CHAPTER 15. Indigenous perspectives
I ntroduction
It might be said that, in a book such as this, perspectives from the world’s First Peoples should be included. This expectation might also be said to be underscored by the fact that despite there being an estimated 370 million Indigenous peoples1 in the world, living in more than 70 countries, and representing ‘a rich diversity of cultures, religions, traditions, languages and histories’, Indigenous peoples ‘remain on the margins of society’ ( The Indigenous World 2006 International Work Group for Indigenous Affairs 2006 — cited in WHO 2007d, with reference to IWGIA 2006). Worryingly, Indigenous peoples are grossly over-represented ‘among the world’s vulnerable groups, suffering low incomes, living in poor conditions and lacking adequate access to employment, education, safe water, food and health care services’ (International Council of Nurses [ICN] 2003b: 1). Furthermore, although epidemiological data is ‘scanty’, what data do exist point to the following health impacts on Indigenous peoples (ICN 2003b: 1; see also Hughes 2003):
▪ Life expectancy at birth is 10–20 years less than for the overall population in a country.
▪ Infant mortality rates are 1.5 to 3 times greater than the national average.
▪ Malnutrition, often associated with land displacement and contamination of food supplies, and communicable diseases (malaria, yellow fever, dengue fever, cholera, tuberculosis) affect a larger proportion of Indigenous peoples.
▪ Substance abuse (smoking, alcohol, drugs), cardiovascular diseases, diabetes, unintentional injuries and domestic violence are significant health and social problems. Many are associated with lifestyle changes resulting from acculturation.
Commensurate with these demographics, the impacts on Australian Indigenous health have been conservatively estimated as follows (noting that, due to incomplete data, it is suggested that the disparities shown may, in some instances, be greater than has been estimated):
▪ Life expectancy at birth is 17 years less than for the non-Indigenous Australian population.
▪ The median age at which death occurs in Indigenous Australians is between 42.4 years and 54.3 years, being the age below which 50% of people die.
▪ Infant mortality rates in children under 1 year of age are around twice that of the national average.
▪ Babies born to Indigenous women are more than twice as likely to be of low birth weight than are those of non-Indigenous women.
▪ Cardiovascular disease is a leading cause of death for Indigenous males and females, with the number of deaths recorded being 3.1 times more for Indigenous males and 2.6 times more for Indigenous females than non-Indigenous persons (male and female).
▪ Diabetes is a significant health problem among Indigenous people and although it is not possible to reach a single estimate of prevalence, it is nonetheless estimated that in Indigenous peoples aged 35–44 years, the prevalence of diabetes is five times higher than that reported for non-Indigenous Australians, with associated mortality rates being 23 times that of non-Indigenous Australians.
▪ Death rates from chronic kidney disease are 10 times higher than for non-Indigenous people, with Indigenous males between the ages of 25 and 34 years and 45 and 54 years recording 38 and 31 times the rate for non-Indigenous males, and Indigenous females recording 57–58 times the rate for non-Indigenous females.
▪ Suicide rates are approximately 40% higher than the general population.
▪ Communicable diseases (including tuberculosis, pneumococcal disease and parasitic diseases) are all more prevalent than in the non-Indigenous population and constitute a significant burden of ill-health and suffering on Indigenous peoples.
▪ Unintentional injuries and domestic violence are all significant health and social problems that constitute a significant burden of ill-health and suffering on Indigenous peoples.
▪ Educational attainment is half that of the non-Indigenous population.
▪ Unemployment is around five times the rate of the non-Indigenous population.
▪ Median family income for Indigenous peoples is slightly more than just one-half of that for non-Indigenous people (Thomson et al 2007).
According to Thomson et al (2007), there is no doubt that there have been significant improvements in health in some areas. However, in other areas of health there has also been a marked deterioration. On this point, Thomson and his team write ‘the gap between the health status of Indigenous people and that of other Australians is still very, very wide’ (Thomson et al 2007: 31). Citing a report by Oxfam Australia (2007), they further point out that a recent comparative analysis of national health data for Indigenous populations in Australia, New Zealand, Canada and the US has found that ‘Australia ranks bottom in the league table of first-world nations working to improve the health and life expectancy of Indigenous people’ (Thomson et al 2007: 39).
In light of these and similar figures, there is a strong case to be made for Indigenous health to be treated as ‘a special moral imperative’ for which we all share collective responsibility (Morgan & Allen 1998). In keeping with this imperative, as Morgan and Allen (1998) persuasively argue in relation to the health of Australian Aboriginal peoples, health stands as an ‘appropriate site for restitutional action’, which accordingly needs to be situated as a primary locus of action encompassing the complex, interwoven and ‘enmeshed’ processes of recognition (of past wrongs), restorative justice (to repay some of the ‘accrued moral debts’ owing to Aboriginal peoples), and ultimately reconciliation (see also Johnstone 2007c; Thomas 2004). In writing and revising this book, however, and in reading various texts on achieving ‘health justice’ for Indigenous peoples (see, e.g. Bartlett 1998; Behrendt 2003; Hughes 2003; Moreton-Robinson 2004), I have been mindful of a number of things. First, I have been mindful that no matter how well intended I am and how well informed I might be about the many issues affecting Indigenous peoples, I do not have the legitimated authority to situate myself as the voice (or even a voice) of the world’s First Peoples.
