Rural health is never far from political controversy. Often an issue makes the headlines and there are feverish announcements and great promises about taking definitive action. Then a little time passes and the politicians involved come to the realisation that there is no 'quick fix' or 'single fix' for what are complex issues, and the will to maintain the passion for the issue fades as the story disappears from the front page of the newspapers. Recently, we have all witnessed an extraordinary response to the Little Children are Sacred1 report that documents the appalling conditions in which many Indigenous children in the Northern Territory are growing up. The report suggested an urgent but multifaceted long-term response to a very complex problem.
There is no issue in health care that is as emotionally charged as child abuse and neglect. In many ways there are parallels between the way the community recoils in horror at the magnitude of the problem of child abuse in this country, just as they do when the issues surrounding the inequalities in health care and outcomes that confront many Indigenous communities in Australia are publicised. One major parallel between child abuse and its sequelae, and Indigenous health issues, is that both these enormous problems in our society are, in the main, hidden away from mainstream society as not relevant in the day-to-day life of all Australians.
Child abuse has only been recently recognised as a problem, with the first reports of physical abuse of children appearing in the literature in the 1960s2. There may be those who claim that the problem of child abuse is only recent but I somehow doubt it. One could draw a parallel with Indigenous Australians only being granted the right to vote some 40 years ago3. This is an important time marker as to when the relative disadvantage of Indigenous Australians in our society became public knowledge. Over the last 40 years there has at least been some progress in documenting the size and impact of these two problems, but there is still much to be done about preventing both Indigenous inequalities and child abuse from continuing to be major issues for our society.
As a paediatrician I deal with the sequelae of child abuse and neglect every week. When you are training you learn only about the clinical signs that allow you to detect a suspected case of child abuse and neglect. Initially, I was under the misconception that this work was all about trying to prove who was guilty, and somehow feeling it was my role to be 'getting even' on the child's behalf - in this way making our society a more just place. It is now 18 years since I commenced work as a paediatric resident at the Royal Alexandria Hospital for Children, Sydney, when it was still located at Camperdown, and I saw my first baby with a fractured femur. I remember the feelings of anger that welled up within me as I tried to come to terms with a badly injured infant crying in severe pain that had been inflicted by inexperienced, financially disadvantaged, frightened and yet remorseful young parents.
A response fuelled by anger does no good in cases such as these. I have learnt that child protection work is not about 'getting even'. It is about trying to put back together the shattered pieces of a family that has reached the crisis point of an abused child finally being recognised as 'at risk'. This is an ongoing process, for these children and their families need to be supported and their needs met for years after the episode of abuse has been identified4. Recent research has shown that the majority of children who have been in and out of home care have significant mental health, developmental and learning difficulties5,6. These families need strategies put in place to prevent further children from being abused. And those who have been abused need access to treatment and remedial education to allow them to reach their potential.
In 90% of cases of substantiated child abuse the child remains within its family of origin. A 'police state' approach to child abuse does not improve the lot for children who grow up being abused. Health policy leaders in child abuse are now looking at ways of building and developing resilience in the critical early years of an abused child's development. This should be done by supporting children identified as being at risk and their families. Initiatives like 'Families First' that include home visiting programs for new mothers are now in place and will hopefully make an impact on the incidence of child abuse and neglect in the future7. This is a long-term investment strategy that eventually is massively more economical than investing in more police and more jails as a deterrent for child abuse. It does, however, require a far-sighted politician to invest $1 now to save $20 in two decades spent on the criminal justice system if we do not look after disadvantaged children today.
It is now some 2 months since the Little Children are Sacred Report was released with a great deal of surrounding political hype, calling for the need for an emergency government response. It is clear to all that this is a complex problem and that there is no 'quick fix' solution to the crisis. The focus of the response to date appears to have been a 'police state' approach. It doesn't appear to have focused on how to improve outcomes for child victims of abuse, nor on how to strengthen those families where child abuse has occurred, in order to prevent further cases of abuse.
It has been reported that 85% of notifications for suspected child abuse occur in non-Indigenous children in Australia8. The lessons that will be learned in trying to address the problems confronted by Indigenous abused children in the Northern Territory need to be applied to the rest of the 256 000 suspected episodes of child abuse that are notified nationally each year, and the 23 000 children who currently live in foster and out-of-home care in Australia. Certainly Indigenous children are over-represented in this group; however, it would be a great mistake to consider that the problems identified in the Little Children are Sacred report are specifically Indigenous, or rural - they are, sadly, a national problem that requires a sustained national response.
The Indigenous communities in the Northern Territory with all their associated problems, like the children in Australia who have been abused, need to be considered on the asset side of Australia's ledger of wealth. As a society we cannot be allowed to see these two groups as liabilities to be simply eradicated or hidden. We need to strengthen the weakest and most vulnerable links in Australian Society. If we simply remove them, shortly afterwards a new weakest link will be identified as suitable for removal.
The essence of our society's humanity is in how we care for one another, particularly those in need. As health professionals, teachers and academics we need to ensure that we continue to advocate for disadvantaged groups, such as the children referred to in the Little Children are Sacred report, so that the government response is more targeted towards improving, rather than removing, the problem.
Peter Dominic Jones
University Department of Rural Health & Rural Clinical School
Faculty of Health, University of Newcastle
New South Wales
1. Northern Territory Government of Australia. Inquiry into the Protection of Aboriginal Children from Sexual Abuse: Little Children are Sacred. (Online) 2007. Available: www.nt.gov.au/dcm/inquirysaac/ (Accessed 28 August 2007).
2. Kempe CH, Silverman F, Stelle BF, Droegemueller W, Silver HK. The battered-child syndrome. JAMA 1962; 181: 17-24.
3. Attwood B, Markus A. The 1967 referendum: race, power and the Australian Constitution, 2nd edn. Canberra, ACT: Aboriginal Studies Press, 2007.
4. Barber JG, Delfabro PH, Copper LL. The predictors of unsuccessful transition to foster care. The Journal of Child Psychology and Psychiatry and Allied Disciplines 2001; 42: 785-790.
5. Tarren-Sweeney M, Hazell P. Mental health of children in foster and kinship care in New South Wales, Australia. Journal of Paediatrics and Child Health 2006; 42: 89-97.
6. Jones PD, Psychiatric diagnoses in children in foster care in rural NSW. Journal of Paediatrics and Child Health 2005; 41: S9-10.
7. New South Wales Government. Families first. (Online) no date. Available: http://www.familiesfirst.nsw.gov.au/public/s26_homepage/default.aspx (Accessed 30 August 2007).
8. Australian Institute of Health and Welfare. Child protection in Australia 2004-2005. AIHW cat no 26; Child Welfare Series no 38. Canberra, ACT: AIHW, 2006.