I'm back home in Derby.

The good news: after more than 8 weeks, we finally have a broadband connection at the house. The order went into Telstra for a phone and broadband ADSL connection on January 23. Today it is live, finally, after many phone calls and finally intervention from the DAHS CEO pulling strings. It wouldn't be so bad except in the middle of the whole FUBAR situation the president of Telstra was on the morning news explaining that connecting remote and rural doctors and medical centers in the North of Australia was "their highest priority". Pity the poor bastard at the bottom of the list.

The bad news: driving home tonite, it had just gotton dark and started to rain and I hit a cow. I had already slowed down and suddenly a whole herd was standing out in the road in the rain, and even pumping brakes like mad I couldn't stop or steer around them. I am ok, but poor cow- I had to call the police to go back out the 20km south of Derby to put it out of its misery. Thank god for the "roo catcher" on the front of the Patrol- it is all dented in. Sorry cow. I am never going to hear the end of this from the other Dr Charles at DAHS, who refuses to drive at night, saying, "its just blood on the road" whenever you do. He was right.

Finally, all of the above is of miniscule importance compared to the following article. My problems are trivial. If you wondered why I've taken time and effort to blog about Aboriginal Health and DAHS, then read this:

From: Aboriginal Health System Needs Revamp

Monday Mar 26 19:29 AEST
A report into the death of an elderly Aboriginal patient, who died when he was left alone at a remote airstrip in the Northern Territory, has warned of more tragedies unless urgent action is taken.

The 78-year-old indigenous elder was flown home to Kalkaringi, about 600km south of Darwin, on August 21 last year after being treated at Katherine District Hospital.

The man, who was almost blind and could not walk unaided, had no escort on the chartered flight and there was no one to meet him when he arrived.

The man, whose name can not be used for cultural reasons, was left at the airstrip and his body was found in nearby bushland one week later, after police had abandoned their search.

A month after his death, the NT health department vowed to tighten transfer procedures.

Rather than just faxing the details of patient itineraries to their local clinics, the department said it would now follow up with telephone calls as well.

But an independent investigation into the man's death - commissioned by the Health Department and the Katherine West Health Board - warned on Monday of more deaths under the current system.

"Under existing arrangements, and in the absence of a centralised coordination process around the Patient Travel Scheme (PTS), the potential for further adverse incident ... is considered a high risk," the report said.

Despite the fact there are about 8,000 patient transfers - mostly by plane - to small, remote communities each year, investigators found there was no system of checking to make sure people got home safely.

The report recommended improving communication with remote clinics and insisted pilots never leave a patient alone at a remote airstrip.

"There are gaps in the communication processes around the operation of patient transport to and from the remote communities that need to be addressed as a matter of priority," the report said.

It also recommended the NT government recruit Aboriginal clinical staff at Katherine Hospital and other regional health services.

NT Health Minister Chris Burns welcomed the findings, calling the death "a tragic incident that should never have occurred".

"The system failed this man," he said.

"I am deeply sorry this happened and for the distress caused to the man's family."

At the time of the man's death, his niece Josie Crawshaw-Guy accused the health department of "hard-core, systemic racism".

The death prompted the Australian Medical Association (AMA) to call for a royal commission into the state of Aboriginal healthcare in the territory.

Checks have revealed at least one other case of a bungled patient transfer investigated by the NT coroner in the past three years.

In early November 2001, a 67-year-old man with dementia and severe acidosis and hyperkalemia - too much potassium in the blood - was put on a bus from Darwin hospital to Katherine without an escort.

He was later found by relatives under a tree dressed in his hospital pyjamas near the tourist information centre in Katherine.

His only possession was a bus ticket and the man died in Katherine Hospital from acute renal failure three weeks later.

