Roadmap to recovery: Reporting on a research taskforce supporting Indigenous responses to COVID-19 in Australia.

In April 2020 a Group of Eight Taskforce was convened, consisting of over 100 researchers, to provide independent, research-based recommendations to the Commonwealth Government on a "Roadmap to Recovery" from COVID-19. The report covered issues ranging from pandemic control and relaxation of social distancing measures, to well-being and special considerations for vulnerable populations. Our work focused on the critical needs of Aboriginal and Torres Strait Islander communities; this paper presents an overview of our recommendations to the Roadmap report. In addressing the global challenges posed by pandemics for citizens around the world, Indigenous people are recognised as highly vulnerable. At the time of writing Australia's First Nations Peoples have been largely spared from COVID-19 in comparison to other Indigenous populations globally. Our recommendations emphasise self-determination and equitable needs-based funding to support Indigenous communities to recover from COVID-19, addressing persistent overcrowded housing, and a focus on workforce, especially for regional and remote communities. These latter two issues have been highlighted as major issues of risk for Indigenous communities in Australia It remains to be seen how governments across Australia take up these recommendations to support Indigenous peoples' health and healing journey through yet another, potentially catastrophic, health crisis.

INTRODUCTION

On 3 April 2020, the Group of Eight (Go8) convened a taskforce of more than 100 researchers to develop a report on the challenges Australia faces in recovering from the COVID‐19 pandemic (Go8 2020). The report envisaged a Roadmap to Recovery. The taskforce was asked to provide independent, research‐based recommendations to the Commonwealth Government, addressing key issues such as pandemic control, relaxation of social distancing measures and travel restrictions, in addition to longer‐term issues such as well‐being and special considerations for vulnerable populations. The recommendations discussed here focus on the needs of Aboriginal and Torres Strait Islander peoples and their communities in the recovery from COVID‐19, recognising that self‐determination is a necessary condition for Indigenous health.

COLLABORATIVE REASONING PLATFORM

Central to the Roadmap to Recovery process was the strategy of including researchers from a wide range of scholarly backgrounds, from well‐established academics to early career researchers (ECRs). Whilst the focus of the Roadmap to Recovery was on pandemic control, the inclusion of ECRs and social scientists ensured that contending analyses and divergent thinking were assessed on their merit, not on the position, seniority or disciplinary orientation of the contributor. The month‐long collaboration process was facilitated by the Hunt Laboratory for Intelligence Research using their Smartly‐assembled Wiki‐style Argument Marshalling (SWARM) project cloud platform. The SWARM platform was initially funded by a US Intelligence Advanced Research Projects Activity (IARPA) scheme, in order to pursue advances in collaborative reasoning. The platform enables “contending analyses” through a process of sharing resources and draft reports, feedback and rating, and group selection of high‐quality contributions (van Gelder & Rozario 2018). Important elements of the SWARM process include an initial period of anonymity to manage social dominance effects and recognising the need to create “social warmth” (Sinnott et al. 2019, p. 412). The SWARM platform relies on mutual encouragement and shared credit for collaboration, which functions to support interaction between users and the refinement of contending ideas.

Researchers could contribute to any question or issue across the project, but the in‐built mechanisms of rating and feedback functioned to ensure that contributions made based on expertise and familiarity with the research were most highly valued. Those contributions were critiqued by other users, voted on, and incorporated into draft reports, until the third week of the project. At this point, subgroups coalesced around specific questions, anonymity was lifted, and draft reports were circulated offline. The expertise of Indigenous researchers was prioritised and supported by non‐Indigenous colleagues engaged in the question:

What are the special considerations with regard to Aboriginal and Torres Strait Islander peoples and their communities through the recovery process?

BACKGROUND

In preparing our report, we firstly recognised the global challenges posed by pandemics for citizens around the world but noted that Indigenous peoples are particularly vulnerable from the historical and ongoing experience of colonisation. Indigenous people in Australia and worldwide experience disproportionate impacts of pandemics (Walsh & Rademaker 2020) and ill‐effects long after the response phase (La Ruche et al. 2009; Flint et al. 2010; Rudge & Massey 2010; Trauer et al. 2011). During the 2009 H1N1 pandemic, Indigenous communities in Australia experienced reduced and delayed access to care, and cultural differences in approaches to healthcare, resulting in excessive morbidity and mortality.

