Few of us blame the Government for this virus pandemic but on a dreadful day when Australia has twice as many new cases as China (and a 60th of the population) we have to ponder whether we have done enough. Peter Wener in the Atlantic points to a major issues in the USA such as, “… the decision to test too few people, the delay in expanding testing to labs outside the Centers for Disease Control and Prevention, and problems in the supply chain. These mistakes have left us blind and badly behind the curve, and, for a few crucial weeks, they created a false sense of security. What we now know is that the coronavirus silently spread for several weeks, without us being aware of it and while we were doing nothing to stop it. Containment and mitigation efforts could have significantly slowed its spread at an early, critical point, but we frittered away that opportunity.” It sounds a lot like us. Five hundred people getting together at the moment is NOT safe. It is very hard to get tested, and we are being told it may be more difficult.
We have seen TV presenters, film stars and politicians come down with the virus. These people certainly mix with more people than we do day to day, but there are not many of them. So if we extrapolate back from their numbers and determine the rate of infection we will arrive at figures many orders of magnitude above that being reported. Let’s face it:
It is infectious, it is deadly and we need to stop it.
Economic predictions of impact are unlikely to be accurate and should not be listened to. Minimising the spread of the virus will have the most positive economic impact. Short, sharp, severe. Norman Swan has been getting air time to promote more health of the nation approaches. If we stop the growth, we can reopen schools and kindergartens. We can probably keep schools open now for children of emergency workers, health workers and other services that are understaffed.
Most of all we need to consider testing. At the moment we are testing a lot of worried people and groups of people who are in contact with an infected case. If we take a community view rather than an individual view and extreme social distancing is in place, we can check one member of a potentially infected household with symptoms and declare it positive or negative. That household should then be supported at home. Children are likely to be infected very quickly and have no difficulty. The disruption of treating individuals in this situation is massive and quite likely to lead to asymptomatic people thinking they are clear. Household members over 70 in infected households can be removed if asymptomatic and offered alternative accommodation if they do not have the virus after brief quarantine and testing.
Small towns with limited movement in and out can test the first locals with fever, and no travel or contact, as sentinel cases. If the sentinel febrile person is negative then we can assume safely that other fevers in that community are almost certainly negative for a period – perhaps the next seven days. This will be especially important when we add the usual winter viruses to the mix. Obviously any new arrivals with symptoms must be tested.
Regions, such as Central Australia, Cape York and Northern Western Australia (and many others) lend themselves to a regional community approach with community-based testing. The experts on our nation’s 60,000 year old cultures are at grave risk and require extreme measures of preservation. This requires checking all arrivals into the region (which is often one or two roads and an airport or two) and testing any of these who are symptomatic or develop symptoms over the next 14 days. We can tell them when we check them at the regional boundaries. In two weeks they become part of the “viral control” community. We will need sentinel testing in communities, perhaps one or two tests per week. The extraordinary thing in Central Australia is that this will require less than 100 tests a week. If we can “bank” the saved tests, we will be able to carry out contact tracing in the way Singapore has done.
If we are short of tests, lets think about how to use them effectively. It is time for extreme social distancing. Whatever we are putting in place, we need to know where the virus has spread.
I have been moved by the wonderful Toni Morrison, one of my thought mothers, to consider racism from the oppressors point of view. I am a white man, tall, middle class and educated. I work as a doctor of medicine, a powerful role in our country. I have been rewarded with an Order of Australia Medal, probably by people a lot like me (but I do not know). I am ‘in the driving seat’, so to speak, but I have chosen, with the relentless encouragement of Mimi, my ‘specialist in life’, to drive off the track.
I find myself in a position where Aboriginal people employ me. I have two levels of Aboriginal executive above me (who are both women) and the organisation is controlled by an Aboriginal board. I mention this as it is not a common environment for someone like me to work within. It is a very well run organisation, the best I have experienced, very motivating and with great working relationships. It is challenging and I feel good about it.
