General News Opinion — 04 November 2013
Indigenous health must have culture at its core

Anthony Dillon’s article in Inquirer last Saturday responded to our article on closing the mental health gap published the week before. It is good that indigenous mental health is getting the attention it deserves, and we welcome a robust national debate.

In that spirit, we address some inaccuracies in Dillon’s piece. For while he opens his article by identifying the “complex puzzle” of indigenous mental health issues, such awareness does not constrain him from then making reductive statements that create a misleading picture. These should not stand unchallenged.

Dillon begins by stating most Aboriginal Australians are “virtually indistinguishable from non-Aboriginal Australians in how they think and act” simply by virtue of non-indigenous ancestry; further, that we are being “kept in a museum” by “left-elitist” leaders with a “romanticised” view of culture.

He then takes two more breathtaking leaps over the evidence base: first, that accepting cultural difference and designing mental health services to account for it is actually creating a barrier to Aboriginal people accessing the services they need; second, that the foundation to good mental health is self-esteem, and that esteem-boosting employment is the real panacea to poorer mental health.

Let us set the record straight.

Mental health conditions include depression and anxiety through to post-traumatic stress, self-harm, psychosis and other kinds of mental illness. The data shows indigenous Australians suffer higher rates of these conditions across the board.

The causes are, as Dillon states, complex. For instance, trauma from exposure to abuse or violence, or repeated exposure to racism, is a major issue, as is intergenerational and trans-generational trauma from forced child removals. The compounding effect of psychological distress, genetic predispositions, trauma and substance abuse can tip some of us into mental illness.

Psychological distress can lead to mental health conditions, but not necessarily. An authoritative 2008 survey of more than 13,000 indigenous Australians identified poor health, accidents, the deaths of friends and relatives and drug and alcohol abuse as the top causes of psychological distress among them.

Unemployment, as terrible as it can be, and as much as it needs addressing, does not feature too highly as a determinant of mental illness. Nor should we expect it to be a cure. In fact, Dillon’s proposition that employment might be the one-size-fits-all panacea that has been hiding in plain sight all along is simply unsupportable.

What we can agree with Dillon about is that employment, and the self-esteem that results, are among the protective factors against the onset of mental health conditions. But if he values these protective factors, we fail to see why he does not include culture in the mix.

Report after report has positively associated strong and resilient indigenous Australians with cultural practice and pride in who they are.

As for the proposition that culturally appropriate health services act as a barrier, this is perhaps the most dazzling and deceptive act of mental gymnastics Dillon manages to perform. First, we feel the need to point out that indigenous Australians are free to use general population mental health and other services if they choose to. Last time we checked, we failed to notice any picket lines of “elitist-left” Aboriginal leaders barring the entrance.

However, many indigenous Australians do not use such services. In 2010-11 about 360,000 (60 per cent of the total population) used dedicated Aboriginal and Torres Strait Islander health services (including Aboriginal community controlled health services). These are culturally appropriate health and mental healthcare services. While for a minority we grant a remote location may deem they have no choice, for most a choice was made: they voted with their feet. And this is, we hazard, precisely because such services accommodate cultural differences and provide a safe environment that is free of racism.

Critically, these are not “second best” services as Dillon implies. Research demonstrates such services achieve better outcomes for indigenous Australians, particularly in maternal and child health, and in relation to chronic disease.

The provision of culturally appropriate healthcare and mental healthcare is so ingrained in contemporary medical practice, associated with positive outcomes, and supported in the literature, as to almost put it beyond question. Dillon is free to use whatever services he likes, but to suggest indigenous Australians who choose a culturally appropriate service are somehow the victim of political correctness is as insulting as to suggest that most of us are “virtually indistinguishable from non-Aboriginal Australians in how (we) think and act”.

Dillon finishes his article with an apparently much-needed piece of advice to indigenous Australians, that “government is not solely responsible for (your) wellbeing.”

Well, with respect, we know that already. That is why we established the first of these culturally appropriate health services back in the 1970s, and without government assistance. That assumption of responsibility and leadership by Aboriginal and Torres Strait Islander people themselves continues to this day.

Tom Calma is a former Aboriginal and Torres Strait Islander social justice commissioner. Pat Dudgeon is a member of the National Mental Health Commission.

This article first appeared in The Australian on 2 November, 2013.