In the context of COVID‐19, we suggest that the effects of the inevitable associated economic recession already under way will exacerbate inequality across the social determinants of health including housing, water and energy security, nutrition and employment (Markham et al. 2020, p. 1). This pandemic has highlighted and reinforced preexisting racial inequity and long‐standing shortfalls in health policy (Bond & Whop 2020). There is a real concern that COVID‐19 will compound existing health issues in Indigenous communities partly due to the restrictions on community mobility and interaction with health services and others, including kinship clans and communities (UN Expert Mechanism on the Rights of Indigenous Peoples 2020). Less contact with health services also has the potential to heighten risks as a result of underlying health conditions not properly being managed or assessed (Garg et al. 2020). Additionally, we focused on the ways Indigenous organisations have shown exemplary leadership in their response to COVID‐19. To support their work and the continued recovery effort, we made four key recommendations regarding (1) self‐determination, (2) housing, (3) data sovereignty and (4) workforce. Adequately addressing these issues relies on enabling Indigenous governance through needs‐based funding and Indigenous‐led initiatives.

HEALTH INEQUALITY AND THE IMPACT OF PANDEMICS ON INDIGENOUS PEOPLES

At present, approximately 800,000 people in Australia identify as Indigenous, and most (approximately 80 percent) live in cities and non‐remote areas (ABS 2018). The median age of Indigenous people is 15 years lower than non‐Indigenous Australians, with higher mortality rates making early middle age and older Indigenous people especially vulnerable (ABS 2018). Indigenous Australians have higher rates of health problems, such as high blood pressure, respiratory and circulatory disease, obesity and diabetes (AIHW 2018; ABS 2019), as well as higher rates of psychological distress compared with other Australians (McNamara et al. 2018, p. 145). Indigenous peoples also experience significant barriers to accessing healthcare services (Peiris et al. 2008, p. 985). Preventable hospital admissions and deaths are three times higher for Indigenous people, due in part to the failure of the “close the gap” policies (DHA 2013).

In the 2020 Closing the Gap report (DPMC 2020, p. 6), the government outlined the need to accelerate improvements in Indigenous peoples’ outcomes by engaging in partnerships through community‐led, strengths‐based approaches. During the COVID‐19 pandemic, self‐determined measures have been put in place by, and to mitigate risks for, Indigenous communities (Milroy 2020). These measures have resulted in overwhelmingly positive outcomes, including, at the time of writing, 69 cases of infection amongst Indigenous people representing 0.8 per cent of all cases in Australia; notably, for “all Australian cases, completeness of the Indigenous status field was approximately 91 percent” (Department of Health 2020a, p. 10).

SELF‐DETERMINATION AND THE COVID‐19 RESPONSE BY INDIGENOUS PEOPLES

A key attribute of the success of the COVID‐19 Indigenous response has been the extent of self‐determination by Indigenous organisations; their strategic leadership has mitigated risk and promoted protective measures during the early phases of the outbreak. In practical terms, these acts of self‐determination include, for example, Land Councils assisting communities by prohibiting access permits for non‐essential travellers and developing key distancing health messages in local languages, and Aboriginal community‐controlled health services developing local preparedness and response plans. Communities themselves have imposed restricted travel to and from communities and have implemented considerable efforts to protect elders, and found solutions to secure isolation and quarantine facilities where housing stock is limited (including facilitating decentralisation to homelands to reduce overcrowding in large townships).

