Dr Kerryn Phelps, AMA President to the ATSIC National Treaty Conference, Canberra
Good morning ladies and gentlemen. I am privileged to have the opportunity to speak today at this important conference. I thank ATSIC for the invitation.
At this year's AMA National Conference, I released a Public Report Card on Indigenous Health.
The Report Card assesses the progress or lack of progress in Australia on the health of Aboriginal and Torres Strait Islander peoples.
It notes achievements that have occurred, including those in regional programs.
It examines the progress or lack of it as compared to countries such as New Zealand, the US and Canada.
It also looks at the related areas of education and social justice.
The outlook on all counts - despite advances in certain areas - is, overall, pretty bleak.
We need a solution or solutions - a catalyst for change.
Incremental change and occasional funding - usually around election time - is not enough.
It is time for a sea change.
I want to talk today about the potential impact of a treaty or treaties between the Federal Government and indigenous Australians on the health of indigenous Australians.
Allow me to set the scene.
Despite the good intentions of many, the health of indigenous Australians remains a national disgrace.
It is a blot on our human rights record.
It is a blot on the Australian ethic of a 'fair go'.
That is why I am here today to say that I believe - the AMA believes - that a treaty, an agreement, could be a positive step towards improving the health of indigenous Australians.
It is now official AMA policy. The AMA Public Report Card on the state of indigenous health is a product of the AMA's focus on the problem, and I will talk about this a little later.
There are many terms to describe an agreement between our Government and indigenous Australia in use at the moment - lasting agreements, contracts, compacts or treaties - depending on which side of the debate you are coming from.
The term you choose may well be based on how nervous you are about the word 'treaty'.
I will use the term treaty - or treaties. It is a term used freely overseas in countries where such agreements have led to improved health outcomes for their indigenous peoples.
The AMA has a long history of advocacy in Indigenous Health and, as AMA President, I have made it one of my priorities
Last year I announced the AMA's support for ATSIC community consultations regarding the potential of a treaty between Australian governments and Aboriginal and Torres Strait Islander communities.
The AMA Federal Council formally resolved to support the exploration of a treaty or treaties in order "to achieve targets which measurably improve the quality of life and health outcomes for indigenous people".
The AMA also signed the joint statement entitled For Achieving Justice for Indigenous Australians prepared by ACOSS and signed by members of the community welfare sector.
We supported this process because of the frustration with the current lack of commitment by governments to do what is required to break the cycle of poverty and ill-health in Indigenous communities.
Commitment is needed. Strategic plans are needed. Proper targeted funding is needed. Goodwill, humanitarianism and cooperation are needed.
Australia should have better health outcomes for indigenous Australians sooner, not later - in the foreseeable future, not the long term.
There must be a binding commitment to equity in health service delivery for indigenous communities - the remote ones and the urban ones.
When we talk about improvements in living conditions - and access to health and education services - for all Aboriginal and Torres Strait Islander communities, the AMA has encountered what Professor Ian Ring calls "industrial deafness".
Out of sight and out of mind. It's always somebody else's problem.
The current approach is all about piecemeal funding and programs, and pacifying words.
What is missing, though, is the necessary level of funding or commitment to stop the deaths and relieve the suffering of Aboriginal communities as a matter of urgency.
I'll say it again - the state of indigenous health in this country in the 21st century is a national disgrace and an international shame.
I have seen it first hand, and I will be making a return visit to the Top End later this year.
I have had the privilege of visiting a number of remote Aboriginal communities and have seen the lack of basic services that other Australians take for granted.
If you visit these communities, don't expect clean drinking water everywhere you go.
Or hot and cold running water, for that matter. Not there.
Proper sewerage and sanitation? No.
Or basic housing? No again.
As for around-the-clock medical services, you're dreamin'!
When you consider the plight of Aboriginal Medical Services in urban areas, you will appreciate that the health needs are not confined to remote areas.
The AMA Report Card I mentioned earlier shows that, overall, precious little progress has been made in improving the health of Aboriginal and Torres Strait Islander people.
Their health continues to be the worst of any population group in Australia.
There are stark and continuing differences in infant mortality rates - three times the national rate.
Indigenous mothers have twice the number of low birth weight babies.
Life expectancy and death rates are sad reading when compared to other Australians.
At birth, in 1999, a non-indigenous Australian could look forward to a life 20 years longer than an indigenous Australian.
I'm no statistician, but 20 years - the gap in life expectancy - is almost a lifetime in itself.
In terms of the major causes of death, Indigenous Australians die of the same major causes - cardiovascular diseases, respiratory diseases, cancer, and endocrine diseases such as diabetes - but they die in greater numbers and at younger ages.
They also suffer from conditions such as endemic skin infections, trachoma and rheumatic fever - conditions usually more typical of underdeveloped countries.
