Introduction by Croakey: A senior Aboriginal health leader has urged the health sector to step up in supporting Indigenous communities and organisations in their advocacy for justice, improvements in the social determinants of health and for better health outcomes.
The defeat of the national Voice in last year’s referendum makes the voice of Aboriginal Community Controlled Organisations “more important, not less important”, according to Dr Donna Ah Chee, Chief Executive Officer, Central Australian Aboriginal Congress.
“More than ever, we need to keep speaking out on behalf of our communities, and we need your support in doing so,” Ah Chee said in her Douglas Gordon Oration at the Public Health Association of Australia (PHAA) Preventive Health Conference 2024 on Larrakia Country in Darwin today.
Making a powerful call for action on the political determinants of health, she warned that focusing solely on health promotion and illness prevention at the level of individual people is doomed to fail for Indigenous peoples. “Worse, it can reinforce the disempowerment of our communities.”
Ah Chee’s speech, titled ‘The politics of prevention: Aboriginal community controlled health services from self-determination to post-Referendum’, is published in full below. She received a standing ovation.
Donna Ah Chee:
Good afternoon brothers and sisters, ladies and gentlemen.
I pay my respects to the Larrakia people, traditional custodians of Garramilla, the land on which we are meeting today, and to their Elders past, present and emerging.
I would like to thank the Public Health Association of Australia for inviting me to give the 2024 Douglas Gordon Oration.
My name is Donna Ah Chee.
I am a Bundjalung woman from the far north coast of New South Wales, but I have lived in the Northern Territory for over thirty years.
This afternoon I would like to talk to you on the topic of The Politics of Prevention: Aboriginal community controlled health services from self-determination to post-Referendum.
In doing so, I speak as the CEO of Central Australian Aboriginal Congress, one of the largest and oldest Aboriginal community controlled health services in the country.
But I also speak as a member of the so-called ‘Fourth World’, which is to say colonised Indigenous peoples.
And I would like to make the case that in the colonial situation, in the Fourth World, you cannot take the politics out of prevention.
This is because in the Fourth World the major determinants of health relate directly to power and the exercise of colonial authority.
Sometimes that power is exercised with explicitly hostile intentions.
For example, the massacres that are still a recent part of the Northern Territory’s history; the forced dispossession of people from our lands; and the stealing of children from our families.
The profound intergenerational effects of these events continue to be felt today.
They are part of the family history and lived experience of every Aboriginal person in the country.
But these facts are often ignored despite their huge effect on contemporary life and health.
The Fourth World experience
Sometimes the power of the state is exercised in a supposedly more benevolent mode – but which nevertheless excludes or marginalises Aboriginal voices.
We can see this in the development of many policies and programs that are meant to benefit us, to ‘close the gap’ as the current slogan has it.
But the exercise of power over us by others, whether intentionally hostile or with so-called ‘good intentions’ can never address the fundamental drivers of ill health: poverty, dispossession, discrimination, and at their root, powerlessness.
As I say, every Aboriginal person experiences this.
This is at the heart of the Fourth World experience.
And any attempt to improve the health of our communities, including through ‘prevention’ services and programs, is embedded within these power relationships.
Which is another way of saying that it is inherently political.
Doomed and disempowering
In this situation, focusing solely on health promotion and illness prevention at the level of individual people is doomed to fail.
Worse, it can reinforce the disempowerment of our communities.
For example, providing nutrition education to individuals in our communities has its place.
But unless such programs also address food security, and the growing poverty in our remote communities, an individual approach can merely add to the burden of powerlessness many people carry.
Instead of an individual approach to health promotion and illness prevention, I want to describe what politically engaged prevention looks like, one that addresses issues of power at a collective, population health level.
In doing so, I will use the example of the Aboriginal community controlled health service sector in the Northern Territory, and Central Australian Aboriginal Congress in particular.
Let me start with some personal history.
Like many of you here, I am not from the Northern Territory, but have made it my home.
My first visit was in the late 1980s.
I was enrolled in an adult education course at Tranby Aboriginal College in Sydney, and preparing to go to university.
But when we completed the Tranby course, all of the students went on a field trip: Lake Mungo, Uluru and then Mparntwe/Alice Springs.
Six months later I had moved to Alice Springs and had begun working at the Aboriginal adult education organisation there, the Institute for Aboriginal Development (IAD).
Central Australia opened my eyes to what our communities could do once we got organised and we worked together.
