The AIHW has recently (26 February 2019) released a report
titled Northern Territory Remote Aboriginal Investment: Oral Health Program July
2012 to December 2017 (link
here).
I don’t propose to attempt a comprehensive summary the
report as it is very accessible and easy to read. A quick scan of the graphs
and tables will give any reader a good sense of progress. Not unexpectedly, remote
children appear to have higher levels of poor dental health than their mainstream
counterparts.
In terms of service delivery, preventative services, primarily
involving fluoride varnish treatments, appear to have grown consistently (off
an almost non-existent base in 2012) over the past five years (see figure 2.2).
In terms of fissure sealant services, numbers have decreased slightly since
2013 (figure 2.4) and in relation to clinical services, numbers of services
peaked in 2013, fell dramatically in 2014 and 2015, and are still below the
2013 levels in 2017 (figure 2.6).
In terms of outcomes, while the proportion of Aboriginal
children with tooth decay remains extremely high, over time those proportions
appear to be reducing. So in the period 2009 to 2017, the proportion of 1-3
year olds with tooth decay went from 73% to 43%; for 8 year olds it went from
93% to 88%; for 11 year olds it went up from 69% to 75%; and for 12 year olds
it went from 81% to 68% (see page 16). While this is positive news, it also
suggests that it will be decades before we attain parity in dental health
outcomes.
Two appendixes discuss a number of data issues and
limitations. The report is not based upon a comprehensive survey of all dental
services across the remote parts of the NT, and thus there is no guarantee that
the data which this report is based on is telling us the full story.
Nevertheless, like most AIHW reports, this report appears
to be well researched, thorough, and reasonably accessible notwithstanding a
degree of social and bureaucratic complexity.
However, the report raises a number of policy issues that
are beyond the AIHW remit, but nevertheless demand consideration and attention.
The program being assessed is a Commonwealth program that
is limited to the NT. It is a direct descendant of programs begun as part of the
NT intervention and the subsequent Stronger Futures era. This raises the
immediate question: what is the state of play in other remote jurisdictions? The short answer is that we don’t know. My
guess is that the outcomes are likely to be similar or worse (unless there is a
particular jurisdiction that is delivering outstanding dental services to
remote communities).
A second issue that the report fails to mention relates to
the causes of high levels of poor dental health. The discussion of preventative
health in the report is limited to health related prevention (largely the
application of fluoride varnish treatments). Yet it is widely understood that
the causal links between consumption of sugar and high sugar drinks and tooth
decay are crucial.
These issues thus raise two further significant and related
issues for policymakers. First, are governments allocating enough financial resources
to both preventative and clinical dental services in remote Australia? In
addition, are the programs that exist effective?
Second, are there wider policy responses to poor remote
dental outcomes that ought to be pursued, or pursued with greater vigour? For
example, should there be tighter regulation or higher taxation on high sugar
drinks? And as a further aside, what are
the soft drink manufacturers and retailers doing in terms of their corporate social
responsibilities to diminish the impact of poor dental health on children?
These are not simple policy issues, and design of
appropriate policy interventions require careful consideration. However, we
appear to be in a largely policy free zone at present.
The PMC website includes a number of reports related to
dental health of Indigenous Australians. One of the more recent, the Aboriginal
and Torres Strait Islander Health Performance Framework 2017 Report (link
here) notes inter alia in a
section on ‘Implications’:
Implications
Available data indicate that dental health is worse for Indigenous Australians than for other Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14), healthy diets on limited budgets (see measure 2.19), attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08)...
Available data indicate that dental health is worse for Indigenous Australians than for other Australians, for both children and adults. Barriers to good oral health include cost of services (see measure 3.14), healthy diets on limited budgets (see measure 2.19), attending services for pain not prevention, insufficient education about oral health and preventing disease, public dental services not meeting demand, lack of fluoridation in some water supplies, and cultural competency issues with some service providers (see measure 3.08)...
Prevalence estimates
for oral health conditions for Indigenous Australians are based on out-of-date
and incomplete surveys—further data development is a priority for this
performance measure.
In the 2018 Closing the Gap statement in the
chapter on healthy lives (link
here) the Government mentions efforts by Outback Stores (a government owned
stores company operating in remote communities) to reduce sales of sugary drinks,
and notes also that:
The Australian Government has developed a strategy to reduce
the sales of highly sugared products sold in stores in remote Indigenous
communities. The store is often the main - or only - source of food and drinks
in remote communities, so a reduction the amount of sugared products sold in
the store is an effective way of reducing the amount sugar products consumed.
The strategy is being implemented in stages through until June 2020, focusing
on sugary drinks and expanding to other high-sugar products such as
confectionary.
In the 2019 Closing the Gap Report at page 137 (link here), there is mention of Outback
Stores operating in 37 remote stores (the Outback Stores website refers to 38
stores), and provides further mention of its store based sugar reduction strategies.
But no reference to a wider strategy applicable to all remote community stores,
and no mention to widening the strategy to confectionary. Perhaps the reference
in the 2018 report was just to the Outback Stores footprint, which is less than
a quarter of all remote stores.
The Outback Stores Annual Report for 2017-18 (link
here) provides further detail on their sugar reduction strategies, built
upon a foundation of price incentives and a support grant from PMC of $500k. What
is less clear is whether PMC is doing anything substantive beyond the Outback
Stores footprint. The indications are that it is not.
To sum up, we have an excellent report from AIHW addressing
only one of the five jurisdictions encompassing remote Australia. It outlines
serious dental health issues affecting scores of thousands of children. Its focus
on measuring the scale of preventive services is limited to health interventions.
There is some indication that Commonwealth policymakers have been focussed on
addressing other wider causes of poor dental health in remote communities, but
only in an extremely limited way and only in a small proportion of remote
communities.
To be blunt, in relation to levels of dental health across
remote Australia, the available evidence indicates that we know there is a
problem, we don’t know how extensive it is, and we aren’t prepared to do what
is necessary to address the wider causes of the problem. Admittedly, probably
another twenty health issues across the remote indigenous health domain require
focussed attention.
But the question remains, how will we close the gap on remote
Indigenous dental health let alone remote Indigenous health status generally when
governments are focussed on signalling they are doing something, but are not
prepared to devise, develop and implement the substantive policies which might
make real inroads?
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