The rate of hospital admission is about twice the rate of the non-Indigenous population - reflecting a greater disease burden and a lack of access to primary health care.
For dialysis, the rates for 1998/9 were 7-11 times higher.
When I was in Bidyadanga in the Kimberley just a couple of years ago, they had a dialysis room but they couldn't use it because they had no electricity.
They had a generator but it couldn't be commissioned because it needed to be housed in a shed to protect it from the weather.
But the shed cost $5000 to build and the community didn't have the money - so they had no dialysis.
So people with kidney failure had to move from their home community to Perth - all for the want of a tin shed.
Such figures and anecdotes highlight the continuing lack of life opportunities - let alone quality of life - for Indigenous Australians as opposed to the population overall.
The health differentials have been around for so long that a mythology has been established - a mythology that it is all just too hard.
Another mythology is that indigenous health is already inundated with money, and to spend more is to throw good money after bad.
The tooth fairy has more credibility than that claim.
If you look at the international situation, however, you get a different picture about what is possible and what has to be done.
The United States, Canada, and New Zealand have been able to narrow the health differentials between their Indigenous and non-Indigenous populations.
For example, they have narrowed the difference in life expectancy between indigenous and non-indigenous populations to between 5 and 7 years, rather than 20.
In Australia, the infant mortality rate - that is, the number children dying before their first birthday - dropped significantly in the 1970s.
But for indigenous Australians the rate has remained about two-and-a-half times that of the total population.
By comparison, in New Zealand, the Maori population had an infant mortality rate of 7 per 1000 live births in 1998 compared with 5 per 1000 for the total population.
In the United States, the indigenous populations have an infant mortality rate of 9 compared with 7 for the total population.
So progress is achievable.
There is no excuse for Australia to continue to lag behind the achievements of similar civilised societies.
What has led to these improvements internationally?
A few obvious things spring to mind:
Improvements in environmental and public health measures
Initiatives relating to social justice, and
The adequately funded provision of primary health care.
But what has Australia achieved in these areas?
Our Report Card indicates that there are major and continuing problems in access to primary health care.
Not only has there been little evidence of overall improvement in recent years, it's worse. The evidence actually shows that access has declined.
In the 2001 Community Housing and Infrastructure Needs Survey, fewer communities surveyed had daily access to a female Aboriginal Health Worker compared to 1999 - down from 60 per cent to 52 per cent in two years.
Fewer of these communities had daily access to a doctor compared to 1999 - down from 11 per cent to 9 per cent.
Where there is culturally appropriate and adequately supported primary health care, preventive care and early intervention is possible rather than health care workers just trying to pick up the pieces and patch up disasters.
In many cases, this will inevitably mean less need for later hospital admission.
Access to these vital basic services should be a right for all citizens in a modern egalitarian society - but it's simply not there for many indigenous Australians.
Let us now have a look at public health and community facilities. Are things better there?
The Community Housing and Infrastructure Needs Survey collected data on the provision of clean water, electricity and sewerage systems.
Overall, the numbers of communities without clean water, sanitation, electricity and sewerage have decreased. That's the good news.
Clearly there have been improvements and ATSIC should be commended for its role in bringing these about.
But the bad news is that there are still significant and unacceptable gaps in these essential services - services that the rest of the community quite rightly takes for granted.
Long hot showers, clean toilets and endless fresh water are not the order of the day in remote indigenous communities.
There is also the issue of maintenance of facilities.
It is not much use installing a generator if it does not work.
A sewerage system that constantly overflows is not a community asset.
New housing that does not meet cultural or environmental needs will not fix the housing problem.
Partnership and planning and mutual understanding will help eliminate problems and waste.
And this applies to the provision of health and medical services, too.
To what extent has the government shown the necessary financial commitment to restore equity in health service provision?
The AMA Report Card shows that the overall funding of all health programs for Aboriginal and Torres Strait Islander people shows a real increase of 15% between 1995/6 and 1998/9.
This increase is welcome but still falls well short of the level required to fund indigenous health services on a needs basis.
A couple of years ago, Professor John Deeble estimated that, if health services for Aboriginal and Torres Strait Islander communities are to meet real needs, two dollars should be spent on an indigenous person for every one dollar spent on a non-indigenous person.
That's not happening - far from it - but it should be.
Even then, I doubt if we'd see equality in health outcomes for some time.
Professor Deeble estimated that the amount required was an additional $245 million per year over 1995/6 funding levels. Several years down the track, even that increase would be insufficient.
The sad reality is that nothing remotely like this level of funding has been made available. We are still working with crumbs from the table.
What about funding for primary health care?
Aboriginal Community Controlled health services provide a model of community based and accessible health care throughout Australia.
They show how a community can shape its own health care and take responsibility for its own health.
