Madeleine attended the 71st World Health Assembly in Geneva in 2018. She is currently studying a Bachelor of Medicine and a Bachelor of Surgery at Curtin University.
Inadequate food security is a significant contributing factor in poor health-related outcomes for Indigenous Australians living in remote areas within Australia. In order to alleviate this issue, two recommendations are proposed. The first offers a solution to the issues of cost and supply of fresh fruit and vegetables through the establishment of a body of hydroponic greenhouses in remote Australia. The second deals with issues of demand for fresh fruit and vegetables by providing a comprehensive education program on healthy eating. Together, these recommendations aim to empower Indigenous Australians living in remote areas to make healthy food choices and ultimately, decrease the rate of diet-related Non-Communicable Diseases (NCDs) in this population.
Context and Background
Addressing the risk factors for Non-CommunicableDiseases (NCDs) should be a priority for the Australian government due to the significant health burden this creates nationally. In 2015, over 91% of Australian deaths were a result of NCDs compared to worldwide where this statistic is 70% (WHO, 2015). In Australia, the NCDs with the highest mortality rates include Cardiovascular diseases, Cancer, Chronic Respiratory Diseases and Diabetes (WHO, 2015). High body mass index caused approximately 50% of all diabetes and 20% of cardiovascular disease with 2% of the total burden of disease and injury in Australia attributable to low fruit and vegetable consumption (Australian Institute of Health and Welfare, 2016).
Australia is party to the World Health Organisation’s(WHO) Global Action Plan for the Prevention and Control of NCDs. This plan focuses on reducing by 2025 four main risk factors: alcohol, unhealthy diets, smoking, and physical inactivity (WHO, 2017). A think tank through the Australian Health Policy Collaboration was established in 2015 to provide recommendations on how to meet these goals of reduction. Two of the proposed recommendations were related to unhealthy diets but both were predominantly set within an urban context and largely focused on reducing salt intake. (McNamara et al. 2015). These recommendations become less applicable to people living in remote Australia whose barriers to healthy eating are broader and more challenging due to the restricted accessibility of healthy foods (AIHW 2016).
The Australian Bureau of Statistics divides Australia into five classes of remoteness based on communities’ relative access to services with Level 0 being Major Cities of Australia (Australian Bureau of Statistics 2016). Rural Australia is defined as Level 2 (Outer Regional Australia) whilst remote Australia is Level 3 (Remote Australia) and Level 4 (Very Remote Australia). Proportionally, the prevalence of these NCDs is higher in rural and remote settings in Australia. Coronary heart disease is 1.2 to 1.5 times higher, and diabetes is 2.4 to 4 times higher in rural and remote areas compared to major cities (AIHW 2016). Given the higher proportional rates of mortality from NCDs in rural and remote Australia, addressing risk factors like unhealthy diets specifically in this setting should be a priority for the Australian Department of Health and Indigenous Affairs.
“The relationship of remoteness to health is particularly important for Indigenous Australians as they are more likely to live outside of metropolitan areas than non Indigenous Australians” (AIHW, 2014). In 2014, 1.6% of non-Indigenous Australians lived in remote and very remote areas compared to 20% of Indigenous Australians (AIHW, 2014). Problems around the accessibility of fresh fruit and vegetables in remote Australia largely speaks to the bigger issue of food insecurity for Indigenous Australians. In a 2012-13 ABS survey, it was found that 31% of Indigenous Australians living in remote areas had reported running out of food and not being able to afford more compared to 3.7% of non-Indigenous Australians nationwide (ABS, 2013). Furthermore, only 8% of Indigenous Australians met the daily requirement for intake of vegetables (ABS, 2013). Food costs were also found to increase dramatically in rural settings; one study found that in remote areas of Northern Territory, food costs were 49% higher compared to Darwin (Northern Territory Department of Health, 2013). The groups suffering from food insecurity are disproportionately represented by remote Indigenous Australians, whose isolation by distance only further increases the challenge in accessing healthy, affordable foods (National Rural Health Alliance, 2016). Therefore, these recommendations as outlined below are tailored specifically towards improving food security for Indigenous Australians living in these areas.
Recommendation one: increase the supply of fresh fruit and vegetables through Hydroponic Greenhouses
In order to make a long-term impact on the improvement of food security for Indigenous Australians in remote regions, policy recommendations must ensure they provide empowerment to local people. Hydroponic greenhouses provide a way for Indigenous Australians to grow and sell vegetables on their own terms with year-round yields. Once fully established and set up, the proposed greenhouses are completely community-run with no outside involvement and would provide a steady source of income and employment for the community (Food Ladder, 2018).
