the other paper I promised to post, about Indigenous health care...

This is a paper I wrote comparing the health systems and policy approach of the indigenous people of Australia, Canada and the United States. I talk about how culture will have to be taken into consideration during the policy making process and be infused into the policy decisions themselves. I promised some people I would post this in a few of the forums, so here you all go.



CULTURE SHOCK: THE INHERENT PROBLEMS IN INDIGENOUS HEALTH

PROLOGUE: A PERSONAL INTEREST

On August, 29 2005, I was on the phone with Montana State Coordinator of Indian Affairs, Reno Charette, discussing several issues pertaining to Montana’s Indian tribes. I am a Blackfeet Indian, raised just outside of Cut Bank, MT, on the Blackfeet Indian Reservation, and the purpose of our discussion was the possibility of my moving back to my home state to pursue a run for an open State Senate seat in 2006. The district is predominantly Indian and I was eager to catch up on what the governor’s office had planned for the state’s indigenous populace.

The biggest Indian-related policy state initiative has been the funding of what is known as “Indian Education For All,” a concept that has been in the Montana Constitution for nearly 30 years, yet had never been fully funded by the state’s policymakers. In 2004, Montana elected both a Democratic governor and legislature for the first time in over 20 years, and each were eager to fund the program, which consists of teaching Indian culture and history from all of Montana’s tribes to all of Montana’s students, Native and Non-Native. Funding had been the main sticking point for decades on this issue. However, insensitivity and ignorance, if not an element of racism, played a significant role as well.
Ms. Charette told me that while the state senate was debating the funding issue, one state lawmaker stood up and said something to the effect of: “ Why do we even need Indian Education For All? Are there even any Indians that exist anymore?” To say the least, I was stunned! In this day and age, a state lawmaker making such an insensitive and incognizant statement, is wholly inexcusable if not unconscionable. But it brings to mind an important aspect of policy as related to all indigenous people. The concept that countries with indigenous populations will have to recognize that culture is an important aspect of policy solutions.

Certainly the indigenous people of Australia, Canada and the United States -the countries I will analyze in this paper - have been besieged with many socioeconomic problems, one cannot discount them when interpreting policy effects. And, since the focus of this writing will be on health care I should note that the socioeconomic determinants of a people definitely have a direct effect on the health of the group. Poor people tend to be sicker than those who are better off financially. No doubt. But this is not to say that recognition of cultural aspects is not important in health care either. It is.

Indigenous people have virtually all suffered grievous treatment at the hands of their occupiers, Australia, Canada and the United States each are no exception. However, the shunning of culture in these country’s policies, is not all because of negative reasons. Often good people, especially those in the Western tradition of government, seek to help indigenous populations with blinders on.

They believe they know what is best and that they need to help the poor, suffering Indians or Aborigines; it’s a classic case of White Man’s burden. This is as predominant, and just as important, in health care as anything else. To policymakers or other impassioned figures looking to actively help the indigenous tribes, culture is probably not an essential element of their own lives, let alone of their perception of health care. They don’t fully understand how it permeates the whole being of an indigenous person and their community. So it is ignored.

The cause of this concept is that countries with indigenous populations have historically ignored cultural aspects in health care policy solutions, the effect of this inaction, will be a movement in which these populations will force policymakers to look at integrating a cultural component to health care policy in the future. Much in the manner that Montana did by incorporating Indian culture into education. And, in the future, when a policymaker wonders if indigenous people exist or not; if cultural aspects are necessary additions to policy, they can see proof in the movement around them.

All they have to do is take the blinders off.
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INTRODUCTION TO INDIGENOUS AFFAIRS AND SOCIETIES
There are a great many similarities in the indigenous people of Australia, Canada and the United States. In all three countries, each group tends to suffer from many of the same social and economic ills. Often egregious events in their pasts are similar. For example, all three minorities have been displaced from their natural homes, and were forced to live in reservation or reserve communities. They all suffer from higher incidences of alcohol addiction and unemployment rates than the non-indigenous populations of their respective countries. They tend to make a lower median living wage and are much more likely to live in poverty: this can correlate to inadequate nutrition, substandard housing and a lower quality of life. Decades of lackluster educational systems and less chance for socioeconomic advancements are also devastating common themes shared by the groups.