So Toni has asked for people ‘on the other side’ to describe what racism is. My first piece on this difficult topic was with Waiting for the world to change. I am interested in how the presence of white people changes things in my setting and if this is how institutional racism works. This is not about how redneck we are, or how vile. Rather, how there is an accepted code that gives white people more authority in social settings. There are a couple of subtle ways I have seen this being played out.
Aboriginal people in the Northern Territory use words in everyday discussion that are not so common or acceptable in mainstream culture. I did not notice this when I first came to work in Central Australia but now I do. I have used the ubiquitous terms ‘gammon’ and ‘budju’ for sometime having raised a family in the NT. I now use swear words a lot more at work than I did. I have become reasonably comfortable with the work “cunt”, not when it is used in hate, but in many contexts. Budju is also a word for vagina but is now used by all Territorians to describe very attractive people of both sexes. I am sure this word is acceptable in any setting.
Like my Aboriginal friends and colleagues, I do not say things that might offend when there are too many white fellas about. I wondered about this; about why Aboriginal people change their language when talking to non-Aboriginal people? Why Aboriginal people might stop being Aboriginal when a white person comes close?
Toni Morrison wrote:
“I have always myself felt most alive, most alert, and most sterling among my own people. All of my creative energy comes from there. My stimulation for any artistic effort at all originates there. The compulsion to write, even to be, begins with my consciousness of, experience with, and even my awe of black people and the quality of our lives as lived (not as perceived). And all of my instincts tell me that both as a writer and as a person any total surrender to another culture would destroy me. And the danger is not always from indifference; it is also from acceptance. It is sometimes called the fear of absorption, the horror of cultural embrace. But at the heart of the horror for me is what I know about what the history of the culture that pervades this country have been.”
Toni Morrison “Hard, True and Lasting” in A Mouth Full of Blood.
Lukas Williams, the wonderful young change advocate from Gan’na Healing, told me a story about one meeting he attended in a desert community where he was living. He was talking and projecting slides onto a make-do chipboard screen nailed to a post. The large group of local men who attended these meetings were chatting around the fires for warmth. Lukas put up a drawing of Captain Cook landing on Australia’s shore and waited until people grew silent. He started to talk about sovereignty. As the talking slowed to quiet, a large rock came flying through the air and smashed through the screen leaving a dark hole.
There was an immediate hush: uncomfortable silence. A snigger echoed in the far back of the group. Then more, some now laughing. Then, with the explosive urgency of freedom, a massive outburst of laughter filled the air. It rang and rang and echoed off the nearby mountains.
I was waiting to board the plane from a community back to Alice Springs and a young client who I had seen the day before was in the queue. It was great to see she had decided to move on. She had a pillow and a lot of hand luggage as well as her chubby young baby. I offered to carry something and she held out her pillow. I took it. We walked to the plane together sharing a little history and contemplating the new life she was heading towards. She beamed hope and liberation from a very tough time in her life.
On the plane she went to the back, row 23 and I stopped at row 1. I told her I would ask a hostess to bring the pillow down when she was settled in. I put on my headphones and started to listen to John Mayer. Once the door was shut, I asked a lively young, very blonde and Aussie hostess who came from the back of the plane if she could give the pillow to the tall young woman in row 23 with a baby. She looked at me quizzically, turned her head to one side, pursed her lips, but took the pillow. I was puzzled that she hadn’t noticed the striking appearance of the woman, and I wondered if there were a lot of babies in row 23.
She came back and checked, “You mean the dark one?”
“Yes”, I said.
I worried for that young woman from the bush who will be trying to make her way in mainstream Australia. It is tempting to try and understand what was going on in the young hostess’s mind. She was clearly a caring and well intentioned young person. I think we need to own the state of the young hostess’s mind as a nation and realise how far we have to go to educate ourselves and embrace our Indigenous peoples and cultures. When it comes down to it, the complex cultures of our ancient forebears define our space in an increasingly global cultural ‘mash-up’. The alternative is that our collective ignorance defines us.