I'm leaving Perth this morning, after being here for 3 days for Medical Coordinator meetings, and a recruitment fair for 4th year students. Monday night each RCS site had a booth a the University Club, where we hosted an information session for next years potential Rural Clinical School recruits. The turnout was great, with over 130 attendees looking at our 62 slots for next year. My Derby Lads sent along a disk of their photos which I played on my laptop at the booth, amongst the travel brochures and giant boab nut Vicki picked for me from the Derby golf course.

Derby Lads Recruiting Photos CLICK ON PICTURE TO SEE ALBUM

The most frequent question from students was, "Does Derby have a nice beach?". Oh well, despite the wine and hor d'oerves served, these are very young people. The flip side, as you can see from my Lads photos, is they are full of energy, which is fun. Check out the picture of the snake- it generated a lot of interest!

I've enjoyed the two days. Its been great to hear about the other sites, and discuss ways we can improve out students's experiences. And it is worth the trip to Perth just to listen to our Head of School, Campbell Murdoch tell his rural practice stories, and watch him schmooze with the students.

Friday we woke up to booming thunder and heavy falls of warm rain. This was a concern as I was rostered to fly out at 0645 AM to Kandiwal. The Derby Aboriginal Health Service partners with Jarrugk Health Services to provide physician clinics in remote communities in the Kimberly. Vicki drove me and one of the 6th year medical students out to the aerodrome in the rain. The tides were exceptionally high, and salt water was lapping out of the mudflats into the marshes at the edges of the runway as we arrived. While we watched the sky clear to the east, word came that the runway in Kandiwal had also received a heavy wetting, and was too muddy to land on that morning. So the mission was scrubbed and rebooked for next Friday. I returned to the office and saw walk-in patients the rest of the day, and prepared for my trip to Perth this week for the quarterly RCS Coordinators meeting.

Both Derby AHS and Jarrugk are Aboriginal Community-Controlled Health Services (ACCHS). The medical care situation for Aboriginal people in the Kimberly is complicated and has taken me awhile to sort out. Aboriginal patients in most of Australia have three choices for healthcare services. First, there is the State health system. All Australians are entitled to medical care through their State hospitals and Community Clinics. If admitted to a State hospital, the care is generally free or very low cost. While there are private hospitals in the major cities like Perth, they generally do not do charity care. If they bill Australia Medicare, the patients are responsible for the difference in private billings, which is usually quite substantial. So private hospitals are an option only for Aboriginal people who have integrated enough into the Western mainstream to acquire private health insurance.

The second option is GP care. All Australians are encouraged to have a GP who provides them care, covered by Australia Medicare (which covers all ages in Australia, not just the elderly.) Unfortunately, there are widespread shortages of GPs in Australia, especially in rural and remote areas, like the Kimberly.

The last option for Aboriginal people is to seek care at an Aboriginal Medical Service (AMS). The first AMS was founded by volunteers in Redfern in 1971. Initially AMS received no government funding. The governments’ argument over the years has been that they provide a perfectly good healthcare system through the State hospitals and clinics, so why should they fund AMS’s? So for a long time the first AMS were funded by donations and staffed by volunteers. Some of the first AMS actually received large grants from charities in Germany who were concerned about the plight of Aboriginal people!

AMS’s recognize several principles. First, they are community-controlled, run by a board of local Aboriginal people. In this way they are much like a local school board or hospital board in the U.S. and may vary in performance depending on local leadership and vision. But given the history of Aboriginal people, community control is essential. One must recognize that these are a people whose lives were controlled, until very recently, by “Protectors” who decided where they could live, who they could marry, and whether or not to take their children away from them. Many Aboriginal people were removed from their homes for leprosy and remanded to Sanitariums, causing great family and social disruption. And with the legacy of discrimination in Australia, every Aboriginal person can tell you stories of family members maltreated in State hospitals, often recently. In fact, for a long time there existed a “separate and unequal” system of “Native Hospitals” run by the States. Even Aboriginal people with money and health insurance were turned away from the general State Hospitals and sent to the Native Hospitals where care was clearly second rate. So you can understand why ownership and control of their own health delivery system is a very big deal.

