Background

Aboriginal and Torres Strait IslanderFootnote 1 people continue to have the greatest health disparities of any population group in Australia. Life expectancy for Indigenous people continues to be lower than for their non-Indigenous counterparts with current estimates at 10 years less than the national average (Australian Bureau of Statistics 2013). The rate of potentially avoidable (i.e. treatable and preventable) mortality for Indigenous people is estimated at 3.5 times higher than for non-Indigenous Australians (Australian Bureau of Statitstics 2013). The health disparities experienced by Indigenous Australians are embedded within the context of Australia’s colonial legacies. Historical and contemporary policies and practices affecting Indigenous people as a result of British colonisation have also affected the health outcomes of Indigenous people (Kunitz 1990). Fundamentally, the social injustices resulting from colonisation influence the underlying determinants (including biological, environmental, social and political determinants) that result in inequitable health for Indigenous Australians. The purpose of this review is to identify how colonisation has been shown to lead to the social injustices experienced by Indigenous Australians in the health literature. Additionally, it also aims to identify determinants of social injustice that could be used to explain health disparities that are due to colonisation.

In 2005, the Human Rights and Equal Opportunities Commission’s Aboriginal and Torres Strait Islander Social Justice Commissioner released the ‘Social Justice Report 2005’ emphasising the need for a bilateral agreement across all levels of governments in order for Australia to demonstrate its commitment to achieving equality in health status and life expectancy between Indigenous and non-Indigenous Australians within a generation (Aboriginal and Torres Strait Islander Social Justice Commissioner 2005). Although a bilateral agreement has not been achieved, the Australian Government has begun to demonstrate its commitment through the signing of a statement of intent with other organisations. The National Partnership on Closing the Gap in Indigenous Health Outcomes provides the framework by which to achieve equality for Indigenous people in health, housing, early childhood development, education, economic participation and regional and remote service, to thereby reduce the health inequalities and social injustices experienced by Indigenous people (Commonwealth of Australia 2009).

To address these inequities, the recent objective of ‘Closing the Gap’ has aimed to address socioeconomic disadvantage and the life expectancy of Indigenous people through two broad strategies, namely providing equitable policies and providing equitable primary health systems (Holland 2015). A precondition for organisations to participate in the ‘Closing the Gap’ strategy requires the recording of Indigenous people’s identification (Commonwealth of Australia 2009). Specifically, the strategy includes ambitious targets involving monitoring variations in life expectancy, mortality rates for Indigenous children under five, accessibility to early childhood education for Indigenous children in remote communities, education achievements in reading, writing and numeracy and year 12 attainment rates, as well as employment outcomes for Indigenous and non-Indigenous people. Since its implementation, the ‘Closing the Gap’ strategy has failed to address the underlying social determinants that are known to affect the health and wellbeing of Indigenous Australians, such as service accessibility and the provision of collaborative health literacy resources. As reported in the Prime Ministers Report 2015, progress is considered ‘on track’ to meet only two of the seven targets to achieve Indigenous social justice (Department of the Prime Minister and Cabinet 2015).

Social injustice occurs in the context of colonisation. Specifically, colonisation is described as a form of domination and can be defined as the forcible takeover of the land of Indigenous peoples and the exploitation of the land and the people, ignoring the laws and customs and the rights of Indigenous people (Australian Museum 2015; Horvath 1972). The experience of colonisation has been absorbed across and within generations of Indigenous people. Because of this, addressing the social determinants that contribute to social injustice is central to advancing the services and systems that can challenge inequitable health outcomes for Indigenous populations (World Health Organization 2008). In Australia, the Aboriginal and Torres Strait Islander Social Justice Commission was established in response to the Royal Commission into Aboriginal Deaths in Custody and the National Inquiry into Racist Violence (Australian Human Rights and Equal Opportunity Commission 1991). Following the release of the Social Justice Report 2005, the Human Rights and Equal Opportunity Commission with Oxfam Australia developed the ‘Close the Gap’ campaign; in 2008 this campaign became responsible for the largest injection of funds, on paper, into addressing disparities in Indigenous health—a total of $1.6 billion (Fredericks et al. 2012, pp. 350–372).

