health infrastructure in some Aboriginal and Torres Strait Islander communities. The Royal Australasian College of Physicians describes these health inequities as ‘both avoidable and systematic’.18 This legacy remains to be fully addressed and is a significant barrier to the full enjoyment of the right to health for Aboriginal and Torres Strait Islander peoples.

3. Indigenous health and human rights – Key principles

The International Covenant on Economic, Social and Cultural Rights (ICESCR) includes the right to the enjoyment of the highest attainable standard of physical and mental health (article 12); the right to an adequate standard of living, including adequate food, clothing and housing (article 11); and the right to education (article 13).

Article 2 of the Covenant requires that governments take steps, to the maximum of their available resources, with a view to achieving progressively the full realization of the rights recognized in the Covenant. It also requires that all rights be enjoyed on a non-discriminatory basis.

The right to health, and these related rights, have been recognised for some time. But it is only in recent years that detailed consideration has been given a rights based approach to health. This framework therefore offers a relatively new perspective on the factors necessary to address health inequalities and ensure to all people the right to the enjoyment of the highest attainable standard of health.

Overall, the human rights based approach to health has the following components. It:

  • emphasises the accountability of governments for socio-economic outcomes among different sectors of civil society by treating these outcomes as a matter of legal obligation, to be assessed against the norms established through the human rights system;
  • establishes fundamental principles to guide policy development – such as that Indigenous peoples are not discriminated against and are provided with equality of opportunity, including through recognising their distinct cultural status;
  • highlights that governments have immediate responsibilities to guarantee that the right to health will be exercised without discrimination of any kind, and to take deliberate, concrete and targeted steps towards the full realisation of the right to health;
  • recognises as legitimate, and as non-discriminatory, the establishment of specific programs for particular groups (such as based on race) which are taken with the purpose of addressing inequality;
  • establishes that the obligation of government is to respect, protect and fulfil the right to health, which requires a combination of responses ranging from refraining from committing harmful acts, introducing measures to prevent others from committing such acts, and taking positive steps to realise the right to health;
  • emphasises process for achieving improvements in these outcomes, with the free, active and meaningful participation of Indigenous peoples being critical;
  • establishes criteria against which to assess health policy and program interventions to ensure that services are appropriate, accessible, available and of sufficient quality, and that they also do not fall below a core minimum or essential level of rights;
  • requires governments, working in partnership with Indigenous peoples, to demonstrate that they are approaching these issues in a targeted manner, and are accountable for the achievement of defined goals within a defined timeframe; and
  • places the burden on government of justifying that it has made every effort to use all available resources at its disposal in order to satisfy, as a matter of priority, the right to health.

A rights based approach to health has begun to be operationalized throughout the United Nations structure through the Common Understanding of a Human-Rights Based Approach to Development Cooperation.19 The Common Understanding emphasises, inter alia,  that:

  • People are key actors in their own development, rather than passive recipients of commodities and services;
  • Participation is both a means and a goal; and
  • Strategies should be empowering, not disempowering, and encourage active engagement of all stakeholders.

These human rights considerations are critical in addressing the social determinants of health.

  • Social determinants of Indigenous health in Australia

(a) Links between health status and socio-economic status / poverty

Indigenous peoples in Australia experience socio-economic disadvantage on all major indicators. For example:

  • At the 2001 National Census, the average gross household income for Indigenous peoples in Australia was $364 per/week, or 62% of the rate for non-Indigenous peoples ($585 per/ week) .20
  • At the 2001 Census, the unemployment rate for Indigenous peoples was 20%; three times higher than the rate for non-Indigenous Australians21.
  • Nationally in 2004, Indigenous students were also half as likely to continue to year 12 as non-Indigenous students22.