Another important component of AMS’s is their staffing by local and Aboriginal personnel. DAHS is fortunate to have many well-trained Aboriginal Health Workers (AHWs), as well as nurses. The Health Workers are Aborignal people who have undergone training similar to what an “LPN” or practical nurse would receive. They work in the Clinic as a first point of contact for Aboriginal patients, taking histories and helping triage. They often operate independently from physicians and may follow sets of standing orders to provide patient services. For example, they perform a large number of wound care visits and dressing changes.

Finally, Aboriginal Medical Services have a different focus than the State system. State hospitals and clinics are generally problem-oriented. They see illness, wounds, accidents, alcoholism and its effects as short-term problems to be “treated and streeted” for the most part. While they do provide childhood immunization clinics and some preventive services, this is not their main focus. In contrast, AMS primary purpose is to improve the health of Aboriginal people as measured by less illness and lower death rates. We do this at DAHS by providing opportunistic screening. Every time a patient presents, the front desk prints out a sheet of overdue services from the Ferret computer system. We have a full-time worker who enters results and services rendered into Ferret, keeping it up to date. Thus, when a patient presents with an ear infection, I am likely to be prompted to get a urine sample to test for STDs, renal failure and infection; draw blood to screen for undiagnosed diabetes and check for high cholesterol, and counsel the patient about smoking, alcohol abuse and diet. You can see this expands a 10 minute visit into a 30 minute one, at least. But having the Aboriginal Health Worker to prescreen the patient and begin some of those services helps me get the job done. And frankly, without a health service structured to provide the time, teaching and support for patients, none of these services would get done. The AHWs provide a lot of support and continuity. For me as the physician, they also provide much background information. Because they live in the community, they can often fill me in on what they know about family problems, legal difficulties, terrible housing situations, drug and alcohol problems, etc. AHWs also understand the cultural barriers, such as skin group problems, and “Men's Business” vs “Women’s Business” that can get in the way of providing needed services.

DAHS is really well focused and administered for this mission. I am very pleased to be part of the organization, and it is a great place to learn about Aboriginal health. I saw my first case of leprosy this week, and the staff were really supportive in getting me the materials and help I needed to assess the case. And we also booked the patient into the Women’s Clinic day so we can catch up on her other health needs.

For me the Aboriginal Health part of this job is much more challenging than the student teaching. Lately when considering the overwhelming needs and problems of Aboriginal people, I have been thinking of Loren Eisley's famous story of the dancer on the beach and the starfish, and it keeps me going. “I can help that one.”

The wind blew the rain horizontally through the slats of the outdoor shower stall. I dropped the soap dish cover and it was gone in a flash, caught in the air jetting past my feet. The flimsy stall walls shook, and the thunder boomed from 360 degrees, echoing back and forth between the high canyon walls of Jarlmadangah community. Lightning broke the pitch blackness with actinic flashes showing branches, leaves and muddy dirt flying across the canyon floor. The rumbles from above shook the earth. I stepped out of the shower and was immediately wetter.

This happened on our 2nd night in Jarlmadangah. My three medical students and our Registrar, Marina, joined with 8 students from Broome and their faculty for a 2 day Aboriginal Health workshop in this small community of about 150 people.

Jarlmadangah is 150 km southwest of Derby. We drove out about 100 km on the Great Northern Highway, and then took a gravel road south. Twenty km down the washboard, an unmarked right turn took us through low scrub inhabited by the occasional group of cows. As we twisted and turned through the scrub, the rusty cliffs of the Grant Range appeared on the horizon, and before we knew it, we were driving between rocky walls into a 30 km long sheltered canyon. We arrived at midday in 100 degree heat in time for a welcome lunch in the small Clinic building.
This consists of two small prefab trailers, with a room built between them serving as a waiting room. The clinic has air-conditioners, but they were laboring. (Also, the community generates its own power. When I worked the Clinic in Jarlmadangah the Monday before, we lost power for 20-30 minute intervals four times during the day. In 20 minutes, a metal trailer becomes an oven in that heat.)

