Basil Hetzel Oration: The COVID‐19, racism, mental health and smoking crises

I recognise and pay my respects to the Traditional Owners of the land and pay my respects to Elders past and present.

I am Kungarakan and Iwaidja, and I am writing from the Larrakia nation in Darwin. I pay my respects to the Larrakia peoples. I respect their cultures, their knowledges, and their unbroken connection to country. The Larrakia peoples lived, loved, raised their families and cared for this country for millennia before the arrival of the British, which saw so many dispossessed of their lands, cultures and languages across the nation and, of course, the introduction of western diseases.

It was an honour to deliver the 2021 Basil Hetzel Oration. I acknowledge and respect the invaluable work of Dr Basil Hetzel AC in international health, including on iodine deficiency disorders in Papua New Guinea. Papua New Guinea is our closest neighbour, and approximately 2.1% of the population is fully vaccinated against COVID‐19.¹ We must recognise that the response to COVID‐19 among our neighbouring countries and around the world is essential if we are to respond to COVID‐19 successfully.

The COVID‐19 pandemic has presented challenges and opportunities for Aboriginal and Torres Strait Islander peoples. Aboriginal and Torres Strait Islander peoples are at increased risk from COVID‐19 given the higher prevalence of health risk factors amongst our populations, implicated with coloniality and systemic racism.2, 3 However, the experience of Aboriginal and Torres Strait Islanders has meant that we have taken the pandemic seriously from the outset. In bringing prevention measures to communities, Indigenous skill and excellence have been highlighted. We must use this momentum to address ongoing issues among Aboriginal and Torres Strait Islander peoples brought through colonisation, systemic racism and associated health inequalities.⁴

These are challenging times. We all struggle with rapidly changing environments and emergency protocols, put in place for the greater good of the community, that affect our day‐to‐day lives. In particular, our communities and our frontline and essential workers and their families have faced great hardship, and we thank them for all their work and sacrifices. We acknowledge that this level of effort is not sustainable over the long term and there is a real risk of burnout. We have a health sector that has been under immense pressure for a long period, with ongoing uncertainty.

But we have witnessed many successes in the COVID response.1, 5 For example, the Torres Strait rapidly mobilised the vaccine rollout, actively protecting the health and wellbeing of Torres Strait Islander people, and recently the ACT has reached the milestone of >97% of its population fully vaccinated.⁶ These wins should be recognised and celebrated, especially as we continue to fight the COVID‐19 battle on multiple fronts. We recognise that community plays a vital role in achieving these positive results. The key to an effective response to COVID‐19 lies within community and in coming together at the local, national and international levels.⁷

Although we are weathered from COVID‐19, we have learned many lessons. We need to pause to acknowledge our successes and key learnings; and to reset, re‐energise and relaunch.

Our successes

In 2020 and 2021 we have seen emergency protocols and responses set up and refined almost in real time as evidence has become available. High‐quality and timely data has been critically important. For example, as part of the COVID‐19 response and for routine health care, the capture of information such as smoking status and Aboriginal and Torres Strait Islander identity has helped to inform appropriate program design and service provision.

At the beginning of the COVID‐19 pandemic, comprehensive testing sites and infrastructure were widely established and expanded across the country, and cutting‐edge infection prevention and control measures were implemented overnight.5, 8 We have improved and streamlined online bookings for many services and access to hand hygiene. Minimal touch surfaces and maximised no‐touch surfaces have become increasingly common and normalised. We have automated doors and improved client traffic flow through healthcare facilities and waiting rooms to minimise COVID‐19 transmission. All of these advances have minimised the spread of contagious diseases.1, 8 Hand hygiene alone has had a positive impact, particularly in remote communities, where school‐based and children‐driven health and hygiene messaging is encouraged, promoted and reinforced. We can and should expect that these types of measures will continue once we move out of the pandemic.

We have also seen improved access to telemedicine, particularly in rural and remote settings,⁸ and reflected in the recently launched National Preventive Health Strategy 2021‐2030. Technology has been used effectively to assist contact tracing and support active community communication, with many mobile apps and QR (Quick Response) codes developed, evolved and widely implemented. COVID‐19 tests are also accessible, with COVID‐19 test waiting times updated in real time.

We have learned that clear, consistent, coordinated, timely and reliable communication is critically important, and we are continuing to learn about how to best communicate and engage with the public.⁹ Our Chief Health Officers and Chief Medical Officers have directly communicated with households on a daily basis, outlining the next steps in the fight against COVID‐19. We have seen the important role that medical, allied and public health professionals and organisations have in engaging, communicating and accurately informing the public. However, it is clear that there are ramifications when communication is not effective.⁹ We have seen an increase in the dissemination of misinformation⁹ through social media ‐ something public health continues to grapple. This was a useful lesson.