Research has demonstrated associations between an individual’s social and economic status and their health. Poverty is clearly associated with poor health.23 For example:

  • Poor education and literacy are linked to poor health status, and affect the capacity of people to use health information; 24
  • Poorer income reduces the accessibility of health care services and medicines;
  • Overcrowded and run-down housing is associated with poverty and contributes to the spread of communicable disease;
  • Poor infant diet is associated with poverty and chronic diseases later in life;25 and
  • Smoking and high-risk behaviour is associated with lower socio-economic status.26

Research has also demonstrated that poorer people also have less financial and other forms of control over their lives.27 This can contribute to a greater burden of unhealthy stress28 where ‘prolonged exposure to psychological demands where possibilities to control the situation are perceived to be limited and the chances of reward are small.’29 Chronic stress can impact on the body’s immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems from diseases of the circulatory system (notably heart disease)30, mental health problems31, violence against women and other forms of community dysfunction.32

(b) Linkages between perceptions of control and chronic stress

In the National Aboriginal Health Strategy (1989), Indigenous peoples stated that their health status is linked to ‘control over their physical environment, of dignity, of community self-esteem, and of justice. It is not merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity’33.

In making these assertions, Indigenous peoples anticipated developments in social determinants theory over the 1990s. It is now generally accepted that an individual’s perceived lack of control over their lives can contribute to a burden of chronic, unhealthy stress contributing to mental health issues, violence and substance abuse34.

This is the experience among Indigenous Australians. For example:

  • An indicator of chronic stress in a population group is high rates of high-risk health behaviour, notably substance abuse.35  In 2002, just under one-half of the Indigenous population aged15 years or over smoked on a daily basis36. One in six reported consuming alcohol at risky or high risk levels.37
  • High rates of mental health problems also indicate chronic stress in a population group. 38 In 2003-04, Indigenous people were up to twice as likely to be hospitalised for mental and behavioural disorders as other Australians.
  • Hospitalisation rates for assault or intentional self-harm may also be indicative of mental illness and distress. In 2003–04, Indigenous males were 7 times more likely, and females 31 times as likely as for males and females in the general population; hospitalisation rates for intentional self-harm was twice as high.39

Relatively permanent, negative features of the social environment trigger chronic stress: intergenerational poverty, racism, and so on. It can impact on the body’s immune system, circulatory system, and metabolic functions through a variety of hormonal pathways and is associated with a range of health problems, particularly diseases of the circulatory system.40 These are currently the biggest killer of Indigenous people in Australia.

The WAACHS found that the environmental safety and the emotional and social health of Indigenous children improved with isolation (that is, those in remote communities had better mental health). Children living in Perth had significantly poorer (in fact, five times worse) emotional and social health than those living in very remote communities. The report concludes that traditional cultures and ways are protective against poor environmental safety and emotional and social health.41

To the degree recognising Indigenous peoples’ right to self-determination supports communities to regain control of their lives, including through the maintenance of traditional cultures, it can be understood as having positive health impacts. It is also a stepping-stone to the goal of social and economic equality. Experience from overseas confirms that Indigenous communities’ control over their own affairs can be crucial to their social and economic regeneration42.

(c) Evidence of the health impact of Indigenous community control of health services

Aboriginal community controlled health services an excellent example of how communities can be empowered by exercising control of local services. While the fact of control may in and of itself be expected to bring broader health benefits, the ability of communities to decide on, and address, their own health priorities has been found to increase the impact of primary health care in communities.43

For example:

