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Engaging with holism in Australian Aboriginal health policy – a review

Engaging with holism in Australian Aboriginal health policy – a review Background: The ideal concept of Aboriginal holistic health is centrally placed in Australian Aboriginal health policies and strategies. Its effective uptake promises, as advocates suggest, reorienting the complex Australian health system to enable health improvements. However, continual reminders assail us that Aboriginal health is shocking, appalling, disastrous, disgraceful and damning. Could incapacity to engage effectively with the concept undermine health system improvements? The aim of this review of Australian literature was to identify the range of meanings attached to Aboriginal holistic health and engage with their implications for the health system. Results: In terms of literature synthesis I found that policy makers cannot rely on this approach to provide coherent arguments for meaningful engagement with the concept because authors in general: are uncritical and un-reflexive in the use and interpretation of the concept; often provide no reference for their understandings; tend to alter the concept's definition and constituent elements without justification; ignore the wide range of mainstream literature about holism and health; and fail to acknowledge and examine the range of Aboriginal concepts of health. I used the ten themes from this literature to highlight implications for the health system, and found that a most profound contradiction exists in the acceptance of the English language concept 'holistic' as immutably Aboriginal. Additionally, a range of contradictions and mixed messages within the themes challenge the validity of the concept. Significantly, with the boundary of the concept constructed as diffuse and ethereal, the diverse and uncritical literature, and mixed thematic meanings, it is possible to justify any claim about the health system as holistic. Conclusion: It seems not so much incapacity to engage, but incapacity to coherently articulate Aboriginal concepts of health, which prevents advisory bodies such as the National Indigenous Council to imbue whole-of-government approaches in accordance with Aboriginal values. 1970s, the concept of holism is advocated as providing 'a Background The seemingly entrenched poor health status of Australian new way of thinking in Aboriginal health' [2]. The concept Aboriginal peoples is for the Commonwealth Govern- is often acknowledged as the Aboriginal definition of ment 'a glaring and intractable problem' [1:90]. Since the health (hereafter the Definition): Page 1 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 1: Characteristics of the Health Professional Literature* Health is not just the physical well-being of the individ- ual, but the social, emotional, and cultural well-being of Structure n % Origin n % the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life [3:ix] Book 6 4 Professional Association 5 3 Policy 9 6 Research Centre 10 7 However, beyond the Definition there is little detail as to Monograph 10 7 Multi-institutional 15 10 Inquiry Submission 10 7 University 16 10 the general and specific effects for the health system that Health Strategy 18 12 Other 22 15 acceptance of the concept implies. Therefore, in order to Journal Article 43 28 Aboriginal Organisation 24 16 develop an improved knowledge base, a standard Report 48 31 State Government 25 16 approach for policy makers is to perform or commission Commonwealth Government 35 23 a literature review on a topic, and then distil the key themes and related meanings. Thus, a greater understand- Total 153 100 Total 153 100 ing may be achieved to enable more effective transfer of meanings into the complex Australian health policy envi- Year n % Citation Source n % ronment. The genesis of this study began with a question often faced by policy makers: what is the holistic concept 1988 – 1990 1 1 NAHS 36 24 of Aboriginal health and how does it affect health policies, 1991 – 1993 6 4 Other 19 12 1994 – 1996 19 12 None 98 64 strategies, and programs? From a review of Australian 1997 – 1999 36 24 Total 153 100 Aboriginal health literature emerged ten themes that I use 2000 – 2002 74 48 as focal points to highlight a number of conflicts and ten- 2003 – 2004 14 9 NAHS Definition 18 12 sions complicating policy makers' effective engagement of Unknown 3 2 Aboriginal holistic health. Total 153 100 Results Literature Characteristics *n = number; % = percent of total; citation source refers to the referenced source of holistic. Table 1 shows the diversity of the 153 publications detected (structure), with journal articles (28%) and reports (31%) constituting the bulk of publications (59%). In terms of publication origin, a total of 39% came from governments compared to 16% from Aboriginal Discussion organisations, followed by 15% from 'other' – publica- There is no definitive source providing a comprehensive tions with no explicit organisational affiliation. In terms grounding framework to enable effective engagement of year of publication, the release of the National Aborig- with the concept of Aboriginal holistic health. Therefore, inal Health Strategy in 1989 is followed by a steady and policy makers have to navigate and interpret a diverse rapid increase to peak at 74 publications in the period health literature and assemble disparate messages into 2000–2002. The citation source is the explicit reference by saleable policy options. In this discussion, I attempt to the authors of their source of holistic, with 24% referring show how an examination of this literature raises a to the NAHS, 12% to 'other' sources such as Aboriginal number of tensions underlying attempts to meaningfully reports and research, and 64% providing no source. The transfer Aboriginal cultural concepts into health policy. Definition was directly cited as the source of holistic in This was a text-based study as access to and use of easily 12% of the publications. accessible published literature is a prime tool in a policy maker's kit. However, it is important to note that the study Content and Thematic Analysis findings would be improved through interviews and the Table 2 shows the themes of Aboriginal holistic health. inclusion of unpublished literature and transcripts of The number of times a theme occurred in the literature, as speeches and presentations. Nevertheless, the outcomes evident in the examples, are counted (n) and presented in of literature reviews are often the first point in establishing ascending order. the conceptual framework of health policy, strategies and programs. Elements of Aboriginal Holistic Health Table 3 shows the number of times (n) that authors stated Immutably Aboriginal? constituent elements of the concept. The elements from The literature conveys a strong sentiment that holism is the Definition were overall the most commonly stated embodied by Aboriginal people (Table 2), and therefore it (italicised), with other elements included (non-italicised) was necessary to find and understand its original source. at a lower number. The Definition was apparently first written in 1974 by the National Aboriginal and Islander Health Organisation Page 2 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 2: Thematic Boundaries Constructing Aboriginal Holistic Health* Theme n Problems with the Aboriginal holism 9 Examples: difficult to define; holistic health care compounds unrealistic expectations; holistic concept is used to distract health services from their core business; and data definitions and standards not adequately developed to encompass holistic view. Concept Confusion 17 Examples: ecological model, WHO definition of health, primary health care, ethnomedicine, and social medicine. Consistent with Comprehensive Primary Health Care 26 Examples: holistic comprehensive primary health care; CPHC is holistic; supports provision of CPHC; and holistic CPHC services. Essential to Improved Health Status 27 Examples: it must be understood that when the harmony of these interrelations is disrupted, Aboriginal ill health will persist; improvement of Aboriginal health depends upon more holistic systems; and a holistic approach to the delivery of services is essential to the improvement of Aboriginal health. Opposite of the Western, Biomedical Approach 29 Examples: holistic lifestyle opposite of European lifestyle; not built around specialities or body parts; in contrast to mind/body dichotomy of biomedicine; and body parts programs conflict with principle of holistic health. Exemplified in Aboriginal Community Controlled Health Services 38 Examples: Indigenous services insist on an holistic understanding; Aboriginal medical services incorporate an holistic approach; Aboriginal community controlled health services take account of the holistic context of service delivery; and they deliver holistic primary health care. Mainstream Health System Failure 39 Examples: fragmentation of roles; lack of coordination; areas that affect health outside the health portfolio; and vertical and inflexible programs. Broad View of Health 42 Examples: broader context of health; whole of life cycle; multi-faceted view of health; and encompass all aspects of life. Embodied by Aboriginal People 59 Examples: the holistic view of health traditionally held by Indigenous people; Aboriginal concepts of health are holistic; acceptance of Aboriginal peoples' holistic view of health; and a holistic Aboriginal concept of health. Underpinning Philosophy of Health 75 Examples: Aboriginal holism should be an underlying principle and philosophy of policy, program development, service delivery, strategies, and practice. *n = number of instances a theme was evident in statements (NAIHO, now the National Aboriginal Community Con- Aboriginal health literature it is unclear from where trolled Health