There was an increase in Government funding to Aboriginal Community Controlled Health Services from 1996/7 to 1998/99 from $90 million to $136 million after which the funding plateaued.
Against this backdrop, the AMA Report Card shows a significant increase of almost 40% in episodes of care delivered by these services between 1997 and 2000.
Aboriginal Community Controlled Health Services need a dramatic increase in funding and resources if they are to continue their important work at levels necessary to meet the need.
The Commonwealth Government has introduced a new Primary Health Care Access Program in acknowledgement of the key role to be played by community based health care.
This is promising and welcome.
But you can't hope to have a successful Primary Health Care strategy unless you have a skilled healthcare workforce at the coalface.
A recent consultants' report to OATSIH conservatively estimated that a 59% increase in the number of doctors is required along with a 24.3% increase in the numbers of nurses.
More Aboriginal and Torres Strait Islander people must become involved in the health workforce, and we must do all that we can to encourage them to get involved with training and education.
A government workforce strategy recently became available after extensive consultation.
However, the strategy is yet to offer new funding or specific targets and timeframes.
There is no National Training Plan included, for example, to train the health personnel required.
There is a new draft National Strategic Framework for Aboriginal and Torres Strait Islander Health.
It has been produced with the assistance of the National Aboriginal and Torres Strait Islander Health Council and is awaiting sign-off by all Health Ministers.
Again, extensive consultation has occurred.
Again, the rhetoric is strong and the words promise much.
But again there is no new funding program to enable the promises to be delivered.
While it is appropriate for States and Territories to be able to set their own targets, I maintain it is possible to specify overall targets for the whole of Australia or for the specific target outcomes.
It has to happen.
At the moment the rhetoric is empty without funding and commitment.
While I have focused on health so far today, I am equally concerned about education.
They are linked. If you improve one, you improve the other. Better education leads to better health. And if you are healthier, learning comes easier.
On the other hand, if education standards fall so do health outcomes. And if you are sick, learning is harder.
Health impairments in children impair their ability to attend school and to learn.
There is evidence that there has been some improvement in educational outcomes for Aboriginal and Torres Strait Islander children - in particular in improving the overall attainment of reading benchmarks and in school retention until year 12.
But it is an uneven achievement. There is evidence that in rural and remote areas educational outcomes are actually worsening.
It is essential that culturally and linguistically appropriate education is provided to all Indigenous Australian children.
Education needs to continue into adult life so that opportunity in the workforce is opened up for all Australians.
This applies also to the provision of a suitably equipped health workforce, which includes a significant number of Aboriginal and Torres Strait Islander people.
So where does a treaty fit into this argument?
The recently tabled report - Social Justice 2001 - raises serious concerns about Australia's progress in achieving the effective exercise of indigenous rights.
It is an anomaly that Australia does not have a treaty. It is the only Commonwealth country colonised by the British that does not have one in some form.
It is an anomaly that has left the rights and obligations of Australia's indigenous peoples unclear.
It has led to an historical legacy of unfinished business so that issues such as indigenous health have no framework for progress.
It is crucial to have an agreed way to approach and resolve issues that affect and involve indigenous Australians - a way that is understood by politicians and Aboriginal and Torres Strait Islanders and the general public.
We need a way that inspires unity, not divisiveness.
A treaty, like any contract between parties, imposes responsibility on both sides.
Both sides must be accountable…obligations are two-way.
The contribution that a treaty can make is to acknowledge the past, to build a greater sense of justice in indigenous communities, and to promote a greater understanding in the general community.
On the other hand, it is up to indigenous communities and leaders to suggest the ways in which they might most productively tackle problems such as violent behavior, alcohol and substance abuse, as well as arrange of public health measures at a local level.
It is important that indigenous communities have the means to be able to set up meaningful sustainable business and employment opportunities.
Results must be documented.
Benchmarks must be set.
There is no point in signing a treaty, celebrating it, then consigning it to a museum. Both sides must commit to fulfilling it in good faith.
Treaties are not, of course, a panacea - they have not automatically led to improvements in any simple or direct way overnight.
Treaties can be negotiated on terms that are fair or unfair.
They have not always been honoured, especially in their entirety.
And the meaning of the Crown's treaty obligations has been the subject of debate in countries such as New Zealand and Canada.
Treaties have typically dealt with rights to land both by the Crown and the indigenous people, as well as the rights of Indigenous peoples to payments, goods and services.
Mostly the goods and services listed in the treaties did not specifically include health services.
An exception is Treaty 6 in Canada. Here the goods and services appear to include health. In the language of the time, there is direction for the provision of a "medicine chest" for the use of Indian peoples.
The treaties did, however, establish a special fiduciary relationship between the indigenous peoples and their Federal governments, which has influenced the provision of health services.
In New Zealand, the Treaty of Waitangi has been incorporated into New Zealand law and all executive proposals for legislation have to report on consistency with Treaty principles.