At the federal level, the National Aboriginal Community Controlled Health Organisation (NACCHO), state, territory and regional peak organisations, as well as member organisations from across the country, have participated in a national Aboriginal & Torres Strait Islander COVID‐19 Advisory Group directly reporting to the Chief Medical Officer and the Australian Health Protection Principal Committee which feeds directly into the National Cabinet. Co‐chaired by NACCHO and the Commonwealth Department of Health, this group developed the National Management Plan, clinical guidelines and specific initiatives to prepare remote communities for COVID‐19, early in the pandemic phase (Department of Health 2020b). Recognising that there is some time to go before the COVID‐19 pandemic is hopefully addressed; we made four recommendations based on the self‐determination that has been at the forefront of Indigenous crisis and recovery efforts. These recommendations were based on the consideration of current government responses, the importance of equitable needs‐based funding and the profound risks of policy failure for Indigenous lives and livelihoods.

GOVERNMENT RESPONSES AND EQUITABLE NEEDS‐BASED FUNDING

The core requirement in both the acute and recovery phases is evidence‐based policy, relying on quality research that prioritises local experience. Such policy must be developed and led by Indigenous peoples, based on Indigenous values, funded on a needs basis, with clear accountabilities and systematic evaluation. We noted that Canada has acted decisively in prioritising Indigenous peoples’ health by supporting pre‐established First Nations governance structures. The $302 million COVID‐19 Economic Response Plan gave Indigenous leadership the flexibility needed to design and implement community‐based solutions to the pandemic (Government of Canada 2020). Canada’s health response to COVID‐19 equates to $270 per Indigenous person, whereas Australia's current response – with around $15 million of new spending – equates to less than $20 per Indigenous person (Wilson 2020).

The COVID‐19 response has involved an unprecedented level of cooperation and collaboration between governments and the Indigenous community health sector, which augurs well for future partnerships and deserves both recognition and funding. The research is clear on the need for governments to effectively engage and partner with Indigenous communities particularly during pandemic responses (Massey et al. 2011). To support and consolidate these extraordinary partnerships, there is a pressing need for sustainable funding to Indigenous organisations. The Australian government has allocated $74 million to mental health (IAHA 2020), $57.8 million to remote communities (Hunt 2020) and $123 million to Indigenous businesses (Wyatt 2020). We also suggest that the increase in social security payments during COVID‐19 is a critical step in alleviating poverty (Altman 2020). So, whilst we applaud the current level of collaboration and community control (Department of Health 2020b, p. 6), we stress that existing inequalities must not be exacerbated by this pandemic (Bond & Whop 2020; Markham et al. 2020).

RECOMMENDATIONS TO GOVERNMENT

The working group made four recommendations made to the Roadmap to Recovery (Go8 2020) regarding:

The right to self‐determination and to lead coordination

An immediate increase in the supply of housing

COVID‐19 Indigenous data sovereignty

Aboriginal and Torres Strait Islander health workforce review.

Recommendation 1: Self‐determination and coordination

Under the international norm of Indigenous self‐determination, the United Nations encourages governments to include Indigenous peoples’ representatives, leaders and traditional authorities in emergency and health response committees, and indeed any entity dedicated to COVID‐19 response and recovery (FAO 2020). In addition to the national Aboriginal & Torres Strait Islander COVID‐19 Advisory Group (Department of Health 2020b), we note that community‐controlled healthcare has shown commendable innovation through the crisis. The response from Indigenous communities (Archibald‐Binge & Geraghty 2020; Gordon et al. 2020; Haskin 2020) and organisations (e.g. Gayaa Dhuwi 2020; Kimberley Aboriginal Medical Services 2020; NACCHO 2020) has been swift and effective, a possible explanator of outstanding outcomes to date.

The report (Go8 2020, p. 150) notes the creation of COVID‐19 taskforces led by Indigenous health services to coordinate and implement effective localised pandemic responses. We recommended the continued financial and logistical support of Indigenous COVID‐19 response mechanisms in all jurisdictions. This recommendation is based on the right of self‐determination for Indigenous people to keep their communities safe, recognition of ongoing local cultural practices and the need for efficiency in pandemic responses. Indigenous health services are most familiar with the social determinants of health in local areas, relevant cultural considerations, and are the better equipped to advise on funding allocation according to local needs. In the light of an expected shortfall between emergency support and high community need, funding allocation is most efficient when conducted in partnership with Indigenous health organisations. Supporting the expansion of Indigenous COVID‐19 taskforces to oversee this process during the recovery phase enables efficient and localised engagement with each jurisdiction across the Commonwealth.