Organisation, NACCHO), however I could 'holism' originated. not obtain Beaton's citation [5]. The 1989 National Abo- riginal Health Strategy (NAHS) appeared as the next likely Furthermore, no publication in the Aboriginal health lit- source. Since the release of the NAHS the explicit use of erature referred to the extensive non-Aboriginal literature 'Aboriginal holistic health' in publications increased from on holistic health. Holism occurs in mainstream health 6 references in the period 1991–1993 to peak at 74 refer- documents such as the National Health Priority Action ences during 2000–2002 (see citation source, Table 1). Areas [6], and the Victorian government's Municipal Pub- lic Health Planning Framework [7]. It is a popular key- In 24% of these publications, authors explicitly cite the word in the Australian Journal of Holistic Nursing; is a NAHS as their source of holistic health (Table 1), in which philosophy extending into the realm of medical doctors it is mentioned twice – first on page 60 and the second as 'alternative' or 'complementary' medicine [8-11]; and is much deeper in the document: advocated as underlying a 'new kind of GP' [12]. Neither these strategies nor two reviews of holism and health in The Working Party has endorsed the need for a wholistic the non-Aboriginal literature referenced or discussed Abo- approach to improving Aboriginal health. This approach riginal perspectives [8,13]. will encompass social, cultural, political, economic, envi- ronmental and physical factors, not all of which are easy Among the five 'reviews' about Aboriginal understandings to quantify. [3:219] of health, when using 'holistic' none investigated the root of the word [14-18]. This uncritical acceptance is mirrored However, the NAHS did not provide a source for 'holistic', in the only research project based on the concept [19,20]. a practice repeated in 64% of the publications (Table 1). However, the Oxford English Dictionary and the Barnhart Additionally, the NAHS does not explicitly link 'holistic' Dictionary of Etymology stated that the terms holism and and the Definition (which occurs on page x), although holistic were coined in 1926 by the biologist and former 12% of publications did (Table 1). Therefore, within the South African Prime Minister Jan Christiaan Smuts [21- Page 3 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 3: Inter-related Elements of Aboriginal Holistic Health* consider the heterogeneity of Aboriginal cultures [27]. This has significant implications for consultation mecha- Element n Element n nisms, as outline further below. Ideological 2 Economic 9 Finally, a profound contradiction exists in that 'holism' in Lifestyle 2 Mental 9 text originates from a Western source, but the NAHS states Nutrition 2 Physical Environment/ 11 Infrastructure that 'Aboriginal culture is the very antithesis of Western Service Environment/access 2 Individual 25 ideology' [3:ix]. Furthermore, although exclusively writ- Education 3 Spiritual 29 ten in the English language the NAHS is referred to as an Governance 3 Well being 29 'Aboriginal document' [28]. If culturally based concepts Identity 3 Community (development, capacity, 32 allude to a range of meanings, and if 'such meanings leadership) delineate the conceptual field within which action devel- Life-death-life 5 Emotional 33 Land 6 Physical 33 ops' [26:65], then whose cultural base is it? Political Environment 6 Cultural 35 Whole-of-life-view 6 Social 38 Essential to Improve Health? Family 7 The uncertainty about holism's 'Aboriginality' disempow- ers the idea that it is essential to improve health (Table 2). *n = number of instances an element was stated Adding to this is the variation of wording and constituent elements of the Definition. For example, NACCHO use this version in their 2003–2006 business plan: 23]. Their definitions have obvious connections with the Aboriginal health is holistic, encompassing mental health Definition, where both invoke the interconnectedness or and physical, cultural and spiritual health. Land is central 'whole' aspects of holism: to well being. Crucially, it must be understood that when the harmony of these interrelations is disrupted, Aborigi- 'parts of a whole are in intimate interconnection, such nal ill health will persist. [29:5] that they cannot exist independently of the whole, or can- not be understood without reference to the whole, which This significantly diverges from the Definition – where is thus regarded as greater than the sum of its parts' did the social and community go and how did land [22:828] become central? To what specific interrelations do they refer? In trying to clarify the interrelated elements, in the 'to designate the tendency in nature to produce wholes literature most of the time authors replicated elements (i.e. bodies or organisms) from the ordered grouping of stated in the Definition (Table 3), while other elements unit structures' [23:307] are added, subtracted or modified without a justification for doing so. The Definition is frequently inserted into It could be surmised that the appropriation of an English documents in cut-down, re-worded and re-phrased ver- language construct was necessary as it is claimed that: sions. This is from the National Aboriginal and Torres Strait Islander Health Strategy: Framework for Action by Govern- '... while Aboriginal languages do accommodate the com- ments (hereafter the Framework): plex inter-related constructs involved, Western languages cannot and nor can the relevant Aboriginal constructs be A holistic approach: recognising that the improvement of translated' [24:90] Aboriginal and Torres Strait Islander health status must include attention to physical, spiritual, cultural, emo- Perhaps this partly explains why the concepts of mwarre, tional and social well-being, community capacity and punyu, and wankaru [15,25,26] do not receive any in- governance. [27:2] depth attention. Additionally, the cross-cutting rivalries and intra-cultural conflict within Aboriginal Australia The Framework was developed by the National Aboriginal could be another reason, as the advocacy of one term from and Torres Strait Islander Health Council, agreed to by all one Aboriginal group is seen as an offence to other governments, and critically, it claims Aboriginal owner- groups. It also seems difficult to believe that after thirty ship through extensive consultations. This places the con- years of existence of the concept, Aboriginal health leaders cept in a central strategic position to frame actions in the and health professionals could not better articulate its health system. However, how can it be given due merit meanings, or the meanings of other concepts. An under- considering the implications about its cultural validity in standing of the meanings attached to these concepts combination with a selective use of constituent elements would prove valuable to policy makers who are advised to and shifting definitional boundaries? Page 4 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Mixed Messages However, there seems to be a degree of connection Furthermore, in considering the integrity of the publica- between biomedicine and holism because the phrase 'not tions, they come from a wide variety of authors from dif- just the physical well-being of the individual' of the Defi- ferent disciplines, writing in different styles of publication nition seems to connect with biomedical constructions. with various organisational affiliations (Table 1). Their Additionally, both the NAHS and the Framework heavily understanding, interpretation and application of holism depend on biomedical indices (statistics of illness) in the when they write about Aboriginal health are questionable. construction of health need. Therefore, there are points of This is evident in the mixed messages of confusion, oppo- connection between Aboriginal concepts of health or sition, connection and alignment between Aboriginal and well-being and biomedical knowledge, as Anderson has Western ideas of health. noted [26]. There is conceptual confusion (Table 2) where some Furthermore, there seems to be some alignment between authors explicitly link holism to the World Health Organ- Western and Aboriginal views as both accept the need for ization's definition of health, an ecological or ecosystems a broad view of health. The 1948 WHO definition of approach, a new public health approach, and a systems health underpins the 1978 Declaration of Alma Ata as model of thinking [30-37]. The working party of the accepted in Australian through the 1979 'Health for All' NAHS quoted the WHO definition of primary health care policy [15]. These developments precede the NAHS in full [3:x], without questioning its cultural origins. Addi- (1989), and there are similarities between the Definition tionally, the Framework states that: and the WHO version of health. The Australian health sys- tem is also more accepting of other world views in what Within the health system, the crucial mechanism for Heather Eastwood (2000) calls a 'postmodernist move- improving Aboriginal and Torres Strait Islander health is ment' that challenges the superiority of the positivist, the availability of comprehensive primary health care modern world view. Also, policy makers are more aware services. [27:1] of the need to consider ethnicity and culture in health pol- icy [48]. The acceptance and uptake of this Western approach appears unproblematic in the NAHS and the literature These confusing messages detract from the clarity needed where Aboriginal holistic health is consistent with com- to support the theme of Aboriginal holism as an under- prehensive primary health care (Table 2). Further confu- pinning philosophy of health (Table 2). What they also sion ensues through the conceptual overlap with primary signal is that both Western and Aboriginal societies are care, comprehensive primary health care [38,39], and ver- heterogeneous and contain a multiplicity of health con- tical primary health care, which 'forms only a part of com- cepts [26,49]. Moving the discussion from a conceptual prehensive primary health care, which is a broader, level to the service delivery level, the literature contains holistic approach to health problems' [40:146]. These dif- further contradictory meanings. ferences appear trivial, but their philosophical underpin- nings have important implications for operationalisation Which Health System Failure? into health system [38,39]. Aboriginal people access both Aboriginal-specific and mainstream health services [38,50]. This contrasts with a Both the mainstream and Aboriginal health literature theme suggesting the failure of the mainstream health sys- position holism as opposite, counter, or antithetical to the tem to address Aboriginal health (Table 2), principally Western biomedical model of health [8,13,26,41-45]. because health 'is holistic, a concept that many Western Three senses to this discourse emerge from the literature, models of healthcare delivery fail to identify and therefore the most prominent being the health professions past accommodate' [42:222]. Nevertheless, some advocates ethos of colonialism – 'the domination of Aboriginal are fervent that mainstream services should [51], and have health care by the medical model approach fitted well [52] become more holistic. Therefore, it is no surprise that with other assimilation policies of the period' [3:59]. In a the Commonwealth Health portfolio: second sense biomedicine, in contrast with holism, is said to devalue or disregard personal and societal social, eco- is pursuing a two pronged approach, which aims to both nomic, environmental and cultural factors on health improve accessibility and responsiveness of the main- [33,46]. A third sense relates to biomedicine's Enlighten- stream health system and to provide complementary ment rationalist heritage which tends to emphasise a action through Indigenous specific health programs. mechanistic view of the body, reducing 'health' to an [53:161] absence of biochemical and physiological symptoms [33,47]. The efficacy of this policy seems justifiable as large poten- tial gains in Aboriginal health could be realised through Page 5 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 reorienting Australia's $66.6 billion health system [54]. Health Professional Separatism? Advocates readily support work to improve mainstream In terms of health service delivery, authors are quite will- system access following from many initiatives developed ing to claim that Aboriginal people embody holism in the NAHS and the Framework. Additionally, govern- (Table 2). For example, within ACCHS 'the Health Worker ments fund and support more than 100 Aboriginal com- role is driven by a holistic approach' [66:xiii]. Further- munity controlled health services (ACCHS) initiated since more, the Queensland Department of Health ' under- 1971 [24,50] that are said to exemplify holism (Table 2). stands that recruiting Indigenous peoples will better Published literature from ACCHS would assist policy position Queensland Health to... develop a holistic makers in clarifying service delivery implications of approach to health' [67:3]. These meanings imply a strict holism, however only 16% of the publications came from separatism between Aboriginal people and ACCHS and Aboriginal organisations (Table 1). non-Aboriginal people and mainstream services. Some descriptive literature is available [55,56] but none An implication of this is seen in the definition of commu- based on evaluations of their relative effectiveness [57], nity control where 'Aboriginal people must determine and although community controlled service delivery is often control the pace, shape and manner of change and deci- uncritically proclaimed as 'an uncontested good' [57:4]. sion-making at local, regional, state and national levels' Furthermore there is an array of different types of Aborig- [24:77]. Seemingly in agreement, the Australian Medical inal service delivery models covered under the banner of Association (AMA) supports Aboriginal holism [68]. holistic services, ranging from dedicated Aboriginal med- However, they staunchly defend placing doctors at the ical services to multi-purpose cooperatives with health as centre of primary health care: 'the AMA strongly recom- part of their overall function, to separate substance misuse mends that all PHC should be delivered through general services [56]. This lack of critical evaluation research is a practice' [69:4] and emphasise 'The unique clinical skills major impediment to understanding the efficacy of of GPs in providing holistic/social care' [69:2]. Addition- ACCHS, and how the lessons of their operations could ally, in spite of the assimilation label attached to the med- influence mainstream health system reforms. ical profession in the NAHS, the NAHS Working Party accepts the WHO primary health care model developed This adds to the theme where some authors note prob- under the conceptual umbrella of the WHO definition of lems with the concept (see Table 2), which include that health. This was developed by experts (professors and relying on it may divert attention and resources away from medical doctors) with a background in social medicine, the core business of health services, and lead to difficulties one of whom became the first Director-General of the in establishing effective measures and indicators WHO [49]. [49,58,59]. However, they fail to elucidate specific criteria and evidence for their assertions. These factors combine In practice, mainstream doctors question their own scien- with the findings outlined above mean any argument for tific training in providing health care [8], and there is an success of failure of the health system has limited empiri- increased number of both doctors working in Aboriginal cal basis for justification. As such, the Commonwealth health services, and of Aboriginal doctors [50]. Medical could justify saying that: doctors receive particular criticism in Aboriginal health, but they have a significant role in the advocacy for Aborig- The health needs of Indigenous Australians are largely met inal rights and in working with Aboriginal organisations through the funding and delivery of mainstream health [70]. Medical educators have access to medical curricula services, with services specially targeting Aboriginal and improvements to incorporate Aboriginal health [71,72]. Torres Strait Islander people complementing these main- There also exist a wide range of internet resources specifi- stream services. [60:v] cally targeting the health professional [73-75]. The propo- sition of separatism between Aboriginal and non- In a broader sense, often accused of poor coordination Aboriginal people, concepts of health and antithetical, Commonwealth Government agencies are beginning 'to unchanging cultures appears undercut by the willingness engage in holistic thinking and think beyond the bound- of health professionals to challenge culturally established aries, conceptualise broad outcomes, and understand norms, and to be culturally sensitive in their approach. areas of commonality' [61:53]. However, government officials face a maze of uncoordinated Indigenous struc- Implications for Health Policy and Strategy Development Processes tures to navigate [62]. Of the thousands of Aboriginal organisations the potential exists for an 'Indigenous order I posed the question earlier: could incapacity to engage of Australian government' [63], but attempts such as coa- effectively with the concept undermine health system litions of Aboriginal organisations [64,65] fail to present improvements? I have shown that through the medium of coherent policy positions. literature synthesis that effective engagement is not Page 6 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 possible which is a significant barrier for systemic reform ences to any Aboriginal concept of health. Significantly, because health strategy construction relies heavily on pub- the COAG reporting framework effectively orients all lished literature. This partly undermines the theme of an commonwealth ministers to produce efforts consistent underpinning philosophy of health (Table 2) as accepted with this framework. It is therefore questionable whether as an explicit policy principle by the Victoria, Northern Aboriginal concepts and knowledge could receive full Territory, New South Wales, Queensland, and Western argumentation and explanation in these processes, Australia Governments, and as advocated for as a policy because policy 'is the outcome of the competition principle by professional associations and a range of non- between ideas, interests, and ideologies' [81:3]. As such, Government organisations. given the heterogeneity of Aboriginal cultures, ineffective transfer of meanings through written and oral communi- However, arguably more meaningful engagement occurs cation, undercut by rivalries and intra-cultural conflict through oral communication. Consultation meetings preventing national Aboriginal unification, then the include a wide range of Aboriginal and non-Aboriginal approach of the Howard government of dealing directly people across the country. This multitude of voices project with individual Aboriginal communities could well be preferences through ideological, institutional, profes- justified [82]. sional, and cultural perspectives. While advocates may agree with the concept in principle, each could be tapping Conclusion into their particular view of holism. For example, some I conclude that literature synthesis cannot provide an medical literature suggests doctors view 'holistic answer to the question: what is the holistic concept of treatments' as alternative or complementary medicine Aboriginal health? Rather, policy makers can justify any such as