As critical primary healthcare clinics are forced to close for some weeks in Central Australia due to the pandemic’s impact upon staffing, health leaders are calling for ‘vaccines-plus’ strategies to check COVID transmission, as well as better support for and investment in the Aboriginal health workforce.
In the articles below, Croakey’s Alison Barrett speaks with Dr John Boffa from Central Australian Aboriginal Congress, and Dr Elizabeth Moore, Public Health Medical Officer from Aboriginal Medical Services Alliance Northern Territory, also shares concerns about the workforce crisis and the need to address housing and other determinants of health.
Alison Barrett writes:
A leading public health expert has urged governments to do more to tackle the COVID pandemic in the wake of a related workforce crisis forcing the closure of important primary healthcare clinics in central Australia, with worrying implications for the health of Aboriginal and Torres Strait Islander people.
The Central Australian Aboriginal Congress (Congress) made the decision to close each of their five town clinics for one day each week from the beginning of August until the end of the month to help manage a shortage of healthcare staff.
Congress delivers services to more than 16,000 Aboriginal people living in Mparntwe/Alice Springs and remote communities across Central Australia, including Ltyentye Apurte (Santa Teresa), Ntaria (Hermannsburg), Wallace Rockhole, Utju (Areyonga), Mutitjulu and Amoonguna as well as many visitors.
Dr John Boffa, Chief Medical Officer Public Health at Congress, told Croakey that he was concerned recent major gains made in life expectancy for Aboriginal and Torres Strait Islander people in the NT will be reversed without urgent efforts to fix the Territory’s current primary healthcare crisis.
He said the latest Omicron wave in addition to rhinoviruses (common colds), influenza and provision of routine primary care has taken a toll on staff sick leave, in a system that was already struggling pre-pandemic.
“Basically, we’ve got the biggest workforce crisis we’ve ever had now,” Boffa said.
“There are all these viruses that are going around that are causing more severe illnesses than previously. A lot more staff are off on a daily basis than normal, on the back of more unfilled positions than normal and greater difficulty recruiting, particularly nurses and midwives but also doctors, Aboriginal Health Practitioners, psychologist and other allied health staff.
“There is also the need for staff to take a well-earned break after the ongoing stress of the last few years and staff have accrued a lot of annual leave. This has all helped to create the perfect workforce storm.”
Due to international and state border closures, the NT was able to stave off many COVID cases in the first two years of the pandemic. However, as with other states and territories, cases, hospitalisations, and deaths from COVID increased from the end of 2021.
As of today, NT has reported a total of 94,396 cases for the entire pandemic and 59 deaths. Last month, the Royal Darwin Hospital reopened two COVID-dedicated wards to ease the pressure on the health system during the latest Omicron wave, a strategy not used in Darwin since earlier this year.
While Congress has managed to keep all their remote clinics open, Boffa said that to maintain services as close to normal as they could, “without burning out their staff and creating an unsafe workplace”, Congress will close their town clinics on a rotating basis one day each week until the end of August.
Rather than closing one clinic down for a longer period – which would mean inequitable access for patients close to that clinic – they decided to close each clinic for one day each week and redeploy all staff to the other clinics.
“That means that we can still maintain very good continuity of care on four days a week and get most people to book in and get seen on those days when their clinics open. But we can also make sure we’re able to provide sufficient staff numbers across the board each day in the clinics that are open,” Boffa said.
This strategy will also allow better flexibility and the ability to maintain healthcare in town without a flow on effect on the remote clinics – “we think shutting remote clinics is a real travesty. It should be an absolute last resort”, Boffa said.
Many of the NT Government remote clinics had yet to resume the “level of care and access that they had before COVID”, he added.
Boffa told Croakey that while things have been tough in the region since the end of 2021, the latest COVID wave on top of an already stressed system is having a big impact, and expressed concerns about the wider impacts upon health.
Once “primary healthcare starts going backwards and access goes backwards“, he said it would not be long before we see the impact of that on a range of health outcomes.
Vaccine-plus strategy needed
Boffa said Congress is trying to vaccinate people and increase rates of third, fourth and children vaccination immunisation but that the ‘vaccine-only strategy’ was not enough to reduce the impact on the health system.