The first step in challenging health disparities is accurate conceptualisation of the issue (Kilbourne et al. 2006). With regards to Indigenous people, there are both explicit and implicit assumptions that disparities exist due to the social injustices that the Indigenous population have experienced as a consequence of colonisation. While health disparities are not only due to experiencing social injustices, those disparities that are due to social injustices are potentially preventable. This matter has previously raised questions about defining disparities, measurement considerations (Braveman 2006; Whitehead 1992) and questions of responsibility and about how injustices are challenged (Krieger 1994, 2001).

The definition of health will also have implications for identifying the scope of the relationships between colonisation, social injustice and health. The health of Indigenous people is well known to be more than simply the absence of illness or disease (National Aboriginal Health Strategy Working Party 1989). Health through the Indigenous perspective encompasses the health and wellbeing of the culture, the land, the community and the spirit (National Aboriginal Health Strategy Working Party 1989; Gracey and King 2009; King et al. 2009). This interconnectedness is all encompassing, across life and death (National Aboriginal Health Strategy Working Party 1989). Good health and wellbeing for Indigenous people therefore includes not only the individual’s health and wellbeing but also the health and wellbeing of culture, country, community and spirit (National Aboriginal Health Strategy Working Party 1989). This raises questions about how best to construct practical approaches to capture the lived experiences of Indigenous people. This includes encompassing the different values and understandings of Indigenous people as well as addressing the complex interplay of factors when measuring colonial impacts upon health. Furthermore, direct measurement of colonial impacts on Indigenous health requires a decolonised lens. Decolonisation approaches can capture how Indigenous health, as defined by Indigenous people, is affected by social injustice as an agent of colonisation. A systematic approach has been taken in reviewing the health research literature to elucidate how the effects of colonisation and the resulting social injustices are described as relating to the health of Indigenous Australians.

Methods

Search strategy

A comprehensive literature search strategy was developed. This included four concepts: the population group (Aboriginal and/or Torres Strait Islander or Indigenous people); colonisation; health indicators (life expectancy, morbidity, mortality) and social justice indicators. The specific search operators are as follows: Aboriginal = Aborigin*, Indig*, TSI, Torres*; Colonisation = Coloni*; Health = ‘health indicator*’, ‘health index*’, ‘health measure*’, ‘epidemiology’, ‘public health’; Social justice = ‘social justice’, ‘social injustice’. The search strategy was applied to the following five electronic databases: MEDLINE, Australian Institute of Aboriginal and Torres Strait Islander Studies (AIATSIS), Web of Knowledge, Google and Google Scholar.

Criteria

Articles were included if they met the search strategy, were published in the English language and included Australia in the analysis. We excluded books and news articles to ensure all included articles, reports and edited volumes were peer-reviewed. However, our search did not produce any edited volumes. To generate contemporary results in the light of the current impacts of colonial practices (i.e. improved data quality and improved access to services, etc.), publications were limited from 1 January 2000 to 31 December 2014.

Article selection

Articles were selected in two stages. The first stage involved two reviewers (author 1 and author 2) screening potentially relevant abstracts identified by the search strategy and excluding those that were clearly irrelevant or duplicates. The second stage involved assessing the remaining abstracts against the selection criteria. Where the abstract did not provide sufficient information for a decision to be made, the full text article was retrieved and assessed for eligibility. Disagreements on eligibility were resolved by discussion between the two reviewers. Articles that were included in the review were then critically appraised by the two reviewers and data was abstracted using a project-specific data abstraction tool developed by author 1.

Article abstraction and data items

We abstracted information from included articles in accordance with the internationally recommended Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)—Equity Extension guideline (Welch et al. 2012) to provide transparent and complete reporting. The data items collected on the abstraction tool included the geographic locality and/or subpopulation and/or community where the study was undertaken, the methodology used in the article and the determinants identified as having a relationship to either colonisation and/or social justice.

Information synthesis

We created a summary table (“Appendix”) of the evidence abstracted from the articles to clearly identify determinants of Indigenous health that were shown to be due to social justice/injustice as a result of colonisation. These are described further in the discussion.

