What’s the evidence, what’s working, what’s not and what are the issues and opportunities for the future?
On 11 July 2014, more than one hundred clinicians, policy makers, community members, academics and consumers joined the Key Thinkers Forum in Darwin to discuss Alcohol, tobacco and other drug use: What’s the evidence, what’s working, what’s not and what are the issues and opportunities for the future.
This was the third forum of its kind and as with previous forums, a briefing paper was sent out to everyone involved prior to the forum. The paper can be found at:
Comprehensive notes were taken at the event in order to develop this ‘Poche Opinion’ on the topic. The scope of the discussion on the day was focussed on rural and remote and therefore we will not be able at this time to make specific recommendations about urban populations or solutions.
The facts about alcohol, tobacco and other drug use and Aboriginal and Torres Strait Islander health
Data taken from the Northern Territory reveals that the Territory is drinking alcohol around 30% more than the rest of the country. By capita the average amount of alcohol being consumed in the NT is 13.4 litres compared with 10.3 litres, which is the national figure for people aged 15 years and over.
While 90% of non-Indigenous Territorians consumed alcohol as compared to 50% of Indigenous Territorians, about 90% of Indigenous Australians consumed alcohol at high risk levels compared to 30% of non-Indigenous people. Also, the age of Indigenous Australians drinking at high levels is spread – it is not largely confined to the young, as is the case with non-Indigenous people.
The total social cost of alcohol in the Northern Territory is over four times the national rate at $642 million per year or over $4,000 per adult compared to $943. More than 90% of those costs are associated with those higher risk levels of alcohol.
There are similarities between alcohol and tobacco. In Australia about 14% of the population are current smokers. In the Territory’s Indigenous population about 50% are current smokers. While generally in Australia there is a decline in people smoking, there is much less evidence of change in the Indigenous population. Again, this manifests in very high costs for the Northern Territory in the order of $764 million or $5,150 per person aged over 14 years.
Evidence from the Northern Territory Midwives Collection reveals that the next generation is at risk as pregnant Indigenous women are not responding to the warning messages around drinking and smoking during pregnancy as much as non-Indigenous women are.
From looking at the statistics it looks like the national picture is slightly more optimistic than the situation in the Northern Territory, however, there remain questions around how these statistics are collected and whether that process could be improved. These concerns are that the statistics are average and do not look at specific communities or areas, and that it is also difficult to separate urban and rural populations. In light of this, it has been suggested that the statistics be split to give us a better sense of where the changes need to take place and what we should be targeting in specific situations.
There are many programs that are working at present and can act as a model for communities and services still in need.
- the LGANT smoke free areas policy, which has reduced smoking in cars and homes by 46% on the Tiwi Islands
- the Heart Foundation’s ‘Healthy Spaces and Places’ strategy
- the successful volatile substance legislation in Maningrida, which has all but eradicated the issue there
- the Fitzroy Valley community led program targeting FASD
- the Groote Eylandt model of alcohol management, that is proving effective
- The Juninga housing project, an example of successful community housing And more generally:
- Plain packaging for tobacco products and the government’s ‘tacking Indigenous Smoking’ programs (though there has been concern expressed about the lack of information regarding the future of government funding for the latter)
- Restricted access to alcohol, with take away limited to light strength beer in a Fitzroy Valley community
- Suicide prevention programs on the Tiwi Islands and in Eastern Arnhemland communities
This short list is by no means exhaustive- there are other effective programs which have shown strong results however, they tend to be working in isolation at present so we are looking to duplicate such models in order to benefit further communities.
Across the board, we can see that a lot of successful models are community led. They include role models and leadership. Experience has shown that these initiatives provide an effective way to communicate with community and youth in particular.
And what’s not…
There are still many aspects of substance use that remain problematic.
Insufficient funding is an issue in terms of development of successful programs such as those listed above, as is uncertainty around continuation of funding for successful programs. Government policy around funding is narrowing the scope of responses for dealing with drug and alcohol problems. In fact, there is a general lack of local political support of programs in any sustained way and no equity on where prevention is being provided or how it is being applied. The same can be said for supporting Indigenous Alcohol and Other Drugs (AOD) workers. Lack of job security has forced many who have been trained and who have become passionate about the work they are doing to seek employment elsewhere.
Unfortunately the major focus from government has always been at the wrong end of the spectrum. Treatment rather than prevention, and punishment for alcohol related offences rather than support for addiction. The way policy tends to deal with related offences is through fining offenders (seen mainly in the area of alcohol), which does not solve the issue. Fines for public drinking in the Northern Territory are currently very expensive and this is leading to imprisonment for fine default, which again does not address the underlying issues of the drinking. This, coupled with the fact that the alcohol industry is resistant to change and lacks engagement with the affected parties and their carer organisations creates a vicious cycle in which policy refuses to attend to underlying issues and looks at applying ‘band aid’ solutions. Other obstacles to clear treatment plans are the high density of alcohol outlets, ongoing advertising for alcohol and the lack of change in the consultation process around licensing.
