Parents-in-TrainingJanuary 15, 2019
Imposter PhenomenonJanuary 15, 2019
Working in Alice Springs didn’t give Dr Eliza Milliken all the answers to improving Indigenous health. It did, however, force her to ask some hard questions about the limits of a medical system that fails to acknowledge the impact of history.
Alice Springs is a town gated by a split of red rocks bisecting the West MacDonnell Ranges called “The Gap”. Driving into town, the first thing that strikes you is that it’s more beautiful than expected. The name “Red Centre” doesn’t prepare you for the green-and-silver of the spinifex and the stark white and warm yellow of the ochre. In the morning, the mountains are rose-gold to compliment the rose-coloured sky. Around town you can watch birds of prey ride heated updrafts, and on the highway eagles as big as dogs refuse to move for approaching cars, protecting their lunch of broken kangaroo bodies. In the Desert Park out of town, functionally extinct species, such as the kitten-sized mala, live in tiny surviving colonies within the walls of their marsupial utopia, protected from the feral cats, camels and hunters.
Writing about working in the Northern Territory (or “The Territory” as locals call it) seemed liked a good idea during our week-long road trip in a rusty Subaru from Sydney to Alice. The basic concept: report back with some on-the-ground learning about bridging cultural divides to help doctors who see First Nations patients in the minority. However, driving North I remained under the illusion that we are unified in the goal of addressing inequality between First Nations people and new Australians. Malcolm Turnbull’s rejection of the Uluru Statement of the Heart shows that we are not. This, and the fact that I realised that a suburban white girl has no real credentials to speak on the experience of First Nations Australians, made me worried I shouldn’t comment. There are plenty of better informed First Nations doctors (and patients) who could say more useful things than I can and I don’t want to suggest I have authority or speak for the experience of others.
Nevertheless, there are some good arguments for white-fellas (and white doctors especially) speaking up about the health of First Nations Australians. Firstly, the negative, racist responses my husband and I frequently received when telling people, white-like-me people, that we were doctors in Alice made me think that a little bit of dissent, even from a silver-spoon suburbanite, doesn’t hurt. For example, the well-dressed older lady who informed me at a party that treating harmful alcohol use in Indigenous communities was “a waste of time because those people have traits”, while in the next minute joking that I would need a crate of shiraz “smuggled in” into the dry town. A NSW-based farmer unleashed a string of racial slurs at us just hearing the words Alice Springs. Even a locum consultant in the town itself mumbled “well just think about where Aboriginal people would be if we white people hadn’t come!” I was too taken aback to even reply – this, after all, was a person being exceedingly well renumerated with taxpayer dollars to care for Aboriginal patients. More pressingly, non-Aboriginal Australian doctors have an imperative to publicly reject the phenomenon historians call ‘The Great Australian Silence’; a term denoting the refusal of British-descended Australia to acknowledge the reality of how this Nation was formed. At present, two opposing narratives exist. The term ‘Frontier Wars’ is used by historians to describe the violent ingress of European colonisers into this continent. Using primary sources, this narrative tells of the officially-sanctioned massacres, racist policies, and the Stolen Generation. There is another narrative, dubbed ‘The Silence’, which is a glib but often stringent dismissal of Australia’s violent history – along the lines of John Howard’s description of Australia as “formed without strife of warfare”. This may seem irrelevant to the provision of individual patient care but it’s not. This thinking, and the narrative that gets accepted by those in charge of research dollars and access to healthcare, informs the way we provide care at every level. The Great Silence underpins health inequality between First Nations Australians and new Australians.
Therefore, we must not be silent.
Despite breathless reports from some media outlets, racial tension is not an everyday reality, and Alice is not a tinder box waiting to ignite. It’s a very pleasant place to wander around, get a nice coffee and visit the art galleries and the Megafauna Museum. Even better, to buy some art off the street from local artists. It would be wilfully ignorant to pretend racial tensions do not exist at all. Growing up in the beach suburbs of Northern Sydney you can live under the illusion that colonialism is a completed – rather than dynamic – process; but that’s impossible in Central Australia. Official census data puts the Aboriginal population in town at under 50%, but most people living in and around Alice are First Nations Australians. This discrepancy comes from the fact that in addition to the Arrernte peoples who have lived in the centre for some 35 millenia, visitors from surrounding areas such Walpiri and Anangu travel to Alice for business and leisure, thus the population regularly expands and contracts. Despite the non-Aboriginal population having only been present for some 80 years, there is, for the most part, a huge inequality in the way the two groups live. First Nations people often reside in town-camps which can be poverty stricken, lack running water and electricity, and may become violent at night. Visitors to town often sleep on the dry Todd River bed and hypothermia is common in winter. Vandalism, a predictable form of civil disobedience, is commonplace. Long-term white inhabitants tend to refer to “Problems In Town” with a capital ‘P’ the way people in Ireland talk about “The Troubles”, and with a lot less self-reflection.