Greenhouses refer to an enclosed space that protects produce from the outside environment with essential UV radiation for plant growth supplied by artificial lighting (Department of Water and Environmental Regulation, 2018). It is a method of sustainable agriculture that is not reliant on growing conditions such as correct sun or rain exposure that are barriers to growth in remote Australia. Hydroponic refers to a technique of growing plants in a soilless container system that is isolated from the ground where the plants receive all their nutrients from the feed water solution they are grown in (Department of Water and Environmental Regulation, 2018). This technique also uses significantly fewer amounts of water that is also recyclable. For example, it was found that hydroponic greenhouses reduce the water requirements for growing fresh tomatoes from 300 L/Kg down to 4 L/Kg (Nederhoff & Stanghellini, 2010). This is significant when considering the lack of water supply in remote Australia.
Hydroponic greenhouses present a sustainable solution to the problem of accessibility to fresh fruit and vegetables in remote Australia. At present, the fresh produce must travel long ways to reach local stores, decreasing quality and increasing costs (Western Australia Department of Health, 2013). The higher costs of the fruit and vegetables mean that fewer people buy the produce, aiding in the rising costs and less produce ordered by local grocers (Northern Territory Department of Health, 2013). Greenhouses provide a way for fresh fruit and vegetables to be locally produced and available at a much lower price. This would help increase food security in remote Australia by empowering locals by giving them the choice to preference healthy options. The barriers of cost, quality and quantity make healthy fruit and vegetable options uneconomic. By addressing these barriers through greenhouses, Indigenous Australians living in remote areas are given a more equitable chance at making healthy food choices.
Food Ladder is an ‘Australian-based not-for-profit that installs sustainable hydroponic climate-controlled greenhouses to grow commercial quantities of vegetables in remote Indigenous communities’(Food Ladder 2018). Food Ladder encourages full community ownership of the enterprise. After helping to establish the greenhouses through the construction and training of its workers, Food Ladder leaves the community. Although easily contactable, training manuals provide comprehensive coverage of problems and how to fix them including youtube videos (Food Ladder 2018). At present, there are two greenhouses in operation, both in Arnhem Land. Six months after becoming operational, there has been a reported 5% increase in fruit and vegetable consumption within the community (Food Ladder2018). Hydroponic greenhouses have the potential to be scaled up and rolled out across many different remote communities in Australia. The program has the capacity to empower communities, provide employment, increase food security and decrease the rate of NCDs in remote Australia. However, before scaling up the program, the reliability, applicability and cost-effectiveness of hydroponic greenhouses need to be tested.
While the initial cost of establishing hydroponic greenhouses is expensive, the cost is insignificant when compared to the Federal Government annual expenditure on NCDs and the empowerment gained for Indigenous Australians with improved food security. It is estimated to cost between $200,000 to $300,000 (depending on size) to establish, run and maintain a hydroponic greenhouse in remote Australia (Food Ladder, 2018). It is unrealistic to propose that every remote community in Australia receives a greenhouse, however, establishing a number of greenhouses in every State and Territory could prove to be cost-effective to the Federal Government. Currently, NCDs cost the Australian health system over 7.74 billion dollars (Willcox, 2014). In remote Australia, the rate of diabetes in Indigenous Australians contributes significantly to the burden of disease and to the gap in life expectancy between Indigenous and Non-Indigenous Australians (National Rural Health Alliance, 2016). Therefore, a program tailored to improve accessibility to fresh fruits and vegetables in remote Australian communities could help decrease the economic burden of NCDs in remote Australia.
Monitoring and Evaluation Framework for pilot program
Due to the cost of establishing hydroponic greenhouses, it is recommended that a pilot program of 14 additional greenhouses be set up across Australia and monitored for two years. The goal of the pilot program is to test the link between greenhouses increasing accessibility to fresh fruit and vegetables and decreasing the rate of unhealthy eating in remote Australia. To examine the applicability of hydroponic greenhouses in different environments, two remote communities in each State and the Northern Territory should each house a greenhouse. To ensure the effectiveness of the program, the communities must be empowered and willing participants and, therefore, will be chosen through an application process.
Although shown to be successful short-term, the longevity of hydroponic greenhouses is yet to be tested to make sure they continue to be low cost with a low failure rate. A framework needs to be established to monitor the different communities that have hydroponic greenhouses every three months for the next two years. Monitoring of the greenhouses themselves could be done through an on-site logbook that is updated weekly including any breakages or additional costs the greenhouses occur (Food Ladder, 2018). Monitoring of fruit and vegetable consumption every month could be achieved through a partnership with the local fresh food retailer. This monitoring framework has been successfully utilized in a number of government reports examining food security in remote Australia (Northern Territory Department of Health, 2013; Western Australia Department of Health, 2013). Due to communities’ remote locations, the local food grocers provide a good indication of the food purchased for consumption. This data will help determine whether increased accessibility to fruit and vegetable correlates to increased demand and by proxy, healthier eating habits. Finally, The Flying Doctors Service visits to the communities could be tracked to determine the rate of NCD-related cases that require hospitalisation over the pilot program period (Royal Flying Doctors Service, 2018). These combined methods of monitoring over a period of two years should be a good indication of whether hydroponic greenhouses provide a feasible solution to the issues of accessibility to fresh fruit and vegetables in remote Australia.