Results

A total of 36 articles were included in the review. The included articles and their characteristics are summarised in Table 1. An outline of the selection process for those articles included and excluded is provided in Fig. 1. There has been an increase in published articles over the past 10 years that discuss health inequalities in the context of colonisation. The methods used for the majority of these were narrative or synthesis reviews and there was limited empirical evidence used to describe the effects of colonisation on social justice and Indigenous people.

Table 1 Summary of characteristics of articles included in the review
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Fig. 1
figure 1

Systematic flow diagram of selection of articles for review

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While Indigenous people were the sub-population of interest, 15 articles discussed public health professionals’ (as public servants, health workers and health writers) and health care service provider’s perceptions of colonisation. These articles addressed subjective observations and potential models of care within institutions. These institutions recognised that hegemonic constraints upon Indigenous worldviews were the direct result of colonisation and a driver of health inequities. There was a gap in the literature explicitly describing social injustice as a determinant of health disparities. However, factors specific to Indigenous health disparities due to colonisation were identified within the literature. Further details are provided in the findings.

Findings

This is the first review to date that identifies how the colonial impact on social injustice is described with regard to the health of Indigenous Australians. The purpose of this review was to elucidate the available evidence that describes the direct and indirect effects of colonisation on social injustice and, therefore, Indigenous health disparities in Australia. The narratives throughout the articles describe the effects of colonisation that result in inequitable health outcomes for Indigenous people. The literature also identifies specific determinants of health that are the result of colonisation. This review aimed not only to identify and advocate for empirical indicators that could be used to measure the magnitude of the effects of the social injustices experienced by Indigenous people due to colonisation. It also aimed to identify known effects of colonisation that are the potential mechanisms that have advanced social injustices and which can be used to explain health disparities.

The colonial context of contemporary Indigenous health disparities

Indigenous health disparities in Australia are embedded within a colonial context. The literature from this review illustrates a variety of ways in which colonisation is an underlying determinant of Indigenous health. Specifically, the legacies of historical government policies that affect both contemporary policies and health service provision were identified. For example, colonial policies introduced the misconception that Indigenous people were the property of the colonisers resulting in the subordination of Indigenous people (Arabena 2006; Nelson 2009). This unequal power distribution continues to be seen within Australian society resulting in Indigenous people being presented as poorer, less educated, marginalised and sicker than non-Indigenous people. The articles in the review acknowledge a number of colonial policies and actions directly affecting health including: the forced removal of Indigenous children; government regulation and management of the income of Indigenous people; displacement and regulation of Indigenous people; and forced disconnection from Indigenous identity, traditional lands and culture (Anderson and Kowal 2012; Arabena 2006; McDonald et al. 2010; Nelson 2009; Oliver 2013; Sherwood 2013; Tsey et al. 2010). Articles also highlighted that the views of the colonisers included the perceptions that Indigenous people were depraved, in decline and/or in need of protection (Anderson and Kowal 2012; Anderson et al. 2006; Blyton 2009; Gracey and King 2009; Thomas et al. 2014). From this we have seen a deficit model of Indigenous health emerge within health systems and across health reporting. In this sense, the resulting social injustices due to colonisation can be seen as the silencing of the Indigenous persons’ right to have ‘the highest attainable standard of health conducive to living a life with dignity’ (United Nations Committee on Economic, Social and Cultural Rights 2000).

Health determinants attributable to colonisation

Specific determinants of Indigenous health as a result of colonisation have been identified in the literature (Anderson and Kowal 2012; Bennett 2009; Blyton 2009; Christou and Thompson 2013; Funston 2013; Gracey and King 2009; King et al. 2009; Krieg 2009; Lea 2005; Littleton 2005; McDonald et al. 2010; Oliver 2013; Parker 2010; Passey et al. 2011; Pyett et al. 2008; Rowse 2009; Sherwood 2009, 2013; Sweet et al. 2014; Tsey et al. 2010; Vickery et al. 2007). Health determinants attributable to colonisation can be thought of in terms of deficits (negative factors contributing to ill health and disease) or assets (positive factors contributing to health and wellbeing). Generally, the impact of colonisation is described in the articles as adversely affecting Indigenous people resulting in disparities in life expectancy, the burden of disease and vital statistics for Indigenous people (Bennett 2009; Gracey and King 2009; Kelly 2006; King et al. 2009; Nelson 2009; Parker 2010; Rowse 2009). Some of the potentially measurable determinants of Indigenous health identified in the literature are briefly discussed.