Recommendation 2: Housing supply

The ability of families to self‐isolate and quarantine effectively has been a significant issue in the crisis phase of COVID‐19. Many communities face critical housing shortages and associated overcrowding in urban, regional and remote areas documented over many years (AIHW 2014; 2020a, p. 115). Inadequate housing has a direct impact on the ability of local health services and communities to ensure social distancing, as well as immediately exacerbating a complex set of interrelated issues including family safety, preexisting overcrowding and ageing infrastructure (Cripps & Habibis 2019, p. 7). During COVID‐19, the housing crisis has been exacerbated by people returning from urban centres to ancestral country. Whilst this has led to reconnection with family and country for many people, addressing isolation and growing communities, a lack of basic infrastructure compounds preexisting health concerns. Many communities remain vulnerable to COVID‐19 without any ability to isolate and this is particularly the case for Indigenous communities in south‐eastern Australia who lost housing and infrastructure in the 2020 bushfires and floods (Williamson et al. 2020, p. 11).

Cultural and social support

In considering the cultural impacts of the pandemic, we note that social isolation is contrary to Indigenous cultural practices. Enforcing travel bans, movement restrictions and quarantines will disproportionately affect Indigenous populations (Logie & Turan 2020, p. 2). Isolation policies are also likely to have negative consequences within and beyond Indigenous communities, including stress, hardship, interpersonal issues, family violence, alcohol misuse, and suicide risk (Dudgeon & Hirvonen 2019; Klower 2020). These consequences are felt differently across the life‐course, gender and place. Housing is the most critical issue exposed by the crisis and must be addressed as the urgent first‐order issue, in both the short‐term to accommodate isolation and quarantine measures, and in the longer‐term to aid in recovery and preparedness for future crises. The most vulnerable Indigenous people include victims of violence, the homeless and incarcerated, those impacted by natural disasters, people with disability and chronic illness, as well as Elders and members of Stolen Generations who have experienced historical and colonial trauma (Menzies 2019, p. 1526). In remote communities, the early strategy of returning people to Country may have limited Indigenous women’s access to support, making them even more vulnerable to family violence and unable to undertake meaningful safety planning (Hocking, 2020).

Young people and policing

Our report focused on the vulnerability of Indigenous young people as a particular concern. Not all Indigenous households have ready access to quality education, technology or reliable Internet to support children’s learning. However, because Indigenous young people are removed from their families and placed in out‐of‐home care and juvenile detention at historically disproportionate rates (AIHW 2020b, p. 15; 2020c, p. 11), they are exceptionally vulnerable in this pandemic. In their endeavours to minimise the risk of transmission, jurisdictions have stopped or limited face‐to‐face contact between young people in care or custody and their families. Whilst some jurisdictions have offered alternative communication, not all families have access to these, nor are they always age‐appropriate or child‐friendly. This exacerbates the distress and anxiety Indigenous families experience (Australian Human Rights Commission 2018). Similarly, the interrelationship between child abuse and neglect with family violence has long been established (Commission for Children & Young People 2016). With concerns already raised about the increase in family violence during the acute phase of COVID‐19, it is likely that mandatory reports of children’s exposure to violence will increase. We note that children and young people in out‐of‐home care are also vulnerable to “crossing‐over” into juvenile justice system (Baidawi & Sheehan 2019, p. 2). Given increased police discretion during the pandemic – noting the history of overpolicing Indigenous communities – Indigenous young people are likely to be even more at risk from police harassment. Overpolicing, fines for breaching social distancing regulations and “move on” notices with no alternative housing support all exacerbate risk for an already vulnerable cohort.

