Social Determinant of Indigenous Health


The general acceptance that social inequalities are implicated in the health inequality is not new. This notion that dates back at least to the medieval times in Europe, where observations were made of unusually high rates of diseases among miners has generated controversial concerns (Benzeval, Judge & Whitehead, 1995). Bartlett (1998) notes that “social medicine- association between social conditions and poor health- was undertaken from the 17th century in Europe” (p.39). John Sow cited in Berkman & Syme (1979) pioneered the work of malaria research by mapping cases of cholera in London and sourced infection to a public water pump, thus leading to recognition that there was need to provide safe water and sanitation. However, the controversial nature of the problem in terms of political connection has led to various observations that link capitalism to the declining health of the indigenous people (Berkman & Syme, 1979). For example early critics of the nature of the governments response pointed out how diseases like ‘black lung’ among miners appeared to be linked to the poor ventilation of mines; however mine owners did nothing about this problem because of their desire to secure profits (p.186).

Interestingly, several researches in Australia have focused more on the relationship between social, political and economic conditions and health status (Labonte, 1999). More recently there has been more research work in the relationship between these factors that have cited the materialist’s basis of health inequalities (p.49). It is demonstrated that Australians at the lower end of the social economic hierarchy tend to suffer more ill-health and that those health differences are based on socioeconomic position and have no age boundary (pp.49-50). While poorer people are more likely to go hospital, they are less likely to take advantage of the available preventive measures to disease control (p.50). These inequalities are apparent from the earliest age among Australian children i.e. children from lower rank of the socioeconomic groups tend to have lower birth weights, higher rates of developmental problems and are more likely to experience poorer adult health in later years than children from higher socioeconomic groups (Labonte, 1999; Hunter, 1996).

Notably, this debate has very little to do with health as such, but is concerned with the way in which the specific conditions in a country produces unequal health outcome. This paper seeks to highlight the ‘Social gradient’ and ‘diminishing inequality’ in the context of needing to create ‘political will’ relate to improving Aboriginal and Torres Strait Islander health and well-being. It focuses of the interconnection between poverty and ill health, and poor politics coupled with policy issues and the health initiative failures.

Aboriginal and Torres Strait Islanders health

It is common knowledge by every measure that the life of the Aboriginal and Torres Strait Islander population is low as compared to that of non- Aboriginal and Torres Strait Islander population. More worrying is the recent data that show that this gap continues to widen yearly, more so since the beginning of this decade (Labonte (1999). According to Labonte (1999), Aboriginal and Torres Straight Islander Health and wellbeing is a holistic concept that entail all aspects of physical, emotional, social, spiritual and cultural health.

The poorer health profile of these people have been said to have attributed to the lower life expectancy, 18-19 years less than the non-Aboriginal and Torres Strait Islanders (Kunitz, 2004). Poverty and policy failures are some of the main factors that have been associated with this worrying trend. About 35% of the deaths occurring among the Aboriginal and Torres Islanders is as a result of circulatory diseases such as heart diseases, the other 35% die from injury, cancer and respiratory (Kunitz, 2004). The death rate among the Aboriginal and Torres Islanders is higher, and at a more tender age from diseases which can easily be prevented (p.129).

The social determinants

The health of the population is related to the features of the society as well as its economic organization (Evans, Barer & Marmot, 1994; Saggers & Gray, 1991). This fact has provided the basis for improving the Aboriginal and Torres Islanders population’s health. While there is an understandably much concern about appropriate funding for the health services with the belief that the service provided should be based on the best evidence of effectiveness, it is important to note that health is a matter that goes beyond the provision of health services (Evans, Barer & Marmot, 1994; Adler, Marmot & Stewart, 1999).

Poverty and the Aboriginal and Torres Islanders Health Provisions

It is a historical knowledge that the Aboriginal and Torres islanders are at the edge of the economic system, and strikingly this fact still remains intact despite the various concerns that have been raised. In discussing this concept, it is important to acknowledge the role played by unemployment, lack of income and less or no education in the poverty perpetuation.


A recent data suggest that only slightly less than a half of the Aboriginal adults were in the Australian labor force, far much lower than 75% of the non-Aboriginal people (ABS, 1998). Considering the fact that the 40% include even those working in the community development employment programs and the ones searching for jobs, the relative income for the Aboriginal community is at lower end of the welfare ladder (ABS, 1998; Humphery & Japanangka, 1998).