ANTHONY Dillon’s article in Inquirer last Saturday responded to our article on closing the mental health gap published the week before. It is good that indigenous mental health is getting the attention it deserves, and we welcome a robust national debate.

In that spirit, we address some inaccuracies in Dillon’s piece. For while he opens his article by identifying the “complex puzzle” of indigenous mental health issues, such awareness does not constrain him from then making reductive statements that create a misleading picture. These should not stand unchallenged.

Dillon begins by stating most Aboriginal Australians are “virtually indistinguishable from non-Aboriginal Australians in how they think and act” simply by virtue of non-indigenous ancestry; further, that we are being “kept in a museum” by “left-elitist” leaders with a “romanticised” view of culture.

He then takes two more breathtaking leaps over the evidence base: first, that accepting cultural difference and designing mental health services to account for it is actually creating a barrier to Aboriginal people accessing the services they need; second, that the foundation to good mental health is self-esteem, and that esteem-boosting employment is the real panacea to poorer mental health.

Let us set the record straight.

Mental health conditions include depression and anxiety through to post-traumatic stress, self-harm, psychosis and other kinds of mental illness. The data shows indigenous Australians suffer higher rates of these conditions across the board.

The causes are, as Dillon states, complex. For instance, trauma from exposure to abuse or violence, or repeated exposure to racism, is a major issue, as is intergenerational and trans-generational trauma from forced child removals. The compounding effect of psychological distress, genetic predispositions, trauma and substance abuse can tip some of us into mental illness.

Psychological distress can lead to mental health conditions, but not necessarily. An authoritative 2008 survey of more than 13,000 indigenous Australians identified poor health, accidents, the deaths of friends and relatives and drug and alcohol abuse as the top causes of psychological distress among them.

Unemployment, as terrible as it can be, and as much as it needs addressing, does not feature too highly as a determinant of mental illness. Nor should we expect it to be a cure. In fact, Dillon’s proposition that employment might be the one-size-fits-all panacea that has been hiding in plain sight all along is simply unsupportable.

What we can agree with Dillon about is that employment, and the self-esteem that results, are among the protective factors against the onset of mental health conditions. But if he values these protective factors, we fail to see why he does not include culture in the mix.

Report after report has positively associated strong and resilient indigenous Australians with cultural practice and pride in who they are.

As for the proposition that culturally appropriate health services act as a barrier, this is perhaps the most dazzling and deceptive act of mental gymnastics Dillon manages to perform. First, we feel the need to point out that indigenous Australians are free to use general population mental health and other services if they choose to. Last time we checked, we failed to notice any picket lines of “elitist-left” Aboriginal leaders barring the entrance.

However, many indigenous Australians do not use such services. In 2010-11 about 360,000 (60 per cent of the total population) used dedicated Aboriginal and Torres Strait Islander health services (including Aboriginal community controlled health services). These are culturally appropriate health and mental healthcare services. While for a minority we grant a remote location may deem they have no choice, for most a choice was made: they voted with their feet. And this is, we hazard, precisely because such services accommodate cultural differences and provide a safe environment that is free of racism.

Critically, these are not “second best” services as Dillon implies. Research demonstrates such services achieve better outcomes for indigenous Australians, particularly in maternal and child health, and in relation to chronic disease.

The provision of culturally appropriate healthcare and mental healthcare is so ingrained in contemporary medical practice, associated with positive outcomes, and supported in the literature, as to almost put it beyond question. Dillon is free to use whatever services he likes, but to suggest indigenous Australians who choose a culturally appropriate service are somehow the victim of political correctness is as insulting as to suggest that most of us are “virtually indistinguishable from non-Aboriginal Australians in how (we) think and act”.

Dillon finishes his article with an apparently much-needed piece of advice to indigenous Australians, that “government is not solely responsible for (your) wellbeing.”

Well, with respect, we know that already. That is why we established the first of these culturally appropriate health services back in the 1970s, and without government assistance. That assumption of responsibility and leadership by Aboriginal and Torres Strait Islander people themselves continues to this day.

Tom Calma is a former Aboriginal and Torres Strait Islander social justice commissioner. Pat Dudgeon is a member of the National Mental Health Commission.

– See more at: http://www.theaustralian.com.au/national-affairs/opinion/indigenous-health-must-have-culture-at-its-core/story-e6frgd0x-1226751513383#sthash.9p0FlPPE.dpuf

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