That time was one of excitement, and passion … and political conflict.
The Northern Territory Government was motivated by a deep belief that it governed for the non-Aboriginal settlers, and against the interests of Aboriginal communities and our rights.
This took many forms.
For example, there was the proposal in 1988 by the Northern Territory Government to build a dam across the Todd River outside Alice Springs.
This was strongly opposed by the traditional custodians of the area as it would have flooded a number of important women’s sacred sites.
However, the Combined Aboriginal Organisations (or CAO) of Central Australia organised to support the traditional owners.
Barbara Flick, the CEO of IAD, would take me to meetings of the CAO to expose me to this important political forum.
I was inspired by those meetings, and by the sophistication with which all the different organisations – the Central Australian Aboriginal Legal Service, the Central Land Council, Tangentyere Council, IAD and Central Australian Aboriginal Congress and others – worked together.
Eventually, their campaign was successful, when the Federal Government was forced to step in to ban the dam’s construction and protect the sacred sites.
Powerful history
This was the first time I had encountered Congress, the Aboriginal community controlled health service based in Alice Springs.
But the organisation already had a significant history at that time, and one that I would like to briefly share with you.
Congress was established in 1973.
It arose as part of an earlier period of Aboriginal political activism during the 1960s and 1970s, a time which saw the 1967 Referendum, the Wave Hill walk-off of 1966, the Freedom Rides and increasing demands for land rights and calls for the end of assimilation and discrimination.
Neville Perkins, one of the key founders of Congress, later recalled how at the end of 1972:
“I spoke to people around the place and we talked about having [an] organisation that would represent the rights of Aboriginal people generally. It was mainly the bush communities who were really interested in having this Congress in town … and therefore we got a lot of support from Western Arrernte mob, Eastern Arrernte mob, Walpiri mob, Pintubi mob, Papunya [as well as] some people in town.”
On 9 June 1973, more than 100 Aboriginal people from both town and bush came together in Alice Springs and formally established what became known as Central Australian Aboriginal Congress.
From the start, Congress was an explicitly political organisation, formed to advance the rights of Aboriginal people, as was indicated by its name, modelled on the Indian National Congress of Mahatma Gandhi.
Soon, it started running services – a Tent Program to provide shelter for people, and a Night Pick Up Service to transport people who had been drinking and keep them safe.
And in 1975, Congress was established as an Aboriginal medical service for the Aboriginal people of the town.
Over the years, Congress gradually developed a comprehensive model of culturally responsive primary healthcare.
The aim has always been not just to treat those who are ill, but also to prevent illness through acting on its causes.
However, none of this was easy, especially in the early years.
It was achieved in the face of considerable opposition from many in positions of power in the Northern Territory beyond.
As Neville Perkins recalls:
“We had to fight the Northern Territory Health Department and the Commonwealth Health Department because they were against having an Aboriginal medical service.”
That we weren’t necessary because we duplicated mainstream services.
That we weren’t necessary because Aboriginal people didn’t want to use our services.
That we, as Aboriginal people, weren’t capable of running health services.
Over the years, these arguments have been shown to be false.
But underneath them was frequently the unstated opposition to Aboriginal self-determination, to Aboriginal people claiming and exercising their rights.
It was about the exercise of power.
I don’t want to imply that all those working for the government held these views.
Even during the years of greatest opposition to our sector during the 1970s, 1980s and 1990s, there were always those inside Government – Aboriginal and non-Aboriginal – who did their best to support our communities.
These allies deserve our acknowledgement and gratitude.
But in the end, it was the actions of our people on the ground that proved decisive.
Over the years, more and more of our communities in Central Australia established their own health services, usually with Commonwealth Government funding.
But it was rarely easy.
It was usually a struggle to get the bureaucracy to accept that our communities were capable of doing this, of getting them to relinquish their power.
What has changed?
So here we are in 2024.
After 50 years of Aboriginal community controlled health services in Central Australia, what have we achieved?
What has changed in the health status of our diverse communities, and what contribution has our sector made?
These are the questions that the Congress Board of Directors sought to ask in the lead up to Congress’ celebrations to mark 50 years since the organisation was established in 1973.
Under their leadership, Congress set up the History Project to see whether Congress and other community controlled health services had made a difference to our health.
I’d like to thank all those who worked on the History Project for Congress.