acupuncture, relaxation, massage, and hypnotism answer based on the diversity of the literature, subsequent [8,41,43]. themes and range of meanings. Furthermore, I question the cultural basis advocates attribute to the concept as Additionally, strategies receive ministerial endorsement immutably Aboriginal, which undermines the credibility after processing through a hierarchy of advisory and con- of its use. In terms of the range of Aboriginal concepts sultative committees. For example, in the development of available, the effective transformation of their meanings the National Aboriginal and Torres Strait Islander Nutrition into the health system could be enhanced through coher- Strategy and Action Plan, the majority-Aboriginal working ent and articulate written and oral communication. The party was in effect a sub-sub-sub-committee of the lack of knowledge about them is serious barrier that endorsing committee: the Australian Health Ministers should be addressed through more research. This would, Advisory Council [76]. This and other endorsing councils in part, enhance the capacity of policy makers to engage do not include an Aboriginal person to explain the com- meaningfully and confidently with Aboriginal concepts of plexities and nuances of Aboriginal cultural concepts, and health. However, further attention needs to be given to thus revert to understandings from the literature or from the processes of health policy and strategy development their own perspective, clearly as many authors do in the so that these meanings receive adequate consideration literature. and argumentation in written and oral forms. Otherwise, health outcomes for Aboriginal people may continue It could also be argued that one Aboriginal person on along an appalling path. endorsing committees would be insufficient, given the hundreds of Aboriginal groups in Australia. This extends Methods to the validity of the majority Aboriginal membership Literature Detection mandate of steering committees, as each may draw on dis- The Australian Aboriginal health literature was defined as tinct cultural concepts, such as mwarre, punyu, and Australian publications on Aboriginal affairs with a health wankaru. The in-group rivalries are well noted between specific focus or section and which explicitly stated the different Aboriginal tribes as well as between urban, rural terms 'holistic' or 'wholistic'. Publication detection and remote communities [77,78]. Finally, the insignifi- occurred using the search string: (Aborig* OR Indige- cant number of Aboriginal people in all the health sys- nous) AND (holistic OR wholistic) AND health, applied tem's structures – in 2001 only 0.9% of health care to the databases of Informit: APAIS (health, public affairs), providers were Aboriginal [79:18] – precludes occupying ATSIhealth, CINAHL, Health and Society, Australian Med- enough positions to give adequate force to oral transfer. ical Index, Rural; as well as MEDLINE and PubMed. Results from each database were cross-referenced and It is perhaps for these reasons that the new reporting duplicate items removed, with periodic repeat searches framework for the Council of Australian Governments ensuring new publication capture. Additionally, snowball (COAG), set in the Overcoming Indigenous Disadvantage: searching of journals enabled capture of older publica- Key Indicators report [80], has a complete absence of refer- tions and those not listed in the databases. Finally, Page 7 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 which was a component of a Master of Public Health degree delivered Aboriginal affairs reports were detected through relevant through the Menzies School of Health Research. government and organisational internet sites and searched for key terms. The publication characteristics are References shown in Table 1. 1. Hilless M, Healy J: Health Care Systems in Transition: Australia 2001 Copenhagen: European Observatory on Health Care Systems, World Content and Thematic Analysis Health Organisation; 2001. 2. 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Bell K, Couzos S, Daniels J, Hunter P, Mayers N, Murray R: Aborig- and support during the study. Thank you to Yin Paradies, Emma Kowal, and inal Community Controlled Health Services. In General Prac- Jane Lloydfor constructively critical comments on drafts of this paper. A tice in Australia: 2000 Canberra: Commonwealth Department of scholarship from the then Cooperative Research Centre for Aboriginal and Health and Aged Care; 2000:74-103. Tropical Health provided a stipend for six months to complete the study, 25. Devanesen D: Traditional Aboriginal Medicine Practice in the Northern Territory. Quarterly 2000, 33:10-13. Page 8 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 26. Anderson I: Aboriginal Well-being. In Health In Australia: Sociolog- Organization. Migrants, Minorities and Health: Historical and Contem- ical Concepts and Issues (2nd ed) 2nd edition. Edited by: Grbich C. Syd- porary Studies 1997:272-290. ney: Longman; 1999:53-73. 50. Dwyer J, Silburn K, Wilson G: Consultant Report No 1. National Strate- 27. National Aboriginal and Torres Strait Islander Health Council: gies for Improving Indigenous Health and Health Care Canberra: Com- National Strategic Framework for Aboriginal and Torres Strait Islander monwealth of Australia; 2004. Health: Framework for Action by Governments Canberra: NATSIHC; 51. Social Health Reference Group: Consultation Paper for the Development 2003. of the Aboriginal and Torres Strait Islander National Strategic Framework 28. Murray R, Bell K, Couzos S, Grant M, Wronski I: Aboriginal Health for Mental Health and Social and Emotional Well Being 2004–2009 Can- and the Policy Process. In Aboriginal Primary Health Care: An Evi- berra: Commonwealth Department of Health and Ageing; 2003. denced Based Approach (2nd edition) Edited by: Couzos S. Melbourne: 52. Urbis Keys Young: Evaluation of the Emotional and Social Well Being Oxford University Press; 2003:1-36. (Mental Health) Action Plan Canberra: Commonwealth of Australia; 29. National Aboriginal Community Controlled Health Organisation: 2001. National Aboriginal Community Controlled Health Organisation Business 53. Commonwealth Department of Health and Aged Care: 2002–2003 Plan 2003–2006 Canberra: NACCHO; 2003. Portfolio Budget Statements Outcome 7: Aboriginal and Torres Strait 30. Hetzel B: Communication and Health – Health as an Islander Health Canberra: Commonwealth of Australia; 2001. Ecosystem. Medical Journal of Australia 1990, 153:548-551. 54. Australian Institute of Health and Welfare: Australia's Health 2004. 31. Barlett B: An Aboriginal Health Worker's Guide to Family, Community and AIHW Cat. No. AUS 44 Canberra: Australian Institute of Health and Public Health Alice Springs: Central Australian Aboriginal Congress; Welfare; 2004. 1995. 55. Office for Aboriginal and Torres Strait Islander Health: Better Health 32. Khoury P: Aboriginal Health as a Social Product. In Second Care – Studies in the Successful Delivery of Primary Health Care Services Opinion: An Introduction to Health Sociology Edited by: Germov J. Mel- for Aboriginal and Torres Strait Islander Australians Canberra: Common- bourne: Oxford University Press; 1998:57-74. wealth of Australia; 2001. 33. Knight J: Models of Health. In Second Opinion: An Introduction to 56. Shannon C, Longbottom H: Consultant Report No 4. Capacity Develop- Health Sociology Edited by: Germov J. Melbourne: Oxford University ment in Aboriginal and Torres Strait Islander Health Service Delivery – Case Press; 1998:136-155. Studies Canberra: Commonwealth of Australia; 2004. 34. Hetzel B: Historical Perspectives on Indigenous Health in 57. National Centre for Epidemiology and Population Health: Common- Australia. Asia Pacific Journal of Clinical Nutrition 2000, 9:157-163. wealth Grants Commission Indigenous Funding Inquiry Submission. IfI/SUB/ 35. Devitt J, Hall G, Tsey K: An Introduction to the Social Determinants of 0060 Canberra: Commonwealth Grants Commission; 2000. Health in Relation to the Northern Territory Indigenous Population. Occa- 58. Australian Bureau of Statistics: The Health and Welfare of Australia's sional Paper Series No. 6 Darwin: Cooperative Research Centre for Aboriginal and Torres Strait Islander Peoples 2001 Canberra: Common- Aboriginal and Tropical health; 2001. wealth of Australia; 2001. 36. Devitt J, Hall G, Tsey K: Underlying Causes. In The Health and Wel- 59. Wilson J: Remote Area Aboriginal Health Services for Manag- fare of Territorians Darwin: Northern Territory Government; ers: Key Practice Challenges. Australian Journal of Rural Health 2001:9-18. 2001, 9:138-140. 37. Mathews S, Jenkin R, Frommer M, Tjhin M, Rubin G: When Research 60. Commonwealth Department of Health and Aged Care: Health and Reports and Academic Journals are Clearly Not Enough. Strengthening the Aged Care Portfolio Submission to the Commonwealth Grants Commission's Links between Aboriginal Health Research and Health Outcomes. Occa- Inquiry into Indigenous Funding Canberra: Commonwealth Grants sional Papers Series Issue No. 4 Darwin: Cooperative Research Centre Commission; 2000. for Aboriginal and Tropical Health; 2001. 61. Management Advisory Committee: Connecting Government: Whole of 38. Anderson I, Young H, Markovic M, Manderson L: Koori Primary Government Responses to Australia's Priority Challenges Canberra: Aus- Health Care in Victoria: Developments in Service Planning. tralian Public Service; 2004. Australian Journal of Primary Health: Interchange 2000, 6:24-35. 62. House of Representatives Standing Committee on Aboriginal and 39. 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Brown N: Reflections on the Health Care of Australia's Indig- library/pubs/rp/1998–99/99rp27.htm] enous People. Journal of Quality in Clinical Practice 1999, 19:211-222. 