As a whole, each minority group has a lower life expectancy, higher rate of illness, are less likely to graduate from high school, more likely to have human problems such as violent tendencies and have a higher chance of spending time in jail than members of the average population. Local governments are often inept, corrupt, or lack the power to make a major policy difference for these populations. In the United States, for example, tribal governments can make policy, but they then have to get approval from the regional Bureau of Indian Affairs superintendent, who then shoots up the policy through a long bureaucratic system. Little if anything is done and, even then, the change is quite gradual. Often, because of their lack of resources Aboriginal and Indian populations are heavily dependent on the aid of their federal governments.

Uniquely, indigenous governments and their people tend to have a special relationship with the federal governments of the countries they are in. Reservations and Reserves are considered protectorates of their federal governments. They have a certain type of autonomy, yet, in many ways, they still function as an occupied people.
The U.S. perhaps differs slightly in perspective in that their sovereignty allows them to do several actions on their own. They can coin their own money for example, and unlike Canada, tribes in the U.S. can substitute a state or federal tax with their own tribal tax. Now this could be beneficial in retaining their own autonomy for health services. Canada’s tribes pay provincial taxes, however, since they are interested in taking control of their own health care, one possible helpful funding solution could be the institution of their own tribal tax, in replacement of the provincial one. The U.S. tribes function specifically as nations within a nation, however, and need not answer to the state on mostly anything, with one obvious exception being Indian casinos.

Interestingly enough, tribal people all had to give up the right to organize a military force. As protectorates of the federal governments, and I suspect because of past conflicts, they cannot organize anything resembling an army or militia, yet in all three countries, indigenous people can serve in the military. These odd instances typify the complex, often fragmented, relationships indigenous people have with their governments. However, the key idea in all of this is the American Indian tribes in the U.S. have sovereignty, while the tribal people of Canada and Australia are more associated with self-determination. Before I go on, it is important to understand that in both cases these are limited concepts, for example, the Navajo tribe may have sovereignty, but it’s a limited sovereignty, as external forces can be extremely controlling.

Sovereignty is an autonomous state in which a tribe is subject to it’s own decisions without controlling interests effecting internal matters. Self-determination, in this sense, is the freedom over one’s own choices, but also the determination to have a say in any external decisions. So what stands out to me, in this case, is that Canadian and Australian Native peoples are looking to use external policy decisions as a way to get control of their community health care. They want to determine that right for themselves, and I’ll get into this more later. U.S. tribes have some influence in the system by exerting sovereignty on a local level, but they appear to prefer the tribal government to federal government relationship which exists. As of now, all three indigenous groups are dependent on their federal and/or regional governments for health care. None are looking to fully change that anytime soon, nor could that be absolutely possible, but each are looking at different ideas to give them more say in their own health care. The difference, as stated earlier in the paragraph, is that the U.S. tribes are somewhat content with the basic system, while the aboriginals of Canada and Australia are more intent on changing the structure of the relationship.

From a cultural standpoint indigenous societies tend to be more communal than the rest of society. A community, its people, its customs, its intricacies, become a comfort zone for the people who live there. Traditions are hard to break. Even in people who are, by and large, assimilated into mainstream societies. For example, in all three countries, many tribal people have been reliant on certain natural resources for hundreds of years. Say that a tribe has a strong fishing or whaling tradition. That is still prevalent in the lives of all members of their tribes even to this day. Whether they are a Torres Strait Islander from Australia or a Makah Indian from Neah Bay, Washington here in the United States, the tradition that has always been a tribe’s life’s blood will always be. While this may seem trivial in a way, it is fundamental that health providers such as doctors, nurses and local administrators are sensitive to these and other cultural tendencies.

There are four cultural tendencies, as I see it, which could factor in future policy solutions in indigenous health care: language and local traditions, traditional holistic approaches, diet and overall cultural sensitivity. I will quickly describe these and touch base on them again throughout this writing.

Language and local traditions are very tricky. Indigenous people tend to welcome outsiders generously, yet are also wary of them. Tribal peoples have nuance and little things can make a major difference. Indians, especially Northern U.S. tribes tend to joke around with friends and family often. To the point that the teasing appears rude and serious. Yet it is not. It’s a way of showing friendship, as oddly as it sounds. Sometimes outsiders do not get this humor, that could definitely have effects on any outsider, whether they are a health professional, an educator or anything else. Often, indigenous people do not make eye contact, nor do they like it when others do so with them. Some tribes consider this rude, naturally this is more likely to be an issue with the elders, yet it is still an overarching issue that should be known. Elders are also especially revered in all tribal cultures, and they happen to be the group that are most in need of health care. Sensitivity to their idiosyncrasies is helpful, if not essential. Some elders only speak their native tongue as well. While you cannot expect every doctor, nurse and administrator to learn a rather obscure language, you can allow for them to be sensitive to this barrier and the translation process.