  • The Northern Territory Well Women’s Program, which operates in a region with a high proportion of Aboriginal women and has a long history of engagement with women and local Aboriginal Health Services, has achieved a high rate of cervix screening (61%) in the Alice Springs remote area, which is comparable to the rate for Australian women generally (62%). \
  • A mental health project at the Geraldton Regional Aboriginal Medical Service reduced psychiatric admissions of Aboriginal and Torres Strait Islander people to Geraldton Regional Hospital by 58%.
  • Since 2000 the Townsville Aboriginal and Islander Health Service’s Mums and Babies Project increased the numbers of women presenting for antenatal care (from 40 to over 500 visits per month in 1 year). The number of antenatal visits made by each woman has doubled, with the number having less than four visits falling from 65% to 25%. Pre-natal deaths per 1,000 reduced from 56.8 prior to the program to 18 in 2000; the number of babies with birth weights less than 2,500 grams has dropped significantly; and the number of premature births has also decreased.
  • Since 1990 an antenatal program at Daruk Aboriginal Community Controlled Medical Service, Western Sydney has achieved increased awareness among Aboriginal women of the importance of antenatal care. Thirty-six (36) per cent of Indigenous women presented within the first trimester, compared with 21% at Nepean and 26% at Blacktown Hospitals’ antenatal clinics; and women attended more antenatal visits (an average of 10 at Daruk compared to 6 at Nepean and 9 at Blacktown).

(d) Traditional ownership of land and health status

The right of self-determination includes the right of peoples to freely ‘dispose of their natural wealth and resources’ and that ‘in no case may a people be deprived of its own means of subsistence’.

Native title and the title to communally owned land (through the various Aboriginal land rights legislation in Australia) is the ‘natural wealth and resources’ of Indigenous peoples.

As noted above, supporting traditional culture – including customary law and governance structures – is likely to help improve the health status of people living in remote communities. In practice, this also means ensuring Indigenous peoples have access to their traditional lands.

While Indigenous commentators have highlighted the social and culturally related health benefits of access to land,44 many possible positive health impacts are likely including improved diet, exercise, and the reconnection of Indigenous peoples with their traditional economic bases.

The Kuka Kanyini project in Wattaru, South Australia in the Anangu Pitjantjatjara Lands illustrates these benefits.

Text Box:  Case study - The Kuka Kanyini project, Anangu Pitjantjatjara Lands45

The goals of managing country, conserving biodiversity, maintaining culture, providing employment and training and improving the diet of  remote communities coincide in the Kuka Kanyini project. This was initiated in 2003 as a pilot around the remote community of Watarru in the far north west Anangu Pitjantjatjara Yankunytjatjara  (APY) Lands. The project is a local community- government partnership funded by the South Australian Department of Environment and Heritage and the APY land management. The Kuka Kanyini model, it is hoped, will be extended throughout the APY Lands in time.

Watarru has a seasonal population of between 60 and 100 people and is located in an extremely remote part of the APY Lands. It is a lawfully strong, proud and socially cohesive community, generally free of problems like petrol sniffing and domestic violence that occur elsewhere on the APY Lands. However, despite these positive points, a visit to Watarru by staff members of HREOC in 2003 noted high rates of diabetes and other chronic diseases self-reported by community members. There was a limited range of foods stocked at the Watarru community store. Convenience foods high in saturated fat and sugars are often the preferred foods by community members.

Land management is an integral part of the project. This includes maintaining the traditional pattern of fire management regimes that helps minimise the impact of accidental fires that can otherwise devastate the local mulga woodlands from which foods (grubs, mistletoe fruit, honey ants, mulga apples and seeds) and pharmacopeia are found. Fire also is used to encourage regrowth of foods preferred by kangaroos and emus that assist Anangu when hunting. It also includes the control of populations of feral rabbits, foxes, camels, and cats that have had a significant impact on the population of small sized native mammals in the region. Feral camels and horses also foul and damage water sources that native animals rely on and compete with the community for several plant food-sources and are of high cultural significance.

To date the project has exceeded expectations.  It continues to employ a minimum of 12 people on a full time basis, increasing the level of self esteem and valuing the 40,000 years information base of the local people to assist western science.  By combining contemporary and traditional skills the local people are now able to best manage the land. To date, the increase in the physical activity by participants has assisted in the control of diabetes. The guaranteed wage ensures that people are now saving for large items and buying healthy foods.  The increase in self- esteem is obvious with the younger people wanting to participate; young men in particular seek to working with camels and learn fire skills as these are considered prestigious occupations.