This includes Acacia Lewis; Dr Jocelyn Davies; and our partners in the Menzies School of Health Research and the Northern Territory Department of Health, especially Dr John Condon and Dr Yeujen Zhao.
I’ll describe some of the initial results in a moment, but let me start by taking you back to the 1960s and early 1970s, before Congress and the other community controlled health services existed.
At the time, Aboriginal people lived in very harsh conditions.
Family, language and culture were strong, but extreme poverty and poor housing was almost universal.
There were no land rights, and few primary healthcare services especially in remote areas.
What health services existed were marked by overt racism.
For example, the first hospital built in Alice Springs in the 1920s by the Rev John Flynn, was only for non-Aboriginal people.
And from the 1950s the government-run Alice Springs Hospital was segregated into over-crowded Aboriginal wards and largely empty wards for non-Aboriginal people until 1969.
But in the 1970s and 1980s, the Aboriginal struggle for our rights intensified, and the national network of Aboriginal health services began to be established.
This resulted in greater national and international attention on the health of our people, and compelled government to respond by expanding the health services they delivered, especially to remote Aboriginal communities.
And we mustn’t forget the other Aboriginal organisations – the housing associations, land councils, legal services and others – which began and flourished in the 1970s.
So, let me turn to answering that question: after fifty years, what have has changed?
I would like to show you some graphs on a few of the initial findings from the History Project.
Today I want to note the significant changes we have seen in:
- infant mortality
- premature mortality, and
- the health effects of alcohol.
First, infant mortality.
The infant mortality rate is the proportion of children who die in their first year of life.
This graph shows the infant mortality rate for Aboriginal kids in Central Australia from the mid-1980s to 2018.
The yellow line is the rate for Aboriginal children in Alice Springs.
The orange line is for Aboriginal children in remote Central Australia.
And the grey dotted line is for non-Aboriginal children in the Northern Territory.
So you can see an improvement for town especially for the 20 years from the early 1990s, while out bush, we haven’t seen much improvement over this period.
But I think this graph doesn’t tell the whole story, because we only have data for Central Australia back to the 1980s.
But we know that the big gains in infant mortality happened before that.
In the late 1960s and early 1970s, the mortality for Aboriginal infants in Central Australia was estimated as 172 per 1,000 live births.
In other words, 17 percent of Aboriginal kids died before their first birthday.
This was comparable to the most undeveloped places on the planet, and the tragic legacy of colonisation in the Northern Territory.
You can get a better idea of this from this graph, which shows infant mortality for the whole of the Northern Territory going back to the 1960s.
You can see that the big improvement was in the 1970s and early 1980s – just when the first dedicated Aboriginal primary healthcare services were being set up across the Northern Territory.
I just want to remind us all that behind these numbers lie the grief that so many Aboriginal families suffered in losing a child.
And the gap in infant mortality between Aboriginal and non-Aboriginal children is still unacceptably high: child and maternal health is still a major area of focus for our services today.
Let me turn now to Years of Life Lost.
This is a measure of premature mortality – in other words, people dying before their time.
The data the History Project captures only goes back to 1999, but I think you can see here that there have been big improvements since that time.
Life expectancy data also shows that, especially for Aboriginal men, it was not until the late 1990s that things really started to improve from a very low base of 54 years in the late 1990s to 65 years by 2020.
For Aboriginal people in Alice Springs, the Years of Life Lost has halved in 20 years; for remote areas its gone down by about a third.
This means the gap to non-Aboriginal people in the Territory is closing, but still remains unacceptable and tragically wide.
Last, here is a graph showing the rate of alcohol-related hospitalisations from 1992 to 2021 for Aboriginal people from Alice Springs, from remote Central Australia, and for comparison, from the NT non-Aboriginal population.
You can see clearly the accelerating harms caused by alcohol to our people over this period especially up to the mid-2010s when the first effective alcohol restrictions in Central Australia began to have an effect.
I’ll talk about this more in a moment, because it is a key case study of the kind of politically engaged prevention work that Congress has undertaken since its beginnings.
But first, I want ask: what has driven the changes?
There is no certain way of answering that question.
However I think there is a compelling story that we can tell.
Social determinants
The first thing I think we can rule out is the role of the social determinants of health outside access to the health system – education, housing, income, and inequality – in driving significant positive health changes for Aboriginal communities in Central Australia.
Our analysis of Census data shows that while there have been some improvements in some social determinants, mainly in Alice Springs, they are from a very low base.
