Episode 48      28 min 54 sec
Researching Indigenous Health in Australia and New Zealand

Professor Ian Anderson discusses contemporary approaches to health research and education for indigenous Australia. We also hear a New Zealand angle from Assoc Prof Papaarangi Reid of the University of Auckland. With host Jacky Angus.

"And we also need to build opportunities for engaging in the broader economy, so that there a number of key domains which we need to be working within, the domain of government, the domain of economy and the local community, in order to make progress." - Prof Ian Anderson




           



Prof Ian Anderson
Prof Ian Anderson

Professor Ian Anderson holds the Chair of Indigenous Studies at the University of Melbourne. He is also Director of the Centre for Health and Society, and of Onemda VicHealth Koori Health Unit. Ian is Chair of the National Indigenous Health Equality Council, and is also currently the research Director for the Cooperative Research Centre for Aboriginal Health.

Having spent over 20 years in the field of Aboriginal health, Professor Anderson’s experience covers various areas. These have included the provision of heath services, policy development, work as a general practitioner and, more recently, as an educator and researcher.

Ian's current research interests include Aboriginal Health Policy (Primary Health Care Systems, Work Force Development, Health Performance Measurement, Health Information Systems and Research Policy). He also has an interest in Aboriginal Health and History and Society.

Assoc Prof Papaarangi Reid
Assoc Prof Papaarangi Reid

Assoc Prof Papaarangi Reid, a specialist in public health medicine, is Tumuaki (Maori Dean) in the Faculty of Medical and Health Sciences at the University of Auckland.

Papaarangi is also the Director of the Eru Pomare Maori Health Research Centre at the Wellington School of Medicine and Health Sciences.

Her research interests include the analysis and monitoring of disparities between Maori and non-Maori citizens, the construction of ethnicity and indigeneity in the social determinants of health, and the options for progressing equity.

Credits

Host: Jacky Angus
Producers: Kelvin Param and Eric van Bemmel
Audio Engineer: Craig McArthur
Theme Music performed by Sergio Ercole. Mr Ercole is represented by the Musicians' Agency, Faculty of Music
Voiceover: Paul Richiardi

Photograph of Assoc Prof Papaarangi Reid courtesy of Qiane Corfield / Mana Magazine

Series Creators: Eric van Bemmel and Kelvin Param

Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute.

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Researching Indigenous Health in Australia and New Zealand


VOICEOVER
Welcome to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia.  Up Close is available on the web at upclose.unimelb.edu.au.

JACKY ANGUS
Hello and welcome to Up Close, from the University of Melbourne, Australia.  I’m Jacky Angus.  In today’s Up Close we explore the area of indigenous health in Australia, and the challenges this poses for universities and for research.  Aborigines and Torres Strait Islanders represent 2.5% of the Australian population.  In the wake of apology to Aboriginal Australia by the new government in 2008, the Australian Prime Minister made a pledge to substantially improve indigenous health.  A key element here involves better building and sharing of knowledge about health as part of the tertiary education process.  So, what does this mean for the training of doctors and paramedics?  What are the implications for research into health and illness, and how can indigenous people themselves be more involved in the process and more knowledgeable about health?  To address these questions my guest today is Professor Ian Anderson, who holds the Chair of Indigenous Health at the University of Melbourne, Australia.  He’s also Director of the Centre of Health and Society, and of the Onemda Koori Health Unit.  Professor Anderson’s experience covers many areas, most recently as a university educator and researcher.  His own research is cross disciplinary reflecting his broad interest in the sociology of health and illness.  Ian Anderson’s current concern is what he sees as the gaps in education and research on health.  For him, building and transferring knowledge has to be a two way process.  Welcome to Up Close Professor Anderson.

IAN ANDERSON
Thank you.  It’s great to be here.

JACKY ANGUS
Can I start by asking you what is meant by knowledge as a two way process?

