The Intensifying Threat of COVID-19 Among First Nations People of Australia: Making Up for Lost Time

Australia reached a tragic milestone on August 29, 2021, with the first COVID-19 death among the First Nations people. Since then, the SARS-CoV-2 Delta variant has infected First Nations people at twice the rate of other Australians. By mid-October 2021, there were an additional 12 deaths, more than 4500 cases, and 550 hospitalized among the First Nations people.¹ A major concern is that Australia’s states and territories will emerge from lockdown, with the expected surge in cases, when only 47% of Indigenous people (≥16 years old) have received 2 doses of an mRNA vaccine (vs 74% of the general population).²

The lack of federal and state government priority and commitment to First Nations people has undermined excellent COVID-19 planning, strategy, and prevention work by the National Aboriginal Community Controlled Health Organisation, Aboriginal Community Controlled Health Organisations (ACCHOs), and First Nations communities.^3,4 Suboptimal national strategic preparation and changing vaccine advice have resulted in poor access to vaccines, lack of trained workforce to implement the vaccine rollout, and in some communities, vaccine hesitancy. This substantial policy oversight reflects a failure of moral human rights responsibility for Australian First Nations people.

The federal government’s responsibility for First Nations’ health care should have guaranteed its collaboration with state and regionally based Indigenous community-controlled health organizations to defend First Nations people from the health threat of COVID-19.⁴ Instead, not all ACCHOs in each state have been directly given the support and resources required.⁴ Personal protective equipment and vaccine rollouts were directed through state government agencies with inconsistent, and in some states, dangerously slow progress. For example, as of late September 2021, the proportions of fully vaccinated First Nations people 12 years and older were just 15.7% in Western Australia, 24.2% in South Australia, and 23.4% in Queensland.⁵

From the outset, COVID-19 ignited the First Nations people’s historic memory of the devastation brought by diseases carried by White colonizers to Australia in 1788. For the past 233 years, one of the world’s oldest living Indigenous cultures has been disproportionately and mercilessly affected by introduced infectious diseases including smallpox, measles, and HIV. In fact, infectious and noncommunicable diseases often are more fatal to Australia’s First Nations people than they are to the rest of the population.⁶ Studies in the US indicate that racial groups that are minoritized are disproportionately at risk of severe morbidity and death from COVID-19.⁷ In most Western countries, people of First Nations experience disparities in health outcomes that are fundamentally determined by racial, social, and economic factors, and which lead to compromised health status, undermined immunity, and inequitable access to quality health care.^7,8

Australia has moved more slowly than other countries to recognize that suppression, and zero population-level COVID-19 cases cannot be sustained. From the vantage point of low disease prevalence and tightly controlled borders during the pre–Delta-variant period, we watched the disease move rapidly through other high-income countries. We witnessed with great concern its effect on morbidity and mortality associated with poorer baseline health status and racial, ethnic, and economic disparities.⁷ The evidence from the US and other countries on the effects of COVID-19 among First Nations people⁸ should have prompted Australia to launch a federally funded campaign and give it the highest national health priority.

In Far North Queensland where the authors live and/or work, vaccine hesitancy among the community is evident, and fears have been compounded by equivocating federal policy regarding the safety and age-stratified risk of the AstraZeneca vaccine. Furthermore, the ad hoc and inconsistent approaches toward vaccine promotion and rollout among First Nations communities opened a space for anti-vaxxer misinformation and little effort was made to counter it.

The ACCHO programs are First Nations–led, evidence-driven, and culturally centered health services that work in state and regional locations, including the geographically remote and economically marginalized First Nations communities. Many operate in areas with the worst morbidity, mortality, and social statistics. Despite facing resource and legislative constraints to leading vaccine rollouts in every community, the ACCHOs have gained much recognition for their outstanding health prevention work during the COVID-19 pandemic.³ Apunipima is an ACCHO in the state of Queensland and is our collaborator in a mental health project funded by the National Health and Medical Research Council for 4 of the 5 remote First Nations communities included in our study.

Apunipima has been promoting strategies to protect these communities from COVID-19, even using social media to do so.³ Apunipima has also been facilitating vaccine delivery despite constraints related to funding and capacity for administering vaccines in every remote location. To date, First Nations communities in Far North Queensland have kept COVID-19 at bay; however, the threat is looming larger as the whole state of Queensland, with more than one-quarter of Australia’s First Nations population, prepares to open its borders to other states and territories.⁹

Since August 2021, Melbourne and Sydney (Australia’s most populous cities) have experienced exponential growth of the SARS-CoV-2 Delta variant and its associated deaths, illness, and pressure on the hospital system. In the Western local health district of New South Wales, more than half of all the COVID-19 cases occur among First Nations people. In addition to low vaccination rates, the existing economic and social determinants (eg, overcrowded housing) of First Nations people’s unequal health status have become important risk factors in the spread of this disease.^2,7 The frenzied attempts to provide temporary trailer-style housing to First Nations families in Wilcannia, where 60% of the population is Indigenous, have been insufficient.²

The Prime Minister of Australia has argued that vaccination coverage “is not a race,” and his government spent time and resources sending vaccines to countries overseas, without recognizing the need to focus first on all of Australia’s most at-risk communities. Now, First Nations communities are left disproportionately vulnerable, without an evidence-based guiding strategy nor a functioning federal and state government partnership to ensure equitable defense against a disease that could be highly destructive to them.^8,9

The federal government of Australia must explicitly acknowledge this disease as a critical danger to the First Nations people, and it needs to drive, collaborate, and support state and community-controlled health organizations to prepare for and respond to COVID-19. The first step is to urgently expand vaccine coverage by increasing access through a nationally organized but locally led campaign. This effort must be paired with disease prevention and provaccination campaigns designed by First Nations people and communicated by local health workers. To stay ahead of this disease, sufficient safe housing and health care services, such as isolation and quarantine facilities in regional and remote communities, are urgently required across the country. First Nations people want the story of COVID-19 to be one of survival, not yet another traumatic memory of discrimination and loss.

Published: December 30, 2021. doi:10.1001/jamahealthforum.2021.4356

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Reilly L et al. JAMA Health Forum.

Corresponding Author: Susan J. Rees, PhD, School of Psychiatry, Level 1, AGSM Building, University of New South Wales, Kensington, Sydney, NSW 2052, Australia (s.j.rees@unsw.edu.au).

Conflict of Interest Disclosures: Dr Rees reported funding (No. MRF1201404) from the Medical Research Future Fund of the National Health and Medical Research Council of Australia to support mental health research being conducted in the region discussed in this article. No other disclosures were reported.

Additional Contributions: The authors wish to acknowledge the advice, insights, and expertise contributed by Mark Wenitong, MD, (Aboriginal Public Health, Kabi Kabi tribal group of South Queensland), and the cultural knowledge and community-level insights of the following University of New South Wales research assistants: Craig Koomeeta (Apalech Clan, Aurukun Shire Council of Far North Queensland); and Preston Deemal, Thiithaarrwarra, Gugu Yimiithiirr, and Hope Vale (Aboriginal Shire Council, Far North Queensland).