First Nations peoples leading the way in COVID‐19 pandemic planning, response and management

Engaging First Nations peoples in public health emergencies is critical to reducing health inequities

Aboriginal and Torres Strait Islander (respectfully hereafter First Nations) peoples of Australia have experienced poorer health outcomes than the rest of the Australian population during recent pandemics.1,2 In 2009, during the H1N1 influenza pandemic, diagnosis rates, hospitalisations and intensive care unit admissions occurred at five, eight and three times, respectively, the rates recorded among non‐Indigenous people.1,2,3

The vulnerability of First Nations peoples to coronavirus disease 2019 (COVID‐19) is well understood by community leaders and non‐Aboriginal policy makers and clinicians alike. The risks for First Nations peoples from COVID‐19 taking hold are immense — the oldest continuous culture on the planet is at risk. This is because of all of the following interrelated factors: an already high burden of chronic diseases; longstanding inequity related to service provision and access to health care, especially because 20% of First Nations peoples live in remote and very remote areas; and pervasive social and economic disadvantage in areas such as housing, education and employment. Moreover, many of the interventions put in place to curb the spread of COVID‐19 are counter cultural or difficult to implement because of crowded housing and extended family groups living together. This means interruption of cultural life in order to be consistent with new social isolation concepts.

Using lessons learnt from the 2009 H1N1 influenza pandemic, First Nations clinicians, public health practitioners and researchers are strategically leading the way in public health planning, response and management for COVID‐19 alongside our non‐Indigenous dedicated allies.

The omission of First Nations peoples from the 2009 National Action Plan for Human Influenza Pandemic4,5 not only disadvantaged those who most needed protection but failed to identify First Nations peoples as being a high risk population group. Research following the 2009 pandemic found that a one‐size‐fits‐all approach to infectious disease emergencies is unlikely to work — partnerships between communities and government agencies for the management of public health emergencies could be improved,6,7 and future pandemics should ensure that First Nations peoples are appropriately engaged as active and equal participants in pandemic preparedness, response, recovery and evaluation.6,8 During the early days of the COVID‐19 pandemic, we as a community have proactively proceeded to ensure that this occurs.

Recognising that public health measures, containment strategies and risk communication often do not consider the socio‐economic, historical or cultural context of First Nations peoples, it is appropriate that First Nations peoples lead the way in pandemic planning. Pandemic plans developed and implemented with First Nations peoples leading will likely mitigate risks and avoid the oversights of the 2009 response.

On 6 March 2020, the Australian Government Department of Health convened the Aboriginal and Torres Strait Islander Advisory Group on COVID‐19 to provide advice on preparedness, response and recovery planning. The Advisory Group works on principles of shared decision making, power sharing, two‐way communication, self‐determination, leadership and empowerment. The Advisory Group is co‐chaired by the National Aboriginal Community Controlled Health Organisation with the Department of Health and includes membership from the Aboriginal Community Controlled Organisation sector, state and territory government representatives, and First Nations communicable disease experts.9 The Advisory Group links to the Communicable Diseases Network Australia and reports to the Australian Health Protection Principal Committee.

The brief is to ensure that all stages of the pandemic are considered with an equity lens and are proportional to the risk of disease in communities; to discuss and work through logistic issues related to the pandemic, especially in planning phases; and to ensure that these actions are locally led, holistic and culturally safe for communities. The group initially met three times per week and currently meets twice weekly via video or teleconference.

The Advisory Group has provided strategic input into the development of the national management and operational plans for Aboriginal and Torres Strait Islander populations,10 and has significantly contributed to the series of national COVID‐19 guidelines.11 To prepare communities for COVID‐19, Advisory Group actions and advocacy have included:

• Legislative changes: Strong advocacy and input to government has minimised non‐essential travel by visitors to remote communities.12 The enactment of the Biosecurity Act 2015 (Cth) has enabled placement of restrictions on state and territory as well as national borders. In addition, many Aboriginal Land Councils have closed access and refused to issue new permits for visitors to communities within their remit.
• Development of national guidelines on COVID‐19: National guidelines are being developed to ensure that Aboriginal and Torres Strait Islander peoples are accorded priority in the national response.11 Separate guidance focused on remote communities has also been developed, addressing circumstances and logistic challenges in these areas, such as medical evacuation, community‐wide screening, limited isolation and quarantine spaces if initial COVID‐19 cases are detected in this setting.
• Health services planning: Almost all communities with significant First Nations populations have been in preparedness mode and have enacted local action plans to respond to COVID‐19. In many cases, this has extended beyond the development of a local plan and has included initiatives such as reconfiguring clinics to facilitate testing, isolation of suspected cases, and preparing staff in infectious disease training relevant to COVID‐19. The Commonwealth Government has expanded telehealth services (phone and video‐based calls with health providers), ensuring that people with chronic disease and other health conditions can receive consultations.
• Establishing rapid testing in remote communities: The Advisory Group is working with the Kirby Institute to rapidly establish increased COVID‐19 testing capacity in communities across Australia using point‐of‐care platforms (nucleic acid amplification testing) that provide a result within 45 minutes from a nasopharyngeal swab. Overall, 85 rapid testing platforms will be placed in remote and regional settings, using a hub‐and‐spoke model. Trained existing health care workers in communities will be provided with online training in the use of the platforms. This strategy will greatly enhance the ability to rapidly provide test results, reducing times from between 3–10 days to within a few hours for most communities across Australia. This strategy will enable contacts to be tested early and ensure that local action plans and strategies are enacted to minimise community transmission.
• Infrastructure planning: Many communities have planned additional spaces for isolation and quarantine in the advent of an outbreak in communities, which is especially challenging in the context of already overcrowded housing. In some cases, the minerals and exploration industry has offered communities unused accommodation and facilities during the COVID‐19 period.
• Expanding testing sites: The Commonwealth Department of Health has facilitated the opening of general practitioner‐led respiratory clinics, including some in Aboriginal community controlled health services.
• Workforce planning: There is much ongoing discussion about the need to protect and maintain workforces in Aboriginal health care settings. Much of remote Australia is reliant on locum staff who will require quarantining before starting clinical activities within communities, but this places additional strain on existing workforce capacity. Recent outbreaks among health care workers in remote Australia highlight the vulnerability of remote community populations.
• Health promotion materials: Targeted communication resources for First Nations peoples have been developed.13 Health organisations have stepped up and developed local resources appropriate for their own community populations. Many of these can be found on the National Aboriginal Community Controlled Health Organisation website (https://www.naccho.org.au/). Other organisations have also created health education materials to help inform and educate their community populations. In many cases, development of culturally specific resources has been conducted by Aboriginal health workers and practitioners.
• Epidemiological tracking of COVID‐19: Work has commenced to ensure accurate and timely surveillance of cases among First Nations peoples. This will enable responses to be actioned swiftly and prevent loss of precious time in an outbreak situation.
• Infectious disease modelling to help inform approaches: Mathematical models are being used to investigate the best approaches to use in communities once cases are identified. Additional social distancing, isolation, quarantine measures, contact tracing, and testing strategies are currently being developed to inform responses.
• Advocacy: Significant advocacy across all levels of the response continue, such as the ongoing need for adequate supply of personal protective equipment for the Aboriginal community controlled health services sector, quarantine measures and testing guidelines.

Pandemics are a serious public health risk for First Nations communities here and globally. Measures to reduce COVID‐19 risk have been addressed swiftly, based on lessons learnt from the 2009 H1N1 influenza pandemic response. The involvement of communities has been fundamental to early change and action. Making space for First Nations peoples to define the issues, determine the priorities and suggest solutions for culturally informed strategies that address local community needs may reduce health inequities and has the potential to influence system changes. Privileging First Nations voices, within a culturally appropriate governance structure, to develop and implement planning, response and management protocols, can make a real difference. The model has the potential to be replicated where public health agencies and First Nations practitioners and researchers have developed shared understanding. Only time will tell now how we will fare over the coming months.