IAN ANDERSON
I think the very traditional and old fashioned view of universities and knowledge is sort of a – the image of the sausage machine comes to mind.  You have bright young students and ideas in one end and you crank the handle, and then out the other end you get knowledge and ideas and innovation.  I think nowadays we think of this process in a far more dynamic way, and in particular we highlight the idea that the communities who are the benefits of the knowledge also actively engage in that process of innovation and new ideas and thinking.

JACKY ANGUS
How is it going to work out when you’re training doctors?

IAN ANDERSON
That’s a very good education, because in education I think it means that rather than just a focus on educating non-Aboriginal people about Aboriginal health and how doctors can work better with Aboriginal communities.  And we also see a really critical role for indigenous communities in two ways.  Aboriginal communities need to be actively engaged in the education process, and can teach students something about health and health knowledge and health development.  So, we have a very active process for involving indigenous elders in our learning processes, for involving Aboriginal health services and Aboriginal health professionals in the educational process.

JACKY ANGUS
Now I know Professor Anderson you’ve said in some of your talks that things don’t seem to have changed much since you were a young doctor, but it sounds like things are in fact changing.  Are you optimistic about this change?

IAN ANDERSON
Well, I think that there’s been on the broader front a significant health gain over the last couple of decades, particularly in relationship to life expectancy and key areas of death rates for infants or young children.  I think there’s still a significant disadvantage, but I think that one of the other key developments, which is the other bit of that knowledge exchange process is providing opportunities for Aboriginal people in the health educational process.  So, we see, for example, one of the critical roles of universities is to develop educational pathways so that Aboriginal kids can become doctors or nurses or physios.  People often see the benefit of that very simplistically, that these kids are going to go back and work in Aboriginal communities.  A significant number do, but a significant number also go and work in mainstream health context, become cardiologists, become educators, become researchers, and we think that that’s a really fundamental part of the equity benefit.

JACKY ANGUS
At the point of training, does that mean that you see the education of young doctors and medical health science people as actually engaging more with those communities, so they perhaps do a practicum in a community, actually engage with them directly?

IAN ANDERSON
Both ways.  Getting students out into Aboriginal health context, not only in remote communities and rural communities but also with Aboriginal health services in urban areas.  Enabling Aboriginal people to be actively involved in the teaching process through tutorials, getting Aboriginal kids into environments where they’re actually engaging with Aboriginal people, not as patients but as colleagues, and that’s again a critical reason for finding pathways for Aboriginal students into the health sciences.  Young health science students, doctors, nurses, needs to have a space where they’re actually talking, communicating and dealing with Aboriginal people as their peers.

JACKY ANGUS
Can we step a bit and can you outline for us what still are the main problems in health in Aboriginal communities?

IAN ANDERSON
I think there are a number of key challenges that we need to engage with.  Issues around access to affordable quality health care.  We need to address social factors that impact on health such as poverty, educational opportunity, employment.  We also need to build the capacity for indigenous communities to deal with some of the value issues, some of the questions around violence, some of the issues around things that need to change within communities.  And we also need to build opportunities for engaging in the broader economy, so that there a number of key domains which we need to be working within, the domain of government, the domain of economy and the local community, in order to make progress.

JACKY ANGUS
And what are the major illnesses that still affect Aborigines?

IAN ANDERSON
The major causes of death are cardiovascular diseases, heart disease, chronic illnesses like diabetes, and that’s certainly the key things that are worrying us at the moment.  We know that at over the last 20 years we’ve made significant in-roads in Aboriginal death rates, particularly in the infectious diseases.  In relationship to the chronic diseases we’ve made some gains.  We know for example that death rates in Northern Australia due to chronic lung disease have dropped.  We know that death rates due to stroke have remained stable, but death rates due to diabetes and heart disease are still tracking in the wrong direction, although that rate of change seems to have slowed over the last 10 years.  We know that with the cancers we’ve got a mixed pattern.  We’ve got improvement in some cancers such as cervical cancer, whilst the smoking related cancers such as lung cancer are still trending up so that there has been change but it’s change that’s complex.  Some gains in some areas have been offset by things not getting better or getting worse in other areas.