(e) Social determinants as a contemporary reflection of historical treatment

Indigenous peoples are not merely ‘disadvantaged citizens’. The poverty and inequality that they experience is a contemporary reflection of their historical treatment as peoples. The inequality in health status that they continue to experience can be linked to systemic discrimination.

In Australia, this has been vividly demonstrated by:

  • the Royal Commission into Aboriginal Deaths in Custody, which illustrated the links between socio-economic status and imprisonment; and
  • the National Inquiry into the Forcible Removal of Aboriginal and Torres Strait Islander Children From Their Families (or Bringing them Home), which illustrated the inter-generational problems for parenting, health, and care and protection of the removal of children during the assimilation period.

The following examples (both contemporary and historical) demonstrate the negative impact of social determinants on Indigenous peoples’ health.

  • Racism

Racism is a stressor that has been reported to affect both mental and physical health. A 2003 review of 53 studies in the United States found a decline in mental health status as racism increased46. Eight out of 11 studies found links between the elevated prevalence of high blood pressure in Afro-Americans and racism47. There have been very few studies on the impact of racism on the health of Indigenous people in Australia, although experts agree that a correlation with the US studies is to be expected48.

One such study is the Western Australian Aboriginal Child Health Survey 2001-02 (WAACHS). It reported than 21.5% of the Indigenous children under 12 surveyed experienced racism in the previous 6-months. This was associated with increased smoking, marijuana use and alcohol consumption in these under-12s49.

  • Children removed from their families (‘stolen generations’)

The National Aboriginal and Torres Strait Islander Social Survey 2002 reported that 38% of respondents had either been removed themselves and/or had relatives who, as a child, had been forcibly or otherwise removed from their natural family.50

The practice has intergenerational health impacts. The WAACHS reported that the effect on parents was that they had higher rates substance abuse and mental health problems. Their children were twice as likely to have emotional and behavioural problems, to be at high risk for hyperactivity, emotional and conduct disorders, and twice as likely to abuse alcohol and drugs.51

  • Indigenous women as victims of crime

Research conducted by the Social Justice Commissioner on the circumstances of Indigenous women’s prisoners in Australia found that Indigenous women are victims of a complex frame of dynamics upon their lives including violence, poverty, trauma, grief, loss, cultural and spiritual breakdown. 

Indigenous women are particularly vulnerable to intersectional discrimination within criminal justice processes due to the following reasons:

  • the combination of socio-economic conditions faced by many indigenous women; including being more likely than non-indigenous women to be unemployed, to have carer responsibilities for children other than their own, to receive welfare payments and to have finished school at an earlier age; and to be a victim of violence and also more likely to live in communities where violence is prevalent.  These factors combine to make Indigenous women particularly vulnerable and their needs more complex than others.
  • Second, due to the consequences of family violence in indigenous communities, and its impact on Indigenous women.  This has not been grappled with appropriately by the criminal justice system.  Policies and programs provide relatively little attention to the high rate of indigenous victimization, particularly through violence and abuse in communities.  Indigenous women disproportionately bear the consequences of this.

There is a consistent pattern indicating that incarcerated Indigenous women have been victims of assault and sexual assault at some time in their lives. There was also a strong relationship between incarceration and experiences of violence, drug and alcohol abuse, with Indigenous women often entering custody with poor physical or mental health, and at higher risk of self harming when in prison and also soon after release from prison.

As a consequence, the rate of Indigenous women being imprisoned has increased most rapidly in Australia since 2000. Indigenous women also experience extremely high rates of recidivism.

In consultations to identify solutions to address this situation, Indigenous women emphasised the importance of healing to address grief and trauma as a major priority. Strategies need to respond to the circumstances of indigenous women holistically, which seeks to not only address offending behaviours but also focus on healing the distress and grief experienced by many indigenous women and their communities.

Text box 3 below contains a case study of a program that attempts to help heal the trauma experienced by survivors of the Stolen Generation, Indigenous women prisoners and other Indigenous people.