Recommendation Two: increase demand for fruit and vegetables through education
Addressing the utilisation of healthy food choices is essential in improving food security for Indigenous Australians in remote areas. Increasing accessibility to fresh fruit and vegetables will only improve diets and decrease the rate of NCDs if the demand for the fresh produce is there. Therefore, a comprehensive educational program is needed to ensure that the increased supply of fresh fruit and vegetables is reflected in an increased demand. At present, there are a number of programs in place that address nutrition education in remote Australia (Royal Flying Doctors Service, 2018; Eon Foundation, 2018). These programs are extremely valuable. However, the communities with hydroponic greenhouses represent a unique opportunity to run a comprehensive program that can teach locals how to best utilise fresh produce when barriers to accessibility are reduced.
Healthy food education for Primary School students
Children are the population most at-risk for malnutrition, with studies showing that the first 1,000 days of life are imperative and that those who get the right nutrition are ten times more likely to overcome even the most life-threatening childhood diseases (Hoddinott et al. 2011). Furthermore, when children do not eat enough vegetables they become deficient in micronutrients like Vitamin A, B12, Folate, Zinc and Iron. Deficiencies in these micronutrients are linked to a number of different cognitive and physical health problems, including increased risk of child mortality, growth problems and poor cognitive development (UNCSN, 2010). Diseases associated with these deficiencies highlight the importance for children to have access to and eat fruit and vegetables, which are a good source of these micronutrients. Hydroponic greenhouses in remote communities present a way for schools to have access to and ensure children receive the recommended amounts of fruits and vegetables each day. This will help improve children’s nutrition and will have positive flow-on effects to their overall health and cognitive function.
Furthermore, the greenhouses present a unique opportunity for children living in remote communities who might never ordinarily see fresh produce grown, to learn first-hand and become interested in growing and consuming vegetables and fruit. The incorporation of native fruit and vegetables from the particular region into the greenhouses might help encourage interest in the growing process. To be most effective, nutrition education needs to start young as studies show established eating practices in childhood carry on into adulthood (Dudley et al. 2015). Primary schools present a good location for the delivery of healthy eating interventions and where nutrition could be incorporated into the science curriculum in every year (Dudley et al. 2015). This could also include cooking classes and excursions to the local store, where students could apply their understanding of food labels and recommended a daily intake of certain foods, and the greenhouses, where students could see how elements of sustainable agriculture are applied. Studies show that school infrastructure provides an ideal environment to offer continuous learning about good nutrition and to promote healthy behaviours early in life, which has flow-on effects on lifelong health (Lee, 2009). The combination of access to fresh fruit and vegetables with better nutrition education should help decrease the rate of chronic diseases in children living in remote areas of Australia.
Adult nutrition education
Having greenhouses in rural and remote communities provides an opportunity to increase the quantity and variety of fresh fruit and vegetables available to locals. To ensure that the increased supply of fresh vegetables is reflected in increased consumption, community-based programs to promote healthy eating should be utilised. During the establishment of the greenhouses, each community should have a discussion led by elders and local community leaders to decide how best to incorporate healthy eating education into the community. Successful programs utilised in remote communities include community health screenings, traditional cooking classes and yarning circles about healthy eating (Food North, 2003; Puska, 2002). Whatever pathway is chosen, it is imperative that it is community-driven and led by elders and local community leaders.
It must be acknowledged that healthy eating and good food choices cannot on their own significantly decrease the overall rate of NCDs in remote Australia, due to the multifaceted nature of the problem. Additional research is needed on the other social determinants of health such as smoking and alcohol that are aiding in the higher rates of NCDs in remote Australia.
Past government policies on improving food security in rural and remote Australia have failed to make a lasting difference. Innovative and empowering solutions are needed to ensure that the impact of food security on health-related outcomes, such as the rate of NCDs in these areas, is reduced. Without access to affordable, quality fresh fruits and vegetables, the choice of healthy eating is taken away from local consumers. Hydroponic Greenhouses present a relatively affordable solution to the issues of food insecurity experienced in rural and remote areas of Australia. This coupled with a comprehensive educational program on the benefits of eating healthy will help to empower Indigenous people living in remote Australia with the understanding of how dietary choices can directly impact health outcomes, especially for NCDs.
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