Australia voted “No” in a national referendum in October 2023 to have constitutional recognition of Aboriginal and Torres Strait Islander peoples and the creation of an Indigenous federal advisory body—the voice to parliament. This has significant implications for the progress of “closing the gap” between Indigenous and non-Indigenous health outcomes.¹ Poor health outcomes in Indigenous Australians, who have occupied the continent for more than 65,000 years, are well known in key areas of diabetes, otitis media in children, and rheumatic heart disease. In urological terms, substantial outcome gaps exist in the management of urological cancers, with Indigenous Australians 30% less likely to be diagnosed with prostate cancer, 60% less likely to be hospitalized for prostate cancer, and a lesser chance of surviving 5 years following a diagnosis of prostate cancer (63% compared with 72%).²

Figure. Figure used with permission of the University of Tasmania.

The US and worldwide AUA audience may not appreciate that the arrival of the British First Fleet on January 26th, 1788, heralded a period of violent colonialization and dispossession, with Indigenous Australians successively moved on from their lands, murdered, and then further socially disadvantaged with no recognition of their existence made in the original constitution of 1901. The traumatic impacts of forced removal of Indigenous children from their families is still being felt, the policy being in place until 1969.³

Much advocacy by Indigenous groups with successive Australian governments, particularly in the last 16 years, took place to reach the point of the referendum last October. The crucial guiding document, The Uluru Statement from the Heart,⁴ was released in 2007 and involved consultation with more than 9400 Indigenous groups and had bipartisan support.

Constitutional recognition alone is tokenistic and insufficient to provide political stability for the future of Indigenous Australians,⁵ who are subject to much top-down government policy decisions and endless “flip-flops” by vote-seeking governments. The referendum’s success would have given some stability and structure to the process of engagement between the Indigenous population and the government.

Many other interest groups, such as business councils and health organizations, make representations to government. The poverty in Indigenous communities does make representation significantly harder to achieve in the absence of government support. The health inequity, important to urologists and all medical practitioners alike, will not be addressed until there is substantial action to redress the social determinants of health such as poverty, housing, and education, systemic racism, which escalated in the period leading up to the referendum⁶ and is a hangover from colonialization, and the specific management of the health conditions themselves.

Evidence points to the positive impact of community consultation with Indigenous groups has on Indigenous health. For example, during the COVID-19 pandemic, Indigenous Australians had a lower rate of infection than other Australians. This resulted from when the federal government established a consultative advisory body that enabled it to more effectively to establish pandemic controls.⁷

From a health care perspective, the Voice it is analogous to legislated shared care. As clinicians, we inherently feel comfortable with this idea, and increasingly it is an expectation that shared decision-making processes are followed in clinical decision-making. This is grounded in good evidence of improved outcomes.⁸ The referendum was well supported in Australia by over 125 health organizations including the Urological Society of Australia and New Zealand.⁹

Referenda have a poor success rate at the Australian polling box. Voting is compulsory and a “double majority” is required “in the majority of states in the majority of the country” for the vote to succeed. Only 8 of the 44 referenda have succeeded since federation in 1901. Starting off the back foot, the “Yes” vote had enormous early support with most non-Indigenous Australians aware of the plight of the Indigenous community.

Political scaremongering as to the impact of the Yes vote, particularly the details around the Voice, a hurried approach by the incumbent government scrambling to fulfill an election promise, and an alarming rise in systemic racism during the pre-polling period, saw its demise. This is in the face of strong evidence that the autonomy, political stability, and consistency with United Nations recommendations that the Voice would have provided would then lead to improved health outcomes for Indigenous Australians.

The Native American indigenous population share some parallels in term of social and health outcomes. There are historical differences in terms of the processes of colonialism in the US compared with Australia. Nevertheless, the collaborative publication by Anderson et al, which looks at 23 of 90 Indigenous population groups worldwide and their health outcomes relative to their per capita income, demonstrates a consistent pattern of health and social disparities relevant to benchmark populations.¹⁰

Where to from here? After more than a decade of activism, support for recognition for constitutional recognition by all successive governments since 2007, there was much pain, fatigue and grief felt in Indigenous communities on waking on the October 15 to a nation who had, in their eyes, “rejected” them. The government will need to now make good on its commitment to meet closing-the-gap health targets as set out in the national agreement for Indigenous Australians.

A Yes vote would have provided greater certainty for Indigenous Australians that health policy and programs would include Indigenous perspective. However, there are other legislative and nonlegislative ways in which the Australian government can achieve this outcome. Furthermore, good policy-making in this area of policy requires evidence and expert input. Professional bodies in Australia have played an increasingly influential role in promoting cultural diversity practice.^11,12 In this light, we anticipate that the Urological Society of Australia and New Zealand will have an increasingly important role in Indigenous health advocacy.