65. Media Release – New Coalition of Aboriginal Organisations 43. Wearing M: Medical Dominance and the Division of Labour in [http://www.naccho.org.au/newcoalition.html] the Health Professions. In Health In Australia: Sociological Concepts 66. Curtin Indigenous Research Centre, Centre for Educational Research and Issues 2nd edition. Edited by: Grbich C. Sydney: Longman; and Evaluation Consortium, Jojara & Associaties: Training Re-visions. A 1999:197-216. National Review of Aboriginal and Torres Strait Islander Health Worker 44. Dodson M: Aboriginal and Torres Strait Islander Social Justice Commis- Training Perth: Curtin Indigenous Research Centre; 2001. sioner – Second Report 1994 Canberra: Commonwealth of Australia; 67. Queensland Health: Queensland Indigenous Health Workforce Strategy 1995. Brisbane: Queensland Government; 1999. 45. McDermott R, Beaver C: Models for Horizontal Equity in 68. Australian Medical Association: Preventable Chronic Disease Strategies in Resource Allocation in Aboriginal Health. Australian and New Aboriginal and Torres Strait Islander Peoples Canberra: AMA; 2001. Zealand Journal of Public Health 1996, 20:13-15. 69. AMA Position Paper on Primary Health Care [http:// 46. Lewis J: A Dialectical Perspective on the Environment and www.ama.com.au/web.nsf/doc/SHED-5FZ326] Health. In Analysing Health Policy Volume Chapter 8. Edited by: Gee- 70. Media Release – NACCHO and AMA Announce Major Abo- long LH. Allen & Unwin; 1997:1-9. riginal Health Report [http://www.naccho.org.au/NACCHOan 47. Hahn R, Kleinman A: Biomedical Practice and Anthropological dAMA.html] Theory: Frameworks and Directions. Annual Review of 71. Phillips G, the Committee of Deans of Australian Medical Schools: Anthropology 1983, 12:305-333. CDAMS Indigenous Health Curriculum Development Project: National Audit 48. Kimberley Aboriginal Medical Services Council, Effective Healthcare and Consultations Report Melbourne: Centre for the Study of Health Australia, James Cook University: Guidelines for the Development, and Society, University of Melbourne; 2004. Implementation and Evaluation of National Public Health Strategies in Rela- 72. Yaxley L: Aboriginal Health: An Evaluation of the Implementation of Cur- tion to Aboriginal and Torres Strait Islander Peoples: Approaches and riculum, Stage One Melbourne: Royal Australian College of General Recommendations Melbourne: National Public Health Partnership; Practitioners; 2001. 2002. 73. Victorian Aboriginal Community Controlled Health Organisation, 49. Brady M, Kunitz S, Nash D: WHO's Definition?: Australian Abo- VicHealth Koori Health Research and Community Development, rigines, Conceptualisations of Health and the World Health Unit: Teaching Koori Issues to Health Professionals and Health Students – Page 9 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 A Community Report Melbourne: VicHealth Koori Health Research and Community Development Unit; 2001. 74. Kokotinna – A Staff Development Program for Aboriginal and Torres Strait Islander Cultures and Health [http:// www.flinders.edu.au/kokotinna/] 75. Aboriginal and Torres Strait Islander Cultural Awareness Training Program [http://www.nqrhtu.org.au/cap.htm] 76. National Aboriginal and Torres Strait Islander Nutrition Working Party: National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000–2010 Melbourne: National Public Health Partnership; 2001. 77. Weaver S: Australian Aboriginal Policy: Aboriginal Pressure Groups or Government Advisory Bodies? Part 1. Oceania 1983, 54:1-22. 78. Peters-Little F: The Community Game: Aboriginal Self-Definition at the Local Community Level Canberra: Australian Institute of Aboriginal and Torres Strait Islander Studies; 1999. 79. Australian Institute of Health and Welfare: Health and Community Serv- ices Labour Force 2001 Canberra: AIHW; 2003. 80. Steering Committee for the Review of Government Service Provi- sion: Overcoming Indigenous Disadvantage: Key Indicators 2003 Can- berra: Productivity Commission; 2003. 81. Bridgman P, Davis G: The Australian Policy Handbook 2nd edition. St Leonards: Allen & Unwin; 2000. 82. Office of Indigenous Policy Coordination: New Arrangements in Indige- nous Affairs Canberra: Commonwealth Department of Immigration and Multicultural and Indigenous Affairs, Australian Government; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 10 of 10 (page number not for citation purposes) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australia and New Zealand Health Policy Springer Journals

Engaging with holism in Australian Aboriginal health policy – a review

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Springer Journals
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Copyright © 2005 by Lutschini; licensee BioMed Central Ltd.
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Medicine & Public Health; Public Health; Social Policy
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1743-8462
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1743-8462
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10.1186/1743-8462-2-15
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16014165
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Abstract

Background: The ideal concept of Aboriginal holistic health is centrally placed in Australian Aboriginal health policies and strategies. Its effective uptake promises, as advocates suggest, reorienting the complex Australian health system to enable health improvements. However, continual reminders assail us that Aboriginal health is shocking, appalling, disastrous, disgraceful and damning. Could incapacity to engage effectively with the concept undermine health system improvements? The aim of this review of Australian literature was to identify the range of meanings attached to Aboriginal holistic health and engage with their implications for the health system. Results: In terms of literature synthesis I found that policy makers cannot rely on this approach to provide coherent arguments for meaningful engagement with the concept because authors in general: are uncritical and un-reflexive in the use and interpretation of the concept; often provide no reference for their understandings; tend to alter the concept's definition and constituent elements without justification; ignore the wide range of mainstream literature about holism and health; and fail to acknowledge and examine the range of Aboriginal concepts of health. I used the ten themes from this literature to highlight implications for the health system, and found that a most profound contradiction exists in the acceptance of the English language concept 'holistic' as immutably Aboriginal. Additionally, a range of contradictions and mixed messages within the themes challenge the validity of the concept. Significantly, with the boundary of the concept constructed as diffuse and ethereal, the diverse and uncritical literature, and mixed thematic meanings, it is possible to justify any claim about the health system as holistic. Conclusion: It seems not so much incapacity to engage, but incapacity to coherently articulate Aboriginal concepts of health, which prevents advisory bodies such as the National Indigenous Council to imbue whole-of-government approaches in accordance with Aboriginal values. 1970s, the concept of holism is advocated as providing 'a Background The seemingly entrenched poor health status of Australian new way of thinking in Aboriginal health' [2]. The concept Aboriginal peoples is for the Commonwealth Govern- is often acknowledged as the Aboriginal definition of ment 'a glaring and intractable problem' [1:90]. Since the health (hereafter the Definition): Page 1 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 1: Characteristics of the Health Professional Literature* Health is not just the physical well-being of the individ- ual, but the social, emotional, and cultural well-being of Structure n % Origin n % the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life [3:ix] Book 6 4 Professional Association 5 3 Policy 9 6 Research Centre 10 7 However, beyond the Definition there is little detail as to Monograph 10 7 Multi-institutional 15 10 Inquiry Submission 10 7 University 16 10 the general and specific effects for the health system that Health Strategy 18 12 Other 22 15 acceptance of the concept implies. Therefore, in order to Journal Article 43 28 Aboriginal Organisation 24 16 develop an improved knowledge base, a standard Report 48 31 State Government 25 16 approach for policy makers is to perform or commission Commonwealth Government 35 23 a literature review on a topic, and then distil the key themes and related meanings. Thus, a greater understand- Total 153 100 Total 153 100 ing may be achieved to enable more effective transfer of meanings into the complex Australian health policy envi- Year n % Citation Source n % ronment. The genesis of this study began with a question often faced by policy makers: what is the holistic concept 1988 – 1990 1 1 NAHS 36 24 of Aboriginal health and how does it affect health policies, 1991 – 1993 6 4 Other 19 12 1994 – 1996 19 12 None 98 64 strategies, and programs? From a review of Australian 1997 – 1999 36 24 Total 153 100 Aboriginal health literature emerged ten themes that I use 2000 – 2002 74 48 as focal points to highlight a number of conflicts and ten- 2003 – 2004 14 9 NAHS Definition 18 12 sions complicating policy makers' effective engagement of Unknown 3 2 Aboriginal holistic health. Total 153 100 Results Literature Characteristics *n = number; % = percent of total; citation source refers to the referenced source of holistic. Table 1 shows the diversity of the 153 publications detected (structure), with journal articles (28%) and reports (31%) constituting the bulk of publications (59%). In terms of publication origin, a total of 39% came from governments compared to 16% from Aboriginal Discussion organisations, followed by 15% from 'other' – publica- There is no definitive source providing a comprehensive