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Rural health access problems facing the Aboriginal community |
LITERATURE REVIEW
Since 1990, when the Federal government announced ‘A Fair Go’ policy for rural Australians, there has been a constant stream of State and national conferences, workshops and seminars held to educate, debate and investigate all aspects of rural life. A variety of taskforces, expert consultations and units have been set up, including the National Health Strategy, the National Rural Health Alliance, the Rural Health Support Education and Training program and the Rural Incentives Program, to research, facilitate and better manage our country health services.
In the face of appalling health statistics and recent Federal politics, Aboriginal and Torres Strait Islander health has become trendy with a similar myriad of councils and committees, including ATSIC (Aboriginal and Torres Strait Islander Commission), NAHSWP (National Aboriginal Health Strategy Working Party) and NACCHO (National Association of Community Controlled Health Organisations), being formed and funded. Unfortunately, very few of these councils originated from the grass-roots level of community perspective.
Out of this wealth of collaboration and knowledge, hundreds of reports, conference and position papers, mission statements and strategic plans have been issued with similar themes. “Things are not good in the ‘bush’. Depressed rural economies, high levels of unemployment, family breakdown, record levels of bank repossession on rural properties, issues of access and equity, and the list goes on.”(1) It seems this grief is shared and multiplied in the rural indigenous communities, who already “suffer a higher burden of disease and die at a younger age than non-indigenous Australians.”(2)
Any regional problems, such as lack of access to medical services, further compounds the suffering of an already disadvantaged and culturally dispossessed society, and in this fast paced western society, where ease of access and availability are paramount to survival, Koori fourth world health statistics are not surprising to see. “Indigenous people in rural areas were less likely to live within 25 kilometres of services and facilities” and more than half had to travel more than 50 kilometres to a hospital, which correlates directly with poor health outcomes, and “compared with indigenous people in urban areas, indigenous people living in rural areas were also at the greatest disadvantage with respect to availability of health services such as mental health, health promotion, antenatal care, diabetic services, women’s health, baby health and sexually transmitted disease clinics.” (3)
This wealth of information does describe the problems in rural health, but reminiscent of our pattern of organisational hierarchy, this remains a top-down approach and very little research done at the community level reaches the echelons of decision-makers.
In fact such anthropological research remains difficult to even publish in mainstream scientific manuals, still entrenched in Cartesian reductionist patterns of thinking. Physical distance is only one way to define ease of access, and even if taking environmental barriers and transport availability into account, this may still be only a measurable fraction of concerns when dealing across a cross-cultural interface. These other obstacles can be defined as individual or personal, and need to be seen in their field of reference, ie. historical societal structure. “These structural obstacles include:
~ A health system that has become highly institutionalised; where health care is frequently administered in isolation for issues related to personal, family and community care.
~ A history of colonialism, scientific and institutional racism, which has recreated a legacy of negative legislation, minority anxiety and dependency as well as a climate in which many Aboriginal/non Aboriginal interactions are based on mutual stereotypes.
~ Professional structures and demands which sometimes overshadow and override clients’ as well as care givers’ personal needs.
~ A philosophy and concept of health that is based on a biomedical model which focuses on curative rather than holistic health.” (4)
“Traditionally, Australian and many other ‘developed nation’ health services have relied on the individual delivering himself to the system and largely delivering himself up to the system.”(5) As health practitioners we need to recognise the unspoken paradigms of our culture and how our conditioned expectations and beliefs, however unconscious, do effect our interactions and make us sometimes inaccessible to cultures of a different understanding. We are a product and reflection of western culture, and even the physical spaces we occupy, which we expect to confer a sense of safety, expertise, and technological science, clash directly with the indigenous sense of healing.
“Hospitals and large buildings are seen as a threat; bad experiences of the past are associated with large buildings, for example police investigations, community welfare taking children away”. (6)
Our hospital accident and emergency departments, where the Koori person may first have contact with the medical system, are notorious for hurried culturally insensitive assessments and miscommunication, sometimes resulting in misdiagnoses and, as in any state of trauma and fear, the perceived opinions of others has a profound effect. These daily interactions, where profound verbal and non-verbal communication differences cause bilateral confusion, thus compound collective unconscious beliefs. Here, at the coalface, skin colour and language differences can generate subtle role-plays of presumed inferiority, and promote sensations of powerlessness.
This effectively prevents the patient from actively advocating their own needs and feeds into the endless cycle of fear and psychological isolation, predisposing to illness in itself. “Several participants commented that they were “too scared” to take up issues, request services or ask for explanations from hospital workers. They spoke of their experience of “racism” in
hospitals, the “negative attitude” displayed to them, and their perception that hospital staff viewed Aboriginal people as “second in line to white people””. (7)
Koori women it seems, are especially sensitive to such fears, and tend to fall through the cracks in our mainstream systems of health. Patient-doctor “interactions are achieved by acknowledging that the concept of relationships and the definition of compliance exist in western medicine, within the framework of a culturally appropriate interaction model, but this model may not necessarily be suitable, nor indeed desirable, when communicating with Aboriginal mothers”. (8)
In addition, gender taboos make reproductive health particularly difficult to access for indigenous females in a historically patriarchal health system. “The political, social and economic disadvantage affecting many Aboriginal women is compounded when they become mothers under the age of 18 years. The clinical setting of the hospital can be seen as intimidating. Staff attitudes can be perceived as being judgmental or patronising and young women can feel powerless and under confident, anxious about birth or pregnancy, also embarrassed about their changing bodies.” (9)
This embarrassment may be universal, but dealing with this in a system you do not trust or comprehend is highly stressful and leads to avoidance patterns affecting the entire family and often entire traditionally matriarchal communities. “Seeing each instance of a woman avoiding contact with medical care as an individual woman’s problem may seem to provide an explanation for a sequence of events. However, when large numbers of the people who should be served by health care find the experience so distressing that they feel the need to ‘flee’ from it, this is a failure of the system, not the individuals.” (10)
“The Department of Community and Health Services policy is to best use scarce resources by directing their provision to groups at highest risk of ill health and with the greatest difficulty of access.”(11) It is clear that economically, epidemiologically, physically and culturally, indigenous women and subsequently their children, fit this definition, and understanding their needs or overcoming their difficulties cannot come from our commonly paternalistic methods of health delivery.
