COVID-19: Indigenous perspectives
Equity and ethics in a pandemic: Indigenous perspectives
Helen Milroy highlights the impact of COVID-19 and the efforts to contain it in Indigenous communities, how it exacerbates existing vulnerabilities and disadvantages, and how we can ensure Indigenous perspectives are integrated in equitable decision-making frameworks going forward.
During decades of relative stability and prosperity for Australia as a nation, we could not close the gap in life expectancy, health and mental health outcomes and other markers of disadvantage for Indigenous Australians. How then, is this going to change over the course of a pandemic, especially if resources become scarce and access to high-quality intensive medical services is limited?
Numerous reports outline the ongoing inequity in health and mental health outcomes as well as the additional burden of disadvantage and discrimination experienced by Indigenous Australians. In combination, this places Indigenous communities in a state of heightened vulnerability exacerbated by the COVID-19 pandemic. Over the course of the pandemic, the associated measures such as physical isolation needed to ‘flatten the curve’ will also increase the risk for negative outcomes for Indigenous communities.
The pandemic raises a number of significant issues relating to equity, equality and ethical decision making with many valuable lessons to be learnt along the way. We have already witnessed the quick action of many of our Indigenous organisations to support, educate and protect our Indigenous communities. Imagine what could be achieved if these issues of equity, ethical decision making, power sharing and funding were shared equally along with support for self-determination for Indigenous communities.
There have been a number of calls from around the world to support and protect Indigenous communities during the pandemic, many outlining their high vulnerability as well as the ongoing historical legacies of past traumas. Shino Konishi (in this Briefings edition) describes the scale and lessons of the 1789 smallpox epidemic upon Indigenous populations across south-eastern Australia. The Chair of the United Nations Permanent Forum on Indigenous Issues released a message [PDF, 0.1MB] urging countries to ensure Indigenous peoples are informed, protected and prioritised, and exercise their right to self-determination during the pandemic. The message also highlighted the additional concerns related to Indigenous Elders due to their highly valued roles as ‘keepers of history, traditions, and cultures’. In Western Australia, the Department of Health called for the consideration of Indigenous communities during the pandemic due to their heightened vulnerability through the publication of the Aboriginal Ethical Position Statement [PDF, 0.89MB]. The Statement also calls for health service providers to ensure the provision of equitable and culturally acceptable healthcare and for the inclusion of cultural considerations across all areas of pandemic planning.
While it is difficult to predict what the mortality would be for Indigenous communities if the virus were to take hold, health commentators have stated it could be catastrophic. The only way to prevent this is through isolation until a vaccine is available, which could still take many months or years to develop and disseminate. Many concerns have been expressed over how to keep our communities, and particularly our Elders, safe during this time. We have the oldest living culture in the world here in Australia, and our Indigenous Elders are considered as the keepers of our cultures, languages and knowledge systems.
They also have an increased vulnerability due to age, chronic health conditions and the impact of disadvantage.
For many rural and remote communities, the only solution currently has been to isolate families, close borders or shift to outstations within homelands. Many Indigenous people have been encouraged – if not coerced – to return home only to find difficulties with overcrowding, food insecurity and few health and community resources. Australia’s Aboriginal and Torres Strait Islander Social Justice Commissioner June Oscar recently wrote for the ABC about returning to her homelands near Fitzroy Crossing in the Kimberley region of Western Australia in order to assist her community to live out bush. She points out the stark contrast between decades of policy to close down remote communities and now being told it is safer to live out bush. Commissioner Oscar points out that the chronic underinvestment and poor conditions of the remote homelands continue to place people at risk. Although moving to live in the remote communities is part of the right to self-determination, this must now be supported wholeheartedly with a new approach that assists Indigenous communities to not merely live and subsist but rather to thrive in their homelands.
As remote communities closed, much of the mobile workforce also disappeared due to travel restrictions, leaving some communities in a further state of disadvantage. Although the rapid expansion of tele/video health has filled the gap in services in some areas, the coverage outside major regional areas is patchy at best. In some remote locations, communication is reliant on radio transmitters. Again, this brings into sharp focus the lack of investment in infrastructure, capacity building and workforce development in communities.
Access to health services is already limited, particularly in remote locations. Under these pandemic circumstances, the capacity for medical evacuations is complicated and the availability of intensive medical care is limited in regional and remote Australia. Recent experiences of racism and discrimination in health services have already been reported in the media. In larger regional or urban centres, there are concerns as to whether Indigenous people would receive the equitable and culturally appropriate care called for in the Aboriginal Ethical Position Statement if resources become scarce. In the G08 COVID-19 Roadmap to Recovery Report, it was estimated the health needs for Indigenous Australians is 2.3 times higher than for other Australians and called for needs-based funding. Is this possible during a pandemic when this issue has not been adequately addressed for the decades prior?
At this point in time, we have been extremely fortunate to have controlled the spread of the virus in our Indigenous communities but the journey is far from over. With the easing of restrictions and the possibility of a second wave, are our communities safe? We will need to weigh up the risk of returning to the new normal versus the possibility of staying in isolation for prolonged periods of time. We will also need additional resources to manage the unintended consequences of isolation such as the potential worsening of other health and mental health conditions. People are less likely to seek out health services or have reduced access during this pandemic period. Routine screening or treatment for other conditions will diminish, resulting in the worsening of many health and mental health conditions over time.
Mental health experts predict a significant increase in mental health challenges and suicide as the full impact of the pandemic and the associated measures are experienced across the country. In the 2018 AIHW report [PDF, 0.56MB]on Australia’s Health, 30% of Indigenous people reported high or very high levels of psychological distress compared to 11% for the non-Indigenous population. The levels of psychological distress and associated mental health challenges will worsen with the associated anxiety and aftermath related to the pandemic. Currently, there are limited available, accessible and culturally safe mental health services for Indigenous communities, especially in remote locations where there are very few trained staff available. This is even more critical given the shortage of mental health services for Indigenous children and youth, with the potential for long-lasting effects well into adult life.
There have been many ethical challenges associated with the pandemic with difficult decisions made in order to safeguard the community. The COVID-19 pandemic has further exposed the many gaps that still exist and the tenuous nature of some services reliant on a mobile workforce without the infrastructure and capacity to sustain services once borders are closed. Given the continuing impact of our historical legacy, any ethical framework for decision making during this pandemic must consider equity and the plights of Indigenous communities during such difficult and life-threatening circumstances.
What we have also seen, however, is a population that can act swiftly, mobilise resources and change models of care to maintain the health and wellbeing of the nation. We have also seen the great strengths of Indigenous organisations and communities coming together and acting quickly to protect their families. If we can do all of this, then surely we can solve the long-standing health crisis and disadvantage that impacts on our Indigenous Australians to ensure the future wellbeing of all our families.
Helen Milroy is a descendant of the Palyku people of the Pilbara region of Western Australia but was born and educated in Perth. Currently Helen is the Stan Perron Professor of Child and Adolescent Psychiatry at the Perth Children’s Hospital and The University of Western Australia. Helen has been on state and national mental health and research advisory committees and boards with a particular focus on Indigenous mental health as well as the wellbeing of children. From 2013 to 2017 Helen was a Commissioner for the Royal Commission into Institutional Responses to Child Sexual Abuse.