Pub: Sydney Morning Herald
Subsection: The Essay
A shamed nation turns a blind eye
Why is Australia the only place on the planet where indigenous health and wellbeing are going backwards?
TRACHOMA is a disease that starts as conjunctivitis but gradually, with repeated infection, turns the eyelashes inwards so that they scrape the cornea, scarring it, rendering it opaque, causing blindness. As it is easily treated with antibiotics, trachoma is regarded as a disease of poverty and is now unknown in developed countries – except Australia.
Even in the developing world – in Gambia, Malawi and Nepal, where it was once endemic – trachoma and trichiasis (the eye-scraping stage) have all but disappeared. Ghana, Mexico, Saudi Arabia, Iran, Morocco and Oman all now report the disease eliminated. In Australia’s chattering fringes it is also unknown.
But in Katherine, almost a quarter of the children aged five to 15 test positive to trachoma. Without treatment, they’ll go blind. The official incidence in this country is 20,000 among children alone, and that’s just the ones we know about. In more remote areas, cases are often simply unrecorded.
How can this be? How in a nation where the rich and their physicians habitually rort the system to cheat Medicare out of exorbitant cosmetic procedures, in the very nation that produced and reveres Fred Hollows, can avoidable blindness still be rife? Why does the simple fact of it not embarrass us to the point of excruciation, as if it were our eyeballs being grated?
Well, perhaps it does. Perhaps we’re so embarrassed we can’t think about it. So embarrassed we’re happy for the Federal Government to toss yet another $58.3 million at the problem, as it did in February, and hope it’ll go away.
This is a strategy you might call voluntary avoidable blindness. It is abetted by our extraordinarily vivid concept of the continent as a vast, vacant interior ringed (or perhaps girt) by a fertile, febrile megalopolitan fringe where most of us live, deafened by our own frantic chatter.
But it’s a strategy that is unlikely to work. For it isn’t just trachoma, or even just health. It’s housing, hygiene, violence, infant mortality, substance abuse, sexual abuse, education, employment, home ownership, life expectancy, wealth and diet. Across all the parameters, even according to the official Council of Australian Governments report Overcoming Indigenous Disadvantage: Key Indicators 2009, things indigenous are stagnating or getting worse.
Australia is the only place on the planet where indigenous health and wellbeing are going backwards. And yet our attitudes, both to the interior and to what we can no longer bring ourselves to call the “Aboriginal problem” are the same; this thing is too big, too distant and too hard.
It’s hard because it is clear that money won’t do it, and yet money is far and away the best tool we have. Too hard because we feel we have tried everything – assimilation and segregation, missions and camps, paternalism and self-determination, integration, multiculturalism intervention and laissez-faire. Nothing seems to work. Whatever “work” means.
But what if it’s not all “our” fault? What if traditional Aboriginal culture, which we try so hard now to respect, is itself part of the problem? If 60,000 years of nomadic and semi-nomadic tradition have left residual habits that are, in the contemporary context, counterproductive? These are questions no one wants to ask, much less answer, but perhaps that very reluctance is our stumbling block.
Nicholas Rothwell’s book Another Country recognises the two Australias. In one Irrunytju community of 120 people in the Great Victorian Desert, he notes 20 with kidney failure, 26 with diabetes, 13 with hypertension, six with heart disease and 31 overweight. In a fringe Pitjantjara community, he recounts the nightly screaming and violence as teenage girls – “a different one each night” – were raped.
It’s not just outer versus inner, urban versus rural, fertile versus arid; it is also wealth versus poverty, service versus neglect and, let’s face it, white versus black. When you’re in the fertile fringes, it is easy to resent the way Australia is pilloried by the world. It’s not like we don’t try. But the fact remains: Australia is a First World country with a vast Third World country at its core.
Take housing. Housing is key because, as must always have been obvious, decent housing underpins health, health underpins education and education underpins everything.