“The mission of the (National Rural Health) Alliance is to promote the provision of high quality, accessible and appropriate health care in rural and remote areas of Australia through partnership between health consumers and providers.” (12) This sacred vision, although good in intent and shared by all, does not however, help us deal with the reality that faces many of these women, lacking in money, transport, knowledge of available services, social supports, even self-advocacy and caught between cultural paradigms. “Participation has been misinterpreted as meaning the creation of ‘advisory committees’ rather than as facilitating self determination through the provision of appropriate resources.” (13)
What our local social research has told us is that in general the indigenous community is “sick of people coming into the community, talking lots of stats but not coming back and letting us know the results and what is more important, doing something about the results.” (14) Many of the practicing taskforces advise correctly, but as these papers are interpreted by government and managers, they become rhetoric and semantics to argue and debate, rather than implement. “The health of peoples is more affected by politics and economics than doctors and medicine.” (15) In addition, “work that is older than 15-10 years is rarely quoted in the current literature, so that every 10-20 years there is a re-publication of the same issues.” (16)
In terms of rural health access, for example, it has been noted that “distance from specialist services and lack of transport are major access issues. The provision of outreach or mobile services becomes an important access strategy. However it is still important that Aboriginal people are consulted in the development of this strategy and have time to build up a relationship and trust with the service provider.”(17) So involving and asking the community what their priorities are is paramount in the establishment of any such program.
The available research implies that we need to ask, not only about access, be it physical or cultural, but also about knowledge of available services and/or transport facilities, and the financial ability to use these. “It was evident in the town consultations that Aboriginal women were not aware of existing health services and/or felt they needed more information about these services so they could use them more effectively For some women it was clear; no transport and no money means no accessing medical care.” (18)
By asking the people what they want, we will be ensuring their knowledge, their acceptance and their enthusiasm in accessing any subsequent services, and that our available resources are directed to ensure maximum benefit. In a community so wary and jaded by repeated attempts to understand the problem, the most effective method of doing this, it seems, is active social interaction, talking rather than asking, so that yarning over a cup of tea is yet another learning experience for the alert researcher.
REFERENCES
1. Blue, I. Take Mohammed to the Mountain. Presented at the Australian Rural Health Conference, Toowoomba, Qld, August 12-15 1992.
2. Australian Bureau of statistics. Health and Welfare of Aboriginal & Torres Strait Islander Peoples, 1997: 1.
3. Australian Bureau of statistics. Health and Welfare of Aboriginal & Torres Strait Islander Peoples, 1997: 55.
4. Binan Goonj Bridging Cultures in Aboriginal Health. University of New England, 1992:124.
5. Moodie, :158
6. Hetzel, BS. Health and Australian Society, 1990: 60.
7. Australian Rural Health Research Institute. The terminally ill Koori: Their care and their carers, 1997: 33.
8. Kemp, K, et al. Strategies for and problems associated with maximising and monitoring compliance with antibiotic treatment for otitis media with effusion in a remote Aboriginal community. Australian Journal of Rural Health 1994; 2: 26.
9. Dorman, R. Ngua Gundi (mother and child) Program. Aboriginal and Islander Health Journal, September/October 1997; 21, (5): 2.
10. Aboriginal maternal mortality: whose problem? Medical Journal of Australia, November 1993; 159: 571.
11. Dunne, P. et al. Health Services Provision in Rural and Remote Areas: a needs analysis. Medical Journal of Australia, July 1994; 161: 162.
12. Gregory, G. Advocacy for Rural Health Consumers. Health Issues, December 1994; 41: 24.
13. Aboriginal health and a new curriculum for rural doctors. Editorial, Medical Journal of Australia, February 1994: 186.
14. Results of an Aboriginal community survey on the importance of health issues in the northern rivers area. Yagambeh Darung, 1996: 9.
15. Werner, D. Aboriginal health and a new curriculum for rural doctors. Medical Journal of Australia, February 1994.
16. Kamien, M. Rural Health for all Australians by 2000? Australian Journal of Rural Health, 1997 (5): 181.
17. When will you understand us? Aboriginal Women’s Business Health Project Report, November 1995: 19.
18. When will you understand us? Aboriginal Women’s Business Health Project Report, November 1995: 14, 22.
Copyright 2000
Dr Jacqueline Boustany, MBBS (Hons), Dip Paeds, MPH.
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