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.”