Prison systems are not set up effectively to deal with underlying issues either. The system offers little or no support for mental health issues and no support beyond rehab, meaning that people are coming out of prison back to communities that lack housing and infrastructure to support their return. Not only do the issues remain, but they are compounded by returning to a community that has had no education in rehabilitation nor does it provide support for its members. It is thought that conventional models or treatment do not necessarily work in an Aboriginal context, so that new ways of looking at the issues are required. It is acknowledged that some efforts are being made to reform the NT prison system including the making of all NT prisons “smoke free” in 2013.
Suicide remains the leading cause of death in Aboriginal youth and self-harm is also common and exists on the same spectrum. Aboriginal rates of suicide remain 2.6 times as higher than non-Aboriginal and the latest observation is an increase in young Aboriginal girls taking their lives. When looking at substance use, there are more often than not underlying personality or mental health disorders. These do not necessarily attract treatment in mainstream health industry and lead to a vicious cycle of substance use.
So, what do we do?
What are the issues and opportunities for the future?
When it comes to drinking, the national narrative around drinking culture needs to change. We now have evidence for the need to reduce alcohol harm, so we need the courage to implement some solutions. Luckily attitudes are changing and despite issues being amplified in extreme settings, there is growing awareness of the fact that the next generation suffers more.
There are several areas of society that need to be worked with to improve the overall picture, including government, community and industry.
The context of the decision makers is relevant when it comes to how to work with government. In general, the Commonwealth looks at accessibility, the state looks at context and local governments tend to have ‘on the ground’ knowledge. If we can play to strengths of each government, we can make the most of their power to make decisions. An example of this is that recently the Commonwealth has been investing in remote area workforces – placing drug and alcohol workers in remote communities.
Governments have influence over taxation and funding. Taxing makes a real difference in consumption and raising taxes has proven to be equal to harm reduction in the past so we can lobby the government to introduce further taxation increases in order to deter consumption.
Funding for successful programs and Aboriginal controlled centres needs to be secure and long term, with more of an emphasis on the prevention side of the issue. It is also the government’s responsibility to reduce the influence that industry has over policy and legislation. As proven in Fitzroy Valley, advocating for supply measures that foster a safer community and then supporting communities who decide to do so is the key. Industry should not be able to sway decision-making or override decisions. Industry should also contribute more education and resources to treatment protocol as it holds a lot of the responsibility.
On a local community level, funding and services need to be coordinated so as to avoid miscommunication, doubling up and service gaps. Communication and networking are also needed to form a more collective effort. Strengthening what we do as a group will gain the attention of governments.
When it comes to Aboriginal communities there are two repeatedly successful elements: culture and community engagement. Engaging is much more effective than punitive action and pride in culture has a dramatic impact on mental health. If we can work with communities to be empowered around their own solution (this will be different for different communities), then we can work to the strength of the individual contexts. One of the most important focuses is looking at the community narrative around the issue. This will allow us to tap into how best to deal with it. The question that needs to be asked of each community is “What do we need to make us strong?” and Indigenous paradigms and knowledge should be used in the answer to these questions. Communities need to be leaders and provide the necessary support for individuals. Self- determination and cultural reclamation have proven to be able to prevent the escalation of issues, which leads to community and individual resilience. Cultural safety and emotional wellbeing have to be considerations.
As a society, the focus should be on both prevention and treatment. In order to prevent the current picture continuing, education and proper diversion programs from prison are needed. Health education in schools would benefit from talking more about alcohol and current mass communications on healthy living could also be scrutinised and improved.
Social, historical, political and cultural determinants need to be addressed in education with more effort put into Indigenous curriculum in education, especially embedding Aboriginal curriculum in health workforce education. Privilege and racism also need to be addressed in education, especially with a focus to train up health care professionals about how to deal with these issues.
When it comes to treatment, more effort needs to be put into transitional care post-prison and offers of employment. Lessons can also be learnt from the successful implementation of making NT Prisons go “tobacco free”.
Substance use and suicide remain areas where we need clearer data. Evidence, legislation, policy, services and funding need to be explicitly linked in our efforts to change the current picture.
In light of the facts discussed, it is clear that the stop-start funding of programs to date has been a major failing in Indigenous affairs, as have punitive measures. Continuation of such practices ignores known facts about what works and undermine efforts being made to achieve long-term solutions. The success in Maningrida, the Tiwi Islands and Fitzroy Valley did not happen overnight and they did not come from outside. Concerted effort was made from within the community and over a long period of time to effect cultural change.