It leads us to an important aspect, the connection between unemployment and income. The bigger proportion of the Aboriginal and Torres Islander adults who lack employments have low income for their families survival; hence these people highly depend on the welfare programs which are logically insufficient (Flick & Nelson, 2004).

Even though state’s commitment to increase the engagement of this population into more economic activities have been hailed as the way forward, critics observe that these efforts will be counterproductive if the current educational and training program remain the same. This notion is informed by the fact that only an estimated 5% and 6% of the Aboriginal adults had gone past secondary education, compared to the non-Aboriginal people (Dodson, 2004). This fact is a cause for more worries as it goes against research findings on education and poverty. Hunter (1996) findings revealed; “Education is the largest single factor associated with the current poor outcomes for indigenous employment. Indeed, the influence of education dwarfs the influence of most demography, geography and social variables” (p.6).

Considering the insufficient educational outcome among the Aboriginal and Torres Islanders, especially the youth, many experts observe that it would be very difficult if not impossible for families to generate any sustainable income to pass to the coming generation of this group (Kawachi, Kennedy, & Wilkinson, 1999; Kunitz, 2004).

The Poverty Impact on Health

Poverty leads to social inequality and disempowerment (Bartlett, 1998). Compared to their non-aboriginal counterparts, Aboriginal people are more at risk, at least according to the ratings on the socio-economic scale. Bartlett (1998) argues that this phenomenon is worsened by the rapid change imposed on the community that threatens their cultural strength by weakening the long held community values and beliefs. Flick & Nelson (1994) states that this kind of disempowerment is adverse to an extent that “it leads to a spiritual or psychosocial malaise which afflicts much of indigenous Australia and variously surfaces in conditions such as drug and alcohol dependency, and high suicide and accident rates’( p.19).

These inherent social conditions subsequently deepen into the already deplorable condition and hence entrenched patterns of dysfunctions (Coombs, 1998). Studies clarify that dysfunctions is not only synonymous with the communities or specific social groups at phase value but is deeply entrenched into individuals’ who have been exposed to it, subsequently leading to different forms of health problem (Berkman & Syme, 1999). The sense of belonging of the Aboriginal people in the Australian community is further dented by the wide public criticism, especially in most national forums in the recent past (Kunitz, 2004). It possible to conclude that there is still much resistance or even increasing from those in the political office as well as among the ones in the wider community to the Aboriginal people who are tasked with the management of their own affairs as well as increasing their attempts to form corporate sector and community organizations (Coombs, 1998). It consequently follows that at the community as well as the individual level, the ever narrowing options available means high stress for them hence low control of self (p.49). This explains the earlier association of the social alienation and the indulgence to the high risk activities like smoking (Reid & Trompf, 1991; Taylor & Roach, 1998). As time progresses, these high risk activities creates an increasingly cumulative impacts on the lives of the community and individuals, subsequently passed to the coming generations. Flick and Nelson (1994) emphasizes that “it doesn’t take multiple science degrees to appreciate the impossibility of attaining good physical health under such conditions” (p.4).

Politics and the Policy Issues

The Association of the Aboriginal people with the land was disrupted as colonization took effect (Nurcombe, 1973; Rowley, 1978). These people had to struggle to adapt to new situation under extremely very harsh conditions (Rowley, 1978). For instance the traditional hunting grounds were as well as sacred sites were selected for sheep and cattle grazing and the water holes were contaminated (Rowley, 1978; Stilwell, 1996). The alienation of the Aboriginal from the land eventually disrupted their ceremonial life and changed their lifestyles and the family ties, hence their identity (p.171). This was the beginning of the policy challenges faced by the state. As earlier stated, health is a more multifaceted issue that does not really need physical aspect alone. In fact, the gap in ill health between the Aboriginal and non-aboriginal is a clear manifestation that health is not purely physical per se. It is the health policy that has generated a much controversy in the recent past as it is seen as the most critical in offering the desired multi-dimensional Aboriginal health problem.