For example while the proportion of Aboriginal people who have completed year 11 and 12 and the number who have a Bachelor degree or higher has improved, the numbers are still very low.
There are still only around 250 Aboriginal people with Bachelor degrees of higher qualifications in the whole of Central Australia – that’s out of a population of close to 20,000.
The education system is still failing our people.
Housing overcrowding has gone backwards in town and improved slightly in remote communities, but again is still very poor.
Income has improved in Alice Springs and we think this is because of increased employment in Aboriginal organisations such as Congress.
But in remote areas we are seeing increasing poverty and increasing inequality for our people.
This contributes to a significant decline in food security.
So despite the improvements in some areas it is clear that the social determinants cannot explain the improvements in health status.
Drivers of change
So what do we need to look at?
We identify three possible key drivers of positive change.
Firstly, improved primary healthcare, especially following the establishment of Aboriginal community controlled health services in the 1970s and 80s and increases in funding from the 1990s and early 2000s.
The establishment of the community-controlled services I have already spoken about.
The funding increases from the 1990s stemmed from a campaign by Congress and other NT Aboriginal community-controlled health services for better funding.
Specifically, it was for Aboriginal health responsibility to be moved from ATSIC to the much larger budget of the Commonwealth Department of Health.
From 1995, this reform enabled substantial increases in national funding for primary healthcare to be directed through Aboriginal community controlled health services.
This has led to primary healthcare funding in Central Australia going from around $700 per person in 2000 to more than $5000 per person now.
Access to Medicare and essential medicines through the PBS has also been vitally important.
Second, we have seen an improved hospital system.
Historically the NT public hospital system suffered from profound under-investment, limiting its capacity to treat its Aboriginal clients.
This was the legacy of the segregated colonial health system.
However, the election of the first Labor Government in the jurisdiction in 2001 led to a substantial investment in public hospitals.
This improved both the quantity and quality of hospital care available for Aboriginal clients.
Powerful vested interests
The third driver of positive change has been supply reduction measures to tackle substance abuse, particularly alcohol but also the introduction of OPAL non-sniffable fuel to combat petrol sniffing.
I would like to talk especially about alcohol supply, because it is an excellent case study of the kind of politically-engaged public health prevention work that Congress is committed to.
From the earliest days, Congress acted to address and prevent the harm that alcohol was doing to the lives of people in Central Australia.
While the Congress community recognised that treatment, rehabilitation and media campaigns were necessary, these approaches would fail unless there was also action on the supply of alcohol in Alice Springs and across Central Australia.
To prevent harm – and especially the violence against Aboriginal women – we had to reduce the supply of alcohol, and that meant taking on some powerful vested interests.
For many years, any attempt to address supply was strongly resisted by government.
But Congress never gave up, speaking out publicly and demanding an evidence-based approach to reducing harm by reducing supply.
Finally in 2018 the rising levels of alcohol-related harm forced the Northern Territory Government to introduce a range of reforms including a minimum unit price for alcohol and police auxiliaries on take-away outlets in regional centres.
All of these reforms had been part of our advocacy, and were informed by the best available evidence from around the world on what works to reduce alcohol related harm.
And they worked, to the benefit of all of Territorians, with significant reductions in alcohol-related assaults, domestic violence and alcohol-related Emergency Department presentations.
This graph shows the effect of alcohol policy on alcohol-related domestic violence assaults in Alice Springs.
You can see the green column shows a 21 percent reduction in the average monthly number of alcohol-related domestic violence assaults in town after the introduction of the reforms in 2018.
But the story doesn’t end there: first we had COVID, which increased DV in Alice Springs just as it did all over the world – that’s the yellow bar in the graph.
Then in July 2022 the Northern Territory and Federal Government allowed the Stronger Futures regulations which kept Aboriginal town camps and living areas ‘dry’ to lapse.
Congress – along with numerous other Aboriginal community voices – had warned that the result would be a wave of alcohol-related harm in the town.
Voices, context ignored
Unfortunately, this time the Government ignored Aboriginal community voices, the restrictions lapsed and as you see from the red bar in the graph, domestic violence assaults sky-rocketed, increasing by 93 percent over these months.
We saw similar catastrophic rises in assaults, property crime and Emergency Department presentations.
This led to national and even international media attention on alcohol-related violence and disorder in Alice Springs.
Much of the reporting was sensationalist and betrayed a barely concealed racism.