Alice Springs is named after the waterhole on the Todd River just north of the town which was the life source for those building and operating the telegraph station that connected Australia with the rest of the British empire. Kangaroos collect in the evening and dig for the water which hides below the surface of the sand. It was just one of many watery sources of life that cower in the massive ravines and gaps between the heads and tails of the caterpillar shaped mountains: Yeperenye dreaming. With the arrival of the cattle and the destruction of these waterholes, people have come to rely on bore water in these parts. Fracking is understandably very unpopular, while concern is growing that the heavy metals in some bores may be damaging kidneys.
This underground water is not all good, but without it people can die walking around here in summer. One of my registrars had a near miss climbing Mount Gillen, a nearby peak in the Western McDonalds. He was evacuated to Adelaide for an angiogram. Another doctor from the hospital died doing the same seemingly trivial exercise in the extreme desert heat. You can feel that death lives near here; whether it is in a wild flower in a patch of parched sand, or a car in a terminal state creeping along the Stuart Highway bursting with shadowy passengers. Cars often don’t make it to any normal grave and their bodies are everywhere.
Central Australia strikes me as the Centre of Palliative Care for Holden Commodores, our national iconic automobile. They come here in various but often rather morbid states and they are driven until they have nothing more to give. They usually die at home, rather than on the highway, but there are still many deaths by the road. There is, fortunately, a roaring organ donor program which operates once a senior mechanic considers that there is no useful life left in the beast. Dismantling then occurs, usually passed to friends and family members who have Commodores with some life left in them and can benefit from the transplant. Initially wheels and lights will be respectfully removed leaving the car at rest. Eventually larger organs will be required and the car turned over to remove suspension and other replaceable parts.
Organ donation does result in a genetically mixed and rather mosaic breed of Commodore. These may have one trip left in them, requiring simply that the cost of the transplant and fuel is less than any other form of transport to get where people have to go. I remember, years ago, at Mosquito Bore 300kms or so to the north east of Alice, being stunned by the massive din and cloud of dust heading towards the little outstation and collection of humpies that housed some of Australia’s premier artists at the time. As the apparition materialised, it turned into a red dust-coated white Commodore with no windows and no tyres, running on flattened metal rims. The only gleaming evidence of success was six sets of very white teeth between dusty lips that appeared from the low slung vehicle in the dimming light, all chuffed to have made it. The vehicle died right there, exhaling steam and smoke.
For some people in Alice Springs, the value of Commodores is quite different. They are symbols of Australian engineering and are to be shined and cherished and made to live until well after their life expectancy. They creep around the town and mostly slink into garages and get covered from the damaging sun. They live a lot longer but their lives are distinctly mundane and rather vain. Seeing other Commodores hurtling towards an early death, roaring over miles of corrugations and breathing thick red dust, brings tears to their eyes. They fantasise about eternal life and their descendants taking care of the beautiful automobile.
Culture has a lot to say about how we live and die. A short exciting life is of interest to many and some will invest in freezing their bodies in the hope of living forever. Mainstream urbane society is grappling with their own need to control the moment they die; all the more understandable in the face of the grotesque ability of medicine to keep us alive. For those members of our population who do not expect or wish to live forever, for whom the pace of life includes the march to death and for whom it all passes rather more quickly than we would want, the call for voluntary assisted dying does seem somewhat out of place, or even repugnant. Further, as a member of a society that has killed Aboriginal people in large numbers, and as a doctor seeking an easy death for a suffering patient, I can easily be seen as propagating this history. There are also major risks for family members openly suggesting that it is time for a loved one to die. Blame is standing, waiting with death. It gets more even more complicated. The four doctors at Congress who work in aged care (who are considering carefully our role in other people’s deaths), the palliative care specialist from the hospital and the compassion filled social worker who has worked in the field for many years are from six different cultures. None of them Aboriginal. If we combine this with the workers in the new Palliative care hospice and the nursing homes, you can multiply that many times. But zero times anything is still zero. There is an extraordinary mismatch of cultures, views, love, delight, sorrow, empathy and compassion. But almost all our clients are Aboriginal. It is unfathomable for everyone.
