The Role of the CSANZ in ‘Closing the Gap’: An Indigenous Cardiologists Perspective
Article Outline
The definition of Indigenous health as a human rights issue has signaled a major change in ideology, which has the potential to unite governments, health organisations and the Indigenous community to achieve improved health outcomes for Aboriginal and Torres Strait Islander (ATSI) people. Whilst much of the debate will focus on specific policies, programs and interventions, the greatest challenge lies in bridging the divide between mainstream and Indigenous definitions of health, wellbeing and identity. This article provides an Indigenous perspective on the role that the Cardiac Society of Australia and New Zealand might play in bridging this divide so that we can ‘close the gap’ in life expectancy for ATSI people.
Keywords: Indigenous, Aboriginal, Torres Strait Islander, Cardiovascular, Mortality
At the National Indigenous Health Equality Summit in March 2008, the Close the Gap Statement of Intent was signed, committing government, health organisations and Aboriginal communities to achieving equality in health status and life expectancy between Indigenous and non-Indigenous Australians by the year 2030 [1]. The Statement of Intent is more than symbolic, and marks a significant paradigm shift in that it correctly identifies the discrepancies in Indigenous and non-Indigenous health outcomes as a human rights issue.
The Indigenous health construct is far removed from that of the mainstream. For Indigenous people, mainstream health services are often impersonal and alienating; this is exemplified in the bureaucratic idiom of these services with terms such as “patient separations”, “diagnostic related group” and “length of stay”. As a patient in most tertiary hospitals, there is barely enough time to record your personal details let alone undertake a full exploration of the cultural context in which your illness has occurred.
Although Western medicine is making the shift from the traditional authoritarian model toward a more holistic patient centred model of care, there is still a chasm between mainstream and Indigenous health philosophy. It is hardly surprising therefore, to observe the disconnect between mainstream and Indigenous health services which has occurred to varying degrees around Australia.
Despite significant advances in recent years, mainstream services still tend to identify Aboriginal people in a stereotypical fashion; namely on the basis of skin colour and geographical location. This reliance on visible difference as a means to identify Aboriginal people has meant that many mainstream services are often unaware of the Indigenous communities they service, limiting their ability to provide culturally appropriate care. Reflecting the systemic nature of this problem, Indigenous health statistics from hospitals in Victoria, New South Wales and South Australia are often excluded from national surveys due to the unreliable identification of Aboriginal and Torres Strait Islander (ATSI) people in these states [2], [3].
Another pervasive stereotype in mainstream Australian culture is that of the ‘drunk Aborigine’. This image persists despite Indigenous adults being more likely than non-Indigenous people to abstain from alcohol, remote Indigenous people being more likely to have never consumed alcohol and chronic high risk drinking rates being equal to non-Indigenous Australians. In contrast to alcohol, tobacco use in the Indigenous community has received significantly less attention in the media and, until recently, in government policy and program funding. This is despite 50% of Indigenous adults being daily smokers and smoking being the leading cause of death and disability for Indigenous Australians [4], [5].
So, do misperceptions result in mismanagement?
Whilst this is difficult to measure, a retrospective analysis of the National Hospital Morbidity Database for principle procedures in Indigenous patients is illuminating [6]. Published in 2002, this study revealed that Indigenous patients were 47% less likely than other patients to have a principal procedure recorded for every ICD or International classification of disease class. Consistent with these observations, Coory demonstrated significantly lower rates of revascularisation in ATSI patients, with ATSI patients being 22% less likely to undergo percutaneous coronary intervention or bypass surgery following an infarct [7]. The assertion that case complexity accounted for the observed difference in coronary procedure rates was discounted after a review of The National Hospital Morbidity Database revealed that the greatest discrepancies in coronary procedures actually occurred in the least complex patient groups [6]. Improved understanding of these systematic barriers could translate to earlier diagnosis and treatment of cardiovascular (CV) disease with the potential for rapid improvements in Indigenous CV mortality.
