When the First are Last – The Right to Wellbeing of Australia’s Ancient Cultures
In Thessaloniki it is easy to contemplate the wisdom of the ancestors. I have the same feeling of admiration for Australia’s ancient cultures when I ponder the magnificent forty-thousand-year-old rock art galleries on Jawoyn country near Katherine in the Northern Territory. The longer timelines of history tell us much about the rise and fall of civilizations, especially the crucial role of knowledge, resilience and adaptation in the steady advances of the human species. After my sixty years of world wandering, encountering a good number of the world’s brightest men and women in many fields, I now agree with the Harvard biologist, Edward O.Wilson that if we so wish Earth by the twenty-second century can be turned into a permanent paradise1. What is required, Wilson states with memorable optimism, is “an ethic of simple decency to one another, the unrelenting application of reason, and acceptance of what we truly are.”2 With these inspiring principles in mind, I believe that the wellbeing of Australia’s First Peoples is one of the greatest national challenges facing us today and if we meet this challenge it will make our society far greater and even an inspiration to the world.
As most of you will know, for many years the OECD has ranked Australia as a world leader in quality of life. Yes, Australia is also one of the most expensive countries to live in today but if we look closely at the health and happiness index, measurements that are indeed broad and deep, this should be cause for genuine satisfaction. Yet at the same time young Australians are warned that they may be the first generation in history to have a shorter life expectancy than their parents. The obesity epidemic challenges our complacency, a national tendency to rest on our natural abundance and good fortune.
The state of Indigenous health in also should challenge each one of us to ask why do we have this poverty and ill health in the heartland of such a highly developed nation? Why am I often the oldest man as I walk the red dirt streets of the remote Aboriginal communities? Why do Aboriginal people in the Northern Territory have a life-expectancy gap of 15-21 years, about 50% higher than the national Indigenous average of 11.5 years for men and 9.7years for women? All of these official estimates, I will demonstrate, underestimate the real disadvantages faced by the First Australians.
Like our Prime Ministers we may go on talking optimistically about Australia’s top quality of lifeand our endeavor to Close the Gap but most Aboriginal people know from a very young age that their lives are not going to be as healthy as the rest. Many feel trapped in poverty and are constantly reminded that their lives will be cut short by chronic illnesses. In the remote communities especially, the procession of funerals seems never ending. Diabetes, renal illness, cancer, strokes, hypertension and heart disease, a cluster of preventable, lifestyle related diseases and illnesses, is cutting the heart out of another generation.
This health emergency for Indigenous Australians and the increasing threat to the life expectancy of all younger Australians is occurring at the same time as Australia celebrates its top ranking in the quality of life index. I want you to draw the connection here. Totally preventable, treatable, life-style illnesses are the common threat. There are of course some important differences between Australia’s two worlds of people and we will explore them carefully. But to improve health for all Australians, to build a truly healthy society, we need to recognize that health is a state of mind, as well as of body.
As highly educated medical and legal professionals maybe you have mastered this duality of mind and body. Or have you? Let me be the counselor for a moment and ask you to settle back in the chair and tell me about your health.
I am delighted to hear that less than 5% of you medical professionals are smokers. This compares very favorably to the 19% of other workers who still smoke. 3
We also know that most of you do not abuse your health by drinking more than two standard drinks of alcohol a day, just 13% of you do, compared with about 23% of other Australian workers.
Well, just as some of you might be getting very comfortable, stretching out with a smile on my couch, I must ask you, delicately, why 58% of doctors are overweight or obese? This is only slightly less than the 63% of workers generally who are overweight or obese.
I also need to bring up the disturbing survey of 14,000 doctors and medical students by Beyondblue3.4This indicates that 1 in 5 medical students and 1 in 10 doctors had suicidal thoughts in the past year, compared with 1 in 45 people in the wider community. For those under 30, sometimes working 50 hours or more a week, levels of high psychological distress and milder depression and anxiety are far greater than among the general population. The Beyondblue survey also indicates that there is a considerable degree of stigma towards doctors with depression and that many of you also experience racism and bullying.
The equally confronting assessment for those of you who are lawyers, barristers or judges, is that an estimated 60% of your profession also experiences moderate to high levels of psychological stress. Several studies have indicated that legal professionals and law students are more likely than other professions to report moderate to severe symptoms of depression and to have used alcohol and other drugs to manage your feelings.5
What is happening here? Even for two of the professions with the most education, including, in the case of doctors, scientific training to understand the serious health risks caused by obesity, the nature of depression and the impact of alcohol on fuelling mental illness, we can see very clearly that for doctors and lawyers too, health is a state of mind and body.