Recommendation 3: COVID‐19 Indigenous data sovereignty

We recommended that the Aboriginal & Torres Strait Islander COVID‐19 Advisory Group be maintained until the pandemic threat is eliminated and that principles of Indigenous data sovereignty are used to support data sharing and decision making. To support the maintenance of public health and clinical responses, we recommend comprehensive data collection and sharing to all parties in order to support public health messaging and ongoing research. Where possible, community‐controlled health organisations should be supported to ensure data collection is undertaken sensitively and in a timely manner, following the principles established by Maiam nayri Wingara.

Research into the effects of COVID‐19 on community well‐being will be required to evaluate how Indigenous peoples have fared through COVID‐19. Data on mainstream service uptake, presentation to emergency departments and suicide behaviours during the pandemic must be made available to relevant institutions to support pandemic response and recovery. A comprehensive understanding of indirect and longer‐term effects of the pandemic will provide important and necessary learnings for future pandemics and crises. Such research must be Indigenous‐led and based on Indigenous philosophies and current best scholarly and culturally ethical practice. In order to conduct this research and support rapid decision making, issues of data quality and sharing must be addressed within Indigenous approaches to data and research quality (Kukutai & Taylor 2016, p. 14).

The COVID‐19 recovery will depend on how much damage is inflicted in communities, by both the virus and the measures used to contain it, as well as on the degree of self‐determination communities have to manage their own pandemic responses. It is imperative that the virus is contained. This will require careful tracking of virus epidemiology and rapid reporting to properly understand and respond to infection impacts on highly vulnerable Indigenous communities and workforces. Evidence‐based strategy and data are key, as is ongoing support for community‐led recovery.

Recommendation 4: Aboriginal and Torres Strait Islander Health Workforce Review

The COVID‐19 pandemic has highlighted vulnerabilities in local workforces that are highly dependent on staff from out of community, interstate and even New Zealand. Long‐term initiatives to build local capacity are needed, given the significant issues which have arisen in relation to available workforce (including the need to isolate fly‐in‐fly‐out or drive‐in‐drive‐out locum staff and local Indigenous staff who are unable to work). We strongly recommend that NACCHO, as a lead agency, instigates a health workforce reform process in partnership with all jurisdictions. This will need to encompass:

An analysis of how to increase and retain Indigenous health practitioners across Australia. This will help reduce the reliance on overseas and out‐of‐community locum staff providing services to remote and regional communities.

Rapid upscaling of Indigenous public health and infectious disease expertise so that each Department of Health in each jurisdiction relies on senior Indigenous advice.

Surge workforce planning in communities to anticipate future outbreaks of COVID‐19 and other diseases.

There is a need to ensure Indigenous health workers are supported to provide the best care for communities, especially in areas with preexisting staff shortages. Indigenous people in more remote areas must make the final decision about their readiness to open communities to non‐essential workers and other visitors. The health of people in these communities is generally poor, elders are highly vulnerable, and communities must be entitled to exercise their right to self‐determination in matters of life and death (United Nations 2007). We suggest that workforce planning is both an urgent and practical measure in pandemic response that supports these rights.

CONCLUSION

The scope and number of recommendations to the Go8 Roadmap to Recovery report were necessarily limited by the breadth of the project, which included 11 areas ranging from suppression strategies to travel restrictions to civic engagement and mental health (Go8 2020). In proposing these four recommendations, we aimed to take into account the breadth of the social determinants of health, issues of deeply entrenched poverty, the need for adequate financial support for Indigenous health and other organisations and the need for ongoing, increased, and unconditional social security payments to address deep poverty. We acknowledge the negative impacts of social isolation policies, concerns around family safety and overpolicing, and we stress the importance of equitable, needs‐based funding. Although these recommendations apply to the entire Aboriginal and Torres Strait Islander population, the diversity within this population must also be recognised.

In making these recommendations, we noted that the research clearly and consistently demonstrates that a strengths‐based, community‐led approach is the only effective way of working with Indigenous peoples. Self‐determination and connection to community, culture and the advice of elders are critically important in times of crises. At the time of writing, it remains to be seen how governments across Australia respond to these recommendations, as Indigenous people continue to be resilient and innovative in response to yet another, potentially catastrophic, health crisis.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.