Australia is an affluent nation currently enjoying strong economic growth and a health system that is amongst the best in the world. In contrast, life in Aboriginal communities is scarred by hopelessness - by any measure - housing, education, employment and health. Aborigines lag far behind the general community, but nowhere are the problems more extreme than in Aboriginal health. While most Australians are living longer than ever before, Indigenous Australians are dying almost 20 years before other Australians, and infant mortality rates show increasing inequalities between Aborigines and non-Aborigines.

A report released on 21June by the Australian Institute of Health and Welfare, the Australian Government Agency for Health and Welfare statistics and Information, reveals that little has improved in the last 10 years, despite government funding designed to elevate the health and living conditions of Aborigines. Aboriginal people make up approximately 2.4% of the total Australian population; the damning report shows that 70% die before the age of 65, compared with 20% of non-Indigenous Australians. The average life expectancy for Aboriginal males is 59, compared with 77 for non-Indigenous males.

The other alarming fact that pervades the Indigenous health picture is the increasing death rate for Aboriginal infants, which at 11.4 infants per 1,000 births, remains three times higher than those of other non-Indigenous infants. (In comparison, the rate is 78 per 1,000 births in Tanzania, and 4.0 per 1,000 in the United Kingdom.) These disparities in infant mortality are indicators of significant inequalities in social and economic status and in the availability of effective health services. Such measures of life expectancy and infant mortality correlate strongly with the best predictors of state failure.

This data is consistent with a paper published by Oxfam Australia in March this year, which brought together recent research comparing Indigenous health standards in Australia, New Zealand and Canada; commonwealth countries with similar histories and socio-economic circumstances. While New Zealand and Canada have made considerable advances in life expectancy and infant survival rates of their Indigenous people, Australia is falling behind.

"The visible improvements in indigenous health in New Zealand and Canada show us that success is possible if we invest properly in comprehensive primary health care for Indigenous people," said Andrew Hewett, Executive Director of Oxfam Australia. "The Government must find the political will to make Indigenous health a national priority." According to the Australian Medical Association, Australia is underfunding Aboriginal primary health care by at least AU$400 million a year.

In addition to increased funding and resources, the Oxfam paper calls for an approach to improved health that supports Indigenous community control and participation in decision-making in the planning, management and delivery of health programs and services. The application of these strategies in New Zealand and Canada demonstrates that progress in Indigenous health can be achieved through partnerships, and the delegation of community control to local Indigenous organisations.

For many Australians who rarely leave their comfortable coastal cities, the realities of primary health care in rural communities in the desert are worlds apart. The report found that poor nutrition, obesity, smoking, violence, alcohol and substance abuse are the major causes of death and illness; poor nutrition and obesity being increasingly associated with diabetes, heart disease and cancer, further causes death among the Aboriginal adult population. Overcrowded housing, unsafe drinking water and poor sanitary conditions were also contributing factors. All of these issues correlate strongly with other marginalized groups such as the African-Americans.

The amount of trauma and loss suffered by almost all Aborigines living in town camps or communities in the north of Australia is appallingly high. Dozens of dispossessed and alienated Aboriginal communities across Australia also have critical problems with alcohol and drugs. Not surprisingly, these places record some of the highest suicide rates in the world.

Despite widespread recognition of the urgent response needed to the deteriorating health care standards for Australian Aborigines, continuing polarised debates about policy and rights only serve to move consensus further out of reach.

The figures published in the report by the Australian Institute of Health and Welfare prompted Tony Abbott, Australia's health minister, to call for a "new paternalism". Abbott, a coalition frontbencher closely aligned with the conservative Prime Minister, John Howard, proposed sentiments that echo an earlier, colonial-style approach. "It seems that the fundamental problem here is not lack of spending, although it could always be higher, but the culture of directionlessness in which so many Aboriginal people live," said Abbott. "It's not necessarily a white administrator - it is someone who in otherwise dysfunctional communities can actually make decisions and get things done."

Aboriginal leaders have responded with outrage. "You can't just have unilateral government action through law and order," said Noel Pearson, Cape York Aboriginal Leader. "You've actually got to work in partnership with the sober people, with the good people, to build ownership of those social order measures."

"It was paternalism that condemned generations of our people to poverty and welfare dependency," said Professor Larissa Behrendt, from the group Australians for Native Title and Reconciliation. "Contrary to what Minister Abbott claims, self-determination has never been tried in Australia. Indigenous people have always been managed and governed by non-Aboriginal politicians and bureaucrats. Minister Abbott's views are driven by his own rigid ideological position, not by the evidence of what actually works."

Australia's Aborigines are one of the most powerful examples of our human diversity of culture, language and spirit, yet they are often disadvantaged and marginalised. A crucial issue for Aboriginal people is that of representation; policymakers and health professionals must enable Indigenous people to achieve equity with inclusive consultation. Progress made in New Zealand and Canada using this practice shows that success is possible. The Australian government must consider democratic processes that empower Aborigines and facilitate their full participation as equal partners. Aborigines deserve more effective solutions from government, including a determination to return to the Aboriginal people responsibility for their own lives.