Text Box: Case study - Sacred Site Within Healing Centre

The Sacred Site Within Healing Centre was established in Adelaide in 1993. Sacred Site provides grief and loss counselling services to Indigenous people, as well as making presentations and conducting training with government departments and community organisations on the effects in Indigenous communities of unresolved grief and trauma.

Sacred Site was established due to concerns that mainstream counselling services were not appropriate in addressing the grief and loss of Indigenous people. An underpinning belief of the Sacred Site program is that Indigenous peoples' unresolved grief is a major contributing factor to the range of social and health issues which exist in Indigenous communities today.

Healing strategies used at Sacred Site seek to:

* Create an awareness about the impact of losses and the unresolved grief that results;

* Create and develop grieving ceremonies;

* Recreate women's business and ceremonies;

* Recreate men's business and ceremonies; and

* Recreate rites of passage for young people.

Overall, Sacred Site attempts to assist Indigenous people understand their grief and loss in a holistic sense which includes the effects of colonisation. The program also aims to assist people working with Indigenous people to understand issues of grief and loss.

  • Reconciliation

In 1991, Australia commenced a formal process of reconciliation with Indigenous peoples. The Council for Aboriginal Reconciliation made its recommendations to the nation in 2000. The federal government responded to these recommendations by emphasising the need to address ‘practical’ issues such as disadvantage, as opposed to ‘symbolic issues’ which they described as including recognition of rights, a treaty and a national apology to the Stolen Generations, and other forms of reparation.

‘Practical reconciliation’ rests on an artificial division between measures that are described as practical as opposed to symbolic.52 But, as social determinants theory would suggest, no such clear distinction exists – there are interdependencies between many of the dimensions of Indigenous disadvantage; including how social and historical factors can influence contemporary Indigenous practical outcomes.  At the moment a more lasting and meaningful reconciliation process is the task of future generations. 

5.  Recognising social determinants as a contemporary reflection of the impact of colonisation – international developments

Recognising the contemporary impact of colonization on Indigenous peoples globally remains a major challenge for the international community and the United Nations. It is also a major challenge for those seeking to understand the social determinants of health among Indigenous communities.

At the launch of the Second International Decade for the World’s Indigenous People, Ms Mililani Trask vividly described this challenge. She stated:

Governments speak of ‘poverty’ while Indigenous Peoples speak of ‘rights’. Within Indigenous territories, poverty is also defined by power deficits, lack of self-determination, marginalization and lack of mechanisms for meaningful participation and access to decision-making processes… Poverty alleviation must start from Indigenous Peoples own definitions and indicators of poverty…53

Applying the Millennium Development Goals to the situation of Indigenous peoples, she continued:

the effort to meet the targets laid down for MDGs could in fact have harmful effects for indigenous peoples such as the acceleration of loss of lands and natural resources or the displacement from those lands. (The MDG indicators need to be redefined to be relevant to indigenous peoples by taking into consideration)… culturally appropriate indicators, redefining the process of impoverishment caused by dispossession of ancestral lands, loss of control over natural resources and indigenous knowledge, devastating social and environmental impacts, impacts from militarization and conflict and forced assimilation into the mainstream society and integration into the market economy.54

She concluded:

The human-rights based approach to development is essential to the achievement of the MDGs. The MDGs must therefore be firmly grounded on a rights-based approach, to have meaning for Indigenous Peoples.55

The United Nations Permanent Forum on Indigenous Issues (PFII) have identified that to address these concerns there is a need for processes for indigenous peoples ‘to identify gaps in existing indicator frameworks, examine linkages between quantitative and qualitative criteria, and propose the development of indicators that are culturally-specific, measure exclusion, and reflect the aspirations of indigenous peoples’.56

The PFII convened a meeting in Ottawa in February 2006 to this end. 57 It identified numerous challenges at the national and international level in developing appropriate indicator frameworks and linking these to the Millennium Development Goals. They stated, inter alia, that:

  • Indicators must place significant emphasis on indigenous peoples’ inherent values, traditions, languages, and traditional orders/systems, including laws, governance, lands, economies etc. Collection of data and development of indicators should, therefore, also represent indigenous peoples’ perceptions and understanding of well-being. It was noted, however, that not everything relating to indicators development undertaken by governments is relevant to indigenous peoples and not everything that indigenous peoples perceive can be measured. 
  • Indicators should also focus on the interplay between indigenous and non-indigenous systems (social, political and economic, colonization, industrialization) that result in a series of impacts, such as racism and discrimination, migration to urban centres, youth suicide and disconnection to land and culture.
  • Indicators that demonstrate inequities and inadequacies in government funding for indigenous peoples’ programming and services should also be developed.  This data can be illuminating by linking funding levels to mandated areas of government responsibility, assessing their accountability and projecting demand and other impacts into the future. 
  • There should be a balance of comparative indicators to assess well-being among non-indigenous and indigenous peoples, and indigenous-specific indicators based on indigenous peoples’ visions and understandings of well-being.58

The Workshop recommended that ‘the United Nations should identify and adopt appropriate indicators of indigenous identity, lands, ways of living, and indigenous rights to, and perspectives on, development and well-being’ and that these indicators should by applied in performance measurement and monitoring processes by the UN system, as well as its member states, intergovernmental organizations and other development institutions.59

Accordingly, the Workshop proposed a series of indicators that could be further considered at the national and international level based on the two key themes of:

  • Identity, Land and Ways of Living; and
  • Indigenous Rights to, and Perspectives on, Development.

The Workshop noted that ‘more exact indicators need to be developed in a measurable form, with full participation by indigenous peoples from all regions’.60 The proposed indicators relate to the following issues:

  • Maintenance and development of Traditional Knowledge, Traditional Cultural expressions and practices;
  • Use and intergenerational transmission of indigenous languages;
  • Support of, and access to, bilingual, mother tongue, and culturally appropriate education;
  • Ownership, access, use, permanent sovereignty of lands, territories, natural resources, waters;
  • Health of communities – including community safety, community vitality, and support for safe and culturally appropriate infrastructure;
  • Health of ecosystems;
  • Patterns of migration;
  • Indigenous governance and management systems;
  • Free, prior, informed consent, full participation and Self-determination in all matters affecting indigenous peoples’ well-being;
  • Degree of implementation/compliance with international standards and agreements relating to indigenous peoples’ rights; and
  • Government funding for indigenous peoples’ programs and services.61

6. Conclusions and lessons

This paper has addressed a broad range of issues. It seeks to demonstrate the connections between low socio-economic status and poverty, and health outcomes. It demonstrates that the social determinants of health for Indigenous peoples reflect more than just their relative disadvantage. It also reflects the non-recognition and non-enjoyment of their human rights and of their distinct cultural characteristics.

Indigenous peoples globally have actively noted the importance of a human rights based approach to addressing their disadvantage and to ensuring the survival of their cultures.

An approach to social determinants that fails to recognise the fundamental connections between health status and the enjoyment of human rights will fail.


[1] Throughout this chapter I refer to Aboriginal and Torres Strait Islander peoples as ’Indigenous peoples’. In doing so, I acknowledge the distinct cultures and societies of different Aboriginal peoples and Torres Strait Islanders. The term ‘peoples’ is also used to recognise the collective dimension of the livelihoods of Indigenous people, with distinct cultural beliefs that differentiate them as a group from other Australians.

[2] For a detailed discussion of the statistics see Aboriginal and Torres Strait Islander Commissioner, Social Justice Report 2005, Human Rights and Equal Opportunity Commission, Sydney, 2006, pp17-29, available online at:

[3] United Nations Committee on the Rights of the Child, Concluding Observations – Australia, Unedited version, UN Doc: CRC/C/15/Add.268; United Nations Committee on the Elimination of Racial Discrimination, Concluding observations of the Committee on Australia, UN Doc:CERD/C/AUS/CO/14, para 17.