The Commodores provide some evidence of different attitudes and approaches to mechanical death and the value of a iconic vehicle to all sectors of the community. I have heard that the Commodore takes to the dirt roads better than other cars, that it uses less fuel than the Troopie and that parts are easy to get. I asked a wily hitchhiker coming back from the Santa Teresa Sports Festival on the weekend why Commodores were so sought after in the bush. He initially paid homage to the ubiquitous Toyota 4 wheel drive, but the answer was relatively simple. “That Commodore’s got more pipes”.
I have been in Alice Springs for over 6 months and it already defines my life a little. The beauty and the people. I have been playing quite a lot of music and the town tolerates my rough attempts at Leonard Cohen or Ryan Adams. Kate and Jacko’s lives are filled with music. Wendy, Kate and Richard have played a lot. Ross puts together most of the town’s musical events. Vath, a GP from Darwin who now lives in Adelaide, walked the Larapinta Trail last week and stopped by to sing at the Water Tank Cafe with us. She got a ‘kitchen cheer’ which is an indication that you are doing OK.
It is hard to describe the clarity of view in this place, in colour or in black and white. It is as though the sky has been lifted off. Like you have no top to your skull. You feel like you can see forever and you pretty much can. Vath told me that when she was lying down at night out west of Alice she thought the stars were a cloud glowing. The dark bits of sky stand out, not the stars that sparkle in a confluent mass. Hard to describe if you didn’t see it.
I am already quite angry about how hard it is to recruit staff to Alice Springs, despite working for an extraordinary Aboriginal organisation that has developed the model of community control here in Australia. I’m not alone, but people who have been here a while just smile and get on with the job. It has been and remains their struggle. Locals say they are ‘spinifex people’, a bit sharp, but very resilient. JL, one of the wonderful senior Congress people I work with now, said it to me in 1993 in Darwin to explain away some of the edge in his voice as he advocated for Central Australian health care. It doesn’t take long to discover the shared experience of being south of the legendary Berrimah line – an imaginary line now marked with traffic lights and road trains just south of Darwin. It immediately unites all Territorians living in the bush and the other towns in the NT. It is very hard to believe that people can’t see things the way we do; and they are oh so clear to us!
Central Australia is an ideal opportunity for learning to be an excellent health practitioner and Congress is deeply committed to providing training for all health professionals. Congress has been nominated as “GP Training Post of the Year” for 2017 and we hope this might come off this year; we are often in the short list!
But we have 300 people in Alice on dialysis and a heap of premature morbidity. Fifty percent of the Central Australian population of 40,000 is Aboriginal. Infectious disease walks tall and strong. Wander around the wards and notice the difference in who is there. It is not at all like a hospital in Towoomba or Armidale. You’ve got to come here, let your eyes adjust, to get a clear view. It’s like they see the stars and we see the dark bits.
While not giving up on trying to change things so that Alice Springs is not the only remote town in Australia where GPs cannot do their 6 months rural training, I want to share with you the sorts of jobs that I think need doing here. I am hoping I might pique your interest if you are a health professional, and your support if you are not. Copy and send a link to this page if you know someone who might be interested.
First, I believe that working for a mature Aboriginal community controlled organisation and joining their struggle to achieve health parity with other Australians is a very honourable use of medical, nursing and other health skills. We are 350 or so people and more than 200 of us are Aboriginal. It means working as an equal with people of different backgrounds and languages; who know their community and its needs intimately. It means taking direction from the Board about priorities and strategies that matter to the community. It means being trusted by the community in a way that is humbling but demands responsibility.