Second, I have been mindful that while many of the issues contained in this book are of interest to nurses — and may even constitute a priority area of concern for some nurses — they are not necessarily of interest to or represent a priority area of concern for Indigenous peoples (e.g. given their poor life expectancy relative to the overall population in a country, it is not difficult to imagine that a more pressing concern for Indigenous peoples is how to live a full life span at all, not how to die with assistance — be euthanised — at the end of it). Third, I have been mindful (as indicated above) that Indigenous peoples are among the most stigmatised and discriminated against group in the world and accordingly are vulnerable to what Martha Minow (1990: 20) calls the ‘stigma of difference’ and the ‘moral pathology of prejudice’ that underpins it. (According to Minow, the stigma of difference is so potent that it ‘may be created both by ignoring it and by focusing on it’.) Thus, ironically, by providing a focus on Indigenous issues in this work I might have inadvertently fuelled the ‘stigma of difference’ and a ‘moral pathology of prejudice’ against Indigenous peoples, rather than progress a ‘respect of difference’ and a ‘moral therapy’ of inclusiveness and a ‘pro-attitude’ towards Indigenous peoples. Fourth, and in respect of the views of the late Irihapeti Ramsden (2002), an influential Maori nurse leader and activist in New Zealand, I have been mindful that including material relevant to Indigenous communities carried the risk of making Indigenous peoples ‘exotic’ to bioethics and nursing ethics and as ‘subjects’ of discussion, rather than as equal co-participants in a discourse aimed at challenging and changing the status quo. Fifth, I have been mindful that there are persons who are members of various Indigenous communities who are willing and able powerfully to ‘speak for themselves’ on the issues that matter to them and their communities, and that such people must have the opportunity to speak on their own behalf.
Sixth, I am mindful that we have passed the end-point in the Decade of the World’s Indigenous Peoples (1994–2003) and that, as shown above, the health of Indigenous peoples remains in a state of scandalous compromise. I am also acutely aware that, despite the ‘progress’ of our thinking in modern times and our ethics, Indigenous peoples the world over continue to suffer enormously from the legacies of colonisation, continue to bear the impact of policies ‘seeking to assimilate them into the dominant population’ (and culture), and continue to ‘suffer significantly from the effects of environmental degradation, armed conflict and the application [of] western development models’ (ICN 2003b: 1).
Last, as the granddaughter of a woman who was a descendant of the Ngati Raukawa people in New Zealand, I am reminded that the personal is also political. My grandmother’s story, once told to me when I was a young child, of her being smacked by her pakeha (White-New Zealander) teachers for speaking (‘being’) Maori at school has left a lasting impression on me, as has her premature and suffocating death from pulmonary tuberculosis (which I once heard referred to as ‘Maori chest’) when I was just 12 years old. Thus, in my case, the political is also personal. When reflecting on my own personal story (and the loss not only of my grandmother, but of her mother’s and her grandmother’s culture and language) I am reminded that ‘personal and intimate experience is not isolated, individual, or undetermined, but rather is social, political, and systematic’ and that ‘no life-area is too trivial for political analysis’ (Kramarae & Treichler 1985: 333). By this view I am mindful that the life experiences and ‘voices’ of Indigenous peoples stand (and ought to be recognised) as the methodological starting point for engaging in ‘a positive project of constructing and developing alternative models, methods, procedures [and] discourses’ (adapted from Gross 1986: 195). Likewise in the case of bioethics and nursing ethics: the lived experiences of Indigenous peoples should also be taken as the methodological starting point for identifying and addressing what Indigenous peoples regard as the ‘paramount’ ethical issues affecting their communities and how they think these issues can best be addressed.
Because of the above considerations, Indigenous perspectives have not been ‘woven’ into the chapters of this book. Nevertheless, this is not to say that no voice at all should be given to the issues of concern to Indigenous peoples. The question is how best to ‘voice’ these concerns.
In recognition of the above points, it seems appropriate that, in concluding this work and given its authorship in the cultural context of Australia, an Australian Aboriginal person should ‘voice’ the issues at stake and should have the ‘last word’ on what matters. There are two reasons for this: first, the interests of Indigenous peoples (the Aboriginal and Torres Strait Islander peoples in Australia) have often (too often) been left hanging on the last words of culturally dominant non-Indigenous spokespersons who have had no real regard or commitment in promoting or protecting the interests of Indigenous peoples. Second, by providing the last word, an Aboriginal spokesperson will also be at the forefront of providing the ‘first word’ of a new conversation on what I think could be appropriately described as a ‘new Indigenous ethics’, and how nursing ethics might evolve in the future and find (‘fit’) this with new Indigenous ethics and thereby reflect better the needs and interests of the worlds First Peoples. To this end, the concluding remarks of an invited honorary address given by Dr Sally Goold, OAM, a distinguished and widely respected Australian Aboriginal nurse, are reprinted below.