Indigenous people, whether they are Australian Aborigines, First Nations of Canada, or American Indians from the United States, are numerous and diverse with time honored holistic traditions, often dating back thousands of years. They are some of the oldest surviving cultures in the world. Indigenous holistic approaches focus often on prevention, they also incorporate individual and family values. They take an approach that accentuates social and mental well-being as well as physical wellness. Interesting enough, the Tucson Indian Center offers different holistic approaches to wellness, including acupuncture, which is not a traditional indigenous treatment, but does fit into the same realm of philosophy. Any effective health care solutions for indigenous people in the future, will have to incorporate holistic medicine in the equation for sure, as this is the one cultural element consistently prioritized highly by each group.

Diet is another important cultural factor regarding indigenous health, and, surely, will be for the foreseeable future. Indigenous people are plagued by rampant obesity, and diabetes has been an epidemic for sometime. The tribes of U.S. and Canada have a far more serious problem than the Australian tribes do, however, diet and obesity is still important for them, as they still have a higher rate of diabetes than the rest of the Australian populace. For many indigenous people, diet is so important because, as a people, they haven’t been eating Western food for all that long. They went from eating wild game and local grains and vegetables, to getting government rations, such as lard and flour, in a few short years in the 19th century. Some rural oriented or isolated tribes have only recently came across modern fast and junk foods. For instance, the Pima Indians of Southern Arizona are among the fattest people in the world. Over half of the tribe is overweight and diabetic. Their diets consist of junk food, fatty fried bread and Indian tacos, as well as the usual high rate of alcohol use that is often seen in Indian people. They are not far removed from being strictly a desert people, and their cousins in Mexico, essentially the same Pima tribe except they are separated by a man-made border, are a much thinner people, who live off of traditional Indian staple foods, such as corn and beans. Unfortunately, this problem with indigenous diets, is one that is of epidemic proportions, so much so that diseases related to obesity, especially diabetes, have to have unique cultural considerations in indigenous health care.

As for overall cultural sensitivity, there are many factors layered into this. Redundantly, the three just mentioned, language and local traditions, holistic medicine and diet, figure in prominently. The other aspect I will mention is similar to the same concept that the state of Montana has taken with regards to “Indian Education For All.” Similar, in that, any medical professional who works on a reserve or reservation may be looked upon and required to have a cultural credential. For example, a doctor who has worked on a reserve or reservation in one of the countries before, would certainly have credentialed experience in working with indigenous people. On a different level, if a medical professional, took a workshop or say had, 6 credits in indigenous related college courses, that may qualify as a useful credential as well. Policymakers may want to ensure that any health professional who wants to acquire these credentials, should have the opportunity to do so cheaply or with no personal cost. A possible enticement too, may be reimbursement or a tax break. Also, it would be beneficial to encourage indigenous people themselves to enter the health care field. All three countries offer excellent scholarships and provide many opportunities for indigenous scholars to enter the medical profession. This could only be beneficial to everyone in the long run.

SYSTEM OVERVIEWS AND HEALTH STATUS
The health systems for the general populations of Australia and Canada are both Medicare programs. National single-payer insurance that covers all residents of those countries. However, indigenous people do have slightly different roles in the systems there, which I will get to. Both Australia and Canada incorporate public finance and private delivery, Australia encourages its citizens to enter into a private plan to reduce burden on the national system and Canada has deliberate limitations on the role of the private sector in their system. Australia’s Medicare plan only reimburses a set amount, which varies according to service, and Canada covers all required medical services at no cost to the patient. The U.S. system is much more complex. U.S. citizens receive coverage through various private and public programs. The system is geared much more towards competition and health care is often packaged as an employment benefit. The two major public programs are Medicaid, for the disabled and impoverished, and Medicare for the elderly. While Australia and Canada ensure that every citizen gets some type of coverage with their systems, the United States does not, which has currently left over 40 million Americans without health care.