The lockdowns worked.⁵ We witnessed declining COVID‐19 reproductive rates, minimal transmission and delays in transmission. This bought time for vaccines to arrive and be administered and to upscale healthcare infrastructure, planning and strategic responses and to learn how to manage these challenging circumstances.

Academe has played an important role.⁷ Leading health professionals and epidemiologists have provided critical and timely evidence to inform responses.7, 8 Universities have been instrumental to addressing COVID through graduate programs and workforce development. We have witnessed university alumni and students step up to the demand required with the increasing strong push for robust, timely, evidence‐based public policy.

Public health and our communities have been critical⁹ to our success in responding to COVID‐19 and as we accelerate and maintain the vaccine rollout. The evidence has also highlighted distinct challenges to integrating and supporting primary care in response to infectious disease epidemics that have persisted over time, re‐emerging during COVID‐19.⁸ This information gives us an opportunity to strengthen and improve preparedness in a world where the frequency, virility and reach of infectious disease outbreaks are increasing, as we have witnessed with the growth of the Delta and Omicron strains.

Don't waste a pandemic ‐ ongoing challenges and opportunities

COVID‐19 has provided us with an opportunity for change. It has highlighted racism that has resulted in health inequalities for Aboriginal and Torres Strait Islander peoples, and we must now address these root causes. Also, we have clear indicators of a worsening mental health crisis, particularly for priority populations. Mental health must be supported through appropriate, accessible economic and financial supports where required. Given what we know about the health risks from smoking, we must focus on smoking prevention amongst Aboriginal and Torres Strait Islander peoples.

We must address racism

This is not the first pandemic that Aboriginal and Torres Strait Islander peoples have experienced. Smallpox and European diseases wiped out many of our people, so we do not take COVID‐19 lightly. Evidence has highlighted that more than half of Aboriginal and Torres Strait Islander adults are at increased risk of developing severe illness if they contract COVID‐19 and are unvaccinated.³ This is because Aboriginal and Torres Strait Islander peoples face greater incidence of health risk factors such as cardiovascular disease, diabetes, cancer and smoking³: 59% of Aboriginal and Torres Strait Islander adults have pre‐existing conditions that could increase their risk. These factors exist because of health inequities stemming from colonisation and experiences of racism.³

Ultimately, racism is an organised system of oppression and power: disadvantaging those considered inferior, and advantaging those considered superior.⁴ The ongoing legacies of colonialism and the White Australia Policy continue.4 They are embedded within our institutions and continue to drive inequities in health care; child protection; education; employment; housing; policing; and criminal justice.⁴

But we have learned many lessons through colonisation. As the oldest living cultures, our resilience and experience continue to shine. COVID‐19 has allowed us to change the narrative and highlight Indigenous excellence; Black excellence.⁷ The COVID‐19 co‐design process, for example, has placed Aboriginal and Torres Strait Islander peoples into the driver's seat of the COVID‐19 response and put us at the table with government decision‐makers.⁷ The co‐design process has offered a refreshing opportunity for meaningful collaboration and community benefit. The community‐controlled sector has used its strength, experience and wisdom, in many cases mobilising quicker than government processes to actively delay transmission in a pragmatic manner.⁷ It is important that this momentum and confidence be maintained.

COVID‐19 has highlighted the inequities that Aboriginal and Torres Strait Islander peoples face, and this creates real opportunities to address those issues. COVID‐19 has shone light into some of the darkest corners of our society and highlighted the racism that exists within it. Aboriginal and Torres Strait Islander peoples experience structural and systemic racism,2, 4 which uniquely and actively manifests in many ways, including dispossession of land, child removal policies and disproportionately high incarceration rates. Colonisation has dislocated Aboriginal and Torres Strait Islander peoples from our lands; removed our children; and altered our cultures, our languages, our traditions and our practices as the original inhabitant of this land. The erosion of social structures and intergenerational connectedness, with associated impacts and added stressors resulting from colonisation, has directly and indirectly impacted numerous health and wellbeing outcomes, including mental health and wellbeing.

Unfortunately, many Aboriginal and Torres Strait Islander children have experienced racism during COVID‐19. This is neither new nor rare.² It is well established that Aboriginal and Torres Strait Islander children in particular experience high levels of racism in everyday life.² For many, racism and racial discrimination are everyday experiences, not just during the COVID‐19 pandemic period.² Children in our community are getting sick from racism. Numerous studies in Australian and international studies show that child depression, anxiety, behaviour difficulties, sleep disruption and suicide are all linked to experiences of racial discrimination. And there have been many documented examples of Aboriginal and Torres Strait Islander peoples experiencing racism in the context of COVID‐19. For example, many have reported comments in health care settings that ‘Aboriginal people only get it because they don't wash their hands’. There are also concerns about over‐policing of and unequal consequences for Aboriginal and Torres Strait Islander peoples in relation to quarantine requirements.