Arriving in Alice, I was mostly ignorant to the healthcare needs of First Nations people. This shouldn’t really have been the case considering medical schools have programs to ensure medical trainees get something of a clue before being unleashed on patients. Unfortunately, the teaching still isn’t sufficient for adequate cultural understanding. For example, the NSW Health ‘Indigenous Health’ module (in my memory) required clicking through cartoons of Aboriginal people with hypothetical presentations. In one scenario an elderly woman presented “complaining of bilateral arm tingling”, the eventual punchline; “you’ve missed a stroke!” It was unclear whether you were supposed to have missed a veiled presentation, or whether the well-meaning program designer thought this was a typical stroke presentation. Either way it sure didn’t help me much the first time I did treat a stroke in Alice (end of bed hemiparesis – too bad the hospital isn’t supported for thrombolysis or thrombectomy). Another hypothetical training case featured a woman wanting a bed towards the back of the ward to see the view outside. In the next scenario, the same patient is given the bed at the back but worries she’s being put out of sight as a form of segregation. There was no right answer and in all fairness that’s probably the only thing we can all agree on. With only this kind of training to go on I realised I had better upskill quickly.
Like everyone, I’ve been aware of the data about diabetes, hypertension, renal disease and alcohol-dependence in remote communities since medical school. Things I didn’t know arriving in NT – my patients wouldn’t speak English (as I’d been taught by media that First Nations languages were all dead or dying). I didn’t know what a Ngankari (central desert healer) was, or the central role of singing to illness and healing. I knew the Government did not recognise Aboriginal people as full citizens with voting rights until 1967, but I didn’t know that the last government-sanctioned massacre was only 41 years earlier in 1928 when 17 people from three different Nation groups were murdered near the Coniston Cattle Station. In fact, this was the last massacre considered to have occurred legally, but the killing didn’t stop with the suspension of official state endorsement. The health impact of these historically-recent atrocities is not only intergenerational trauma (something I also learned when I got to Alice is an epigenetic, not a cultural concept), there is other sequelae too. For example, a place where one’s family were massacred may become forbidden for descendants. Seeing a forbidden place may induce an illness that needs to be endured as punishment rather than treated. Cultural practices are often easily dismissed as “non-compliance”. In the most fundamental sense, how likely is it that the same authority that less than a century ago sanctioned mass murder now accurately determines what is in the best interests of the next two generations? The Stolen Generation is the obvious example of why we as doctors should always be cautious of official policies claiming knowledge of “what’s best” for people who had no say in the policies that affect, or more correctly, afflict them. Medical curriculums need to go further than population data and introduce notions of intergenerational trauma, the history of the Frontier Wars, and I would suggest The Names of Places; a multimedia map developed at The University of Newcastle, showing places and dates where First Nations massacres occurred.
This is not to say that progress towards health equality has not been made. Any consultant who has been in Alice long-term will tell you about the Bad Old Days. There was the time of the “Rivers of Blood” when the bottle-o sold a cheap fortified wine that turned normal vomitus blood-red and indistinguishable from exsanguination. The floors of the emergency department “ran blood-red every night” and it was impossible to keep up with who needed a transfusion and scope and who was just pissed, or so the myth goes. The wine was eventually banned. There was also “Todd River Syndrome” or “Todd River Triad” which, depending on who you spoke to, involves a severe burn from falling forwards into a camp fire, a blunt force trauma from a closed fist punch and a GCS of three. The trick? Differentiating who needed urgent neurosurgical input and who was merely intoxicated, with no radiology available overnight. Anecdotally, this presentation lessened with stricter alcohol laws. By the same token, storytellers told me that the Territory Government suppressed the publication of data about patient outcomes to avoid bad publicity for the 2007 Northern Territory Intervention and that it had a negative impact on remote communities – an opinion supported by the Australian Indigenous Doctors Association 2010 Intervention Health Impact Assessment.
It’s not white Australia that has been doing the hard work to push forward the Nation. In 2017, The Uluru Statement from the Heart called not for a massive redistribution of land or wealth, but simply a spirit of “truth telling” as a way forwards. Makarrata is a Yolngu word describing a complex multi-layered concept of conflict resolution, peacemaking and justice. It is derived from a ceremonial practice that seeks to even the scales when one party has committed a misdeed. The Uluru Statement suggested a Makarrata Commission to guide policy affecting First Nations people at the Federal level and guide progress towards a treaty, as Australia remains the only Commonwealth country without one. Unfortunately, this gave Malcolm Turnbull his excuse for an out-of-hand dismissal through the specious claim that the Commission would create “two parliaments”. Turnbull’s flat “no”, without compromise or negotiation, sent a clear message: Australians of European descent still feel superiority and entitlement over and above First Nations People.
I think now I’m supposed to neatly summarise what I “learned” from working in Alice Springs. Unfortunately, I have no neat summary. Our role as caregivers and healers is problematised by our position as the fingers at the end of the long-arm of the Government. Even First Nations doctors must work within a system that does not often recognise and prioritise the health needs of First Nations Australians and a culture that refutes the reality of The Frontier Wars. Working in Alice made me question how much we can really trust any decision we make as clinicians to be objective rather than cultural. In fact, it made me question my very identity as an Australian woman and my government-sanctioned job as someone who heals people. If the Government today won’t listen to the voices that represent First Nations people, as the rejection of the Uluru Statement from the Heart suggests, it seems doubtful that modern Australia, including our medical culture is making sufficient effort to understand and provide for the health needs of First Nations people. The negative health impact of suppression and silencing is complex, but it is also very real. As doctors, we need to acknowledge the social and historical conditions that created the absence of health if we hope to be effective and treat the wounds inflicted and also to be a part of Makarrata.