The gap

By evaluating many of the issues facing Indigenous Australians in the healthcare system we can begin to identify some of the weaknesses as outlined in Part 1. Now we’ve got some sense of the issues, it’s time to start thinking about the possible interventions. ‘The gap’ is a complicated topic; the underlying causes span generations and there is no one simple solution. Keeping this in mind, integrating available evidence with clinical experience, I believe there needs to be a three-pronged approach:

1. Improved education for health professionals
2. Improved partnerships and relationships with Indigenous Australians
3. Increased Indigenous workforce

These issues are complex and there is no way that one article can comprehensively discuss all the possible strategies. Recognising this and reflecting on my personal experience, I will focus on improved education.

Health as defined by Indigenous people

The definition of health for Australia’s Indigenous people extends far beyond a state of no disease; it is holistic and involves social, cultural, emotional and spiritual wellbeing [1]. This does not fit into the neat box of biomedical science taught at medical school. For Indigenous people, it is not enough to simply lecture on the importance of medication or lifestyle modification. Healthcare needs to encompass the entirety of wellbeing, something that is impossible to accomplish without first understanding the context of Indigenous people. We must first appreciate the impact that colonisation and inter-generational trauma have on health and wellbeing. Without this appreciation, we cannot help promote positive change.

Indigenous health education needs to change to help close the gap

Indigenous health is a discipline lacking universally across the health field [2]. At the medical student level, it is limited in scope with content often being restricted to a handful of lectures and assignments or logbooks. Indigenous health has been included in the core curriculum mandated by the Australian Medical Council since 2006 [3], and prior to this, in 2004, the Medical Deans of Australia and New Zealand (MDANZ) suggested that Indigenous health be embedded in the central curriculum [3].

Indigenous health education should be taught from a strength-based model focusing on the positive aspects of Indigenous culture such as strength of community. Part of this includes a recognition of Indigenous practice and health prior to colonisation. An approach founded in the positive aspects of Indigenous health departs from the more common deficit model, which traditionally has focused on disparities [4]. Further, the abridged Indigenous health education that is included in medical school curricula often takes the form of a series of uninspiring lectures and superficial assignments.

My own mandatory experience extended to perhaps a few lectures filled with statistics and one assignment in my clinical years and I could probably count on one hand the number of peers who undertook Indigenous-focused placements. It was only during my elective placement in Alice Springs that I was first truly exposed to Indigenous health. I learned more about Indigenous health and Australia’s Indigenous people in those four weeks than I did during my entire medical degree. It was during those four weeks in Alice that I began to gain an understanding of the challenges facing Indigenous people – from the effects of widespread alcoholism and substance abuse to scabies, growth retardation and the impact of living remotely.

I got to experience first-hand all the things I had only read about but I also got to witness the resilience of Australia’s Indigenous people – an aspect that is almost never taught within the current teaching model.

Medical education on Aboriginal health

Although I can certainly advocate the benefits of clinical placements from personal experience, I acknowledge the challenges and disadvantages of increasing hands-on clinical placements for students. It would be logistically and financially impossible to allow the approximately 20,000 medical students across Australia to undertake a placement within appropriate settings. Further, forcing students who are under-prepared or have no strong interest in Aboriginal health or culture could cause additional damage by unintentional micro-aggressions and ‘symbolic violence’. There should be increased positive Indigenous health education in the earlier pre-clinical years of training to best prepare students and pique their interest. Following this, there should be more pastoral and financial support for those who do wish to undertake Indigenous health placements.

The issues facing Indigenous Australians are multifactorial and therefore require a multifaceted approach to interventions. Improving Indigenous Health education must be accompanied by improved partnerships and relationships as well as increasing the Indigenous workforce. There is a cycle of unengaging methods and low standards in Indigenous health education, perpetuating negative stereotypes and disinterest in medical students. Positive experiences beget positive outcomes, as is well established in rural clinical placements and interest in the rural workforce. My most positive Indigenous health teaching has come from Indigenous people, facilitated by the medical school. These types of relationships foster positive learning environments and maintain interest in Indigenous healthcare.

It is clear that there is no simple solution to closing the gap, but education of medical professionals is a key component of ameliorating disadvantage in this very multifaceted issue. For truly effective solutions we need initiatives that encompass a holistic approach.