Despite ongoing recommendations for a ‘vaccine-plus’ strategy (vaccines, plus other measures including masks, testing and indoor ventilation) by the World Health Organization and other health leaders, Australian governments, with a few exceptions, have been slow to implement and promote such a strategy.
Boffa suggested governments should be looking forward to the next COVID wave and the next pandemic, making plans to ensure healthcare systems do not overload and people are safe.
One way to do this could be to mandate masks during peak transmission of COVID and other infectious diseases, he told Croakey.
Without mandates, he said Australians have shown that they do not wear masks at anything near the level required for significant effectiveness and there is no indication that they are likely to adopt more regular mask-wearing behaviour, which may be vital for protecting elderly, immunocompromised and children who are under-vaccinated and helping health services maintain usual services.
Boffa also called for a massive public education campaign on the importance of high quality N95 masks akin to the famous “slip, slop, slap campaign”. We all need to learn to slap on a mask when we go into crowded indoor spaces and other high risk settings just like we learnt to slap on a hat, he said.
Providing free N95s, as recently announced in Victoria, could be another way to encourage uptake of mask-wearing.
Moving forward, Boffa said a stronger focus on indoor ventilation and air quality was required, something they are exploring at Congress, in addition to maintaining virus surveillance through testing, including triaging before people enter our clinics.
Improved and transparent reporting of excess mortality, broken down by jurisdiction and priority populations, would provide a more accurate indication of the impact of the pandemic on the healthcare system, according to Boffa.
He told Croakey it would also allow the general public to know for sure whether there are harms being created by the difficulties the health system is in as well as the complications that COVID may well be causing in terms of excess cardiac and other deaths.
With pandemics almost certain to become more frequent as global inequalities are not addressed, some major issues needed addressing to ensure populations are able to cope with future pandemics adequately, Boffa told Croakey.
“The first thing is the primary healthcare system, particularly Aboriginal community health services, need guaranteed long-term funding to cope” with future pandemics, Boffa said.
“Communicable disease outbreaks are going to become the norm, not the exception,” which will require a lot of additional recurrent expenses and resources, he said.
There is also an urgent need to address the broader social determinants of health which have led to a differential impact of COVID on Aboriginal people, especially overcrowding which makes safe isolation at home very difficult. This will continue into the next pandemic unless we learn the lessons from COVID.
Boffa also suggested the need for an independent review of the Australian COVID response, implementation of the COVID Senate Committee recommendations and progress on the Government’s commitment to establishing a national centre for disease control.
“It’s a great leveller, in some ways, a global pandemic, and it should be seen as a call to international solidarity and global public health action,” Boffa said.
More information on opening days and times of CAAC clinics can be found here.
Dr Elizabeth Moore, Public Health Medical Officer from Aboriginal Medical Services Alliance Northern Territory, provided additional comments about the broader impact of COVID-19 on workforce issues in the Aboriginal community controlled sector in the NT, acknowledging there are widespread shortages across the NT community controlled sector as well as the government primary healthcare sector.
Elizabeth Moore writes:
Workforce shortages were worsening prior to the pandemic. Since the start of the pandemic, workforce shortages have increased dramatically including through impacts of border closures, and competition for healthcare staff including from staff being needed for urgent vaccination programs.
Since COVID-19 has become widespread, rates of staff being sick or needing to care for family members who are sick have increased rapidly whilst the patient load has also increased. Much of this is due to COVID-19 but it is also due to a severe influenza season and increase in other viral illnesses.
We are very concerned that these ongoing and severe workforce shortages will impact on services’ capacity to meet the health needs of their population, which are high and growing. Most services struggled to maintain primary health care services whilst dealing with the severe COVID-19 wave in January through to April.
Services are now trying to get back to a pre COVID-19 level of activity, but this is difficult due to the burden of COVID-19 and staff shortages /abseentism.
Furthermore, many staff are tired and need a break after very high levels of stress during the pandemic.
If the workforce crisis is not addressed urgently and with longer term actions, Aboriginal health may actually get worse. Already we are seeing adverse trends in critical areas such as rates of childhood vaccinations.
Effective public health measures to slow transmission
There should be clearly defined triggers for reintroduction of an indoor mask mandate when COVID-19 is escalating to reduce transmission and protect both our hospitals and Aboriginal primary health care system.