In Australia, state and territory governments provide funding for indigenous health care through hospitals and community clinics. This, of course, varies slightly from the U.S. tribes who primarily get funding straight from the federal governments. Canada has a much more complex funding system than the other two countries. What is similar to the U.S. and Canada is that the Australian government does provide funding, through the Office For Aboriginal and Torres Strait Islander Health (OATSIH), which allocates funding for a variety of indigenous-specific programs. So they do have a federal component figured into the financing as well. Also similar to both Canada and U.S. tribal health programs, OATSIH-funded programs operate in rural and isolated areas, providing for prevention services such as screenings, and transportation for patients.

Canada is fascinating because, due to different Constitutional views regarding treaties, the federal government has taken responsibility for providing health services to Indians, yet they have no official responsibility to do so. Because of the ambiguity of the situation, the federal government provides service only as the “payer of last resort“. They officially consider the services they provide to be voluntary. Not surprisingly the Indian tribes of Canada have a different view, and believe under treaty obligations that they should be entitled to the service. Now, in both Australia and the U.S. this dilemma does not exist, the governments of those countries officially pay up, at least a portion of the costs anyway.

This has led to a fragmentary health system for the Canadian tribes, financed by a conglomeration of federal, territorial and provincial funds. There is also a movement underway to move control of Indian health care away from the federal government and give power straight to the Indian communities. This has many benefits, and many tribes want this as part of their identity of self-determination, but, some fear that once the turnover happens then the federal government will back away from the responsibility of providing health care services to the tribes. Predictably, Indians are like any other group, they do not speak with one voice on this issue. Some want to go through with the changeover, while others do not.

First Nations tribes are under direct control of 588 million dollars in funds, this specific number is from 2001, however the system is so complex that it’s difficult to figure a precise number spent for total health care. For example, Canadian Indians use provincial hospitals just like everybody else would, but the federal government does not compensate these hospitals for its service. This may be up to 80 percent of the costs out of provincial hospitals in a year. It’s been guessed that the total federal, territorial and provincial health care expenditures for Indian individuals may be as much as twice that of the average non-Indian.

For U.S. Indian tribes the U.S. Congress passed the Johnson-O’Malley Act in 1934, which enabled the Secretary of Interior to contract with states different services for Indians. Health care was, originally, under the supervision of the Bureau of Indian Affairs (BIA). Later on Indian health care was switched to the Public Health Service, and the Indian Health Service (IHS) was created under them in 1955. Generally, because of their unique protectorate status, health care for Indian tribes is considered an entitlement. This is in obvious contrast to the situation of Canadian tribes, and more in relation to the Australian view too.

IHS is the primary federal health service provider for Indians, and it’s mission is to provide a comprehensive health delivery system, while giving tribal institutions the leeway to formulate and streamline their own community-specific programs. IHS works very much like a single-payer system for the patients covered under it. Indian hospitals take care of most basic services and contract out to specialists and other hospitals for other types of care they do not provide. Although, just who and where they contract out to is limited because of budget constraints. Like Australia’s aboriginal system, the Indian Health Service constantly complains about under funding, and, indeed, this is probably true. Indian Health Service Director, Michael Trujillo recently wrote about having a level budget appropriation for the fourth straight year. He described a level budget as a: “reduction of resources of approximately $100 million to account for mandatory cost increases, inflation, population growth, and providing services to newly recognized tribes.” Canadian tribes, on the other hand, are not considered to be suffering from under funding, but more from the inefficiency of an overly fragmented, complex system.

The problems for the Indian Health Service are compounded by the anti-government attitude of the U.S. Congress, who are considering several possible budget cuts that would effect the American Indian populace as a whole, and IHS itself. Already poor and in socioeconomic disarray, severe budget cuts could make American Indian’s health status even worse. The U.S. populace also has a deep-seated mistrust of government, viewing it as part of the problem and not the solution, whereas in Canada and Australia government is not regarded with as much disdain and/or mistrust by both policymakers and the general public.

In all three countries, the health status of indigenous people is not very good. Health status in this case seems to be determinate more by various socioeconomic and environmental problems, than by the quality of health care. In this case, health care itself, is dwarfed by the other problems that indigenous people have to deal with. Australia seems to be slightly worse off than either Canada or the U.S. with regards to the health of it’s indigenous citizens, as they are considered one of the healthiest countries in the world, yet have a bigger general gap between the healthy and unhealthy.