Your attitudes, your crucial lifestyle decisions, your education, all of the social determinants and your work/life balance, are shaping your health outcomes. This should provide life-changing and life-saving insights for you, for patients or clients and especially for those who carry the greatest burden of chronic illness, our First Peoples. What I am driving at here is that if we are going to improve Aboriginal wellbeing then we need to understand why life is out of kilter for so many people.
Now let us examine a significant health behavior where you doctors show a positive lead over the rest of us. Your lower smoking rates are impressive. Yet smoking has a devastating impact on Aboriginal health and so many of these patients seem beyond the reach of your advice. The Western Australian Indigenous Health Survey6 and research in the Northern Territory7 establishes crucial links between Aboriginal smoking patterns and devastating health consequences. For example, about half of all young Indigenous women smoke even during pregnancy. This habit or addiction, combined with their extraordinary poverty and poor nutrition, increases the risk of a dangerously low birth-rate baby.
According to Professor John Bertram’s research team at Monash University6, a global study of patients dying of the Syndrome X cluster of chronic illnesses had one striking common factor.8 It was being born a dangerously low birth-weight baby whose kidneys, even in utero, had not developed the required number of nephrons. By early childhood, according to Professor Bertram, the shortage of these filters was causing the kidney to overcompensate, leading to an increased risk of scarring and premature renal illness.
So this returns us to the urgency of understanding the mind/body connection. While smoking has been on the decline for most Australians, Indigenous people have been heavily hooked on tobacco smoking since the habit was promoted by Europeans in colonial times.9Traditionally Aboriginal people had used the narcotic of the pitjuri bush, the pipe arrived with the Macassans and then it was European colonists who began trading tobacco for safe passage, sex or labour. Tobacco smoking is one of the most damaging aftermaths of colonization contributing to about 20% of Aboriginal deaths today. One in two Indigenous people smoke compared with one in six of the rest of Australians. This prompted Dr Tom Calma, champion of the Close the Gap campaign, to lead an Indigenous anti-smoking effort nationally.
In the past we knew that about half of young Indigenous mothers surveyed had never heard of the QUIT campaign. It is now hoped that the Australia-wide television and print campaign with messages delivered in a different style, a focus on the impact on the Aboriginal family, may impinge. Doctors or anyone working with Aboriginal people need to consider the factors that make it difficult to change this habit.
Understanding the mind/body factors and the social context is essential. Impoverished people continue to smoke in many parts of the world. For many, addiction may appear to bring an intense stimulation, like a junk-food lifestyle or alcohol intoxication. Taking steps to break old habits are much harder if you are so depressed that you don’t care what it is doing to your health or to the health of your unborn child.
For this reason, I find that talking to young women about how not smoking can give them a much stronger chance of a beautifully healthy child is a game changer.
Motivating Aboriginal men to kick bad health habits requires an understanding of their life experience. The older men have been frightened into believing that somehow just being born black is the health curse that sets them up for an early death. I explain why this isn’t so and then share what I have learned from wise doctors in many cultures. I let them in on the secret of Aboriginal men and women who have lived into their nineties. They all avoided the white man’s poisons. I tell young fellers that water is one of the miraculous ingredients of life here on earth and that there is no better drink than cold water from a clean waterfall. It is not a message of prohibition but of tapping into the life force, of what is natural and truly healthy.
As doctors you will have your own patter, no doubt better informed than mine. However it is important to recognize that because Australia was silent about the declining health of Aboriginal people for so long, we need to constantly refresh our approach and assess carefully our success or failure in bringing life- changing health advice to the patients most at risk from smoking and alcohol abuse.
This will be very difficult when many Aboriginal people rarely see a GP. Although the Northern Territory has Australia’s highest per capita ratio of doctors to patients, there is a crucial shortage in remote communities. Aboriginal medical services, the front line service in many remote communities, desperately need skilled practitioners. Various incentives including financial bonuses, have failed to build a rural health service adequately equipped to handle the front lines of Australia’s health emergency. We need men, women and whole families to invest themselves in bringing about a health revolution for all of Australia’s children.