High quality N95 masks worn correctly are very effective at reducing transmission. High rates of mask wearing protect vulnerable people including Aboriginal people noting that over half of the people who have died in the NT are Aboriginal. Provision of free N95 masks to the public as Victoria is doing would be useful. N95 masks are unaffordable for many people on low incomes.
A public education campaign on ways to reduce the impact of COVID including on high-risk people. This should be informed by an evaluation of previous communication campaigns
We need to improve ventilation and air circulation in public buildings including clinics but also shopping centres, restaurants and schools for example
High quality data including regional breakdown of COVID cases and data on all cause excess mortality to enable the public to really see the full impact of COVID-19 including the impact on the health system causing increase in deaths in other areas and the indirect impacts of COVID-19 such as increased rates of heart disease.
Actions to address the workforce crisis
During a significant COVID-19 wave, ACCHSs need to be funded to increase workforce flexibility including local Aboriginal workforce to promote vaccine and support outbreak control measures including assisting people to isolate effectively, plus additional clinical positions to deal with the outbreak and ramp up vaccination.
The services did a fantastic job dealing with the Omicron wave but the response was badly under-resourced in one of the most high need populations in Australia. It was very difficult for services to get additional support to deal with outbreaks even in quite extreme circumstances.
The sector will also need additional support to vaccinate if we have new vaccines released to deal with variants/new strains.
Our sector has been able to access commercial workforce agencies who have been contracted by the Federal government to assist ACCHSs. This is useful but ACCHSs may prefer to find their own staff (who may have worked for them previously and/or who can stay for a longer period of time). They should have this option.
We also need to be careful about perverse incentives with external vaccinators being paid higher hourly rates than highly skilled remote area nurses. Our sector cannot afford to match these salaries but we do not want to lose valuable staff.
There needs to be a priority on international migration programs specifically for the remote and Aboriginal PHC sector. This should be an urgent but also ongoing response. When New Zealand closed its borders early in 2020, the impact on our sector was immediate. There should be greater support and incentives for New Zealand and other international staff to work in remote areas.
We also need regional quarantine facilities to be set up urgently in the event of another serious COVID-19 wave, so that people can isolate effectively. Many people were unable to isolate because they lived in overcrowded accommodation or were homeless.
At the height of the first Omicron wave, there was not consistent support for effective quarantining. Given the housing situation, regional quarantine facilities are particularly important in the NT if we are to limit the impact on vulnerable Aboriginal people.
Medium to long term actions
We need medium to long term actions to ensure that the health workforce is able to deal with the current challenges and future pandemics, which unfortunately are likely to occur more often due to climate change and ecological instability.
Much more focus, funding and support for building an Aboriginal workforce including funding cadetships – Federal government has funded 500 AHP trainee places nationally which is a good start but needs to be continued and significantly increased.
Training on Country needs to be provided to allow people to train whilst meeting their cultural and family obligations. Services need funding for external clinical educator positions to support this workforce.
Programs to rebuild the nursing workforce, which is a critical workforce for our sector. One of our services (Central Australian Aboriginal Congress) has implemented a very successful two-year graduate nurse program based in Aboriginal PHC including rotations in hospitals.
This has been popular and effective. The program needs to be scaled up across the NT thus providing a pathway for nurses to develop a career in remote Aboriginal primary health care.
Increase in ACCHS funding to deal with the challenges of communicable diseases including a syphilis outbreak, which is not under control, increase in rates of acute rheumatic fever/RHD and other communicable disease challenges.
There is also a growing burden of chronic disease including remarkably high rates of diabetes (potentially the world’s highest rate in Aboriginal people in Central Australia). Although there has been some modest funding increases in recent years, they are not sufficient to deal with the growing challenges.
In the long term, high rates of communicable diseases such as Rheumatic Heart Disease are guaranteed if we do not fix the housing situation. It also makes communities very vulnerable to any future pandemics.
There needs to be a greater sense of urgency about dealing with the workforce challenges in Aboriginal health if we want to continue to make progress on closing the life expectancy gap.
Finally, both the NT and Australia should evaluate the COVID-19 response to date to see what we can learn to strengthen the response to this pandemic ongoing and to prepare for future pandemics/emerging diseases.
See Croakey’s archive of articles on primary healthcare