The life expectancy rate, from 1998-2000, is much lower for Indigenous people in Australia than for the general population, Indigenous men live, on average, 56 years and women are at 63, the non-indigenous population is expected to live 77 and 82 years, respectively. While, in this period, an indigenous child was more than twice as likely to be born with a low birth weight. Like their counterparts in the U.S. and Canada, indigenous Australians battle obesity. They are, on average, more obese than the general populace in every age group for both males and females. Putting them at a greater risk for heart disease, type 2 diabetes and kidney disease. In fact, kidney disease is a significant problem for this demographic. Indigenous Australians make up about 1 percent of the population, and 6.2 percent of the people registered for dialysis in the country identified themselves as indigenous. In 2002, the chronic death rate from kidney disease was 7 times higher for Indigenous people.

One other problem that effects the Aboriginal people of Australia, more so than the ones of North America, is the lack of adequate water. Around ¼ of all of Australia’s indigenous people live in communities that are not hooked up to the town’s main water supply. Along with overcrowding and poor housing conditions, Australia’s indigenous people tend have more problems with substandard housing, which could effect their health, than the North Americans do.

In all three countries, obesity and it’s side effects have proven to be devastating. In Canada, a kidney dialysis patient’s care costs up to $40, 000 a year, and over 100, per every 100,000, indigenous people die from circulatory problems a year. Similar to Australia, infants tend to have a low birth weight. In 1999, statistics in the 20- 24 age group for mothers showed that 142 children out of 2,363 were born with a low weight. Interestingly enough, 529 of the 2,363 newborns from that same age group were born with a high birth weight. Possibly beginning life obese, running an even higher risk of diabetes, heart and kidney disease.

Canada does have a longer life expectancy for it’s indigenous people than Australia, at 68.9 years for males and 76.6 years for females. However, that is still over 7 years less for males, and 5 for females than the life expectancies of the rest of Canada. The good news is these figures have been improving steadily for nearly twenty years, so it appears the tribal people of Canada are getting healthy enough to steadily improve their life expectancy, year in and year out.

In the U.S. there are some good signs too. Infant mortality rate declined 58 percent from the time period of 1972-74 to 1994-96, according to the 1998 Indian Health Service report, “Trends In Indian Health.” However, at 6.1 per 1000 live births, this rate is still 22 percent higher than the non-Indian population. U.S. Indians face an even more powerful obesity epidemic than the aboriginals of Australia and Canada. The rate of diabetes-related deaths have increased in all Americans over the course of the last few decades, however since 1981-83, the age-adjusted death rate for Indians has been 93 percent, while all races are at 39 percent. An Indian with diabetes mellitus has a 249 percent more likely chance to die of this affliction than the other races. Also telling is that cardiovascular disease-related death rates are higher in the Indian population as well. In the statistics from 1994-96, Indians had a 13 percent greater chance of dying from heart disease than the general population.

It appears that in all three countries, consistent themes and problems in health status mirror each other. All three have similar problems with low birth weight, lower child mortality and life expectancies, too. Obesity and it’s related problems appear to be at crisis levels for indigenous people, especially those of the United States. The risk factors for diabetes, kidney and heart diseases are all considerable, and those diseases have taken a toll on the indigenous populace of each country without a doubt. However, it does seem that each country is making progress in those areas as well, perhaps not as quickly as in the non-native populations, but they all seem to be doing slightly better. This is probably due to many factors, including health technology, innovation, patient awareness and more cultural sensitivity in the health care process. Access would certainly be a factor in this improvement, as many indigenous populations living in rural and isolated areas, may not have had the same resources for nearby health care twenty or thirty years ago as they do now. Likely the slower rate of progress is hampered by the considerable socioeconomic factors that indigenous groups of each country face, but progress seems to be occurring slow and steady, so that is a positive development that can be built upon.

A LOOK AT THE FUTURE
There is a trend in each country at incorporating culture in the health care and delivery systems for indigenous populations. In Canada and Australia, it’s more of a larger movement to restructure and redefine the governmental relationships that deliver and provide health care. These groups want indigenous communities to take over their own health care systems. Meanwhile in the U.S., tribes seem much more content with the government to government relationships and prefer to exercise their influence by shaping health care on a local level. For these tribes, scarcity of resources and the allocation of adequate funds is a top priority, much more so than the structure of the health delivery system.