tions with no explicit organisational affiliation. In terms grounding framework to enable effective engagement of year of publication, the release of the National Aborig- with the concept of Aboriginal holistic health. Therefore, inal Health Strategy in 1989 is followed by a steady and policy makers have to navigate and interpret a diverse rapid increase to peak at 74 publications in the period health literature and assemble disparate messages into 2000–2002. The citation source is the explicit reference by saleable policy options. In this discussion, I attempt to the authors of their source of holistic, with 24% referring show how an examination of this literature raises a to the NAHS, 12% to 'other' sources such as Aboriginal number of tensions underlying attempts to meaningfully reports and research, and 64% providing no source. The transfer Aboriginal cultural concepts into health policy. Definition was directly cited as the source of holistic in This was a text-based study as access to and use of easily 12% of the publications. accessible published literature is a prime tool in a policy maker's kit. However, it is important to note that the study Content and Thematic Analysis findings would be improved through interviews and the Table 2 shows the themes of Aboriginal holistic health. inclusion of unpublished literature and transcripts of The number of times a theme occurred in the literature, as speeches and presentations. Nevertheless, the outcomes evident in the examples, are counted (n) and presented in of literature reviews are often the first point in establishing ascending order. the conceptual framework of health policy, strategies and programs. Elements of Aboriginal Holistic Health Table 3 shows the number of times (n) that authors stated Immutably Aboriginal? constituent elements of the concept. The elements from The literature conveys a strong sentiment that holism is the Definition were overall the most commonly stated embodied by Aboriginal people (Table 2), and therefore it (italicised), with other elements included (non-italicised) was necessary to find and understand its original source. at a lower number. The Definition was apparently first written in 1974 by the National Aboriginal and Islander Health Organisation Page 2 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 2: Thematic Boundaries Constructing Aboriginal Holistic Health* Theme n Problems with the Aboriginal holism 9 Examples: difficult to define; holistic health care compounds unrealistic expectations; holistic concept is used to distract health services from their core business; and data definitions and standards not adequately developed to encompass holistic view. Concept Confusion 17 Examples: ecological model, WHO definition of health, primary health care, ethnomedicine, and social medicine. Consistent with Comprehensive Primary Health Care 26 Examples: holistic comprehensive primary health care; CPHC is holistic; supports provision of CPHC; and holistic CPHC services. Essential to Improved Health Status 27 Examples: it must be understood that when the harmony of these interrelations is disrupted, Aboriginal ill health will persist; improvement of Aboriginal health depends upon more holistic systems; and a holistic approach to the delivery of services is essential to the improvement of Aboriginal health. Opposite of the Western, Biomedical Approach 29 Examples: holistic lifestyle opposite of European lifestyle; not built around specialities or body parts; in contrast to mind/body dichotomy of biomedicine; and body parts programs conflict with principle of holistic health. Exemplified in Aboriginal Community Controlled Health Services 38 Examples: Indigenous services insist on an holistic understanding; Aboriginal medical services incorporate an holistic approach; Aboriginal community controlled health services take account of the holistic context of service delivery; and they deliver holistic primary health care. Mainstream Health System Failure 39 Examples: fragmentation of roles; lack of coordination; areas that affect health outside the health portfolio; and vertical and inflexible programs. Broad View of Health 42 Examples: broader context of health; whole of life cycle; multi-faceted view of health; and encompass all aspects of life. Embodied by Aboriginal People 59 Examples: the holistic view of health traditionally held by Indigenous people; Aboriginal concepts of health are holistic; acceptance of Aboriginal peoples' holistic view of health; and a holistic Aboriginal concept of health. Underpinning Philosophy of Health 75 Examples: Aboriginal holism should be an underlying principle and philosophy of policy, program development, service delivery, strategies, and practice. *n = number of instances a theme was evident in statements (NAIHO, now the National Aboriginal Community Con- Aboriginal health literature it is unclear from where trolled Health Organisation, NACCHO), however I could 'holism' originated. not obtain Beaton's citation [5]. The 1989 National Abo- riginal Health Strategy (NAHS) appeared as the next likely Furthermore, no publication in the Aboriginal health lit- source. Since the release of the NAHS the explicit use of erature referred to the extensive non-Aboriginal literature 'Aboriginal holistic health' in publications increased from on holistic health. Holism occurs in mainstream health 6 references in the period 1991–1993 to peak at 74 refer- documents such as the National Health Priority Action ences during 2000–2002 (see citation source, Table 1). Areas [6], and the Victorian government's Municipal Pub- lic Health Planning Framework [7]. It is a popular key- In 24% of these publications, authors explicitly cite the word in the Australian Journal of Holistic Nursing; is a NAHS as their source of holistic health (Table 1), in which philosophy extending into the realm of medical doctors it is mentioned twice – first on page 60 and the second as 'alternative' or 'complementary' medicine [8-11]; and is much deeper in the document: advocated as underlying a 'new kind of GP' [12]. Neither these strategies nor two reviews of holism and health in The Working Party has endorsed the need for a wholistic the non-Aboriginal literature referenced or discussed Abo- approach to improving Aboriginal health. This approach riginal perspectives [8,13]. will encompass social, cultural, political, economic, envi- ronmental and physical factors, not all of which are easy Among the five 'reviews' about Aboriginal understandings to quantify. [3:219] of health, when using 'holistic' none investigated the root of the word [14-18]. This uncritical acceptance is mirrored However, the NAHS did not provide a source for 'holistic', in the only research project based on the concept [19,20]. a practice repeated in 64% of the publications (Table 1). However, the Oxford English Dictionary and the Barnhart Additionally, the NAHS does not explicitly link 'holistic' Dictionary of Etymology stated that the terms holism and and the Definition (which occurs on page x), although holistic were coined in 1926 by the biologist and former 12% of publications did (Table 1). Therefore, within the South African Prime Minister Jan Christiaan Smuts [21- Page 3 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Table 3: Inter-related Elements of Aboriginal Holistic Health* consider the heterogeneity of Aboriginal cultures [27]. This has significant implications for consultation mecha- Element n Element n nisms, as outline further below. Ideological 2 Economic 9 Finally, a profound contradiction exists in that 'holism' in Lifestyle 2 Mental 9 text originates from a Western source, but the NAHS states Nutrition 2 Physical Environment/ 11 Infrastructure that 'Aboriginal culture is the very antithesis of Western Service Environment/access 2 Individual 25 ideology' [3:ix]. Furthermore, although exclusively writ- Education 3 Spiritual 29 ten in the English language the NAHS is referred to as an Governance 3 Well being 29 'Aboriginal document' [28]. If culturally based concepts Identity 3 Community (development, capacity, 32 allude to a range of meanings, and if 'such meanings leadership) delineate the conceptual field within which action devel- Life-death-life 5 Emotional 33 Land 6 Physical 33 ops' [26:65], then whose cultural base is it? Political Environment 6 Cultural 35 Whole-of-life-view 6 Social 38 Essential to Improve Health? Family 7 The uncertainty about holism's 'Aboriginality' disempow- ers the idea that it is essential to improve health (Table 2). *n = number of instances an element was stated Adding to this is the variation of wording and constituent elements of the Definition. For example, NACCHO use this version in their 2003–2006 business plan: 23]. Their definitions have obvious connections with the Aboriginal health is holistic, encompassing mental health Definition, where both invoke the interconnectedness or and physical, cultural and spiritual health. Land is central 'whole' aspects of holism: to well being. Crucially, it must be understood that when the harmony of these interrelations is disrupted, Aborigi- 'parts of a whole are in intimate interconnection, such nal ill health will persist. [29:5] that they cannot exist independently of the whole, or can- not be understood without reference to the whole, which This significantly diverges from the Definition – where is thus regarded as greater than the sum of its parts' did the social and community go and how did land [22:828] become central? To what specific interrelations do they refer? In trying to clarify the interrelated elements, in the 'to designate the tendency in nature to produce wholes literature most of the time authors replicated elements (i.e. bodies or organisms) from the ordered grouping of stated in the Definition (Table 3), while other elements unit structures' [23:307] are added, subtracted or modified without a