It may be, as Professor Stephen Duckett of the Grattan Institute proposes, that we can strengthen the remote area health force by using physicians assistants8 who have completed two to three years of medical training.10 There have been local trials of this approach in Queensland and South Australia. The United States uses doctor assistants in this fashion in response to similar shortages of rural doctors. Professor Duckett’s proposal is that the assistants work under the supervision of doctors, taking down patient’s histories, conducting examinations, diagnosis and prescription of treatment or referrals to specialists. In Britain and Canada pharmacists already are performing some of the same work as Australian doctors, immunizing children, re-issuing prescriptions for long-term conditions and managing a care plan for the patients. Professor Duckett has proposed that pharmacists could take on up to 5% of doctor’s workload in rural areas, freeing up at least 225,000 GP visits. Isn’t this the crucial issue here? Who is visiting or managing the care plan for tens of thousands of Aboriginal people who do not access adequate health care from the youngest age until they are bed-ridden with chronic illness?
The Aboriginal remote communities and rural areas generally have the lowest rates of medical bulk billing. This further reduces the chances that these patients will even make it to your office to hear you impart that life-changing and potentially life-saving preventative advice. The challenge is to activate a health workforce that can help move all Australians into an early intervention and prevention state of mind. Are we prepared to make changes that can move us from the sickness industry to genuine national wellbeing, perhaps unprecedented anywhere in the world?
If we all look in the mirror we can see that a majority of Australians, the affluent and battling families, are struggling with the own work-life balance, with the inability to find time to exercise and with limited success in modifying the modern diet that is killing too many of us way before our natural time. I fully appreciate that this struggle involves a majority of doctors as well.
How much more difficult is it then for Aboriginal people when living in extreme poverty in a rich country is a hammer blow to that mind/body health duality? According to a brilliant analysis published by a team from the Northern Territory Department of Health9, up to one half of the Indigenous gap in life expectancy is due to this crippling poverty.11 Global studies indicate that between 70 and 80 per cent of health for all of us is a consequence of the social determinants. Indigenous poverty is a striking sickness trap, accentuating the disorientation and compounding the downward spiral. Many Aboriginal people feel that they are lost in a maze, unable to find their way towards wellness because they are not in control of their destiny, clearly uncared for and even unrecognized in their own land.
Dispossession, disempowerment and disrespect are the persistent themes of most Government policy. Government has been attempting to control Aboriginal people for more than two centuries. When this loss of control is combined with the arrival of new and disastrous health threats, physical and mental illnesses, we have the makings of Australia’s current Indigenous health emergency.
In the Northern Territory there is a contagion of Indigenous youth suicide in many but not all remote communities. We need to look closely at the pattern and appreciate why in some communities where there is stronger Cultural authority there is hope but where tradition is undermined by new factors there is so often despair. Even just twenty years ago Indigenous suicide rates were at the same rate as for all Australians. In the Northern Territory the percentage of all age Indigenous suicide has increased from 5% of total suicides in 1991 to 50% of the total in 2010.12 The most alarming increase is among young Indigenous people aged 10 to 24. Indigenous youth suicide in the Northern Territory has increased from 10% of the total in 1991 to 80% of the total in 2010. In January 2013 the Australian Human Rights Commission reported a 160% increase in the rate of Indigenous youth suicide and a more than five-fold increase in self-harm during the years of the Northern Territory Intervention.
Clearly the government policy of control and assimilation is having a catastrophic impact on Aboriginal life. The Northern Territory Intervention without doubt is the most damaging policy aimed at Aboriginal people since Government policy created the first Stolen Generations. Today we see the removal of Aboriginal children from their families at a rate that threatens a new Stolen Generation. Currently one third of the 40,000 Australian children living in out of family care are Indigenous children.
The crash in Indigenous wellbeing has been accelerating over the last three decades because of the gathering disaster of the chronic illness plague. The historic pattern, including profound dislocation of Indigenous people, cultural obliteration in some cases as a result of invasive westernization and so-called modernization, has seen the shift of hundreds of millions of First Nations people around the world from a balanced diet to one based on too much fat, processed flour and sugar. The abandonment of the more balanced traditional Indigenous diet has been well chronicled by the likes of California’s Weston Price Institute.13. There are new factors, however, global changes to nutrition patterns that are fuelling the obesity epidemic and causing so much harm to Indigenous people.
Dr Robert Lustig12, an endocrinologist at the University of California, is among many scientists who argue that the rising rates of obesity and heart disease are not only due to cholesterol caused by too much saturated fat in the diet. Dr Lustig contends that the rapid change is triggered largely by an increase in sugar, particularly fructose.14 Many people around the world are now consuming up to twenty teaspoons of added sugar a day because food manufacturers have added sugar to sweeten the taste in compensation for a reduction in fat.