Second, Congress is devolving to smaller clinics, with smaller teams (e.g Sadadeen). There are now 10 clinics and there will soon be eleven. This provides a more traditional primary care environment with massively increased continuity of care and accountability compared to our larger service centre at the Gap. Each clinic knows how they are performing: how many long-acting bicillin injections to protect children with rheumatic heart disease have not been given; how many children have been screened for anaemia; and what treatment is being given. The five remote clinics have always worked like this but the organisation is embracing this approach across all our services. The results look very promising. So we have jobs for nurses, Aboriginal health practitioners and general practitioners that involve working as part of a smaller team in a larger organisation. It is more like mainstream general practice but on steroids – the steroid element is the diverse team, the range and degree of medical need and the resources to address these problems. It makes most people glow to work like this.
Third, Congress has two ‘gender protected’ clinics; one for men – Ingkintja, and one for women – Alukura. Alukura is the bigger service with a visiting obstetrician and a midwifery group practice getting underway. There is a lot of general practice to do here and we are looking for a female GP who is very interested in working with a team of GPs, nurses, Aboriginal health practitioners, midwives and an obstetrician. There are jobs for midwives and Aboriginal health practitioners too, especially in the remote clinics but also in the midwifery group practice. It is a spectacular service and will develop your skills dramatically. Ingkintja is the men’s clinic. The men, as I have described, do it tough around here. It is a wonderful experience to hear their stories and successes, trusting in you to do your best for them. It is a place to come and take care of your body and soul and wash your clothes. A male GP who is interested in making a difference in this domain will help a great deal, to assist the registrars and Aboriginal health practitioners and assist in making these services available in all our remote settings.
Fourth, for the time being, is a role for an enquiring and caring doctor who is interested in palliative and aged care. Major decisions also arise in people with end-stage renal failure as we saw with Dr G who so tragically died recently in the Top End. We have 100 people in aged care, a dozen or so in palliative care and over 200 on dialysis. We have programs supporting people at home and also during dialysis. We have Aboriginal health practitioners, nurses and doctors working in the area but without leadership. Who should we recommend for palliative care, dialysis or even a renal transplant? How is the family involved? Are advanced directives or family meetings the best solution to find a way forward for people in different settings? I would love someone interested in this area to come and live here, work with us and see if we can make a difference together.
The last thing to say is that you can work in a very remote setting as much as you would like. Congress has a splendid team of remote doctors, nurses, Aboriginal health practitioners and support staff. Most staff live in the community and fly home for breaks (apart from holiday). We have some people on 8 week cycles at Mutitjulu (discussed elsewhere) or 4 week rotations at Santa Teresa, and we have doctors working 2 days a week at Utju and supporting Ntaria. You can drive to Amoonguna each day from Alice. There is no doubt that this experience is unique and splendid, with all the challenges you might expect. Some emergencies to deal with, some trouble sleeping when the brumbies stampede through town, some ceremony and discovery of what is pure Australia. It is just another aspect of working with Congress, meeting the same objectives with the same meaningful governance.
I have put links in to the pages where you can contact us if this captures your imagination. I hope you will feel safe to get in touch and find out a bit more. There is always some spontaneity in what makes life good.
I have always liked the phrase, “We are what we eat”. Having moved to Alice Springs I am, for the first time in my life, largely in control of what I eat; it is quite an odd feeling. No compromise, no surprises and little innovation, although my frugal nature has stretched me to invent broccoli stem salad which is crisp and tasty. What does concern me is what others have to eat in this remote setting and who decides.
As a child, I was passive in what I ate apart from early forays to the rounded Kelvinator with the big chrome clunky handle for a teaspoon of Nestle’s condensed milk from the shower capped can or a slice of raw bacon. I drank mostly milk or water with the addition of cordial later in childhood.We grew fruit and vegetables and I still enjoy a raw carrot with a little tasty earth attached. I then suffered soggy Sunday evening sandwiches at boarding school and frequent food poisoning from my grandmother’s belief in the superior preserving effects of fresh air over the now square latchless Simpson fridge.