It now provides a legal and ethical framework for more specific proposals on services.
Professor Kunitz, from the University of Rochester in New York, argues that this relationship with Federal governments, as distinct to State or Provincial governments, has been particularly important in ensuring better health service provision for Indigenous populations.
In the US, the provision of the Indian health service has been the only universal Federal health service established.
Professor Kunitz also argues that the treaties have been successful in establishing an initial framework in which further progress could be achieved.
In the last 30 years, treaties have received new attention.
In NZ, the Waitangi Tribunal was re-established in 1975 to deal with claims under the Treaty and to resolve treaty breaches.
In Canada, in 1982, the Canadian constitution was amended to recognise the principle of indigenous self-determination as well as the Treaties.
Their original Treaties have been renegotiated and new treaties negotiated.
Negotiations have been under way with more than half of all First Nation and Inuit communities.
Final agreements that are particularly noteworthy and with implications for health services are those with the Nisga'a in British Columbia and with the Inuit.
In such cases, there are clear budgetary programs and mechanisms for accountability.
The new round of negotiation has provided the opportunity for greater self-governance by indigenous populations in Canada over their affairs.
The Canadian government notes that by this process (it) is "seeking ways to help First Nations people address their own issues of social and economic development, governance and justice, and education and health by honouring the historic treaties and creating new ones".
It is seeking to support the ability of indigenous communities "to promote their aspirations within the framework of Canadian institutions".
It considers that treaties "have stood the test of time".
Treaties have two levels at which they operate - the symbolic and the practical.
Both are important.
It is my hope that by acknowledging the past and acknowledging the status of Indigenous peoples as First Nations - with specific rights arising from that status - we will enable communities to gain the confidence and the means to move forward and contribute fully to their future.
They will have further impetus - a cultural impetus -to take up their obligations and responsibilities to their own communities and to the broader Australian community.
As the Health is Life report points out, "concluding a meaningful reconciliation with Indigenous Australians is likely to contribute to a longer term improvement in their health and welfare".
I'd say that outcome is in the best interests of all Australians.
Communities must have the basis and the means to overcome the despair that underlies the health statistics.
The Canadian Medical Association has linked the transfer of control of political power, resources and lands in Canada, and the accompanying control by Aboriginal peoples of health and social service to the potential for better health.
But we need to ensure improvements are consistent in terms of quality and pace of change.
The Canadian Medical Association warns that "although for some segments this is far advanced and showing results of improved health, for others…the progress has been slow - to the detriment of their health".
In practical health terms, a treaty or treaties between Australia's Indigenous communities and governments has the potential to ensure that the Federal Government makes the deep commitment to equity that is required to make a difference.
The commitment - the humanitarianism - must come from the top.
I note that the Central Australian Aboriginal Congress has stressed that a treaty has the potential to strengthen Aboriginal peoples' access to, and control over, health services and their delivery.
The Congress has called for a treaty to guarantee health services as part of citizenship rights.
I fully support this.
It is critically important that we are able to go beyond the good intentions and rhetoric that has appeared in so many government reports and embrace commitment and action.
Such action must be backed by adequate funding and tied to achieving specified outcomes in defined periods of time.
Canada, New Zealand and the United States have shown it can work.
Ring and Firman have noted that "treaties, no matter how loosely worded, have appeared to play a significant and useful role in the development of health services and in social and economic issues, for the Indigenous people of New Zealand, the United States and Canada".
Given our history of failing to achieve the progress that has occurred elsewhere, I do not believe that we can afford to overlook the negotiation of a treaty as a way of breaking the current impasse.
I commend ATSIC for its work in this regard in carrying forward the consultations with Aboriginal and Torres Strait Islander communities.
There will be fears and concerns that the process of discussing this issue or negotiating a treaty or compact will be divisive.
However, as has been noted by many commentators, a treaty can only include what is agreed by both parties.
In addition, as the UN Special Rapporteur on Treaties has noted, the process has much to offer such as:
The creation of new juridical standards negotiated and approved by all parties
The building of mutual trust based on good faith
Mutual understanding of the other party's vital interests, and
A deep commitment from all to respect the eventual results of the negotiations.
The aspirations of Aboriginal and Torres Strait Islander peoples can no longer be ignored.
It is their right as citizens to have the opportunities that exist for other Australians.
The right to equity of opportunity for health, education and social justice is fundamental.
Puggy Hunter, when telling me the story of a close relative of his who had died at the relatively early age of 51, said to me: "Too many funerals".
Puggy himself died a year later, younger still.
His life's work lives on.
Let's not leave this historical decision to the next Government or the Government after that.
Let's not leave this historical decision to the next generation or the generation after that.
We can do the right thing. We can make a difference.
Let's put a treaty back on the agenda.