In desert regions, just being able to wash faces helps reduce trachoma, while dealing properly with waste helps control the flies that spread it. Washing clothes and bedding, similarly, and reducing overcrowding helps control scabies, a parasitic mite strongly linked to the epidemic renal failure and rheumatic heart disease that is keeping indigenous life expectancy so terrifyingly low.
But ensuring decent housing – not beautiful or even bankable, just robust, functioning, habitable housing – in remote desert communities is a long way from just trucking in some kit sets and considering the problem solved.
Earlier this year, COAG signed the $6.2 billion National Affordable Housing Agreement. Of this, by far the largest part was the $5.5 billion allocated to indigenous housing. This, the Strategic Indigenous Housing and Infrastructure Program, or SIHIP, is not the only indigenous housing program in the country but it is the largest – ever. Hailed as “a new way of delivering housing in remote communities”, it is supposed to provide 4200 new houses and 4800 refurbishments over 10 years.
In fact, in 15 months it hasn’t delivered much at all, unless you count the limitless tangle of committees, reports, acronyms, consultancies, policies and, of course, white-collar whitefella jobs. Money has been spent but few houses produced, if any. The number may be none, as many commentators aver, or 102, which is the best gloss even the relevant minister, Jenny Macklin, can find for it. Either way, it’s pathetic. And the mere fact that it is virtually impossible to check these numbers is itself indicative of the problem.
Paul Pholeros is an architect specifically honoured for his 30 years’ work in indigenous housing. His firm, Health Habitat, set up in 1987 with the medic Paul Torzillo and the public health officer Stephan Rainow, does not build new houses but simply “fixes” ones that are not working. They have developed a testing kit that fits in a suitcase, a preferred list of robust, low-maintenance appliances and a standard set of tools, so that local people can be trained in the work. In the past decade they have fixed 6500 houses across remote Australia and a new two-year contract covers 600 more. So you’d have to say he’s across the issue.
Before the discussion even starts, Pholeros insists on dispelling three myths. Myth 1 is that the problem is too large, too hard; situation hopeless. “Of course it’s solvable. Like any problem, it’s solvable.” In evidence he offers Health Habitat’s track record, at an average expenditure of $7500 a house.
Myth 2 is the idea that the tenants are the issue. “The problem is not the people,” he says with a weary passion, as though he shouldn’t have to keep saying this but will, if that’s what it takes. “The problem is shitty housing.” Bad workmanship, faulty installation and inappropriate fittings – stoves, taps and plumbing selected for low capital cost but without regard to maintenance in a remote, low-service area.
Myth 3 is that “Aboriginal people won’t work”. This, says Pholeros, is nonsense. “Aboriginal and Islander people are enthusiastic improvers of their own housing.” Unlike the Strategic Indigenous Housing and Infrastructure Program, which promises 20 per cent Aboriginal employment but usually manages to find no skilled people on the ground, Health Habitat’s team-based workforce (of almost 1000 people last year) is 78 per cent local and indigenous, people employed as builders and planners, project managers, tradespeople, liaison and database operators.
This has been made possible by Health Habitat’s insistence on education; it trains people, then trains them to train others. This is essential to overcome one of the biggest obstacles to improvement, the sense of being preached at in your own home. “It’s just not possible,” says Pholeros, “for us to do it for them.”
Repeatedly, government efforts prove the most expensive and least effective. The Northern Territory intervention is an obvious example.
The “community clean-ups”, on which people were required to work for the dole (often, they say, without being paid), spent $80 million to inspect or fix an average of 0.9 items in each of 2900 houses, according to the Department of Families, Housing, Community Services and Indigenous Affairs website. Health Habitat, by contrast, under its Fixing Houses for Better Health project, spent $25 million to inspect or fix an average of 17.3 items in each of 5500 houses. This makes the intervention’s per-item expenditure $30,651, more than 100 times that of Health Habitat’s $267.
A similar story emerges from the Federal Government’s own recent review into why the Strategic Indigenous Housing and Infrastructure Program seems to be going nowhere fast. It cites construction packages for Groote Eylandt, the Tiwi Islands and Tennant Creek, where costs almost doubled from an anticipated $450,000 to $750,000 a house.
