How can we create equitable access to hearing healthcare in Australia? Interview with Prof. Tom Calma, Prof. Kelvin Kong and Hon. A/Prof. Boe Rambaldini December 2021, Volume 31, Issue 5

Introduction

Aboriginal and Torres Strait Islander children have among the highest rates of otitis media and hearing loss in the world¹ – and social determinants of health such as hygeine, nutrition and overcrowding of housing are key risk factors for otits media.² From the start of their lives, Aboriginal and Torres Strait islander children experience inequity in hearing health – Indigenous children aged up to 14 years are three times as likely to have otitis media as non-Indigenous children, and are twice as likely to have a long-term ear/hearing problem.³ Hearing loss can have a catastrophic effect on the lives of Aborginal chidren and their families, impacting the life trajectory from childhood development to academic outcomes⁴ through to over-representation in the criminal justice system.⁵ Early intervention is critical to diagnosing and treating ear disease and improving the quality of children’s lives.⁶ However, despite decades of research demonstrating that early detection and timely intervention are key to diagnosing and treating ear disease in Aboriginal and Torres Strait Islander children, not enough progress has been made in providing culturally safe, accessible and equitable hearing health services. In this discussion, Aboriginal and Torres Strait Islander health leaders, Professor Tom Calma, Professor Kelvin Kong and Associate Professor Boe Rambaldini, examine the problems and solutions for creating better, culturally appropriate services to meet the needs of communities where hearing health problems are being neglected.

Professor Tom Calma AO, Aboriginal elder, Kungarakan and Iwaidja nations

Q: How have hearing issues affected Aboriginal and Torres Strait Islander people?

A: We need to recognise that hearing may have its foundations in health, but it is an issue that extends well beyond health; it affects housing, education, employment and involvement with the justice and corrections system. Aboriginal and Torres Strait Islander people are significantly overrepresented in experiencing poor outcomes with all of these, with hearing issues playing a major role.

In education terms, children in preschool and primary school who present with hearing or ear issues, such as otitis media, otitis media with effusion, otitis externa and central auditory processing disorder, experience a compounding impact throughout their schooling and beyond – unless these issues are addressed early and treatment is followed through. Too often it means children are not learning, that they bow out of the education system, and then they get involved in other systems like the corrections and justice systems or the youth justice system and it goes right through to adulthood. We know one study of Aboriginal and Torres Strait Islander people in prison showed that 94% had significant hearing challenge⁷ so that may be what brought them into contact with the justice system at the very beginning.

Q: What do you see as the priorities in addressing these hearing health issues?

A: We need a really strong population health education program, as part of the new National Preventive Health Strategy⁸, to educate our community about the social determinant issues that impact on hearing care, like overcrowded housing and poverty, and the critical importance of early presentation, diagnosis and follow-through with treatment. We need to ensure that funding can be directed to ear and hearing health to ensure that we have a good population health approach like we do with smoking and tackling Indigenous smoking. For example, one thing that people don’t realise is that tobacco and wood fire smoke exposure can cause issues with children’s hearing and their potential later in life. So those relationships, environmental relationships are so important.⁹

Professor Kelvin Kong, Worimi nation

Q: What are the impacts of ear disease on Aboriginal and Torres Strait Islander children?

A: I’ll tell you a story about a cute 2-year-old girl presenting with only two words – not speaking much at all. She was falling over, as her balance was dreadful. She wasn’t engaging with her brother or sister because she couldn’t, and they isolated her because she wasn’t talking or playing and couldn’t keep up in the playground; her younger sister was meeting milestones at a younger age. Not long after she turned two, grommets were inserted in her ears and her improvement was incredible. Just by removing the fluid – in 2 months she was engaging in conversation with the kids, playing, running, dancing and importantly singing along with the other kids. This was my daughter.

If we could address these hearing health problems, then we could make better the lives of so many and maybe change the trajectory for the people affected by injustice, incarceration, lack of employment and lack of education. The frustration and disappointment is that it is not uncommon for me to see patients present with a complication of otitis media. Never is there a complication which has wrecked so many people’s lives and that’s its reality – it’s wrecking someone’s life.

Q: How can we design a healthcare system that provides access and equity for Aboriginal and Torres Strait Islander people?

A: “Closing the Gap”10 is a notion setting us up for failure. Shouldn’t our aspiration be to close the gap, not just get close? It seems we have the wrong system built for the wrong community. It is important to be able to reflect on the structures and systems and be able to change the way you’re doing things to help people because it’s not always going to be the same solution for everyone. It is also important to place historical context on institutional components – systemic barriers that have been in place for a long time.

When you look from a healthcare perspective, what does that mean when we talk about equity rather than equality? There is a real paucity of services that are appropriate. Equity means culturally safe access to services for our people. Racial equity is not just the absence of discrimination, but more importantly, the presence of systems that ensure justice and fairness. We as health professionals must ensure our systems are built so there are fewer faults in the system. If appropriate systems are in place, we can make a huge difference and lifelong changes for Aboriginal and Torres Strait Islander people. The crux of all this is how we, as healthcare professionals, engage with communities, how we build capacity in those communities and leave that knowledge within the communities so that together we can find the solutions and feed them back into a positive pathway; a virtuous circle.

The diagnosis and management of ear and hearing health problems starts in primary health care, so we need to get this right as well as the pathway to specialist services.

Honorary Associate Professor Boe Rambaldini, Aboriginal elder, Bunjalung nation

Q: What is the role of cultural safety in hearing health?

A: I’d like to reinforce the things Kelvin [Kong] has said. Health, to a lot of Australian people, is seen as a place where people go when they need help. However, people have to realise that the health system has played a very huge part, a very damaging card, in the history of our country. When our parents took their children to receive medical treatment, they called the authorities and those kids were removed. So cultural safety is very important; our people want to be able to feel safe when they go to those healthcare places. When you talk about competency, in regards to cultural safety and health services, you need to take account of the historical events that happened in this country and give a true indication of what happened and the role that the health officials played. Because as we know, kids are still being removed today at alarming rates¹¹, so we need to take that into account.

And lots of people say ‘let’s not worry about the past’, but doctors rely on the past to develop a plan to make people well – they want to know if somebody’s got a history of heart disease back there, or a history of diabetes, so they can develop a plan to move forward and make people well. We need them to make our people well emotionally as well as physically.

Q: How can health systems deliver cultural safety for Aboriginal and Torres Strait Islander children with hearing health problems?

A: Cultural safety is having respect and feeling safe and protected in every aspect of life, and it needs to take into account Aboriginal peoples’ customs, culture, history, social positioning, circumstances, hopes and dreams.

Policies and procedures that are part of Western systems and not receiving the same equality as others is not culturally appropriate and has serious consequences for Aboriginal people’s health. Confronting poor behaviour and unsafe behaviour and helping all people to feel safe, as well as inclusion and accountability, are essential to cultural safety.

Acknowledgements

The interview was conducted by the Director of the HEAR Centre at Macquarie University, Professor Catherine McMahon, who is a Guest Editor for this special issue of Public Health Research & Practice on hearing health.

Peer review and provenance

Invited, internally reviewed.