Our hosts were John and Annie Watson, his son Anthony, and the rest of their extended family and community. John and Annie were among the founders of Jarlmadangah. John was born on the Mount Anderson station, where Jarlmadangah is sited. He worked on the station most of his young adult life, only to be fired in the 1970s when the Australian government declared that employers had to pay equal wages to Aboriginal people. This led to mass displacement of people who had been born and lived their entire lives on remote stations, as employers could no longer afford to keep them as employees. Many stations also became economically nonviable as a result of this legislation. The law of unintended consequences prevailed. John and Annie went to live in Looma community, but became unhappy with many aspects of that community, including widespread alcohol use. John had also been active in the Aboriginal land rights movement. After many years, Mount Anderson station was placed in Native Trust and he and Annie founded Jarlmadangah as a drug and alcohol free community. (Despite the Native Trust designation, the people living in Jarlmadangah still do not own or have clear title to their land. This is a concern as there are potential minerals beneath the land, and no guarantee that the government will not displace them again.)

Annie had been trained as a nurse in Perth, and worked for many years in Looma for the state health system. She chafed under rules that kept her in the clinic consulting room 40 hours a week and forbade her from using some of her time to teach and pursue community health and prevention activities. She felt she was just patching up diseases and problems that could have been prevented with community-wide approaches. So when setting up the clinic in Jarlmadangah, she affiliated it with the Derby Aboriginal Health Service (DAHS) which encouraged her to take a community health approach.

We learned these things over the weekend mostly by sitting and talking together. In fact, the main activities of the weekend workshop were simple. We toured the school and parts of the community. The students played extensively with the children. For many hours we sat in a circle in the classroom and listened as John, Annie and Anthony explained their lives and views. I was very proud of all the students for the way to listened generously to the stories and histories of the community. We had meals together outside on the lawns in front of the school. And late Saturday afternoon we all piled into Land Rovers and drove out 15 km across the canyon to climb up the rocks to a sacred waterfall and spring.

I can’t relate all the stories we heard here, but maybe I can give a small example. One of the conversations began with discussing concerns about HIV and sexually transmitted disease. STDs have historically devastated Aboriginal communities, and syphilis is still endemic in the Kimberly. As Anthony discussed community STD prevention activities, the thread suddenly veered off and we went into a discussion of skin groups and long explanation of this traditional Aboriginal concept. Skin groups are a group each person is born into—always different from the skin groups of the parents. Skin groups are intimately bound up into rules in the Aboriginal culture. These rules, among others, famously forbid direct face-to-face conversation between a man and his mother-in-law and her relatives. Intimate, personal information (such as medical concerns) is only to be shared with someone in your own skin group. And the groups also closely govern funeral rules, initiation rites for boys and girls, and even choice of mate. You are not allowed to marry anyone from your same skin group. And each Aboriginal language group and community has variations and different names for the skin groups. The discussion then swerved into a long explanation of funeral rites and customs. They explained the tradition of never speaking a dead person’s name and putting all their photographs away (which explains why many Australian television documentaries begin with a warning that “the following programs include video and photographs of deceased persons”). Finally, after about two hours of wide-ranging storytelling, the conversation came back to STD prevention and the importance of teaching Aboriginal children their culture and heritage as a method of preventing STD spread. This was a fine example of non-Western, circular story-telling structure, and I found it very effective at tying together many concepts. I believe physicians working with Aboriginal people should be aware of this circular structure. The concepts of “chief complaint” and “history of present illness” do not fit neatly into this construction. One huge difference between working in an Aboriginal Health service versus the state health system is that we are given more patient-contact time, and the assistance of Aboriginal Health Workers to encourage patients to tell the stories of their illness, and of how their lives intertwine with their illnesses, in this circular style.