In Aboriginal communities where fresh fruit and vegetables come at a premium cost, the junk food diet and especially sugary drinks takes a terrible toll on health. Infants who displayed high rates of anemia, failure to thrive and stunting, will find their way to the cheapest food in the community shop, the tasty fats, the sweet cakes and ice-creams, and all of those sugar-loaded drinks.
Ah sugar, another white man’s poison! Except we all know that it was our northern neighbours in Papua New Guinea who domesticated the sugar cane plant and gave the world the sugar hit.The great tragedy of the scourge of poor nutrition and global sickness, I have witnessed this in Africa, Central and South America, as well as close to home, is that it usually hits the poorest members of our human family that are the very hardest. This is true of the modern cluster of preventable, treatable, life-style illnesses decimating Aboriginal life.
As medical and legal professionals you cannot change the social determinants for Aboriginal people. But you can raise your voice, use your knowledge and take action. Yours are powerful professions with the wellbeing of a nation in your hands and I urge you to use this power. We must convince government that only by addressing the social determinants can we make even incremental advances in closing our gaps.
When Close the Gap was a political campaign challenging government to do better and to invest strategically in primary health care, I wrote some of the language to sharpen the case in that unifying national campaign. I shudder when I see Government spin doctors appropriating the phrase Close the Gap in truly Orwellian fashion to disempower Aboriginal communities under the crushing assimilation of the Northern Territory Intervention policies.
To genuinely close the gaps we have to shift trust and control to Aboriginal communities. Instead of trust, there is a very old pattern of treachery in Australia’s relationship with its Indigenous people. Every time a promise is made, a law passed or a hand held out in friendship, we seem to betray those good intentions.
Australia took such a very long time to recognize the most fundamental human rights of its Indigenous citizens but soon after we abandoned them to second-class citizenship. We may have stopped classing Aboriginal people as flora and fauna but we forgot that they were human when we removed their children from their families. It took Australia almost two centuries to recognize Aboriginal ownership of the land but as fast as we could we unpicked the Wik and Mabo High Court judgments and appealed against the Native Title settlements. We treated Aboriginal people like lowly domestic servants and then quibbled over the stolen wages. We paid lip service to the right of Indigenous people to speak their languages and pursue their ancient Cultures but relentlessly for more than a decade government policy and so much media have waged war, the Culture War, aimed at discrediting the extraordinary value of Indigenous Cultures.
The great danger of this relentlessly negative assault by one party against the other in the Australian black-white relationship is that it avoids the truth. One side is blindly refusing to look at the evidence. One side is still refusing to listen.
There is overwhelming evidence both here and in the most hopeful Indigenous societies overseas that an essential facet of well being for everyone is creating the strong and positive environment of Cultural security. An indispensable feature of the social determinants that constitute our health status is a sense of control over our destiny, the knowledge of who we are and the feeling that we are valued.
Consider the magnificent body of evidence on Native American problems and progress. After more than three decades of research led by Professors Stephen Cornell and Joe Kalt, the Harvard Project on American Indian Economic Development concludes that “perhaps the greatest development asset Indian nations possess is sovereignty, the power to make decisions about their own futures.” 15 I have witnessed many of the rapid advances made by some First Nations tribes and this form of empowerment is as crucial as education.
While Australian Government continues to deny even a local form of sovereignty and self-determination it fails to recognize the evidence that Indigenous control is essential for Indigenous advancement.
Look closer at the massively expensive Government interventions and you will see that most of them are disempowering for Aboriginal people and therefore ultimately unsustainable and even counterproductive. The public will tire of the cost of these interventions but it is the approach itself that dooms this policy.
Why have we faltered so badly on the homelands to ensure that every family that calls this country home has safe and hygienic shelter? The enormous inefficiency of the government funded housing alliance charged with building houses under the Northern Territory Intervention shows the folly of the contractor approach. Many of the houses that cost in excess of half a million dollars will be the fringe dwelling slums of tomorrow, poorly designed, shoddily built and often located on the wrong sites. I have seen concrete slabs poured onto partly filled mangrove swamps, sweatboxes erected with little cross ventilation, electrical fittings and plumbing poorly installed. All in all the Intervention housing program has bungled a great opportunity.