JACKY ANGUS
And is there an increasing sense of empowerment within Aboriginal communities, say particularly in the rural areas do you think?

IAN ANDERSON
I think that there has been a couple of decades in which Aboriginal have actually been leading the way.  In the 1960’s and 1970’s the Indigenous Rights Movement really kind of sent a message that Aboriginal Australia wants to be in the lead in terms of taking control of Aboriginal futures, taking control of what’s happening in local community.  At a time when this country really didn’t have a universally accessible system of health care, Aboriginal people were setting up voluntary clinics called Aboriginal Community Controlled Health Services in order to make sure that wherever you lived as an Aboriginal Australian, you’d have an opportunity to get basic health care.  We’ve also seen a growing number of Aboriginal people who unlike their parents have had opportunities at university education, becoming doctors and becoming nurses, becoming lawyers, teachers, working in the public service, working on change.  So I think that even though the statistics are still grim and the disparities are quite profound, we have seen positive movements in terms of those health statistics over the last 30 years, and we’ve seen signs of success when Aboriginal people have been able to drive change and been empowered to deliver change.

JACKY ANGUS
I guess it’s still part of a bigger picture too, about Aborigines having access to other sorts of things and getting recognition.  I was thinking of sport, culture, the media and generally playing a part in the wider community.

IAN ANDERSON
Yes, and I think that that’s part of the problem of that media discourse, is that it tends to reproduce a particular image of indigenous Australia, which is an image of despair and not really an image of hope.  And also not an image that actually focuses on indigenous success.  Unfortunately success doesn't…

JACKY ANGUS
It doesn't sell papers.

IAN ANDERSON
It doesn't sell papers.

JACKY ANGUS
Now as a Koori Aboriginal man yourself, Professor, don’t you ever feel overwhelmed by the task?

IAN ANDERSON
No, I mean you grow into that.  My experience is mostly in working in Aboriginal communities here in the south, and I think that I’ve been profoundly overwhelmed by the legacy of people struggling for change, a legacy of people actually making a difference.  And so I’m a part of that generation that’s profoundly aware of what opportunity can do.  I remember once sitting down with a friend of mine, we were first working as Aboriginal health workers about 22 years ago when we were kind of still teenagers and reflecting with her about how things had changed.  And she said that for her mum going to see a doctor was a big deal.  For her mum, it would have been an experience of getting turned away, of not being able to afford it, of being shunned, being kind of put in the corner in the waiting room.  But for her, because she’d grown up in an environment where she’d gone to a local Aboriginal health service that had been set up by the community, hers was much of an expectation that she would actually get good health care.  And that when she turned up to a doctors she expected to be treated with courtesy and that she expected that that doctor would provide the best quality care for her.  And that difference in growing up an environment when you expect certain things, expect what other people in this country take for granted, is a profound one.  It’s a really profound emotional and kind of psychological shift in how much you engage with opportunities in life.

JACKY ANGUS
It’s a positive kind of mark of the barometer too, isn’t it, that things are changing.  Can I look now at research, because you’ve mentioned at the very beginning the sausage factory idea, and even research in a way has had its stereotypes.  What do you feel about research into indigenous health; do you have a model that’s an improvement on the present way of doing research?

IAN ANDERSON
I think there are two problems with the research process, and I’m going to stereotype research now but I’d say that one of the problems is that research ideas have been dreamt up in isolation from the communities from which the research process is implemented.  And that kind of ivory tower model often leads to good research, good questions, but not necessarily the right questions and the right research process.  So the sort of model of research that we have is actually working with Aboriginal communities, but also Aboriginal health services, Aboriginal health policy makers, and actually asking them what are the gaps in knowledge that you think are really critical to improve policy or improve service delivery or to making a difference in Aboriginal health?  And if we were to address those gaps in knowledge, what is the right sort of research question and the right sort of research process?  So that’s the front end.  At the back end of the process, how do we do our research in a way that is going to maximise its impact?  How do we undertake our research and write up the findings of our research and communicate that research, in a way that’s going to capture the attention of the policy maker, that’s going to change the way in which services are provided, which might provide leverage for change in local communities? So that question is really about getting a better focus on our research, but getting a better research process and one which enhances the value of that work.  So rather than publishing in high impact journals only, high impact journals which no policy maker reads or no service provider reads, we think of other ways in which we can build more multi-layered and multi-faceted communication strategies.  So that when we do generate new knowledge, that it can make a difference.  Not so much generating new knowledge, but new ways of problem solving, that we can actually engage the minds of those who are going to use that knowledge.