[4] See, for example, the 2nd and 3rd periodic report of Australia to the Committee on the Rights of the Child (submitted 29 December 2004, UN Doc: CRC/C/129/Add.4, p5) and the 14th periodic report of Australia to the Committee on the Elimination of Racial Discrimination (submitted 1 April 2004, UN Doc: CERD/C/428/Add.2, paras 80-81.

[5] Saggers, S and Gray, D, ‘Defining what we mean’, Editors, Carson, B, Dunbar, T, Chenall, R,, Social Determinants of Indigenous Health, Allen and Unwin, NSW, 2007, pp1-18.

[6] See for example, Vienna Declaration and Programme of Action (25 June 1993) Adopted by the World Conference on Human Rights on 25 June 1993 A/CONF.157/23 12 July 1993.

[7] See Gray, N, ‘Human Rights’ Editors, Carson, B, Dunbar, T, Chenalll, R,, op.cit. pp.253-267.

[8] See further: Social Justice Report 2005, op.cit.

[9] National Aboriginal and Torres Strait Islander Health Council, National Strategic Framework for Aboriginal and Torres Strait Islander Health: Context, NATSIHC, Canberra, 2003, p2.

[10] Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS), The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples 2005, ABS cat. no. 4704.0, Commonwealth of Australia, Canberra, 2005, pxvii, available online at:

[11] Australian Institute of Health and Welfare and Australian Bureau of Statistics, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2005, ABS cat. no. 4704.0, Commonwealth of Australia, Canberra, 2005, p148, available online at:

[12] ibid., p151.

[13] ibid., pxxiii.

[14] ibid., pxxii.

[15] Communicable and water-borne diseases and parasites are indicators of poor health infrastructure. Infants and children are particularly vulnerable to these diseases.

[16] National Health and Medical Research Centre, Promoting the health of Australians, Case studies of achievements in improving the health of the population, AGPS, Canberra, 1997, p35.

[17] Thomson, N. and Brooks,  J., ‘Cardiovascular Disease’, in Editor, Thomson, N., The Health of Indigenous Australians, Oxford University Press, Melbourne, 2003, p186.

[18] Royal Australasian College of Physicians, Inequity and Health – A Call to Action - Addressing Health and Socioeconomic Inequality in Australia – Policy Statement 2005, RACP, Canberra, 2005, p3.

[19] United Nations, The Human Rights-Based Approach to Development Cooperation: Towards a Common Understanding Among the UN Agencies, United Nations, New York 2003, available online at:

[20] Australian Bureau of Statistics, Population Characteristics, Aboriginal and Torres Strait Islander Peoples 2001, ABS cat. no. 4713.0, Commonwealth of Australia, Canberra., 2002, p81.

[21] ibid.  p66.

[22] Steering Committee for the Review of Government Service Provision,  op.cit. p3.19.

[23] See generally Editors Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit.

[24] Fred Hollows Foundation, Literacy for Life, Australian National University, Canberra, 2004, pp10-12, available online at . See also the issues raised in: Malin, M, Is schooling good for Indigenous children's health?, Cooperative Research Centre for Aboriginal and Tropical Health & Northern Territory University, 2003, available online at:

[25] Wadsworth, M., Early Life, in (eds.), Marmot, M. and Wilkinson, R., Social Determinants of Health, Oxford University Press, New York, 1999, p44. Chronic diseases that have poor diet as a determinant include cardiovascular disease, Type 2 diabetes and renal disease. Connections have been made between poor foetal nutrition and the presence of chronic diseases later in life: National Health and Medical Research Council, Nutrition in Aboriginal and Torres Strait Islander peoples - An information paper, Commonwealth of Australia, 2000, p15.

[26] Jarvis, M. and Wardie, J., ‘Social pattering of individual health behaviours; the case of cigarette smoking’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., pp241-244.

