Empowering First Nations is the key to protection against disease

March 4, 2020

Kristy Crooks and Julie Leask say meaningful, respectful and empowering engagement with First Nations people must be central to Australia’s pandemic planning.

This article first appeared in the February issue of the Public Health Association of Australia’s InTouch newsletter.

As China grapples with more than 77,000 cases of the novel Coronavirus – COVID-19 (as of 26 Feb), Australia has been fortunate that just 22 individual cases had been notified to date, and still no deaths here.

SARS-CoV-2, the virus causing COVID-19 disease, appears increasingly likely to become a pandemic. Australia has activated an emergency response plan for COVID-19. Now is the time to engage with communities.

Public health professionals are working overtime around the nation, in both managing the current phase and considering the next. One thing they should be doing now is engaging and talking with Aboriginal and Torres Strait Islander communities (respectfully hereafter First Nations) – part of effective risk communication.

Risk communication is a central aspect of infectious disease event preparedness and response. CJD, SARS, Influenza H1N109, and Ebola have contributed to our knowledge of how to communicate about health risk. Developed after the Three Mile Island nuclear accident in 1979, Risk Communication is defined as:

“an interactive process of exchange of information and opinion among individuals, groups and institutions. It involves multiple messages about the nature of risk and other messages, not strictly about risk, that express concerns, opinions or reactions to risk messages or to legal and institutional arrangements for risk management.”1

Risk Communication originally grew out of challenging environmental hazard issues, with many working in this distinct field, utilising anthropology, sociology and cultural studies, psychology, governance, and global health security. They draw on epidemiology, toxicology, microbiology and virology and many other technical fields contributing to risk analysis and management, and will often find themselves practising risk communication.

In 1988, Vincent Covello, proposed seven cardinal rules of risk communication (see below).2 Guiding principles like these are useful because each situation is unique in its contextual and technical considerations. Accept and involve the public

1. Listen

2. Be honest frank and open

3. Coordinate and collaborate with other credible sources

4. Meet the needs of the media

5. Speak clearly and with compassion

6. Plan and evaluate efforts.

We add another:

7. Prioritise engagement with key populations.

Key populations such as First Nations communities are more likely to be affected by hazards. They will bear a disproportionate burden of the risk as they were with seasonal and pandemic influenza, but are generally not those making the decisions. Potential divides between perspectives of decision makers and communities are larger. Decision makers who are overwhelmed with responding are more likely to base decisions on time pressures and assumptions. Just when decision makers should be more empirical about their decisions, they become less so when it comes to community perspectives. Time and meaningful engagement as an investment in health should be the focus – getting the process right will produce better outcomes. Importantly, it will enhance trust with key populations – the most crucial resource in managing health emergencies.

In Australia, the Chinese community has been particularly affected – those who have been caught in China, those subject to on-shore and off-shore quarantine, those affected economically and socially, such as by racism. Governments at all levels should be proactively engaging with these communities to learn about the impact on them and address these and the questions people might have.

The omission of First Nations people from Australia’s pre-2009 pandemic plan highlights the need for meaningful engagement with First Nations peoples, creating a space where First Nations voices are prioritised and privileged. First Nations communities have already advised us what effective communication, collaboration and culturally acceptable and appropriate infection control strategies could look like.3 Now is the time for public health professionals with governments to begin engaging with First Nations communities on the COVID-19 threat, if they have not already.

One-way communication during an emergency will almost certainly fail in being fully effective because if people feel they are not being heard, or actively engaged, they cannot be expected to listen. For example, recommendations to stay away from others during a period of isolation or quarantine during the pandemic were often unrealistic because of the nature and realities of family structures and ways of living, and family and community obligations were more important than national health policies.

In terms of listening, there is already much known from previous research during the 2009 H1N1 pandemic and after. First Nations public health professionals and academics have recommended that pandemic planning should:

  • be developed early with Aboriginal organisations
  • be flexible to meet local priorities
  • include how to reduce risk in families and in community
  • ensure targeted communication strategies are co-developed
  • have flexible models of health care to access vaccinations and other medical interventions
  • include a stakeholder engagement plan.4

In terms of infection control, one team of researchers heard from First Nations communities in eastern Australia after H1N109.5 They learnt about the importance of:

  • Working with the local go-to people
  • Clear communication
  • Accessible and welcoming health care
  • Households and funerals – quarantine realism
  • Impact on daily events.

Involvement could entail having First Nations people as active participants in a governance capacity at district level creating a space that privileges First Nations voices. This inherently means choosing to listen to other voices less; giving up space and sharing power where First Nations people’s knowledge and voices are prioritised and privileged. For example, Chief Executives of health services could engage with representatives of Aboriginal Community Controlled Health Organisations (ACCHOs), creating a space for engagement, investing time to listen, and sharing knowledge, in an ongoing capacity. An approach such as this could centre and value culture, address First Nations health needs and strengthen partnerships between services. First Nations people must be actively engaged at the outset of any public health emergency planning, response and management, whereby First Nations people make a real contribution, having a real say in defining the issues, suggesting the solutions and participate fully in shared decision-making. Public health responses and actions are more likely to be effective because they are done in a way that reflects cultural ways of knowing and doing.

Now is the time to undo the past wrongs and be more proactive in engaging First Nations peoples to develop culturally appropriate health policy, that values culture, family and community ways. We need to spend less time on the empty rhetoric of closing the gap. What is needed is action. Action that facilitates active and equal participation in the planning, response and management of public health emergencies, that is supportive of community and strengths-based solutions. If we take the time to engage with and listen to First Nations people, learn from First Nations communities, we can build stronger relationships and partnerships, and together we can make a difference.

1. National Research Council. Improving risk communication. (National Academy of Sciences, 1989).

2. Covello, V. T. & Allen, F. H. Seven cardinal rules of risk communication. (US Environmental Protection Agency, Office of Policy Analysis, 1988).

3. Massey, P. D. et al. Australian Aboriginal and Torres Strait Islander communities and the development of pandemic influenza containment strategies: Community voices and community control. Health Policy 103, 184-190, doi:http:// dx.doi.org/10.1016/j.healthpol.2011.07.004 (2011).

4. Crooks K, Massey PD, Taylor K, Miller A, Campbell S, Andrews R. Planning for and responding to pandemic influenza emergencies: it’s time to listen to, prioritize and privilege Aboriginal perspectives. Western Pacific surveillance and response journal : WPSAR 9, 5-7, doi:10.5365/wpsar.2018.9.5.005.

5. Massey, P. D. Pearce G, Taylor KA, Orcher L, Saggers S, Durrheim DN, Reducing the risk of pandemic influenza in Aboriginal communities. Rural Remote Health 9, 1290 (2009).

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