Should the governments of ‘developed’ countries be held responsible for equalizing the indigenous health gap?

Introduction

More than 370 million indigenous people inhabit every habitable continent and territory (1). There is significant variation between and within indigenous populations in terms of world view, culture, political forces, education, socioeconomic status, living conditions, and familial factors. However, many indigenous groups do share a striking commonality: significantly greater rates of non-communicable diseases (NCDs) and a shorter life expectancy when compared to non-indigenous compatriots (2,3). This disparity holds true even for ‘developed’ countries, including Australia, Canada, New Zealand and the United States. For example, among the aforementioned nations the general population of Australia has the highest life expectancy; however, the health gap between the indigenous and the non-indigenous peoples is the widest (4). Arguably, such poor health outcomes are incomprehensible given the high gross domestic product and availability of high-quality health care within these countries. Using Australia as an exemplar context, this commentary will present arguments ‘for’ and ‘against’ the governments of developed nations being held liable for closing the indigenous health gap. We will discuss the history and nature of the health gap, actions needed to ‘close the gap’, and which party has necessary resources to do so.

The Australian government should be held responsible

The historical underpinnings of poor health for many indigenous groups, including Australia, begin with European colonization (1,5). Colonization led to the depression of indigenous lands and resources, leading to ‘cultural genocide’, marginalization, and dependency on the dominant white society (5,6). Subsequently, marginalization not only led to the loss of traditional lifestyles, but poor access to employment, education, social services, and adequate health care (5,6). With their forefathers behind such actions, the current Australian government should take direct responsibility for closing the gap.

Despite the 2008 apology by Prime Minister Kevin Rudd and the Australian Government, there remains a significant indigenous health gap (7). Currently, the indigenous peoples of Australia suffer a burden of disease that is approximately two and a half times greater than the burden of disease for the total Australian population (8). In terms of NCDs, Aboriginal peoples have higher incidence of diabetes (3.4× greater), kidney disease (10× greater), and cardiovascular disease (3× greater) than their non-indigenous counterparts. Of equal concern, Aboriginal peoples suffer from higher prevalence rates of communicable diseases, including shigellosis (2.6× greater), pertussis (54.3× greater), and tuberculosis (6× greater) (8).

To improve indigenous health, the government needs to address all social determinants of health, including living conditions and accessibility to health and social services. The risk of exposure to communicable diseases stems from lack of sanitary cooking/bathing stations, as well as overcrowded houses (7). Through basic health hardware improvements (7), such as increased expenditure on low-income housing and government housing repairs, the rate of disease spread can be reduced. Additionally, poor social and economic circumstances, due to lower employment and educational accessibility, affect health throughout life. Societies that enable all citizens to play a full and useful role in the social, economic and culture of their society will be healthier than those where people face insecurity, exclusion and deprivation (9). The government should claim direct responsibility for providing the funds and services to improve the social and physical determinants of indigenous health.

The Australian government should not be held responsible

For decades, the government has been responsible for the health of the Aboriginal population, yet health disparities between indigenous and non-indigenous Australians persist. A history of discrimination and displacement from land, culture, and family on the part of the Australian government has generated a feeling of mistrust among the indigenous peoples of Australia (10). Such mistrust will prevent the government from gaining traction with the indigenous health gap.

What is most important to consider when approaching indigenous health is that the mere definition of health differs greatly between the government agencies and indigenous groups, thereby impacting the services and programs available (1). Whereas the government operates in terms of a biomedical model of health, the indigenous definition of health encompasses a holistic approach that includes physical, mental, spiritual, and familial well-being (5,6). Furthermore, each indigenous group may face a unique set of health care barriers, including differing colonization histories, language, socio-economic status, access to health care facilities, access to fresh food, and public transportation infrastructure (11). Therefore, public health policy must be specific to a particular indigenous group, and given the long history of unsuccessful government health programming, Aboriginal peoples should be empowered to take control of their own health and well-being.

Where the government should claim responsibility is in funding and evaluating indigenous health initiatives, but this is where the responsibility should end. For example, Apunipima Cape York Health Council, the largest community-controlled health organization in Queensland, Australia, delivers culturally appropriate, family-centered primary health care services to 11 Cape York communities and is funded by a range of government organizations (12). Aboriginal people understand their own populations better than anyone else, and in order to deliver effective, culturally appropriate, and holistic health services successfully, as defined by the indigenous community, there need to be self-contained health care systems run by the Aboriginal peoples themselves, but backed financially by the government.

Conclusions

The government is an institution for the people and is therefore responsible for the well-being of all of its citizens. It can be argued that since the government played a major role in instigating the health gap that now exists between its citizens, they should work to eliminate that gap. However, it must be acknowledged that the Australian Government’s attempts to ‘close the gap’ have thus far been unsuccessful. Alternatively, perhaps the indigenous peoples should be empowered to take charge of their own destiny, with the government simply footing the bill. Such a strategy would entail a number of complex challenges, including but not limited to: (i) Should this funding extended to address the root causes of the health gap, including housing, employment and education? (ii) How should the role of the government change over time? and (iii) What are the challenges for the non-indigenous tax payers? Either way, closing the health gap in Australia will be difficult, and all parties have some responsibility, be it fiscal or directional. This situation is not unique to Australia, with dialogue and lessons to be shared from Canada, New Zealand and the United States.