Jarlmadangah is a small community. They declared themselves alcohol and drug-free, and they have a reputation in Derby as “strictly enforcing” that policy, with the implication that physical and public humiliations might be used if necessary. But they have a belief and pride in their culture and a conviction that passing on their heritage is vital to their survival as a people. And, it is clear that the major focus of the community is their school, and its 47 pupils. They are justly proud of what they have built, and their efforts to preserve and pass on their heritage.

Some days I feel very discouraged when I think of how difficult and impossible the problems of Aboriginal healthcare seem, and of the institutional and cultural barriers. But I am glad to have experienced Jarlmadangah. It has helped me not only understand these problems from a different point of view, but also gives me hope and optimism. It serves as an example of that philosophy found in many cultures, but encapsulated in the Jewish proverb: “It is better to light one candle than curse the darkness.” Thanks, Jarlmadangah, for hosting us.

More pictures are here:

Jarlmadangah Feb 07

Labels: Aboriginal Health, Jarlmadangah

In many countries we have taken the savage's land from him, and made him our slave, and lashed him every day, and broken his pride, and made death his only friend, and overworked him till he dropped in his tracks; and this we do not care for, because custom has inured us to it; yet a quick death by poison is loving-kindness to it.
-Mark Twain, commenting on a story he was told about an Australian settler giving arsenic to his Aboriginal neighbours, in their Christmas Pudding

The Natives were not used to clothes, and houses, and regular hours, and church, and school, and Sunday-school, and work, and the other misplaced persecutions of civilization, and they pined for their lost home and their wild free life. Too late they repented that they had traded that heaven for this hell. They sat homesick on their alien crags, and day by day gazed out through their tears over the sea with unappeasable longing toward the hazy bulk which was the specter of what had been their paradise; one by one their hearts broke and they died.
Twain, on the fate of the Tasmanian Aboriginal people

For Valentine’s Day Vicki gave me a collection of Mark Twain’s essays about Australia, from the book Following the Equator. He visited this Continent a little over 100 years ago, near the end of his life. Remembered today chiefly as a great humorist and for his novels, he is less remembered for his virulent anti-Slavery views and his opposition against racism in all it forms.

Twain was widely read and an astute observer or character. It is sad therefore to read his essays. Vicki and I find them as true today as they were 100 years ago.

We have been learning about Australian history. The earliest explorers declared Australia “terra nullis”, meaning “no one lives here”, despite there being a population estimated at 250,000 to 1 million.. Aboriginal and Torres Strait people have inhabited Australia for at least the last 45,000 years- the longest inhabitants of their territory of any people currently living on Earth outside of Africa.

Aboriginal people, during their long sojourn, developed a culture and indeed a physiology well adapted to living in this dry, hot land. Their culture is so bound up with the country they live in, that they see themselves as belonging to the land (and not the other way around.) The land gives them everything they need, and in return, they are caretakers of the land. Unfortunately, the clash of cultures resulting from Colonization was disastrous to these people. As detailed in the book Guns, Germs, and Steel, native cultures around the world were at a disadvantage when meeting Western Civilization. The lack of exposure to cows and centuries of East-West trading made them excessively susceptible to diseases like TB and smallpox. And the “high technology” of Europeans, expressed as guns and alcohol, finished the job of decimating the population.

Aboriginal people were therefore viewed as being a “dying race”. Overt racism also gave colonists license to mistreat and virtually enslave the survivors. Aboriginals were not seen as people until the 1970s, and their welfare was administered as part of the government department responsible for the entire flora and fauna of Australia- essentially part of the “Department of Fish and Game”.
To make matters worse, a systematic program of removal of children from Aboriginal families, in an effort to “breed out the black” was carried out in the 20th Century (as you can see in the movie Rabbit-Proof Fence), ending only in the 70s. The effects of the Stolen Generation are still being felt in Aboriginal communities and as one person told us, “this still hurts us”. I have met patients who never knew their parents, being removed from the home and raised in Christian orphanages, cut off from their culture and heritage.