We could have begun by empowering Aboriginal communities and paying real wages to involve local teams in the kind of urgent repairs advocated by Dr Paul Pholeros of the Health Habit15 movement.16 The slow pace of new housing construction is not alleviating the dangerous overcrowding and it has taken far too long to get around to home repairs. Yet Dr Pholeros produces convincing proof that wellbeing and safety is advanced rapidly by first reducing hazards such as leaking sewage in areas where children are playing and eliminating dangerous electrical faults.
When Prime Minister Tony Abbott declared so revealingly that we cannot go on endlessly subsidizing what he called the lifestyle choice of living on homelands he displayed a profound misunderstanding of so much about Aboriginal life. Research by Dr Paul Burgess and others at the Menzies School of Health16 confirms what Aboriginal people have always told the Government. For animist people who are ‘of the land’ their wellbeing is clearly superior on the homelands.17 Instead of the social engineering by Federal, State and Territory Governments to pressure families towards larger towns that are ill-prepared to meet a new surge in demand for housing, jobs or even school places, we should be recognizing that in the age of global warming and with increasing population pressures in the crowded cities, Australia needs to embrace a state of the art decentralization that develops and fully utilizes new technologies. The digital advances are coming so rapidly that the future will only be glimpsed now by the brightest scientific imaginations.
Information, education, health, business and communication as a whole are collectively shifting new emphasis to the individual consumer. We need to understand how this matrix works.
I have visited some remote communities where doctors may take a blood test and then send the ‘bloods’ three hours by four-wheel drive on dirt roads to be diagnosed in town before the results allow treatment to proceed. You all know that an I-Stats machine, a portable clinic analyzer, can handle that task in any remote community. Aboriginal medical services need support to utilize the very best of the digital age diagnosis, including tracking patients when they move between remote communities.
Teachers, also, now drive many exhausting hours to spend two days a week visiting Aboriginal students on isolated homelands. Yet connected classrooms can provide a personal learning experience using Aboriginal teachers skilled at communicating with these children. Currently there is little continuity of education for many Indigenous children because of high staff turnovers. This nation will never find the funding to send all 160,000 Indigenous students in the public school system off to boarding school. We need to employ new and more stimulating mediums of education that recognize Aboriginal children have knowledge and skills wherever they live. As part of a global human family all children will soon be accessing more learning in ways we can barely imagine.
Look at the big picture and we should be mightily encouraged. According to the World Bank18 global poverty and illiteracy is rapidly retreating. In Australia’s case we need to show creativity and conviction to address the poverty and illiteracy that remains in the heartland. Fundamentally, we need to understand the logic of David Gonski’s education report and appreciate that to drive towards equity, we must address disadvantage.
This means embracing policy based on sound global evidence and clear analysis here at home that shows us where and how to start by ending the poverty and changing forever those crippling social determinants.
Don’t be deterred by the numbers. I have come home from encounters with global challenges including war, environmental ruin and plagues of illness, so often with a renewed determination that all of our children in Australia can have a far brighter future. In fact, stop thinking of statistics. Look at the challenge as if each one of these patients is one of your own children. I say, these are our children.
We know too what has to be done to improve their chances of a healthy future. The research by Canada’s Fraser Mustard18 shows us how to build on those mind/body health factors. 19For every year of education we add to a whole community of teenage Indigenous girls we add up to four years life expectancy to their first child. This is certainly one powerful way to close the life expectancy gap.
Ken Wyatt, now a two-term Federal Member of Parliament on Health and Human Rights Committees, gave me added scientific incentive for this life-skilling approach some years ago when he shared research which indicates that for each of those extra years of education added to that young Aboriginal mother we also reduce infant mortality by seven to ten per cent.20 Remember that Indigenous infant mortality is still double that of the rest of the population.
Instead of slashing the number of teachers in bush schools as we are told will be happening in the Northern Territory over the next two years, we should regard the education of all Aboriginal children as one of our most important national investments. According to several Nobel laureate economists it is certainly the investment with the greatest national return.
High quality early learning programs for Aboriginal infants could bring extraordinary gains in health and education. Very few of them exist despite the previous government’s pledge to create early learning for all Australian four year olds. In the United States, thirty years of evidence from the Carolina Abecedaria Project shows that participating children and their parents have greatly reduce the health threats of obesity and heart disease through this clever mix of education and health checks.21
The early learning and literacy backpack programs that I helped introduce in 22 remote communities as the honorary CEO of Ian Thorpe’s Fountain for Youth over the past fifteen years, was praised by former Prime Minister Julia Gillard in her final Close the Gaps Report. This was just before Government slashed funding to the twenty best indigenous education projects in Australia
Yet literacy, I believe, can mean life. . Culturally supportive, contemporary and engaging early learning is life changing, as it not only prepares children for learning it helps deal with the disadvantages before they become crippling.
