The more things change, the more they stay the same: enduring inequity in Indigenous health

‘We live in unprecedented times’ is perhaps one of the most overused expressions of the past 18 months. When one considers many areas of daily life – work and health care delivery, travel restrictions, quarantine and public health controls – this would seem almost axiomatic. For Indigenous Australians, there may well be something eerily familiar about these unusual days. Scratch the surface of the specifics and what lies underneath has all the hallmarks of the impacts of colonisation.

This is not the first time that Indigenous Australians have faced the impacts of previously unknown infectious diseases. The arrival of colonisers brought forward immense challenges to Aboriginal and Torres Strait Islander peoples. Among these challenges, tuberculosis, smallpox, syphilis and other sexually transmitted infections cut a trail of destruction. The impact was profound and unequal, to the point where early officials, bureaucratic or ecclesiastic, opined about the ‘inevitable decline of the native’.^1,2 Speculation exists that such impacts were enabled as a tool of suppression and control over this country’s First Peoples³ – a self-fulfilling prophecy of the lie that was terra nullius.⁴ Yet we survived. We endured.

The implementation of public health control mechanisms to manage the COVID-19 pandemic has raised the ire of many Australians, who contend that their inherent freedoms are being eroded. Since colonisation, Aboriginal and Torres Strait Islander peoples have been subjected to inequitable and intense levels of state violence and control⁵ over their laws, lands, cultural expression, freedoms, and movements, and have been subjected to intense levels of discrimination.⁶ These are not new experiences for my people.

COVID-19 infections among Indigenous Australians remain relatively low, yet concern remains as to the inherent inequalities that exist in the risk of infection, and the likely adverse individual and collective outcomes if cycles of infection and transmission become embedded within Indigenous communities. The greatest challenge may well come from long-term impacts of inequity as a consequence of responding to the pandemic.

The burden of public health responses falls disproportionately on populations who are already dealing with multiple layers of health, economic, educational and social inequity. Many families in disadvantaged settings have been less able to rapidly ‘pivot’ to online learning, home schooling, or work from home realities, and face elevated levels of insecurity in employment, finances, and nutrition, made worse by the ‘squeeze’ of pandemic control measures. Indigenous families also experience institutionalised and interpersonal racism, higher levels of psychological distress, are at elevated risk of experiencing, witnessing or being impacted by self-harm or suicide, and talk often of the negative effects of disconnectedness as a key determinant of social and emotional wellbeing. Each of these pressure points are exacerbated in the context of a global pandemic and the subsequent control mechanisms. We face the real danger that inequity will widen over the months and years to come, further driving a wedge between the ‘haves and have nots’ within society.

Despite the salutary warnings of widening inequity, the current low numbers of Indigenous cases of COVID-19 is cause for cautious optimism. This has not come about by chance. The Indigenous response was swift, decisive, highly professional, deeply empathetic, and culturally appropriate, led by Indigenous people and the Community Controlled Health Care sector more broadly. In many ways, the expertise of this response is not unusual or unexpected among those who know, work with or have evaluated Aboriginal Community Controlled Health Organisation (ACCHO) sector capabilities.⁷

Unfortunately, little is known outside of the sector about how important and effective Indigenous leadership and community control is to the health and wellbeing of our people. Led by the Coalition of Peaks, the new Close the Gap agenda⁸ speaks directly to the new relationships required with government to enable a brighter future for our people. The Uluru Statement from the Heart⁹ articulates a meaningful, respectful, and deeply human blueprint for reconciling our nation’s history with the culture, aspirations and needs of its First People. We bear witness to the rise of Indigenous professionals across all walks of life, and the ability for us as sovereign people to define our own future.

It is only through enabling these expressions of self-determination that we can overcome the challenges ahead. Occurring in parallel to the current pandemic, the effects of climate change and more importantly, this nations’ inadequate policy response to climate change, ignores the deeply symbiotic relationships Indigenous people have with Country and the obligation we should all carry to care for it. Indigenous people have long called for increased investment in preventative health, particularly through ACCHOs and comprehensive primary care, as a template for a better future for all Australians. The current pandemic looks likely to exacerbate social and emotional wellbeing issues for all Australians, including the effects of disconnectedness, isolation, loneliness, and despair. The future concerns for collective trauma caused by long-term COVID or post-pandemic distress all point to the importance of our commitment to healing as a foundation for health.

Whilst we dare to dream about a better future for all, there are dark clouds on the horizon. The pandemic has raised the possibility that our children will experience worse health than our generation, and we will witness worsening environmental decline, poverty, inequity, and marginalisation. Unfortunately, there is something all-too-familiar about that.

None.