The results, in a nutshell, are that Aboriginal people have some of the poorest health in the developed world. It took us only a few weeks to discover that many of the distinguished “old men” we saw in town were actually much younger than us. They just look 20 years older, due to poor health and very hard lives.

Aboriginal people don’t suffer the diseases of advanced age, like Alzheimer’s very much. This is because they usually don’t live long enough to become demented. The average life expectancy for an Aboriginal man is about 59 years at birth- which is 20 years less than for other Australians. In the Kimberly, Aboriginal people have high rates of death and disability from cardiovascular diseases, diabetes and kidney failure. I have seen many young people- from children to those in their 30s with severe hearing loss and chronic draining ear infections. And overcrowding- read lack of available decent quality housing- leads to high rates of common infections including parasitic diseases, skin infections like impetigo and lice, and severe diarrheal illness in infants and small children.

This is all over a background of disadvantages in education, employment and a “fair go” at life as they say here. Consider these facts:
• Indigenous unemployment is almost five times the national average. A January 2004 study by the Australian National University's Centre for Aboriginal Economic Policy Research found that labour market discrimination is more likely to manifest in an inability of Indigenous individuals to secure a job, rather than in being paid low wages
• Aboriginal households on average earn about $200 less per week than non-Aboriginal households.
• Aboriginal people are half as likely to have completed schooling and only about 40% are employed.
• Indigenous people are 14 times more likely to be imprisoned than non-indigenous Australians
• Indigenous people also suffer higher rates of crime. A 2001 study in New South Wales found that Aborigines are 5.5 times more likely to suffer domestic violence, 3.4 times more likely to suffer assault, 2.8 times more likely to suffer sexual assault, and 2.5 times more likely to be murdered.
• The Aboriginal infant mortality rate is 2.5 times that of the rest of Australia, with the rate in the Northern Territory four times the national average. Moreover, the number of babies of low birth weight is double the non-Aboriginal average and actually increased over the late 1990s. The figure is higher than those for Ethiopia, Senegal, Mexico and Indonesia.
• Suicide, which many Aboriginal languages have no word or concept for, has risen from the one of the lowest rates in the world to one of the highest in the last 25 years.

In the face of these medical problems, the Australian government was recently found to be spending A$ 225 per person in the non-Aboriginal population, compared to A$ 74 for each Aboriginal person.

Add to this an attitude toward these problems, as exemplified by our taxi driver, the first day we arrived in Australia. He asked why we were here and when told our plans to go to Derby, he commented, “well, they really different and primitive up North- I don’t think they are quite human, you know?” And he was serious and unfortunately not alone in this belief.

As an American, partly a descendant from Colonial ancestors, I am certainly not claiming any moral high ground when looking at these problems. This is just the milieu I am working in. And not everyone is ignoring the problem. More than 30 of Australia's key medical and social welfare groups say Indigenous Australians are dying because of a lack of political will and action and have called on the government to change course. I write about it as background for the next topics I will write about: Jarlmadangah, and DAHS.

Its been raining the last 3 days. We had 16 mm of Rain since 9 AM today. Its high tide, and the mud flats are covered with chocolate water. Mostly we have just had rain and some wind- the brunt of this stuff went south and hit Port Hedland. I have a meeting in Perth on Monday, but we'll see if the planes are flying at all in the next few days... Wore long pants to work today for the first time- it was a chilly morning: 68 degrees on the back porch at 7 AM. Many of the patients are not coming in (they have no cars) so the drivers have been busy picking up people. Vicki's had to knock off her keen gardening and catch up on reading. Overall, good days to take naps, as one of the Aboriginal Health Workers said yesterday.

Last night we enjoyed the second week of dance classes, free and sponsored by the Shire of Derby. These are in the small community center and great fun. About 24 people attended, maybe 1/3 of them "unattached" and just there for fun; in age from ~12 to 50's. We danced the Barn Dance, slow dance, salsa and mambo, and some the teacher made up. Most of the dances are "progressive", meaning one dances one cycle and then the woman moves around the circle to the next guy. Great fun.