justification for doing so. The Definition is frequently inserted into It could be surmised that the appropriation of an English documents in cut-down, re-worded and re-phrased ver- language construct was necessary as it is claimed that: sions. This is from the National Aboriginal and Torres Strait Islander Health Strategy: Framework for Action by Govern- '... while Aboriginal languages do accommodate the com- ments (hereafter the Framework): plex inter-related constructs involved, Western languages cannot and nor can the relevant Aboriginal constructs be A holistic approach: recognising that the improvement of translated' [24:90] Aboriginal and Torres Strait Islander health status must include attention to physical, spiritual, cultural, emo- Perhaps this partly explains why the concepts of mwarre, tional and social well-being, community capacity and punyu, and wankaru [15,25,26] do not receive any in- governance. [27:2] depth attention. Additionally, the cross-cutting rivalries and intra-cultural conflict within Aboriginal Australia The Framework was developed by the National Aboriginal could be another reason, as the advocacy of one term from and Torres Strait Islander Health Council, agreed to by all one Aboriginal group is seen as an offence to other governments, and critically, it claims Aboriginal owner- groups. It also seems difficult to believe that after thirty ship through extensive consultations. This places the con- years of existence of the concept, Aboriginal health leaders cept in a central strategic position to frame actions in the and health professionals could not better articulate its health system. However, how can it be given due merit meanings, or the meanings of other concepts. An under- considering the implications about its cultural validity in standing of the meanings attached to these concepts combination with a selective use of constituent elements would prove valuable to policy makers who are advised to and shifting definitional boundaries? Page 4 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 Mixed Messages However, there seems to be a degree of connection Furthermore, in considering the integrity of the publica- between biomedicine and holism because the phrase 'not tions, they come from a wide variety of authors from dif- just the physical well-being of the individual' of the Defi- ferent disciplines, writing in different styles of publication nition seems to connect with biomedical constructions. with various organisational affiliations (Table 1). Their Additionally, both the NAHS and the Framework heavily understanding, interpretation and application of holism depend on biomedical indices (statistics of illness) in the when they write about Aboriginal health are questionable. construction of health need. Therefore, there are points of This is evident in the mixed messages of confusion, oppo- connection between Aboriginal concepts of health or sition, connection and alignment between Aboriginal and well-being and biomedical knowledge, as Anderson has Western ideas of health. noted [26]. There is conceptual confusion (Table 2) where some Furthermore, there seems to be some alignment between authors explicitly link holism to the World Health Organ- Western and Aboriginal views as both accept the need for ization's definition of health, an ecological or ecosystems a broad view of health. The 1948 WHO definition of approach, a new public health approach, and a systems health underpins the 1978 Declaration of Alma Ata as model of thinking [30-37]. The working party of the accepted in Australian through the 1979 'Health for All' NAHS quoted the WHO definition of primary health care policy [15]. These developments precede the NAHS in full [3:x], without questioning its cultural origins. Addi- (1989), and there are similarities between the Definition tionally, the Framework states that: and the WHO version of health. The Australian health sys- tem is also more accepting of other world views in what Within the health system, the crucial mechanism for Heather Eastwood (2000) calls a 'postmodernist move- improving Aboriginal and Torres Strait Islander health is ment' that challenges the superiority of the positivist, the availability of comprehensive primary health care modern world view. Also, policy makers are more aware services. [27:1] of the need to consider ethnicity and culture in health pol- icy [48]. The acceptance and uptake of this Western approach appears unproblematic in the NAHS and the literature These confusing messages detract from the clarity needed where Aboriginal holistic health is consistent with com- to support the theme of Aboriginal holism as an under- prehensive primary health care (Table 2). Further confu- pinning philosophy of health (Table 2). What they also sion ensues through the conceptual overlap with primary signal is that both Western and Aboriginal societies are care, comprehensive primary health care [38,39], and ver- heterogeneous and contain a multiplicity of health con- tical primary health care, which 'forms only a part of com- cepts [26,49]. Moving the discussion from a conceptual prehensive primary health care, which is a broader, level to the service delivery level, the literature contains holistic approach to health problems' [40:146]. These dif- further contradictory meanings. ferences appear trivial, but their philosophical underpin- nings have important implications for operationalisation Which Health System Failure? into health system [38,39]. Aboriginal people access both Aboriginal-specific and mainstream health services [38,50]. This contrasts with a Both the mainstream and Aboriginal health literature theme suggesting the failure of the mainstream health sys- position holism as opposite, counter, or antithetical to the tem to address Aboriginal health (Table 2), principally Western biomedical model of health [8,13,26,41-45]. because health 'is holistic, a concept that many Western Three senses to this discourse emerge from the literature, models of healthcare delivery fail to identify and therefore the most prominent being the health professions past accommodate' [42:222]. Nevertheless, some advocates ethos of colonialism – 'the domination of Aboriginal are fervent that mainstream services should [51], and have health care by the medical model approach fitted well [52] become more holistic. Therefore, it is no surprise that with other assimilation policies of the period' [3:59]. In a the Commonwealth Health portfolio: second sense biomedicine, in contrast with holism, is said to devalue or disregard personal and societal social, eco- is pursuing a two pronged approach, which aims to both nomic, environmental and cultural factors on health improve accessibility and responsiveness of the main- [33,46]. A third sense relates to biomedicine's Enlighten- stream health system and to provide complementary ment rationalist heritage which tends to emphasise a action through Indigenous specific health programs. mechanistic view of the body, reducing 'health' to an [53:161] absence of biochemical and physiological symptoms [33,47]. The efficacy of this policy seems justifiable as large poten- tial gains in Aboriginal health could be realised through Page 5 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 reorienting Australia's $66.6 billion health system [54]. Health Professional Separatism? Advocates readily support work to improve mainstream In terms of health service delivery, authors are quite will- system access following from many initiatives developed ing to claim that Aboriginal people embody holism in the NAHS and the Framework. Additionally, govern- (Table 2). For example, within ACCHS 'the Health Worker ments fund and support more than 100 Aboriginal com- role is driven by a holistic approach' [66:xiii]. Further- munity controlled health services (ACCHS) initiated since more, the Queensland Department of Health ' under- 1971 [24,50] that are said to exemplify holism (Table 2). stands that recruiting Indigenous peoples will better Published literature from ACCHS would assist policy position Queensland Health to... develop a holistic makers in clarifying service delivery implications of approach to health' [67:3]. These meanings imply a strict holism, however only 16% of the publications came from separatism between Aboriginal people and ACCHS and Aboriginal organisations (Table 1). non-Aboriginal people and mainstream services. Some descriptive literature is available [55,56] but none An implication of this is seen in the definition of commu- based on evaluations of their relative effectiveness [57], nity control where 'Aboriginal people must determine and although community controlled service delivery is often control the pace, shape and manner of change and deci- uncritically proclaimed as 'an uncontested good' [57:4]. sion-making at local, regional, state and national levels' Furthermore there is an array of different types of Aborig- [24:77]. Seemingly in agreement, the Australian Medical inal service delivery models covered under the banner of Association (AMA) supports Aboriginal holism [68]. holistic services, ranging from dedicated Aboriginal med- However, they staunchly defend placing doctors at the ical services to multi-purpose cooperatives with health as centre of primary health care: 'the AMA strongly recom- part of their overall function, to separate substance misuse mends that all PHC should be delivered through general services [56]. This lack of critical evaluation research is a practice' [69:4] and emphasise 'The unique clinical skills major impediment to understanding the efficacy of of GPs in providing holistic/social care' [69:2]. Addition- ACCHS, and how the lessons of their operations could ally, in spite of the assimilation label attached to the med- influence mainstream health system reforms. ical profession in the NAHS, the NAHS Working Party accepts the WHO primary