One of Australia’s leading health researchers, Professor Fiona Stanley, has underscored this link between literacy and life222 arguing that while Cuba is one of the world’s poorest countries, its literacy rate is close to 100% and its free education and health systems lead to a better life expectancy and less infant mortality than in its superpower neighbor, the United States. Saudi Arabia, on the other hand, is a very rich country but has strikingly low literacy rates, especially for women, and as a consequence there is high infant mortality and low life expectancy.
And so I return to my opening thesis. Australia is closer to greatness and happiness as a society than anywhere I have been in over sixty years of world wandering. We need to believe in our egalitarian tradition, our almost mythical sense of mate- ship and equality, because inequalities of all kinds undermine the health of our society. We should be proud of our fine education and health systems but realize that they are not yet providing services equitably.
The well-being of Aboriginal and Torres Strait Islander people, especially children, is the single most important test of whether or not Australia becomes a great society. So I say, let us use every breath.
1 Wilson, Edward O., The Social Conquest of Earth, Liverright Publishing, New York. 2012. Page 297.
2 Ibid page 297.
3 Doctors and Nurses. Are they Taking Their Own Advice Australian Bureau of Statistics.. 2013
4 Beyond Blue National Mental health Survey of Doctors & Medical Students.October 2013.
5 Chan, Janet, Poynton, Suzanne, bruce, Jasmine. Lawyering Stress and Work Culture : An Australian Study. UNSW law Journal. Vol 37 (3) 2014.
6 Western Australia Aboriginal Child Health Survey. 2004-2006. Dr Fiona Stanley & Professor Ted Wilkes. Telethon Institute. http://aboriginal.childhealthresearch.org.au/kulunga-research-network/waachs.aspx 5
7 Decomposing Indigenous Life Expectancy Gap by risk factors. Yueien Zhao, Jo Wright, Stephen Begg and Steven Guthridge. Population Health Metrics 2013.
8 Preliminary Findings in a multiracial study of kidneys in autopsy. Hoy, Douglas-Denton, Hughson, Cass, Johnson, Bertram. Kidney Journal International. 83, 31-37. June 2003.
9 Smoking Kills : The Introduction of Smoking into Aboriginal Society with a Particular Focus on the Hunter Region of NSW. Greg Blyton. University of Newcastle. International Journal of Critical Indigenous Studies. Vol 3.No 2. 2010.
10 Radical Plan to Fix Health Crisis. Dan Harrison interviewing Professor Stephen Duckett of Grattan Institute. Sydney Morning Herald. September 30th 2013.
11 Decomposing Indigenous Life Expectancy Gap by risk factors. Yueien Zhao, Jo Wright, Stephen Begg and Steven Guthridge. Population Health Metrics 2013.
12 Strategies to minimize the incidence of Suicide. Closing the Gap Clearinghouse. http://www.aihw.gov.au/uploadedFiles/ClosingTheGap/Content/Publications/2013/ctgc-rs18.pdf Australian Government. February 2013.
13 Weston A. Price Institute. http://www.westonaprice.org/ 12 The Truth About Sugar. Dr Robert Lustig. University of California. http://thetruthaboutsugar.org/ 13 Sugar – Why We Can’t Resist It. Rich Cohen. National Geographic Magazine. August 2013.
15 Sovereignty and Nation-Building : The development Challenge in Indian Country Today. Stephen Cornell and Joseph P. Kalt. Joint Occasional Papers 2003 No 33. University of Arizona and Harvard University.
16 15 Health Habitat. Dr Paul Pholeros. http://www.healthabitat.com/teams/directors/paul-pholeros/
17 Beyond the Mainstream. Health Gains in Aboriginal Communities. Dr Paul Burgess. Published in Australian family Physician. Volume 31. No 12. December 2008/
18 Poverty in retreat Worldwide. Nicholas Kristof. The New York Times. October 2nd 2013.
20 When Literacy Can Mean Life. Jeff McMullen article, The Griffith Review. Edition 11. http://griffithreview.com/edition-11-getting-smart/when-literacy-can-mean-life
21 Lifelines for Poor Children. James J. Heckman. New York Times. September 14 2013.