Sorry folks, can’t ride a bike or paddle a canoe all weekend. It’s too hot. A more work-related offering this week. Cheers and love, Rod
Working in Aboriginal Australia 15.10.2011
This is my third annual five week stint as a GP locum in the Northern Territory; and for two years I’ve been working Thursdays and Fridays at the Gathering Place, an aboriginal community health centre in Melbourne’s west. The work is similar but different; in Melbourne, most of the patients are pale skinned, and none are living rough in the bush, speaking their own language; the urban community is like a poor white community, with the health problems of being poor in a rich western society, of under-education, alcohol / violence and drug addiction, and the diabetes / cardiovascular / chronic renal disease that bedevils aboriginal heritage. It’s similar in NT, but the patients are black, very poor, often living rough (‘long-grassing’), and it’s a tropical third world health disgrace with very high rates of severe disease – diabetes, chronic kidney disease, ischaemic and rheumatic heart disease, skin infections, lots of VD including syphilis, widespread alcoholism and violence.
The background to these communities is the history of what it is to be an aborigine living on the fringe of a dominant western culture with a recent colonial past. They were crushed by a dominant, racist, alien culture (ours), especially by the loss of their land, and by some pretty determined attempts to eradicate them and their ‘inferior’ culture. They became desperately poor, uneducated, depressed fringe dwellers on the edge of western culture – absorbing its worst elements (eg rubbish food, alcohol-fuelled violence, VD), beset by epidemic levels of nineteenth century diseases, and other western diseases that occur when people adapted over aeons to scarcity consume a tradestore diet. Watching aboriginal kids playing netball beside the open-sided gym where I was exercising last year, you could almost see the progression: fit ten year olds with lithe bodies and long thin limbs, becoming overweight teenagers then obese young adults – with diabetes as early as mid-twenties and life threatening complications, cardiovascular and chronic renal disease by mid-thirties to early forties. There is a significant expectation of getting onto a pension, and many are by an early age. Health care is free at aboriginal health clinics, as is medication and health transport; that was essential, and one of the better decisions by an Australian government.
The hot north of this country is so very different from the temperate south. Arriving in a town you are at once struck by the large number of blacks just sitting or lying about in the street, obviously poor. Debris from drinking litters the streets and the parks, and there’s ample evidence of long-grassing along the banks of the river – little tents and rugs and packs. So arriving by air from ‘down south’ gives the strong impression of having arrived in another country, a poor third world one. Of course it’s very hot (38-42 most of the time here in Katherine) and then there are the wonderful trees – enormous African mahoganies, very large poincianas (flame red or yellow), magnolias, and mangos – all adding to that impression of arriving in a different land, an impression reinforced when you start work. For example, mandatory reporting of sex with a minor begins at age 13, or 14 if the male is more than two years older. One year in an isolated spot I became aware of the potential for retaliation if a patient in my care died – the nurse manager was very keen to get the patient to Darwin, so they could die in someone else’s care. There were death threats to us when we mediated the temporary removal of a badly neglected child from a large family soaked in alcohol and violence. I remember the manager of one large health centre I worked at speaking about her background; she was a tough, impressive leader who’d dragged herself up from inauspicious beginnings. Pregnant at 14 with a violent abusive partner, she said that the only way for a black woman to improve her lot was to get a job then her own house. Sharing a small shack with a large extended family dragged you down, and many black women have to hide both money and food to feed their children. There are high rates of suicide in black communities.
I had an excellent orientation for my first job in aboriginal health, under Katherine West Health Board. Most useful was the information about the different black and white styles of communication. Whereas we value eye-to-eye contact and ‘straight-shooting’, traditional blacks value silence and abhor loud, direct talk. They may consider a question very slowly, taking days to answer. Blacks traditionally declaim to the whole group, rather than directly one to one; power is with the listener rather than the speaker. This can make for difficult communication in some settings eg courtrooms, where magistrates get irritated and blacks frustrated by our lack of empathy. Most of my patients are polite, some are aggressive / defensive (“Im as good as you”) like one well-employed woman I met this week – especially at first encounter. Some are openly, touchingly friendly, like a fine old stockman I remember at Tennant Creek. A significant number are impassive or surly, especially the older folk – perhaps in part because everything is free (part of the curse of welfare), but more likely because of awareness of our role in the plight of their people. One might well ask: ‘If they don’t hate us whites, why don’t they?’ So many of them are so very sick, often at a young age, but there’s a group of fit old people – thin and hardy, many of them old stockmen or more traditional old men and women who haven’t taken up the delights of the trade store or the ‘drink and/or gamble it all on pension day’ cycle. Aboriginal health workers are very valuable, doing much of each health assessment, and often able to communicate in Creole or tribal language. However they are in short supply, especially in more isolated areas; some get caught in the conflict between the two cultures, and give it away. Other possible candidates eschew the rigorous training and on-the job stresses for welfare payments. One excellent AHW, clearly a leader in her community, had only recently got out of gaol when I met her – she had stabbed her abusive partner in a drunken brawl.
The answers to the many and mighty problems of aboriginal communities are neither quick nor easy. One reason for our failure to help them adapt to our culture is the frequent policy shifts that come with changes between liberal and labour governments. Consistency would come from an overarching independent policy body with a long-term perspective – might Noel Pearson’s institute on Cape York be the beginnings of such a body? Longstanding attempts at self-determination seem to be providing part of the answer – I have now worked at a few health services with community-controlled boards, and their health centres seem to work well, as might be expected from a grassroots rather than top-down approach to management. The wonderful Ted Egan – longterm NT public servant, ex NT Administrator, folk singer and author – has written much about solutions to the problems of aboriginal communities, and I recommend his little book ‘Due Inheritance’. Working in these places can be quite challenging, especially in the first 1-2 weeks as you struggle to understand a different organization and especially Communicare, the complex and clunky computer health program that much of NT uses. However when I do these locums I often feel that this is where I should be working, like the impressive full-time doctors and nurses here. There are too many practical difficulties for me to seriously consider that for the time being, and maybe the time and opportunity for such a big change is past.