Town or country: which is best for Australia’s Indigenous peoples?

There has been recent media publicity about the social and health problems in remote Indigenous communities. Some commentators, especially from the Centre for Independent Studies (CIS) and the Bennelong Society (which advocate a free-market approach to Indigenous policy), have suggested that current problems are due to flawed “socialist” policies, which have confined Indigenous people to remote communities where their opportunity to benefit from the mainstream economy has been denied.1,2

Many assertions emanating from these organisations are reflected in recent government policy statements.3,4 For example, the former Federal Minister for Indigenous Affairs in the current government, Amanda Vanstone, referred to remote communities as “cultural museums” and foreshadowed the cessation of funding to small communities that are not “economically viable”.3 Already, cut-backs to the Community Development Employment Program (a well-established Indigenous work-for-the-dole program) and the removal of the Remote Areas Exemption are driving many Indigenous people from remote communities to urban areas.5

The 2006 annual Bennelong Society conference theme was “leaving remote communities”. According to society president Gary Johns, “Aborigines living in remote locations are worse off than their compatriots in town”1 and should be encouraged to leave in search of better opportunities:

To support these proposals, Johns and others suggest that the averaged-out health statistics hide a major differential in the health of remote and urban Indigenous people. If Indigenous people relocated to urban areas, they argue, then health outcomes would improve. Recently, Hughes and Warin from the CIS stated that “the gap of 18 years in life expectancy is an average for Aborigines and Torres Strait Islanders and so underestimates the seriousness of ill-health in remote communities”.2

In referring to the “Coombs experiment”, Hughes and Warin imply that Indigenous people living in remote communities are victims of an experiment led by the respected economist “Nugget” Coombs. As an advisor to successive Prime Ministers, Coombs was an advocate and supporter of land rights and the homelands movement, but not the architect.6 Implying that he was denies the agency of Indigenous people who have struggled for land rights and choose to live on their traditional lands. The suggestion that health data from remote Australia are becoming less available is not correct: data collection has improved recently.7 In fact, because of greater difficulty in Indigenous ascertainment in urban areas, data from remote areas are more reliable.8 Although the data on urban–remote mortality and morbidity rate differences are limited, there is sufficient and increasing evidence to show that the situation is more complex than Hughes and Warin suggest.

It is true that, as with non-Indigenous mortality, Indigenous mortality rates appear to be higher in rural and remote areas than in urban areas, although problems of data quality mean that reported rates should be treated with caution.8 Death rates for the total Australian population show a gradient from lower rates in the major cities to higher rates in very remote areas. Indigenous death rates are substantially higher than non-Indigenous rates in all areas. However, they do not show the same continuous gradient: the death rate for Indigenous people in the inner regional areas is lower than in the major cities, and this rate increases over the outer regional and remote areas, then declines in very remote areas (Box).9

Thus, there are anomalies at both ends of the curve. Compared with the total Australian population, Indigenous people living in major cities appear to be exposed to factors that adversely affect life expectancy, and there appear to be factors predisposing to better life expectancy in very remote areas. There is evidence to support this latter observation.10,11

The Western Australian Aboriginal Child Health Survey yielded significant information on morbidity across different regions. For example, asthma prevalence in Aboriginal children was higher in urban areas, and recurrent ear infections were more common in remote areas.12 The proportions of Aboriginal mothers who smoked or drank alcohol during pregnancy were uniform across the urban–remote continuum, but use of marijuana during pregnancy was higher in urban areas.12 For both male and female children, the risk of emotional or behavioural difficulties was highest in the Perth metropolitan area, declining as remoteness increased.13

Although there are potential problems and biases with self-reported health status,14 the 2004–05 National Aboriginal and Torres Strait Islander Health Survey also suggested a more complex picture than that suggested by Hughes and Warin. Urban Indigenous people were slightly more likely to have excellent or very good self-reported health status than remote Indigenous people, but were also more likely to report fair or poor health status. This is similar to the result in 2001. More urban people reported arthritis, back problems, asthma or eyesight problems, whereas more remote people reported heart problems or kidney disease. Rates of self-reported diabetes, smoking and excessive alcohol consumption were not significantly different across locations.15

Hospitalisation rates appear to be higher in rural and remote areas compared with urban areas.15,16 However, it is difficult to draw conclusions from this trend, because Indigenous people in remote areas may be more likely to be hospitalised than those in urban areas with similar health conditions, as there may be concerns about adequate follow-up, and there may be less pressure on beds in rural hospitals.

Although disease patterns and risk factors may differ in different environments, overall Indigenous morbidity from all causes appears to be similar across the urban–remote continuum. There is certainly little evidence that the problem of Indigenous health is because a large proportion of the Indigenous population currently resides in remote communities. Even if there were such evidence, it does not follow that moving people from remote to urban areas would improve their health.

Social and health problems exist in remote Indigenous communities, but are not confined to remote communities. There are many benefits, including health benefits, available to Indigenous people who live on their traditional land.17 What is needed is more support for programs to improve the health and wellbeing of all Indigenous people, wherever they choose to live.

Indigenous and non-Indigenous death rates* in different geographical localities9

* Deaths per 100 000 population. ARIA = Accessibility/Remoteness Index of Australia. Adapted with permission from the Public Health Information Development Unit, University of Adelaide.