Minding the gap: the dangers of deficit thinking

A relentless focus on poorer Indigenous health outcomes can obstruct efforts to improve them.

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Global protests have prompted introspection in Australia about systemic racial issues, including the disparity in Indigenous health outcomes. However, Indigenous health experts say that viewing the problem through a narrow lens of “deficit” isn’t helping.

In December 2007, a coalition of Indigenous and human rights organisations launched the Closing the Gap campaign, aimed at reducing the disparity in health outcomes between Indigenous and non-Indigenous Australians. The official 2020 campaign report released in February revealed that most of its targets remain unmet.

As the COVID-19 pandemic continues, known racial disparities in outcomes in the US and UK raise alarming questions about whether Indigenous and non-white Australians will be worse affected if infections surge again.

It’s certainly something the government is worried about, with the Health Department warning higher co-morbidities among Aboriginal and Torres Strait Islander populations could lead to disproportionate harm.

THE DEFICIT NARRATIVE

Todd Fernando, a lecturer in medical anthropology at the University of Melbourne and a descendant of the Kalarie people of the Wiradjuri nation, says the government’s assessment of Indigenous health ignores the ways in which Indigenous communities are working to improve their own wellbeing.

He says this way of thinking reinforces Indigenous health as a narrative of deficit and damage, which can contribute to misunderstandings within the health sector and paternalistic attitudes towards Indigenous people.

“A good example of that is around education,” he says. “We know better education leads to better health, and in 2016 the ABS released statistics around education rates and we saw, over a five-year period, a 10% increase in graduation rates.

“That is incredibly important for Indigenous people, considering we’re such a young population.” (The median age is around 23, compared with 38 in the population overall).

Another example of Indigenous-driven wellbeing reform can be found in a recent report in the MJA showing how First Nations people have led the way in COVID-19 planning for their communities. This includes instituting expanded testing, legislation for non-essential travel limitations in Aboriginal and Torres Strait Islander communities, training and expansion in telehealth, and close monitoring of cases among the populations.

Dr Jason Agostino, a GP and epidemiologist at Gurriny Yealamucka (an Aboriginal community controlled health service in far north Queensland) and medical adviser to the National Aboriginal Community Controlled Health Organisation (NACCHO), agrees the narrative around Indigenous health focuses too much on problems and not enough on progress.

He says this can exacerbate the issue through a combination of fatalism and bias.

“There’s been a halving of early deaths from cardiovascular disease over the past 20 years, and we’ve seen smoking rates come down by around 10% in the past 15 years, so there’s massive achievements.

“But people think, ‘I’ve got a bad heart it runs in my family, so I’m destined to die early,’ and don’t appreciate that there’s a lot that can be done.”

He also thinks health practitioners are prone to this kind of pessimism.

“I think for health practitioners, they … don’t appreciate the massive gains happening within communities, and that puts them in a negative mindset when working with Aboriginal and Torres Strait Islander people.”

Dr Peter O’Mara, Chair of Aboriginal and Torres Strait Islander health at the RACGP and a Wiradjuri man, says that the deficit lens imposes a burden on Aboriginal and Torres Strait Islander communities.

While being Aboriginal or Torres Strait Islander does not make a person vulnerable, colonisation, 230 years of racism, poor investment and lack of equity does impact on people’s social, economic, cultural and health outcomes, he says.

“The risk of the deficit model is that it can put the onus for these outcomes on Aboriginal and Torres Strait Islander people and doesn’t recognise that policy and systems need to change,” Dr O’Mara says.

WHAT GPs CAN DO

Mr Fernando’s advice for doctors and healthcare practitioners is to stay updated on the improvements in Indigenous health outlooks, as well as developing a nuanced cultural understanding of why Indigenous people might feel let down by, and lack trust in, the mainstream healthcare system.

“My advice to doctors is to consider all the different facets of it, and not just assume that because a patient of theirs is Indigenous, that they [should] be considered through a damaged and disadvantaged lens,” he says.

These assumptions can be disastrous. The 2019 inquest into the death of pregnant Wiradjuri woman and disability worker Naomi Williams concludes that bias in the hospital context – including assumptions about drug abuse – resulted in failures to identify and treat the life-threatening infection that eventually killed her.

Dr Agostino says practitioners working in Aboriginal and Torres Strait Islander health should also consider the way they speak about Indigenous health, and avoid constant comparisons to non-Indigenous people.

“The fact that Aboriginal and Torres Strait Islander people die early is tragic on its own, we don’t need to say that it’s tragic because it’s 10 years earlier than non-Indigenous people.”

A range of social, psychological and physiological factors contribute to poorer health outcomes for some Indigenous people. AIHW figures show that Indigenous Australians are more likely to have lower incomes, a widely recognised contributor to poorer health.

However, many narratives around Indigenous health focus on these socio-economic factors and ignore others. Mr Fernando says another important contributor to disparities is many Indigenous people lack trust in the healthcare system, due to experiences and inherited stories of racism.

“Historically Indigenous people have been taught this idea that healthcare systems can be a bad experience,” he says. “If we think back to the Stolen Generation, an Indigenous mother giving birth would go in and then have their child stolen, so that creates a level of fear.

“Because Indigenous Australia is still an oral tradition, we pass down those old stories about the things that have happened.”

Indigenous Australians still come up against covert and overt racism in the healthcare system, which can degrade mental health and subvert access to appropriate treatment.

A 2017 report in the International Journal for Equity in Health revealed that 45% of Indigenous Australian families interviewed experienced racial discrimination in the healthcare system.

The report found this racism towards children was associated with higher levels of mental illness, sleep difficulties, obesity and asthma.

The paper also suggested healthcare protocols and processes were geared towards white Australians and could be inconsistent with Indigenous family structures.

Mr Fernando says many Indigenous people are less likely to be believed when they share their experiences with their doctor, for example when discussing levels of pain.

Compounding these societal stressors on health, the nascent field of epigenetics suggests people can carry the scars of their parents’ traumas in their genes, amounting to a heritable legacy of compromised health.

A 2018 report in World Psychiatry describes the process of epigenetic change as: “Environmental exposure may lead to an enduring change in the function of DNA that can be passed to future generations.”

The report concludes these genetic changes are likely to occur not only when parental trauma is experienced with the fetus in utero, but even before conception. This means trauma at any point in a person’s lifetime could feasibly play out in their descendants’ genes. It makes plain the impact historic racism, displacement and abuse continue to have on living Indigenous people’s health.

The field of Aboriginal and Torres Strait Islander health clearly demands a nuanced and flexible approach from healthcare practitioners, appreciating the impact that racism, disadvantage and intergenerational trauma have had without ignoring the significant improvements being made, nor assuming the worst about an individual’s health simply because they are Indigenous.

Amalyah Hart is a freelance journalist with a background in health policy, based in Melbourne