Culture is apparent in the manner law makers are approaching indigenous policy in these countries. In the U.S. Senators John McCain (R-AZ) and Byron Dorgan (D-ND) have introduced legislation to revise and reauthorize the “Indian Health Care and Improvement Act.” It had been reported by the nonpartisan Governmental Accounting Office that the Indian Health Service had delayed or denied payment to 10 of 15 contractors, and many were looking to terminate relationships with the service. Some clinics have to turn away dental and mental health patients as they do not have adequate resources to take care of them all. So, financing the IHS, properly seems to have taken precedent for the time being over an extensive cultural makeover. Although, U.S. tribes still maintain community programs for wellness, prevention and holistic medicine. They also offer, through the Indian Health Service, considerable scholarship and educational resources for Indians to enter the medical field. They also give incentives to any medical professional who wants to serve a residency on an Indian reservation, which is an effective way to educate non-indigenous professionals in Indian culture. So culture still plays an important role in the overall process.

In Canada and Australia, there are larger cultural-based movements at play. Australia, for example has commissioned a framework by the Australian Health Minister’s Advisory Council, to formulate a Cultural Respect Framework working group. In this manner, the aboriginal people are looking to emphasize a community-based program, with a holistic approach to health care. They wish to have more control of their own health care services and to determine the model for themselves, however different this may appear as compared to non-aboriginal outlooks. Australia’s tribes seek to reserve the right to be unique in their approach to health care.

Canada has a similar approach, in that they also seek empowerment by taking control of their own health care services. They are looking to consolidate funding from all the fragmentary sources and create what amounts to, Aboriginal Health Partnerships. In addition to simplifying the funding process, they too, want to emphasize a cultural approach to health care. This approach would be streamlined based on the many different social, economic and cultural nuances of the First Nations people of Canada. Preventive and holistic methods would be prioritized and communities would adapt the health partnerships accordingly to the local populace.

So in conclusion, each indigenous group has their own approach to health care. Canadian and Australian tribes want a more direct voice in their overall health care systems, whereas U.S. tribes are intent on receiving more funding for the existing system. They seem much more content with the federal government’s role as a service provider correlating with the tribes role as a cultural streamliner. However, all indigenous people in the three countries, have unique circumstances that warrant special attention from the health care systems. The plight of socioeconomic problems, poor health status and cultural uniqueness veritably force lawmakers to take notice of the cultural aspects of indigenous people when organizing, implementing and evaluating policy. This permeation of culture into policy solutions appears to be a trend that will only continue to grow.

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Bill Wetzel is a Creative Writing/Political Science major at the University of Arizona. He's the coauthor of "The Acorn Gathering: Writers Uniting Against Cancer" and has been a contributor to Red Ink Magazine.


SOURCES:

“Trends In Indian Health,” 1998-99, www.ihs.gov

“Regional Differences In Indian Health,” 1998-99, www.ihs.gov

“The Future Indian Health Care System,” Trujillo, Michael, 5/5/97, www.ihs.gov

“Challenges and Change" Trujillo, Michael, 11/7/05, www.ihs.gov

“Legal And Historical Roots of Health Care For American Indians and Alaska Natives In The United States, “ Shelton, Brett Lee, Henry J. Kaiser Foundation, 2/04

“Beyond Red Lake- The Persistent Crisis in American Indian Health Care,” Roubidoux, Yvette, New England Journal of Medicine, 11/3/05

“Chapter 10, A New Approach To Aboriginal Health,” Commission On The Future Of Health Care In Canada, 1/ 28/02, http://www.hc-sc.gc.ca/english/care/romanow/hcc0023.htm...

“Royal Commission Report On Aboriginal Peoples,” Canada, 1996, http://www.ainc-inac.gc.ca/ch/rcap/sg/sgmm_e.html

“Australia’s Health 2004,” Australian Institute of Health and Welfare, 2004, http://www.aihw.gov.au/publications/index.cfm/title/100...

“A Best Practice Model For Health Promotion Programs In Aboriginal Communities,” Howie, Royden James, Kuwinyuwandu Aboriginal Resource Unit

“A Strategic Approach To Improving The Health of Aboriginal People In Western Australia, ” Western Australia Aboriginal Health Strategy, 2/3/2000

“Agreement On Aboriginal and Torres Islander Health” States and Commonwealth of Australia with Chairperson of the Aboriginal and Torres Strait Islander Commission, 1996 http://www.aboriginal.health.wa.gov.au/htm/aboutus/agre...