Indigenous health, political will and social responsibility2
There is a lack of political motivation or will, and also a lack of the acceptance, that we all have responsibility for Indigenous Australians who are our most disadvantaged and vulnerable people. While the reasons for distress of the soul have been recognised for many years, little has been done to address the problems. The impact of this on Indigenous health continues to be unrecognised. The effects of the overwhelming feelings of hopelessness and helplessness, demoralisation and despair, due to chronic deprivation and persistent loss and low self esteem, combined with a lack of social justice has had — and continues to have — a devastating impact on the everyday lives of the Australian Indigenous peoples of this country. Without the necessary tools to meet their most basic needs, is it any wonder that their health is poor? I believe that we are all responsible for demonstrating political will and accepting social responsibility and standing up to be counted for the healthcare needs of the Australian Indigenous peoples.
So what needs to be done? Before any sort of healing can take place, the history of this country and settlement must be acknowledged. The wounds of injustices inflicted on Aboriginal and Torres Strait Islander people that have caused so much grief and distress must be accepted as having happened, that they are not stories made up, but fact. This acceptance of history is not to engender feelings of guilt. Those reality factors must be addressed, however. The provision of grief counsellors to provide support for those in need, especially for those of our people who are members of the ‘stolen generation’ children who were forcibly removed from their parents, in an effort to ‘make them white’ under the Assimilation policy, will assist in addressing those reality factors.
Social justice issues must be addressed. These social justice issues are in fact human rights issues that apply to everyone in this country: adequate housing, clean water, sewerage disposal, good access to health care and education. These are not ‘practical reconciliation’ measures, as the former Prime Minister John Howard stated, but are basic human rights that should be available to all.
Abolish racism and racial discrimination. The international Convention on the Elimination of all forms of Racial Discrimination (CERD) was adopted by the UN General Assembly in 1966 and entered into force for Australia in September 1975. But unfortunately, racism is still alive and well in this country. We need, therefore, to look at what can be done on an individual level to combat racism — to provide culturally appropriate care, and to embrace the true spirit of reconciliation in that we can all walk together in peace and harmony. We need to remove the barriers to accessing mainstream health services: people will not go where they are not made to feel welcome. Racist attitudes are alive and well in the health care system with judgmental values and attitudes very obvious on the part of many health care professionals. Aboriginal and Torres Strait Islander people are often treated as if they are invisible and/or as non-persons. There are many good caring people working in health care facilities, but often their good work is undermined by the negative attitudes and behaviours of others.
The education of health professionals needs to be improved. All universities providing education for medical students, nurses and allied health professionals must review their curricula to include the history of Aboriginal and Torres Strait Islander people; cultural awareness and the concept of cultural safety must also be included, to enable people to understand how historical factors impact on people’s health and their lives today.
There needs to be increased recruitment and retention of Aboriginal and Torres Strait Islander health care professionals and recognition of the role they play as health care providers. A diverse workforce can only assist with caring for Aboriginal and Torres Strait Islander people as well as non-Aboriginal and non-Torres Strait Islander people, with the sharing of ideas and experiences.
We as nurses need to and must work together and accept and respect each other’s views if we hope to provide appropriate care for Aboriginal and Torres Strait Islander people with ‘soul distress’. We need to have the capacity and the compassion to acknowledge that Aboriginal and Torres Strait Islander people are actually human beings, and to listen to and hear what the person is saying. If we are able to do these things, we will ensure that Indigenous peoples enjoy the same level of health care services as others, and we will be able to see and be able to hear them and, in doing so, acknowledge that they are not in fact invisible. We as nurses may be able to demonstrate political will and that, in accordance with our social responsibility, we can do something with the power we have.
I leave you with this quote from Sir William Deane (2001):
The ultimate test of a nation is how we treat the most vulnerable and disadvantaged of our people. And from Ann Deveson (1991):
A thing is not impossible merely because it is inconceivable.
Sally Goold OAM3
RMIT University 8 May 2000
(updated 2007)
Endnotes
1. It should be noted that although the term ‘Indigenous’ is used here, its use is by no means universal. In some regions, terms such as ‘tribes’, ‘first peoples/nations’, ‘aboriginals’ and ‘ethnic groups’, are preferred (WHO 2007d). The United Nations and WHO, however, understand the term ‘Indigenous’ to include peoples who:–
– Identify themselves and are recognized and accepted by their community as Indigenous.
– Demonstrate historical continuity with pre-colonial and/or pre-settler societies.
– Have strong links to territories and surrounding natural resources.
– Have distinct social, economic or political systems.
– Form non-dominant groups of society.
– Resolve to maintain and reproduce their ancestral environments and systems as distinctive peoples and communities.
(WHO 2007d)
2. Address given by Dr Sally Goold, OAM, at Storey Hall, RMIT University, Melbourne, 8 May 2000. Updated 2007. Reprinted with permission from Dr Sally Goold.
3. Dr Sally Goold is also the chairperson of the Council for Aboriginal and Torres Strait Islander Nurses (CATSIN). Further information about CATSIN can be obtained by visiting its website at: www.indiginet.com.au/catsin.