JACKY ANGUS
You’re listening to Up Close from the University of Melbourne, Australia.  I’m Jacky Angus and I’m talking to Professor Ian Anderson.  Well Professor Anderson, can you tell me about anything new that’s happening in this area that you feel positive about?

IAN ANDERSON
One of the new developments is the National Indigenous Health Equality Council, which I’m chair.  This council was set up by the Commonwealth Minister for Health, and has really been given a mandate to map out a direction that enables the government to close indigenous health gap.  We think that’s a really exciting challenge, given that this is the first Australian government that has actually signed the pledge and put their hand on their heart and said that in the next generation what they want is see is the elimination of indigenous health disadvantage.  Some of the critical things that we should be doing is getting a focus on improving quality of indigenous health data.  Clearly if we’re going to close the gap we’ve got to be able to measure it, and we still can’t in this country in some regions.

JACKY ANGUS
So what does that actually mean, tracking change?

IAN ANDERSON
Yeah, tracking change through time.  We have at the moment quality mortality or death data for only 60% of the Aboriginal population.  We’ve got to move towards having quality death data for 100% of the Aboriginal population, and that’s a significant challenge.  And there’s another big challenge, which is actually mapping out the milestones for change so that we know that we’ve been given the big mandate to say let’s make a difference in the next generation, but what are the steps along the process.  How will we know in five years if we’re moving in the right direction?  What are the sort of targets that the government should be measuring as milestones on that journey?  We also know – and this has been one of the other big challenges that’s been given to the National Indigenous Health Equality Council, is what’s the workforce that we need for change?  How are we going to ensure that we’ve got the appropriately skilled doctors, the appropriately skilled nurses and Aboriginal people in the health sciences?

JACKY ANGUS
That sounds very positive.  Now, I know Professor Anderson that your interest is not purely national but international, in that you have a wide network of people in other parts of the world doing interesting things along similar lines.  One of these people I understand is Dr Papaarangi Reid of Auckland University.  She’s based at the faculty of Medical [and] Health Sciences there and she’s kindly coming in for a comment.  Good afternoon Dr Reid.

PAPAARANGI REID
Kia Ora, greetings.

IAN ANDERSON
Hi there, Papaarangi, all the way from New Zealand.  It’s good to hear you.

PAPAARANGI REID
Good to talk to you Ian.

JACKY ANGUS
I know that Dr Reid’s work in Maori health and her particular interest in the practice of research, in fact parallels Professor Anderson’s emphasis on the need to counter this tendency to define indigenous health in terms of deficits.  I’d like to start Dr Reid with the first question.  You’ve written and spoken about the value of research that starts out with a non-deficit model of health.  Can you tell me a bit more about that; what does it mean exactly?

PAPAARANGI REID
Well, we need to recognise that sometimes research and data, whether it’s quantitative or qualitative data, is all about power and that people can represent that data in a way which empowers or disempowers another group, and so just recognising the power of research is a really important starting point.  Because my next point then would be research can then be colonising, so from an indigenous perspective we have to make sure that research is liberating rather than continues to colonise us and make us part of the colonial landscape still.

JACKY ANGUS
So what would you do to make sure that it was liberating, make sure that people understood it who were involved in it?

