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Evidence to inform conversations on Aboriginal health issues — in response to COVID-19 and beyond Nearly everyone has been affected in some way by the coronavirus disease 2019 (COVID-19) pandemic, and it is a public health risk for Aboriginal peoples and communities.1 The impacts of the pandemic are pervasive, wide-ranging and continue to affect people and communities differently. Concerns about the indirect impacts of COVID-19, caused by missed, delayed and avoided health care — not as a direct consequence of COVID-19 infections — are shared internationally.2-4 While the prevalence of COVID-19 in New South Wales remains low,5 local data show significant changes in health utilisation across the state. During the 4-month period from March to June 2020, compared with the same period in 2019, face-to-face primary care consultations decreased by 22.1%, breast screen activity by 51.5%, ambulance incidents by 7.2%, emergency department visits by 13.9%, public hospital inpatient episodes by 14.3%, and public hospital planned surgical activity by 32.6%.6 Such decreases are not unique to NSW.7 Before COVID-19, Aboriginal people faced health disadvantages and inequitable access to health care. Any decrease in health care access for Aboriginal people through missed, delayed or avoided health care may lead to further adverse health outcomes and inequities.1, 4, 8 In recent months, we came together as a group of 12 Aboriginal community members from across NSW to share our experiences and perspectives regarding the indirect impacts of COVID-19. We live and work on Eora, Wilyakali, Bundjalung, Yuin and Gumbaynggirr lands. The discussions occurred over three separate sessions, each held a week apart between 24 August and 1 September 2020. Six members of the group (DF, CP, PO, BO, DL and KB) captured the key messages identified from the talks and synthesised the findings into three main themes: community supporting the community; the social determinants of health; and access to health care. These conversations were hosted and supported by the Critical Intelligence Unit established as part of the NSW Health COVID-19 response and the Agency for Clinical Innovation (TDB). Illustrative quotes shared by the co-authors have been selected to demonstrate salient points. The term "mob" has been used throughout to identify who we are and where we are from — our connection to our shared identity as Aboriginal people. Mob are proud of how they are keeping each other safe. It is a point of pride that has strengthened community. Our mob are concerned about the safety of others and our elders. (CP) Aboriginal leaders and Aboriginal community controlled health services are active in responding to COVID-19, drawing on experiences from the 2009 HINI influenza pandemic and implementing culturally appropriate resources.9 Our mob aren't able to connect for sorry business and funerals, marriages and births. The provision of our health care, along with the provision of our social and emotional wellbeing, has changed. And connectivity is the main ingredient for our mob to stay healthy. This is the biggest barrier. (CP) Social determinants are the conditions in which people are born, grow, live and age, and how these factors influence our health and determine health inequalities.11 Cultural determinants of health such as connection to country (land and water), traditional practices and kinship systems promote resilience and support social and emotional wellbeing for Aboriginal peoples and communities.10, 12 The COVID-19 pandemic is likely to amplify the social determinants of health,13, 14 and our concern is these determinants will continue to affect access to health care and increase health inequalities. Increase in government payments has resulted in the one and only shop in community providing food jamming their prices up. The price of food and water is beyond compare when you are paying $10 for a loaf of bread. Because of COVID-19, people don't want to come into town to do their shopping. (DL) Some communities are being hit hard. To give a raw example, people are being refused medical treatment and are driving 600–800 km just to get any sort of medication or treatment around their health. (DL) We are also concerned that a lack of cultural safety displayed during COVID-19 will lead to Aboriginal people being confronted with racism when trying to access health care.15 Deciding to seek health care is difficult, and for some Aboriginal people, access to care has become more challenging during COVID-19 with reduced availability of services. Many doctors and services have temporarily shut their doors to new patients, and this is likely to have a profound impact on people's health. When we look at the provision of health care for our mob, one of the biggest barriers is having to sit in front of a computer. And talk to a computer, rather than a human connection. Our mob like to connect and have a yarn. (CP) If the mob aren't receiving health related treatment, how this is feeding into direct or indirect impacts on disabilities. And how we can pick this up through the health system as disability is not in closing the gap. If we aren't addressing it at a higher level, we are never going to address it at the ground level. (DL) We are also concerned about an increase in risk for our older people living with disability. These risks have been outlined by Aboriginal people with disability and their representative organisations, advocates and allies in international and national calls to action for governments to ensure Aboriginal disability-inclusive public health, social and economic responses to the pandemic that put our mob at the forefront of any future planning in the health system.17 The recent drought, bushfires and now COVID-19 are compounding risk factors for mental health issues and suicide. There is concern that some government measures to control the spread of COVID-19 are triggering for mob — especially for those with trauma histories.18 We know mental health issues and suicide rates are high for our peoples,8, 19 and we are concerned this level of disadvantage will worsen in response to COVID-19. We support the recommendations made by the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention at the University of Western Australia to manage COVID-19 recovery and address adverse impacts.19 The recommendations focus on the right to self-determination, the health and mental health workforce, social and cultural determinants of health, digital and telehealth inclusion, and evaluation that includes Indigenous data sovereignty. These recommendations directly align with our lived experiences and were running themes throughout our discussions and overall assessment of the indirect impacts of COVID-19 in our communities across NSW. We prepared this article to inform future conversations on Aboriginal health issues in response to the COVID-19 pandemic and beyond. Our view is that drawing on the lived experience and realities of Aboriginal peoples, taking firm action on the social determinants of health and working collaboratively with Aboriginal peoples and communities is the most effective way to address the indirect impacts of COVID-19. We acknowledge the contributions of everyone who participated in these important conversations. We acknowledge that as the host of these conversations, NSW Health was privy to the ancient and traditional process of yarning and the respect and sharing of knowledge that this involves. We acknowledge the lands on which these conversations took place, the lands of an ancient and continuing culture, and we acknowledge and pay respect to the elders past, present and emerging of these Aboriginal lands. These lands always were and always will be Aboriginal land. We thank Kim Sutherland and Jean-Frederic Levesque from the Agency for Clinical Innovation and the Critical Intelligence Unit for their ongoing support. No relevant disclosures. Not commissioned; externally peer reviewed.
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