Resulting trauma from colonisation as a determinant of Indigenous health is discussed across much of the literature. Specifically, it includes the terms intergenerational trauma (Funston 2013; Prior 2007; Sherwood 2009; Sweet et al. 2014), trans-generational trauma (Tsey et al. 2010), collective, mass or social trauma (Krieg 2009). Funston (2013) also describes it as ‘invisible trauma’ due to the “widespread denial of the history of invasion, genocide and ongoing oppression of Aboriginal and Torres Strait Islander people”. Krieg (2009) identifies interpersonal racism, prejudice, stress, depression and violence as contributing factors in the ongoing impact of collective trauma. Specifically, institutional racism and prejudice within governance and health systems were identified as persistent issues impacting Indigenous health (Christou and Thompson 2013; Gracey and King 2009). Stress, grief and loss (of language, country and family) are also recognised determinants (Anderson et al. 2006; Prior 2007; Sherwood 2009, 2013; Vickery et al. 2007). Commonly identified manifestations of colonisation impacting the health of Indigenous people include higher rates of family violence, substance abuse and economic deprivation (Blyton 2009; McDonald et al. 2010; Sherwood 2009; Sweet et al. 2014) as well as higher rates of incarceration (Rowse 2009; Sherwood 2009, 2013).

Most health determinants were factors contributing to deficits, however Vickery et al. (2007) describe positive health determinants as ‘decolonisation social determinants,’ which include connectedness to land as well as reconciliation (building positive relationships, respect and trust between non-Indigenous and Indigenous Australians). In a review of archived data, information and oral histories by Anderson and Kowal (2012), it was found that, in Utopia in the Northern Territory, relationships between Indigenous and non-Indigenous people had flexibility, connectedness to culture and land (social cohesion) and collective-efficacy (self-efficacy and social inclusion)—assets contributing to the health and wellbeing of Utopia. The cultural and social structures that were identified in this review contributed to better health outcomes in this community during the changing eras of government policies and leave us interested in how this decolonised approach could be replicated across other communities.

The legacy of colonisation and impacts across generations

There is general consensus that the impact of colonisation on the health of Indigenous people manifests negatively, is highly complex and that this legacy is experienced intra-generationally and inter-generationally. The lack of equity experienced by Indigenous people of the same generation and between present and future generations is informed by the racialised constructs embedded in selected determinants of health and health inequalities (Sherwood 2009, 2013; Vickery et al. 2007). These determinants are linked to colonisation and include marginalisation, incarceration and the justice system, intergenerational trauma, housing and lack of government conscience. The interesting point is that these determinants coincide with historical policies imposed on Indigenous peoples, such as ‘White Australia’ and ‘protectionism,’ and that a lack of redress acknowledging colonial impact is a continuing effector of health inequalities (Kelly 2006; Shahid et al. 2009; Sherwood 2009, 2013; Vickery et al. 2007). Until such time that we see justice and equity in resource allocation to address the determinants of the health of Indigenous people, the complexity of colonial impact will remain for present and future generations.

The primary theme seen in the articles was that historical injustices experienced by Indigenous people affect present-day health inequalities. These injustices have formed a policy-perpetuated cycle that contributes to the marginalisation and lack of government conscience still evident (Nelson 2009; Prior 2007; Sherwood 2009, 2013; Vickery et al. 2007). There is an acceptance of ‘truth’ regarding the negative effects of the period of colonisation upon the health and wellbeing of Indigenous Australians but a persistence of colonial views in contemporary policies that is still playing out overtly and systematically. Importantly, while colonisation is recognised as a direct determinant of the health of Indigenous people today, there exists a major gap in the literature pertaining to social injustice as a determinant in health and health outcomes. While there is paucity in identifying social injustice as a determinant of health, the articles within this review indicate particular determinants of Indigenous health inequalities that implicitly ascribe social injustices to colonisation.