health care model developed This adds to the theme where some authors note prob- under the conceptual umbrella of the WHO definition of lems with the concept (see Table 2), which include that health. This was developed by experts (professors and relying on it may divert attention and resources away from medical doctors) with a background in social medicine, the core business of health services, and lead to difficulties one of whom became the first Director-General of the in establishing effective measures and indicators WHO [49]. [49,58,59]. However, they fail to elucidate specific criteria and evidence for their assertions. These factors combine In practice, mainstream doctors question their own scien- with the findings outlined above mean any argument for tific training in providing health care [8], and there is an success of failure of the health system has limited empiri- increased number of both doctors working in Aboriginal cal basis for justification. As such, the Commonwealth health services, and of Aboriginal doctors [50]. Medical could justify saying that: doctors receive particular criticism in Aboriginal health, but they have a significant role in the advocacy for Aborig- The health needs of Indigenous Australians are largely met inal rights and in working with Aboriginal organisations through the funding and delivery of mainstream health [70]. Medical educators have access to medical curricula services, with services specially targeting Aboriginal and improvements to incorporate Aboriginal health [71,72]. Torres Strait Islander people complementing these main- There also exist a wide range of internet resources specifi- stream services. [60:v] cally targeting the health professional [73-75]. The propo- sition of separatism between Aboriginal and non- In a broader sense, often accused of poor coordination Aboriginal people, concepts of health and antithetical, Commonwealth Government agencies are beginning 'to unchanging cultures appears undercut by the willingness engage in holistic thinking and think beyond the bound- of health professionals to challenge culturally established aries, conceptualise broad outcomes, and understand norms, and to be culturally sensitive in their approach. areas of commonality' [61:53]. However, government officials face a maze of uncoordinated Indigenous struc- Implications for Health Policy and Strategy Development Processes tures to navigate [62]. Of the thousands of Aboriginal organisations the potential exists for an 'Indigenous order I posed the question earlier: could incapacity to engage of Australian government' [63], but attempts such as coa- effectively with the concept undermine health system litions of Aboriginal organisations [64,65] fail to present improvements? I have shown that through the medium of coherent policy positions. literature synthesis that effective engagement is not Page 6 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 possible which is a significant barrier for systemic reform ences to any Aboriginal concept of health. Significantly, because health strategy construction relies heavily on pub- the COAG reporting framework effectively orients all lished literature. This partly undermines the theme of an commonwealth ministers to produce efforts consistent underpinning philosophy of health (Table 2) as accepted with this framework. It is therefore questionable whether as an explicit policy principle by the Victoria, Northern Aboriginal concepts and knowledge could receive full Territory, New South Wales, Queensland, and Western argumentation and explanation in these processes, Australia Governments, and as advocated for as a policy because policy 'is the outcome of the competition principle by professional associations and a range of non- between ideas, interests, and ideologies' [81:3]. As such, Government organisations. given the heterogeneity of Aboriginal cultures, ineffective transfer of meanings through written and oral communi- However, arguably more meaningful engagement occurs cation, undercut by rivalries and intra-cultural conflict through oral communication. Consultation meetings preventing national Aboriginal unification, then the include a wide range of Aboriginal and non-Aboriginal approach of the Howard government of dealing directly people across the country. This multitude of voices project with individual Aboriginal communities could well be preferences through ideological, institutional, profes- justified [82]. sional, and cultural perspectives. While advocates may agree with the concept in principle, each could be tapping Conclusion into their particular view of holism. For example, some I conclude that literature synthesis cannot provide an medical literature suggests doctors view 'holistic answer to the question: what is the holistic concept of treatments' as alternative or complementary medicine Aboriginal health? Rather, policy makers can justify any such as acupuncture, relaxation, massage, and hypnotism answer based on the diversity of the literature, subsequent [8,41,43]. themes and range of meanings. Furthermore, I question the cultural basis advocates attribute to the concept as Additionally, strategies receive ministerial endorsement immutably Aboriginal, which undermines the credibility after processing through a hierarchy of advisory and con- of its use. In terms of the range of Aboriginal concepts sultative committees. For example, in the development of available, the effective transformation of their meanings the National Aboriginal and Torres Strait Islander Nutrition into the health system could be enhanced through coher- Strategy and Action Plan, the majority-Aboriginal working ent and articulate written and oral communication. The party was in effect a sub-sub-sub-committee of the lack of knowledge about them is serious barrier that endorsing committee: the Australian Health Ministers should be addressed through more research. This would, Advisory Council [76]. This and other endorsing councils in part, enhance the capacity of policy makers to engage do not include an Aboriginal person to explain the com- meaningfully and confidently with Aboriginal concepts of plexities and nuances of Aboriginal cultural concepts, and health. However, further attention needs to be given to thus revert to understandings from the literature or from the processes of health policy and strategy development their own perspective, clearly as many authors do in the so that these meanings receive adequate consideration literature. and argumentation in written and oral forms. Otherwise, health outcomes for Aboriginal people may continue It could also be argued that one Aboriginal person on along an appalling path. endorsing committees would be insufficient, given the hundreds of Aboriginal groups in Australia. This extends Methods to the validity of the majority Aboriginal membership Literature Detection mandate of steering committees, as each may draw on dis- The Australian Aboriginal health literature was defined as tinct cultural concepts, such as mwarre, punyu, and Australian publications on Aboriginal affairs with a health wankaru. The in-group rivalries are well noted between specific focus or section and which explicitly stated the different Aboriginal tribes as well as between urban, rural terms 'holistic' or 'wholistic'. Publication detection and remote communities [77,78]. Finally, the insignifi- occurred using the search string: (Aborig* OR Indige- cant number of Aboriginal people in all the health sys- nous) AND (holistic OR wholistic) AND health, applied tem's structures – in 2001 only 0.9% of health care to the databases of Informit: APAIS (health, public affairs), providers were Aboriginal [79:18] – precludes occupying ATSIhealth, CINAHL, Health and Society, Australian Med- enough positions to give adequate force to oral transfer. ical Index, Rural; as well as MEDLINE and PubMed. Results from each database were cross-referenced and It is perhaps for these reasons that the new reporting duplicate items removed, with periodic repeat searches framework for the Council of Australian Governments ensuring new publication capture. Additionally, snowball (COAG), set in the Overcoming Indigenous Disadvantage: searching of journals enabled capture of older publica- Key Indicators report [80], has a complete absence of refer- tions and those not listed in the databases. Finally, Page 7 of 10 (page number not for citation purposes) Australia and New Zealand Health Policy 2005, 2:15 http://www.anzhealthpolicy.com/content/2/1/15 which was a component of a Master of Public Health degree delivered Aboriginal affairs reports were detected through relevant through the Menzies School of Health Research. government and organisational internet sites and searched for key terms. The publication characteristics are References shown in Table 1. 1. Hilless M, Healy J: Health Care Systems in Transition: Australia 2001 Copenhagen: European Observatory on Health Care Systems, World Content and Thematic Analysis Health Organisation; 2001. 2. 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Office of Indigenous Policy Coordination: New Arrangements in Indige- nous Affairs Canberra: Commonwealth Department of Immigration and Multicultural and Indigenous Affairs, Australian Government; Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." Sir Paul Nurse, Cancer Research UK Your research papers will be: available free of charge to the entire biomedical community peer reviewed and published immediately upon acceptance cited in PubMed and archived on PubMed Central yours — you keep the copyright BioMedcentral Submit your manuscript here: http://www.biomedcentral.com/info/publishing_adv.asp Page 10 of 10 (page number not for citation purposes)

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Australia and New Zealand Health PolicySpringer Journals

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