The initial proposals to reform food hygiene regulations in Australia focused on developing a package comprised of nationally consistent food hygiene standard supported by codes of practice and guidelines (Kunitz, 2004). The aim of the reform was to remove unnecessary barriers to prescriptive approach and instead, follow international trends using preventive approach based on risk analysis (Kunitz, 2004). Kunitz (2004) argued that it was a misplaced notion that there would be a subsequent improvement in food handling practices within the food industry and the reform would be consistent with what was needed by these communities.

However, the limitations to such a policy were inherent as it is based on the general population of Australian, without taking into consideration the vulnerable Aboriginal community. Other limitation was that the application of food business in the policy was principally to process food for service to the vulnerable people in the care facility, and was not broad enough to encompass all at risk groups (Kunitz, 2004). Still it assumed other social determinants of health and put all the issues on the food as the only dimension for improving health status of the population (p. 271).

Policy for Aboriginal and Torres Strait Islander

The response to the increased political pressure changed the face of policy formulation on the health status of the Aboriginal people in1967 (Humphery & Japanangka, 1998). The Commonwealth government agreed to conduct a referendum to decide if the discriminatory clauses concerning Aboriginal people were to be removed Dodson (2004). The overwhelming ‘yes’ vote of the referendum was interpreted to mean that the commonwealth should act decisively to resolve all problems concerning Aboriginal and Torres Islanders’ rights (p.31). However, in the ensuing years, the political imperative for the commonwealth government to take action lost impetus and the situation remained the same for much longer (Dodson, 2004).

In 1972, with a change of a new government, Aboriginals people affairs again emerged with more controversy (Mathews, 1997; Dodson, 2004). In 1973 Whitlam as cited in Mathews (1997), in a statement provided at a conference of commonwealth and state ministers concerned with Aboriginal Affairs said: “My government intends therefore to assume full responsibility for policy and finance in respect of Aboriginal Affairs and will take any necessary legislative action to this end” (p.27). It is from this moment that the state and other successive governments began to take seriously to lead and coordinated policy initiatives concerning indigenous affairs across states and territories. Other statements coming from the government quarters have been to “restore to the Aboriginal people of Australia their lost power of self determination in economic, social and political affairs” (Mathews, 1997).

Such kinds of announced statements marked that era of policy approaches that includes the concepts ‘self determination and ‘community control’ (p.99). However, despite this progress, some states still resisted giving the aboriginal people control of their affairs (p.100). The Commonwealth consequently introduced legislations to enable Aboriginal and the Torres Strait Islander people to incorporate so some government initiatives could be progressed. The formation of the indigenous community councils and housing associations and specifically, the National Aboriginal and Torres Strait Health Council were the culmination of the communities’ desire to self-reliance (Ring, 1998).

Health, Housing and environmental health policy

Many observers have criticized the available policies meant to address the state of poor health and living conditions of the indigenous people, describing them as confusing, disappointing, reactive, ad hoc and with single strategies used to address the mix of social, cultural, political and economic factors that underline problems (Ring, 1998). As expected, the environmental health policy initiatives in remote communities have focused on providing the technologies as well as infrastructure such as water, sanitation and housing (p.17). However, the rush to construct new dwelling places for these communities emerged with the issues about the maintenances of health hardware (p.18). As such as such the need to adapt new lifestyle for these places just received hasty considerations and few people had foreseen the inherent problems that may occur (p.19). The rapid introduction of new technologies and the new housings and environments changed the whole dimension of the health policy problems. This is because the target population could not comprehend the new practices required of them coupled with the overcrowding, thus the failure to change behaviors (Ring, 1998). This eventually caused the increased infections among the people (p.51). Some observers stated that the people were not provided with education on how to use the new technologies like the new toilets and new latrines were introduced to the households, or it was provided then it was inappropriate (Dodson, 2004). In essence, little emphasis was placed on the community ability to adapt, especially with no proper education, little resources to improve capacity and inappropriate administrative efforts. Furthermore, the governments’ arrangements for indigenous housing have been fragmented and unstable since Indigenous Community Controlled Housing Organizations (ICCHOs) were introduced (Dodson, 2004).

Aboriginal Children and the Policy Implication

The health issues concerning the Aboriginal community children have been of much greater concern. As studies shows, a child’s health determines the survival health at a later age, and a child who suffers ill health due to opportunistic diseases tends to have a shorter lifespan or just lower life expectancy (Adler, Marmot, & Stewart, 1999; Reid &Trompf, 1991).