Disconnect between western and Indigenous discourses

Another theme that emerged strongly was the disconnect between the western discourse about health, health services and research methodologies and the Indigenous discourse of the determinants that are known, understood or perceived to affect health. This included differences in understandings in regards to the determinants of health. The ongoing divide between the holistic definition of Indigenous health and approaches to measuring health provides opportunities for identifying determinants of health disparities. This issue was highlighted in a health promotion intervention where a remote community required a multilevel approach engaging communities, health services and ongoing government commitment in order to see success in reducing poor outcomes in infectious diseases (McDonald et al. 2010). While direct measurements of the impact of colonisation are impossible (due to abstract constructs of colonisation), there is consensus that social injustice is theoretically, subjectively and empirically linked with poor health and health outcomes of Indigenous people. Social injustice can therefore be used as a framework for addressing the negative effects of colonisation on health. Through this proposed framework there is also potential to address the scope of Indigenous understandings of health.

Measurement issues

The explicit nature of measurement science requires tangible observable indicators that can provide relevant and robust quantitative estimates of health disparities. A range of potentially measurable determinants of social injustice due to colonisation was identified in the articles. However, there are necessary cultural considerations, particularly regarding Indigenous definitions of health and wellbeing. Determinants of health affecting Indigenous people are not solely about the individual but rather the whole community; therefore denial of self-determination is communal rather than individual and should be measured as such if we wish to find accurate ways to estimate the effects of colonisation. This review provides the currently available evidence that describes how colonisation impacts health disparities and how specific determinants of health are attributed to the social injustice experienced by Indigenous people. However, it is beyond the scope of this review to explore the conceptual and methodological considerations that are necessary to provide practical approaches to estimating the effect of social injustices on the health and health disparities of Indigenous people.

Conclusion

This literature review shows that there are many known determinants of Indigenous health that are attributable to colonisation. However, there is a gap in the literature describing how social injustice is related to the health of Indigenous Australians. The concept of colonisation has both historical and present-day connotations that are difficult to capture when addressing the underlying reasons for health disparities. We aimed to reframe the discussion and identify determinants of social injustice that could be used to explain health disparities that are due to colonisation. This review demonstrates that the colonial context in which the health of Indigenous people is experienced is critical when addressing health disparities. Furthermore, there are intergenerational impacts of colonisation that have resulted in a complex array of issues that present on multiple levels in society. This includes direct and systemic actions from and upon individuals, communities, services and governments that may be positive or negative in impact. Specific examples of determinants found in the literature that negatively affect Indigenous health included trauma (with particular focus on intergenerational trauma) that manifests through racism (interpersonal and institutional), stress, prejudice and discrimination, lower socioeconomic status, and higher incarceration rates. Determinants with positive effects included self-efficacy, social inclusion and social cohesiveness. The deficit model of health and western medical framing of health experienced by Indigenous Australians was consistent across the health literature. However, much of the literature also challenges existing western ideas about health by recognising that current Indigenous health disparities are a legacy of historical and current factors impacting all levels of society, from individual to government.

Colonisation deconstructs existing cultures, systems and structures resulting in ongoing unequal power distributions between Indigenous and non-Indigenous people. This has devalued Indigenous ways of knowing and being in present day society. An example of this is in the lack of uptake of Indigenous definitions of health in the governance and health systems that are aimed at supporting Indigenous people, despite the large disparities in health outcomes. The legacy of colonisation is social injustice. Both colonisation and social injustice affect the health and wellbeing of Indigenous people. Despite the effects of colonisation being well recognised, developing indicators that have the potential to disentangle the social injustice that Indigenous people experience due to the effect of colonisation on health requires more attention. Social justice is central to equitable practices across every sector in society, including health. Identifying current social injustices can provide a practical framework for gaining a better understanding of the effects of historical and contemporary colonial policies. Additionally, there is a need to develop a research agenda towards measuring the impact of social injustice as an agent of colonisation across all Indigenous societies, in a bid to provide better evidence to ensure health disparities are being adequately addressed. In order for a country to experience social justice, equitable approaches are necessary to achieve equal opportunities for all sub-populations to participate to their full potential in society (Dodson 1993). This requires identifying the factors that affect social justice and injustice, measuring their effects and then addressing them.