The current generation of Indigenous doctors includes general practitioners, public health physicians, a psychiatrist, ENT surgeon and obstetrician/gynaecologist. The diverse communities we represent inform a range of perspectives on what is required to advance ATSI health in this country. No individual can claim to know all of the solutions; just as no organisation can single-handedly deliver the promise of improved Indigenous health outcomes. Indeed, ‘Closing the Gap’ will require a new era of collaboration that transcends individual egos and political agendas, and more effectively links policy with implementation [1].
We also need to reconsider the processes by which research informs government policy, and how to better identify research that will deliver tangible benefits to Indigenous communities. The increasing number of qualified Indigenous health specialists provides mainstream organisations with a unique opportunity to invest in Aboriginal researchers so that they can be elevated from ‘advisors’ or ‘gatekeepers’ to being researchers in their own right. In the same way that Indigenous health professionals can improve clinical outcomes, Indigenous researchers have the capacity to bring new perspectives to research, which re-define how we view and engage with Indigenous communities.
An example of the different perspective that Indigenous led research can provide is that involving de-centralised Indigenous communities living NE of Alice Springs [8]. Rather than focusing on the negative predictors of Indigenous health, Rowley et al. investigated positive determinants of CV health, identifying self-determination and connectedness to culture, family and land as important factors.
As an academic leader, the CSANZ has the capacity to play an important role in Indigenous health. The potential for the CSANZ to contribute to Indigenous health policy and outcomes is considerable, particularly in light of the society's social, economic and political networks. However, to be effective the CSANZ must develop clear objectives that will translate to practical improvements for Indigenous Australians. As envisioned in the “Close the Gap” campaign, it is time that we strengthened the link between policy formulation and implementation [1]. The likelihood of partnerships with key representative bodies such as the National Heart Foundation, the Australian Indigenous Doctors Association (AIDA) and the National Aboriginal Community Controlled Health Organisation (NACCHO) further reinforces the importance of the CSANZ developing clear objectives from the outset.
Such objectives might include the support and training of the ATSI health workforce with the goal of improving identification, prevention and treatment of cardiovascular diseases in ATSI communities. Additionally, opportunities for community-based Indigenous health workers to gain exposure to cardiovascular medicine would be invaluable and would directly influence the likelihood of Indigenous patients accessing mainstream services. Greater investment in the Indigenous Health workforce will also mean that there will be more Indigenous doctors in the future. By establishing mentoring networks and scholarship schemes the CSANZ has the potential to play a lead role in developing the next generation of Indigenous CV health specialists.
Cultural training that provides the CSANZ's membership with a greater insight into the factors which impact on Indigenous health outcomes is also needed. In a practical sense, this could start with departments of cardiology identifying their aboriginal liaison officers and discussing the needs of their local Indigenous communities.
The support of Indigenous health workers must include a long-term commitment to establishing a framework for leadership that enables capacity building for Indigenous Australians. The CSANZ also needs to consider establishing an Indigenous research agenda and facilitate research that moves beyond documenting disadvantage. The ultimate aim of Indigenous health research must be to deliver measurable improvements for the communities concerned.
Whilst much of the debate surrounding Indigenous health will focus on specific policies, programs and interventions, the greatest challenge lies in bridging the divide between mainstream and Indigenous definitions of health, wellbeing and identity. The definition of Indigenous health as a human rights issue has signaled a major change in ideology, which has the potential to unite governments, health organisations and the Indigenous community to achieve improved health outcomes for Indigenous people. It is time to replace impressions with facts, and define Indigenous communities not on the basis of disadvantage but according to their resilience and future potential.
Acknowledgment
No financial support was received in relation to this publication.
References
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- . Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients. Med J Aust. 2005;182(May (10)):507–512
- . Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community. Med J Aust. 2008;188(March (5)):283–287
PII: S1443-9506(09)00045-6
doi:10.1016/j.hlc.2009.01.006
© 2009 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier Inc. All rights reserved.