Devoid of context or history, it ignored the role of colonisation in setting up the conditions for violence, and the role of profit-taking by the alcohol industry.
But those living in the town knew there was a reality behind the media panic – it was a very difficult time.
So, led by our Board, we intensified our advocacy, speaking out publicly, meeting with policy makers, writing letters, and speaking in the media.
Throughout, we emphasised that Aboriginal culture does not support this violence and that we needed a “both/and” approach to preventing alcohol related harm.
We need both action on the unrestricted supply of alcohol to Aboriginal communities, and long-term investments to address the underlying drivers of destructive drinking.
Fortunately in January 2023, the Prime Minister stepped in and came to Congress with a number of his Cabinet colleagues.
After meeting at Congress with the Prime Minister, the Northern Territory Government reimposed the dry are restrictions, and in addition banned the sale of take away alcohol on two days of the week.
And the Commonwealth Government announced a $250 million injection of funds into Central Australia to address the drivers of alcohol use and violence.
These changes have been controversial or difficult for some in the community to accept.
The level of alcohol consumption in Alice Springs – shown in the blue bar in this graph – fell by 20% after the introduction of these regulations.
With the fall in consumption came a huge fall in alcohol-related harm, especially as experienced by Aboriginal women.
This graph shows a 39 percent reduction in the number of domestic violence presentations at the Alice Springs Hospital Emergency Department after the introduction of the take-way free days and ‘dry area’ regulations.
We estimate that since their introduction, the reforms have prevented well over 500 domestic violence assaults on women in Alice Springs, as well as numerous other harms.
This has not been easy.
It means speaking out publicly, and it often means conflict: with the media, with spokespeople of the alcohol industry, with politicians who have been captured by that industry, and yes, with some in the Aboriginal community.
Not all Aboriginal people see these issues the same way.
But Congress Board of Directors have been firm.
Congress was set up to be a voice for Aboriginal people, and it continues to be that voice, speaking out publicly and strongly to prevent harm to the community.
Beyond the referendum
I would like to end my paper by looking to the future.
We are now in the ‘post-Referendum’ period.
In October last year, the Referendum to alter the Australian Constitution to recognise First Nations people and establish a First Nations Voice to Parliament was decisively defeated, even though Aboriginal people overwhelmingly supported the Voice.
Congress supported a ‘Yes’ vote because we know from our own experience that when we have a say in the issues and programs that affect us, the outcomes are better.
The Voice would have helped to improve the health of our communities, building upon successes we have already achieved.
It would have made Australia a fairer and more inclusive nation.
However, despite the millions of Australians who agreed with us and voted ‘Yes’, the rejection of the place of First Peoples in the nation’s rulebook is a setback for our people and for the nation as a whole.
Some have said that this marks the end of reconciliation in Australia.
There may be some truth in that.
But what I know for certain is that the defeat of the national Voice makes the voice of self-determinant Aboriginal organisations – such as Congress and all the other Aboriginal community controlled health services – more important, not less important.
More than ever, we need to keep speaking out on behalf of our communities, and we need your support in doing so.
For example, the Federal and Northern Territory Governments have recently announced huge investments in education and remote housing in the Northern Territory.
These are welcome, and in terms of prevention, essential.
But with no national Aboriginal Voice, where is the Aboriginal community oversight of these investments?
How will the Aboriginal community voice be heard?
How will we guarantee the public transparency and accountability that is essential if this money is to make a genuine, long-term difference?
One solution is for a treaty with sector-specific agreements which guarantee an Aboriginal voice in particular sectors such as health; education; or housing.
This would build on the success of the NT Aboriginal Health Framework Agreement which led to the establishment of a key joint planning forum between Aboriginal community controlled health services and both levels of government.
Because we know for certain that without empowered Aboriginal people and organisations at the table, ‘prevention’ will be just another word.
Hearing our voices
I hope I have been able to show how Central Australian Aboriginal Congress, in its 50 years of operation, has used its voice to drive system and policy changes that lead to better health for the Aboriginal people of Central Australia.
Congress – along with many other Aboriginal organisations and individuals – has not just accepted the status quo.
To prevent harm in the context of colonisation, we need to exercise our rights and have our voices heard.
This is why for me and for Congress, and for Aboriginal community organisations across Australia, prevention and politics go hand in hand.
** Please note, minor changes were made following publication.
See Croakey’s archive of articles on Indigenous health