[27]In 2002, 54% of indigenous people aged 15 or over were living in households where the household spokesperson reported that household members would be unable to raise $2000 within a week in a time of crisis. Australian Bureau of Statistics and Australian Institute of Health and Welfare, op.cit., pp12-13.

[28] Shaw, M., Dorling, D. and Davey-Smith, G., ‘Poverty, social exclusion, and minorities’, in Editors, Marmot, M. and Wilkinson, R.., Social Determinants of Health, op.cit.,pp32-37.

[29] Brunner, E, Marmot, M, ‘Social Organization, stress and health’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health op.cit, p 17.

[30] ibid.,pp32-37.

[31] Marmot, M., ‘Health and the psychosocial environment at work’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., p124.

[32] Wilkinson, R., ’Prosperity, redistribution, health and welfare’, in Editors, Marmot, M. and Wilkinson, R., Social Determinants of Health, op.cit., pp260-265.

[33] National Aboriginal Health Strategy Working Group, National Aboriginal Health Strategy, AGPS, Canberra, 1989, pix.

[34] See generally, Editors, Marmot, M. and Wilkinson, R., op.cit.

[35] ibid.

[36] Australian Bureau of Statistics and Australian Institute of Health and Welfare, op.cit., p135.

[37] ibid., pp135-137.

[38] Marmot, M., ‘Health and the psychosocial environment at work’, in Editors, Marmot, M. and Wilkinson, R., op.cit., p124.

[39] ibid., p131.

[40] ibid.,pp32-37.

[41] Telethon Institute for Child Health Research, op.cit., pp18-19.

[42] Cornell, S, 'The importance and power of Indigenous self-governance: Evidence from the United States', Speech, Indigenous Governance Conference, 3 April 2002, p1.

[43] Dwyer, J., Silburn, K., and Wilson, G., National Strategies for Improving Indigenous Health and Health Care, Aboriginal and Torres Strait Islander Primary Health Care Review: Consultant Report No 1, Commonwealth of Australia, Canberra, 2004, pp91-106, Appendix.

[44] See generally Burgess, P., and Morrison, J.,  ‘Country’ in Editors, Carson, B, Dunbar, T, Chenall, R,, op.cit., pp177-196

[45] Extracted from Social Justice Report 2005, op.cit.

[46] Williams, R., Neighbours, H. and Jackson, J., ‘Racial/Ethnic Discrimination and Health: Findings from Community Studies’, (Feb 2003), 93(2) American Journal of Public Health 200, p200.

[47] ibid., p201.

[48] See generally Paradies, Y, ‘Racism’ Editors, Carson, B, Dunbar, T, Chenall, R,, op.cit.,pp65-80.

[49] Cited in ibid., p66.

[50] About 8% of Indigenous respondents reported that they themselves had been removed from their natural family. The most frequently reported relatives removed were grandparents (15%), aunts or uncles (11%), and parents (9%). Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Social Survey 2002, ABS cat. no. 4714.0, Commonwealth of Australia, Canberra, 2004, pp5-6.

[51] Stanley, F., Speech at the National Day of Healing, Parliament House, Canberra, 25 May 2005.

[52] For a critique of this distinction see: Aboriginal and Torres Strait Islander Social Justice Commissioner, Social Justice Report 2001, HREOC Sydney 2001.

[53] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at:

[54] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at:

[55] Mililani Trask, Comments on behalf of the Global Indigenous Peoples’ Caucus at the launch of the 2nd International Decade of the World’s Indigenous People, United Nations General Assembly, 12 May 2006, available online at:

[57] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, Available online at, accessed 26 February 2007.

[58] See further: Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, paras 9-20.

[59] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, para 33.

[60] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, para 34.

[61] Permanent Forum on Indigenous Issues, Report of the meeting on Indigenous peoples and indicators of well-being, UN Doc: E/C.19/2006/CRP.3, 20 April 2006, pp 10-14.