Why? Three reasons are given. One, “high-cost locations”. Two, a staggering 50 per cent of the community on Groote Eylandt is affected by the otherwise rare, degenerative spino-cerebellar ataxia known as Machado-Joseph syndrome, so wheelchair use is extraordinarily high. And, three, houses need to be bigger than normal to cope with large mobile family populations.
Like, come on. Was any of this unforeseeable? Where have these people been for the past 50 years, let alone the last two?
A Health Habitat study from 1987, the UPK Report, examined 12 houses, of which five had working fridges and three had working stoves. In 2005, says an Australian Bureau of Statistics report, 3500 indigenous households did not have washing facilities and 1900 did not have “working sewerage” – not even a septic tank or pit toilet (which people are reluctant to use anyway because of snakes).
The Northern Territory Opposition Country Liberal Party spokesman on regional development, Adam Giles, accuses the Government of having spent $100 million to build a mere 40 houses in Alice Springs. The ophthalmologist Hugh Taylor, the Harold Mitchell Chair in Indigenous Eye Health at the University of Melbourne and a former colleague of Fred Hollows, says that, in one community, houses were painted on the outside but left untouched within. He also says that intervention medical assessments left communities so resistant to further check-ups that many children missed out on the trachoma checks that they would normally have had. Much of the information gleaned, about building and health needs, was already known and should have been acted upon, rather than just “spinning the wheels”.
The forensic entomologist Ian Dadour, Winthrop Professor of Forensic Science at University of Western Australia, who has been pushing for years for approval to import dung beetles in a bid to help control trachoma, recalls an instance at a remote Aboriginal settlement 200 kilometres east of Kalgoorlie where taps had been installed but weren’t being used because no one knew how to turn them on.
Macklin says she has already taken action to keep “unit costs” to $450,000 a house (not including land). But for Pholeros, decades of government penny-pinching on capital costs are a large part of the problem; cheap, badly built houses and cheap appliances that are designed for a high-service urban environment and left in a remote desert. “The NT Government,” he says “wants to halve the cost of houses, so they can build twice as many. But if you build crap houses, they’ll all fail.”
Macklin also promises to reduce the program’s administrative costs, from 11.4 per cent to 8 per cent. Eight per cent of $5.5 billion is $440 million. That’s still an awful lot of paper shuffling.
So, what to do? There are glimmerings of hope, such as Melbourne University’s recently announced initiative (led by Hugh Taylor) to wipe out Australian trachoma within five years and World Vision’s recently announced home ownership program in Mapoon, on traditional Tjungundji land on Cape York, which is based on median house prices of $160,000, as opposed to the Government’s $450,000.
But, increasingly, it looks as though there are aspects of Aboriginal hunter-gatherer culture that need to change, in a kind of accelerated cultural evolution, if bronze-age habits are not to go on nurturing bronze-age diseases.
Stephanie Jarrett, whose PhD focused on Aboriginal domestic violence, recently told the Bennelong Society that violence, especially against and about women, was not only intrinsic to pre-contact Aboriginal culture but carried cultural significance in that context. Only through recognition of this fact, she argues, can it be changed.
Dadour says “the white politician gets off the plane and just sees mess and rubbish everywhere, and wants to tidy it up, throw money at it. But it can’t be fixed with money.”
Stephanie Smith, an architect who did her Masters’ dissertation on the town camp at Goodooga, agrees. “You need to keep your targets low; teach people how to make a mud brick, how to fix and modify their own houses.” Smith suggests a system of regional building centres that would send people out into communities to “plant the seed of knowledge”.
Pholeros says “whenever a government says what you’re doing is good, you can be sure it’s not”. He counts his biggest achievement as the production of the National Indigenous Housing Guide, a manual that should be parachuted across the outback but which he has to continually struggle to keep in print.
All agree on one thing. Governments are focusing on keeping control when they need to give it away. Not in the form of money but in a more valuable form, namely, education. For in the end, knowledge is power.
PHOTO: Illustration: Simon Letch, with apologies to Albert Namatjira