PAPAARANGI REID
Well, there’s lots of different ways in which you might want to engage, but first of all we have to believe that qualitative or quantitative data is a representation of us, just as a photograph is a representation, just as a piece of our DNA is a representation of us.  And so therefore we should have as much ethical rights over our data as we do over our DNA, and so I’m interested in the collection and use of indigenous data as an ethical issue.  We should have a level of control over who defines who I am, who defines who an indigenous person is and who says and on what basis.  So the definition of someone’s indigeneity and the responsibility of collecting and managing data, and the way in which that data is analysed and re-presented as results or policy or analysis or whatever.

JACKY ANGUS
Can you give us an actual example of how this would play out in field work?

PAPAARANGI REID
We’ve had generations of Maori health statistics, so indigenous health statistics in New Zealand being published ad nauseum for many decades, and all of it was very negative and it created a scenario where indigenous people didn’t want to own the outcome of that research.  So that led us to not engaging with the data, not engaging with the research, not engaging with the problem, and sometimes not even wanting to label ourselves as indigenous.

JACKY ANGUS
I can understand that, but what I meant was can you give us an example of it being done properly in the field.  What would be involved?

PAPAARANGI REID
Well, first of all, we have to own the fact that we decide who is indigenous.  So first of all, working on definitions of indigeneity and the collection of indigeneity. One of the first things we did was - got involved with the classification of ethnicity.  And all the national data sets from the census data sets through to health data sets.  Then once we have an understanding of how it’s done, we’re happy with the science, we are more likely to start becoming involved and take ownership of that data.  And then we’re more likely to start taking ownership of the outcomes of that data.

JACKY ANGUS
Right, can I go back a step now and ask you Dr Reid, what exactly is happening in Maori health in terms of the sort of data collection that Ian Anderson’s been talking about?

PAPAARANGI REID
In New Zealand we have significant inequalities, inequities in health outcomes all the way through the health sector and in representation in the health workforce.  So we have a different level, but we have very similar inequities in our statistics.  Our biggest concern in New Zealand in the last two decades was actually being undercounted, especially in deaths but really in hospitals and primary health care.

JACKY ANGUS
Why was that?

PAPAARANGI REID
For a number of reasons, but especially related to the processes and especially relating to other people deciding it didn’t matter, other people thinking we don’t have a problem here, we have perfect race relations.  And in fact, when we saw really bad inequalities in health, if you take into consideration the undercounting, the inequalities were much, much worse.  So, the first thing that we had to do was to work out where the true level was with the undercounting, and to move from we need to count indigenous people right to indigenous people have the right to be counted, and to be counted properly.  Because we need to monitor the governments of the day in our respective countries on how well are they doing in indigenous health.  It’s not so that they can monitor us, it’s so, actually, we can monitor the Crown properly.

JACKY ANGUS
Well apart from census taking, what about independent research by Maori academics.  Presumably that’s going on in an acceptable way, and presumably that’s a good way of monitoring the type of research overall that’s going on in universities?

PAPAARANGI REID
Yeah, absolutely.   My point is that first of all you have to have quality data and know the bounds of that quality of that data.  Then you have to be able to analyse that data in a way that engages with indigenous realities and indigenous rights.

JACKY ANGUS
So that’s the policy stage you mean, actually being useful?

PAPAARANGI REID
Not only at the policy stage, but sometimes you can take a piece of data and normally researchers will tell you the data speaks for itself, but actually the data doesn't speak for itself.  We speak for the data.  We say this means this, this shows this, and we use the data often and when we have preformed ideas about what it might…

JACKY ANGUS
When you say we, you’re not talking about participants, Maori participants, you’re talking about academics are you?

PAPAARANGI REID
Academics in general.

JACKY ANGUS
Right.

PAPAARANGI REID
And that has been a problem in terms of generating what is known as deficit theorising, where if we want to examine well why is the death rate different, we gaze at the indigenous death rate and we say, “oh, what is it about indigenous people that makes them die younger?”
“What is the problem with indigenous people?”
Instead of looking at a societal and a structural view, that says what is it in this country when non-indigenous people die here and indigenous people die at this age?  What is it about our society, what is about our structures that we have such a difference?  Some of that difference might reside within indigenous people, but some of it might reside within non-indigenous people within the structures that we have and the society that we have.  And so first of all, making sure our analytical framework is broad enough to look at important structural and social…

JACKY ANGUS
I think Ian might like to ask you a question for our final take if we may.

