Abstract
Having worked at the remote Indigenous mental health coalface for three decades, I have had the opportunity to observe and reflect on a series of ‘problems’. From the emergence of alcohol misuse as a major issue in the 1970s and the parallel dramatic rise in accidents and violence, to the increasing rates of serious mental illness that have attracted attention in the last decade, there has been a four-decade cascade. From the late 1980s suicide rates soared, initially primarily town-based young adult men but later generalizing to remote settings and to women and, later still, children. Cannabis use and its consequences are now a major concern as are the foetal and developmental effects of all of the foregoing and elevated rates of intellectual disability that have been documented across the lifespan. While these are widespread across the Aboriginal and, to a lesser extent, Torres Strait Islander populations, more localized but entrenched problems have also emerged, such as endemic inhalant abuse in remote settings of the Northern Territory through the 1990s and 2000s.
The article by De Leo, Sveticic and Milner in this issue, which confirms earlier findings in terms of gender, age and means, reviews data from Queensland on one element of this cascade, Indigenous suicide, covering roughly the last half of this period [1]. Although the relatively small numbers result in temporal fluctuations, by comparison to studies from Queensland and elsewhere for the fifteen years preceding, the overall rates have been relatively stable. While we know that this is a major issue we are still only able to speculate about what initiated the increase in Indigenous suicide three decades ago, what the relationship is between suicide, the other elements of the cascade and wider social forces, and what sustains high rates of all these adverse mental health outcomes.
As presented by De Leo and colleagues, numerous putative causal or contributory factors have been proffered by a range of researchers and commentators to ‘explain’ Indigenous suicide, most of which would be equally relevant in relation to the other elements of the cascade. Of course none, alone, are sufficient and there is no evidence that interventions based on narrow constructions are effective (indeed the evidence base for effective interventions generally, in relation to all of the problems noted earlier, is vanishingly small).
As explanation, more appealing are broader social/historical interpretations. However, they do not easily lead to interventions and are beyond the responsibilities or reach of the health sector. Health professions and bodies can, of course, provide evidence and advocate for particular ‘global’ actions to address Indigenous political issues, such as Constitutional inclusion, and initiatives aiming to address disadvantage and marginalization, for instance welfare reform or enhancing social and economic control. They can also contribute to local programmes to ‘empower’ individuals, families and communities. All of these goals are necessary and a matter of fundamental rights. Driven from the health sector alone, however, they are unlikely to be sufficient to contain let alone reverse these trends.
Regardless, ‘macro’ level factors are important and there is evidence for what may make a difference; sadly not yet from Australia. For instance, the research of Michael Chandler and Chris Lalonde from British Columbia is relevant [2,3]. They looked for whether there was an association between suicide rates in Aboriginal bands and tribes in that province, and the extent to which those communities effect real influence in decisions about their social and political destinies through self-government, land claims, cultural facilities, and control of education, health, and police/fire services. What they found was dramatic: the more such controls communities had, the lower their suicide rates.
Translating those insights into action in Australia is complicated by the illusory nature of Indigenous political and social ‘control’ [4], but all the more important for that. However, while providing evidence, support and advocacy is important, mental health professionals are likely to remain reactive rather than proactive and focused on consequential, ‘clinical’ problems. Those roles are also important and what most of us have been trained to do. So, I believe we should be guarded lest we medicalize complex social problems and detract from efforts to ensure appropriate sectoral engagement, and modest about what we can do to effect change, but do it. At the same time we should do what we can to improve the clinical services to Aboriginal and Torres Strait Islander Australians. This is a difficult balancing act, as Leonard Syme [5] eloquently noted:
insisting only on fundamental and revolutionary social change is dooming us to programs that will take years and generations to take effect. Since it is difficult to implement such major social change, it is easy to ignore inequalities because, they say, nothing can realistically be done about them. Moral outrage about inequalities is appropriate but may be self-indulgent. If we really want to change the world we may have to begin in more modest but practical ways. (p. 9)