The Australian health policy has been termed to lack the needed ingredients for the survival of the Aboriginal people. Health policies have largely focused on the treatment or eradication of diseases by the use of vaccines and improved medical management (Marmot, Bosma & Hemingway, 1997). Until now there is no concrete policy that may be considered comprehensive or long-term to address the development of the Aboriginal children (p.235). Mathews (1997) observes that in health and other policy areas, preventive activities have received little attention if any, generally only mentioned as a secondary issue. He points out some specific programs like housing. He says that governments have tried to address the housing issue by funding some specific community-based programs to teach the families how best to manage the houses through care and maintain their new homes (p.257). However, the primary aim of these programs appears to be prolonging the lifespan of the housing infrastructure rather than promoting safe hygiene practices and health improvements (p.258).

So the successive governments have not taken the initiative of building long term initiatives to address these complex issues that underlie poor hygiene and living conditions among the Aboriginal communities. According to Kunitz (2004), this short term approach “appears to be a response to the political imperatives of new governments, new ministers and lobbyists” (p.162). Furthermore, there is evidently little research concerning the cause of poor hygiene, housing and poor environmental health conditions in Australian Indigenous contexts just as there has been no systematic approach to learning from the failures and successes of the past policy and programs initiatives (p.63). However, there is much to learn just from reflecting on the history of these policy initiatives, the development of the community infrastructure as well as the epidemiological pattern of health of these people in addition to drawing on some lessons on other programs in other geographical regions. For example, the introducing water and sanitation projects did not automatically lead to behavior change in relation to maintenance of the personal or general community hygiene in a Canada’s vulnerable communities (Adler, Marmot & Stewart 1999).

Critically, the poor living conditions and poor health that is attributed to ill health among the Aboriginal community could be as a result of the successive federal and territory governments failure to uphold generally well recognized public health standards of these communities. Several reasons have been highlighted, namely:

  • There is a popular belief among the current poor sanitary conditions in the residential of the Aboriginal communities are but a lifestyle that is largely related to their culture (ABS, 1998). It is therefore logical to argue from this point of view that intervention at this juncture will definitely lead to undesirable effect of interfering with the culture and beliefs of these people.
  • The fact that the government takes no action means that it suits them as they receive harsh criticism for destructive policy implemented in the past (Dodson, 2004). The health and welfare branch of governments are seen as avoiding the initiative of implementing policies that are seen as authoritative in relation to Indigenous Australian people (p.33).
  • The current penalties for breaching the regulations are considered inadequate and just but another addition to the disincentive for government officers to enforce public health regulations (p. 34). Humphery & Japanangka (1998) observe that evictions and fines at household level when there is actually no alternative housing provided is counterproductive as the same evictees end up in other already congested households. Furthermore, welfare programs that exist in urban areas are not well planned among the Aboriginal communities.
  • As has been observed, there is no single government department that has been tasked with the initiative of addressing the unsanitary condition among the Aboriginal communities, further creating more confusion and lack of responsibility within the governments


It is evident that research findings connecting ill health and poverty have a long history and thus is not a new area as one may assume. In fact, the definition of ‘Health’ according to World Health Organization that put a lot of emphasis on the holistic and multifaceted approach (Berkman & Syme 1999) shows that it has been known for quite some time that health has no single dimension of physical health a lone. This is why an approach relating to empowerment of the community members through such initiatives as education, employment creation, and capacity building are dominant in the current context. More importantly, the whole perspective of advocacy at community level through community segmentations for example through youth, women, aged and other vulnerable people of the society shows that the whole issue of community empowerment for self-reliance is the norm and the only promising approach to helping the marginalized groups. The self organizational approach by the Aboriginal community members that has seen formation of some organizations related to health is an example of the continuous effort by these communities’ desire for recognition in terms of healthcare. If indeed this knowledge is not new, then what prevents adequate implementation for these programs at the community level? What makes the people responsible know and not act?

Looking at all dimensional approaches, these problems are directly linked to the failure of the policies. As stated earlier, the unfounded popular belief confusing culture and ill health, the political interests versus the inappropriate programs implementation and lack of specific government institutional structure to be tasked with the sole responsibility of handling the problems have in part or as a whole contributed to the problems.


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