The World Health Organization has directed nations to prepare for a future influenza pandemic. While many countries have developed comprehensive plans, the needs of marginalized communities have often been neglected. In recognition of these weaknesses in current planning practice we strongly support the call that 'the time is now' for genuine and respectful partnerships to redress yet another omission for Indigenous people1,2.
Pandemic plans emphasise non-pharmaceutical containment measures, including early recognition and isolation of suspected cases, quarantining of contacts, and social distancing. Although the Australian plan recognizes the increased risk for Indigenous people, it does not acknowledge that Indigenous Australians must inform containment strategies if these are to be appropriate and effective for all Australians3. A review of 37 national pandemic plans found that plans, including the Australian plan, inadequately addressed the needs of socially and economically disadvantaged communities in their disease containment policies4.
Indigenous Australians, particularly in rural and remote areas, experience profound social disparity, including overcrowding, excess co-morbidity, poor access to health care, communication difficulties with health professionals, reduced access to pharmaceuticals, and institutionalized racism5. History clearly demonstrates the devastating toll of previous influenza pandemics on Indigenous Australians. During the 1918-1919 pandemic, mortality rates approaching 50% were reported in some Australian Indigenous communities, compared with the national rate of 0.3%6. The leprosy control program used in Aboriginal communities in the past included isolation, incarceration and other punitive measures that caused much fear. The fear drove people into hiding and increased the disease risk for families and communities7.
In order to avoid further marginalization, stigmatization and inequality, we must ensure that the call to 'close the gap' does not become another shallow slogan1. Decisions on appropriate pandemic containment measures need to be made in genuine partnership with communities, recognizing that some cultural practices may amplify or reduce infection risk8.
During a recent focus group discussion with Indigenous people from Aboriginal medical services and Aboriginal health services in a rural area of Australia, concerns were raised about the currently recommended pandemic social distancing and other infection control strategies. Many of these concerns were associated with individual and group memories of intrusive government surveillance and control of Indigenous people in the past. These memories impacted on people's responses to contemporary government policy. Planned policies to control and contain outbreaks may meet with the same passive and active resistance that past government policies provoked9.
Public health experts must work with communities in genuine and respectful partnership to define what pandemic containment measures are culturally appropriate and acceptable. The basis of genuine and respectful partnerships is captured in the human rights approach, which demands that individuals and communities are adequately involved in the decisions that affect their wellbeing. These are essential first steps10. History has shown that Indigenous Australians must be involved in decision-making processes that impact on their health in order to link genuine and respectful partnerships to aspirations for self-determination of Indigenous communities and organisations. The consequences of inflexibly enforcing a non-Indigenous model of containment will be dire.
Peter Massey1, GCPH
Adrian Miller2, MPH
David Durheim3, dRPH
Richard Speare2, PhD
Sherry Saggers4, PhD
Keith Eastwood3, MAE
1Hunter New England Area Health, Tamworth, NSW
2School of Public Health, Tropical Medicine and Rehabilitation Sciences,
James Cook University, Townsville, QLD, Australia
3Hunter New England Area Health, Wallsend, NSW, Australia
4National Drug Research Institute,
Curtin University, Perth, WA, Australia
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2. Huppatz C. 'Sorry' - in word and actions. Improving health in rural and remote Indigenous communities. Rural & Remote Health 8: 876. (Online) 2008. Available: www.rrh.org.au (Accessed 23 March 2009).
3. Commonwealth of Australia. Australian management plan for pandemic influenza, 2008. Canberra, ACT: AGPS, 2008.
4. Uscher-Pines L, Duggan P, Garoon JP, Karron RA, Faden RR. Planning for an influenza pandemic, social Justice and disadvantaged groups. The Hastings Center Report 2007; 37(4). Available: http://www.thehastingscenter.org/Publications/HCR/Default.aspx?id=752 (Accessed 23 March 2009).
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7. Parry S. Of Vital Importance to the Community': The control of leprosy in the Northern Territory. Health & History 2003; 5(1): 1-21.
8. Maher P. A review of 'traditional' Aboriginal health beliefs. Australian Journal of Rural Health 1999; 7: 229-236.
9. Broome R. Aboriginal Australians: Black responses to white domination 1788-2001. Sydney: Allen & Unwin, 1982.
10. Jackson Pulver LR, Fitzpatrick SA. Beyond sorry - the first steps in laying claim to a future that embraces all Australians. Medical Journal of Australia 2008; 188: 556-558.