In March 2021, the Victorian Government announced an inquiry into the impacts of colonisation on Aboriginal people.¹⁰ It is the first of its kind in Australia and will examine the social, economic, and health impacts of colonisation on Aboriginal peoples and communities.¹⁰ This work has the potential to make substantial and substantive change and acknowledge the hard truths so that we can move forward and reconcile together. We can no longer use Band‐Aid solutions that only treat superficially.⁴ We all have a role in facilitating reform and providing the data and evidence that will support efforts to foster safer spaces and inform public policy. It is crucial that we identify and address the root causes of inequity to help promote health and wellbeing.2, 3

We must prepare for the ‘shadow pandemic’

The term ‘shadow pandemic’ refers to the mental health and wellbeing issues we face as a result of COVID‐19 and intervention measures. The potential impacts of COVID‐19 on our mental health and wellbeing were recognised early in the pandemic, including among Aboriginal and Torres Strait Islander peoples.11, 12 Expanded mental health funding and services are vitally important and welcomed. But, in many cases, it may take time to make newly established programs accessible, especially given dire workforce and supply challenges.¹¹

Further, the impact of the pandemic on mental health appears to have disproportionately affected a number of priority population groups: young people; women; those in COVID‐19‐related work; people living with a disability or existing mental health challenges; and those with low incomes, experiencing job loss or living in poor‐quality housing conditions.¹¹ There are clear indicators of a worsening mental health crisis, including for our children. Our children's lives have undergone rapid, major upheavals as a result of the pandemic. The impacts that COVID‐19 will have on their mental, social, emotional and physical health and wellbeing are yet to be fully realised, but we can see them unfolding before our eyes.2, 11

Health and wellbeing supports are critically important, but so are economic and financial supports.¹¹ Many programs and supports remain limited, with barriers that make it difficult or impossible to access them. Economic and financial supports introduced during the recent lockdowns do not have many of the important features that made the 2020 schemes accessible and successful, boosting the economy, easing some personal everyday stresses and supporting people's mental health and wellbeing. The 2020 economic and financial supports were relatively universal. The schemes’ accessibility requirements enabled them to be implemented quickly and to generally reach the people who needed them, including young people and families. Temporary government‐funded economic supports, JobKeeper and the Coronavirus Supplement for Youth Allowance and JobSeeker, introduced in 2020, played a key role in supporting the community, including supporting mental health and wellbeing.

We now need broad‐based and easy to access economic supports that can help to ensure that young workers can stay connected to work and that those who cannot work receive a sufficient level of economic and financial security.

We must use lessons learned to address health risks from smoking

The world now has increased awareness of the importance of public health and epidemiology, and we have a unique opportunity to build on the momentum. In 2020−2021 we saw that, when mobilised, public health and our communities can make large, almost unbelievable advances. Substantive and sustainable population and public health reform requires policy commitment and stability, sustainable funding based on need and a vision to achieve parity for all Australians; and to address the significant and ongoing legacy of colonisation.

We have known for over 60 years that, when used as directed, tobacco will kill you.¹³ Colonisation introduced and continues to support tobacco use. Tobacco was often used in first encounters between colonisers and Aboriginal and Torres Strait Islander peoples as a gesture of goodwill and to establish and build relationships. It was also used as a form of payment in lieu of wages until the mid to late 1960s.¹⁴ This entrenched smoking among Aboriginal and Torres Strait Islander peoples.¹⁴

Colonisation has also actively placed Aboriginal and Torres Strait Islander peoples at the bottom of the socioeconomic ladder – an outcome that has impacted over generations through mechanics of colonisation that have actively excluded us from the education system and the economy. Socioeconomic status is strongly linked to smoking, and other health and wellbeing outcomes, in an unjust, perpetual and predacious cycle.¹⁴ This is one of many reasons many are looking forward to the outcomes of the Victorian inquiry into colonisation, as we continue to experience these impacts.10, 14

Given the magnitude of preventable tobacco‐related death and disease, there is a clear need for sustained and adequate funding to support tobacco control.¹⁵ We must do better. There has been a 9.8% absolute decline in daily tobacco use among Aboriginal and Torres Strait Islander peoples since 2004−05, leading to many lives saved.¹⁶ But Aboriginal and Torres Strait Islander specific tobacco control, such as the Tackling Indigenous Smoking program, and mainstream tobacco control efforts need to be sustained and expanded.14, 16 We must remember that there is no silver bullet or one‐size‐fits‐all approach to reducing tobacco use, or any health issues.2, 6 Overnight success does not happen – it takes time.

Conclusion

The final message: be kind to your friends and families, your children and your communities. And, most importantly, be kind to yourself. Let's reset, re‐energise and relaunch, and make sure the vast health improvements we have achieved can benefit us ‐ and keep us smoke‐free – long into the future.