IAN ANDERSON
Papaarangi, one of the things that you talk about often is the rights to statistical equality.  What do you mean by that?

PAPAARANGI REID
If we do a survey of what the population thinks is important in health, the responses are going to be numerically boosted by a majority of that population.  So the minority views are not going to be heard equally as strongly as the majority.  And so if we just take a simple survey, then we are going to get a dominant majority voice being heard all the time, and so we try and persuade other researchers where there are inequalities in the population they’re studying to make sure that there is an equal voice representation in the survey that they do of that population, so that…

IAN ANDERSON
So, that’s kind of like saying that when we’re doing a survey and we’re looking at minority populations, we actually have to over-sample them, to get more in that sample in order to be able to generate observations.

PAPAARANGI REID
Except, you know, after doing some discourse analysis we wouldn't say over-sample.  We would say that in a normal survey of a population where you’ve got inequalities, you are over-sampling the numerically dominant population. And that in effect, you have to do two parallel surveys.  So, you have to sample in a way that both populations have the same amount of voice that can generate statistically strong views on what's happening in that community.

JACKY ANGUS
Thank you very much Papaarangi for being involved.  We’ll have to leave it there, but thank you very much indeed.  We’re most grateful to you.

PAPAARANGI REID
You’re welcome.  Anything for Ian?

IAN ANDERSON
Thank you.

JACKY ANGUS
Would you like to add to that Professor Anderson?

IAN ANDERSON
I think what Papaarangi has really demonstrated is that one of the kind of arguments and battles that you fight in indigenous health is around measurement.  It’s about the right to be measured properly and the right to have survey methods that actually give you enough of a sample, so that you can say something meaningfully on a statistical level about indigenous health.  But I think more than that to actually say well when we take that information, take that data, that we look at it in a way that is enabling.  We use an indigenous lens to the analysis, and we don’t use those colonial frameworks, which are disempowering and disabling, but we think of ways to analyse data that talks about strengths, that also focuses on some of the broader structural and social issues that impact on health disadvantage.  I think that in some ways New Zealanders and Maori New Zealanders have led the world in terms of their work around data quality, and around bringing a Maori framework into data analysis, and we can learn a lot through exchange.  It just underscores for me again the importance that if we have a strategy in Australia for closing the indigenous health gap, that we really take account of the fact of not only the things we need to do in order to close that health gap, better quality services in health care, better opportunities in education and employment, cracking the problem with the economy.  But we also make sure that we’ve also got a focus at the same time at measuring change, and putting in place the statistical systems and the approached analysis that actually enables us to take those steps forward.

JACKY ANGUS
Thank you very much Professor Anderson, and thank you again for being on Up Close.

IAN ANDERSON
Thank you Jacky.  It’s been exciting and a privilege.

JACKY ANGUS
Relative links, a full transcript and more information on this episode can be found at our website at upclose.unimelb.edu.au.  We also invite you to leave your comments or feedback on this or any other episode of Up Close.  Simply click on the add comment link at the bottom of the episode page.  Melbourne University Up Close is brought to you by the Marketing and Communications Division in association with Asia Institute at the University of Melbourne, Australia.
Our producers for this episode were Kelvin Param, Eric Van Bemmel and myself Jacky Angus.  Audio recording by Craig McArthur.  Theme music provided by Sergio Ercole.  Melbourne University Up Close is created by Eric Van Bemmel and Kelvin Param.  I’m Jacky Angus.  Until next time, thank you for joining us on Up Close.  Goodbye.

VOICEOVER
You’ve been listening to Melbourne University Up Close, a fortnightly podcast of research, personalities and cultural offerings of the University of Melbourne, Australia.  Up Close is available on the web at upclose.unimelb.edu.au.   Copyright 2008, University of Melbourne.


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