But I have a new personal concern which I share with many Aboriginal people here in central Australia. A recent fasting blood sugar was 6.7 mmol/L, a smidgeon short of the ‘diagnostic’ level for diabetes (6.9). Every one of my recent ancestors on my mother’s side of the family have type 2 diabetes – mother Helen and her brother Bruce, their father Bowyer and his sister Molly and their mother (and my great-grandmother) Gig. There must have been some advantage to this common genetic makeup in the past but this clearly pre-dates the establishment of Coles and Woolworths.
What to do? There is a growing proposition as to the power of food, how it affects us, its health giving properties and its unwanted or dangerous contaminants. Messages from health ‘experts’ come and go. I recently learned of evidence that saturated fat in dairy food seems to be health preserving; quite the contrary to the messages of the last 30 years. Similar fat in red meat appears to be less healthy but farmers’ organisations tell us otherwise. Climate scientists warn that domesticated animals produce a lot of methane and consume a massive quantity of water threatening our environment. There is so much information about sugar and fructose and salt and fat that I am totally confused. To find a way forward I generally resort to Michael Pollan’s message, “Each food, not edible food-like substances” and not things manufactured with more than 5 ingredients. A look at the ingredients of ‘milk’ sold in the supermarket will show you it is not easy to live by; milk may consist of milk, unsurprisingly, but the cheaper offerings have a plethora of ingredients. I am at a loss to know how anyone else is processing all this information and particularly if your English is not excellent and your education is limited. What then?
In the aged care homes I have visited in the Top End and visit here in Alice Springs there are a lot of diabetic patients, universally type 2 like my ancestors. This is the slow onset type, usually coming on later in life and the subject of what is described as the world ‘diabetes’ epidemic. As a bizarre consequence of modern life, this condition is becoming apparent in younger and younger people, especially in Aboriginal people in Australia. Lenore Skenazy reported in her speech at the Dangerous Ideas conference in Sydney in 2010 that there were over 700 cases of late onset diabetes in children aged under 10. This maladjustment of insulin production or processing has a variety of causes: genetic causes, like in my family; causes arising during pregnancy; causes in early childhood and the critical effects of diet and exercise throughout life. Working in the Northern Territory I think researchers and doctors totally underestimate the effect of diet, predominantly because it is so difficult to change individual ‘lifestyle’ behaviours as a doctor or dietician. There are also many powerful food and drink companies that need us to buy manufactured food.
My first insight into the profound effects of diet was working in those aged-care homes in the Top End. Aboriginal people would arrive from the bush in a state of frailty or dementia on multiple medications for diabetes. The profound change to the regulation diet at the aged-care home would send many into a confused state due to a very low blood sugar. This is life threatening and brain damaging and never happens to healthy people on no medication, even if they don’t eat for months. As a result, I became accustomed to ceasing people’s diabetic medication on arrival and what I found, most surprisingly, was that I often did not need to reintroduce it. That is to say, when eating an aged-care home diet, most people did not meet the criteria of diabetes requiring treatment. This was shocking to me as most were not exercising, so the entire effect was a change in diet.
In Alice Springs I am also getting to know the Aboriginal people living in aged-care homes. They still appear to be on their medication and many are on Insulin. My first surprise was a patient going into hospital and coming out on a lot less medication for diabetes; apparently she had a hypoglycaemic attack in hospital. But when she got back to the home, her blood sugars went crazy high and we had to reintroduce insulin to regain control of her blood sugars. There was a reluctance from the staff to see this as dietary but it is now clear that her family bring her Coke to drink most days! There are a lot more visitors to the aged-care homes in Alice Springs which may account for the greater need for medication.
Going back to my own blood sugar of 6.7 and ‘near diabetes’, there were some other causative factors involved. I had had a nasty wheezy viral infection and been on a steroid inhaler (relatively low dose) for a couple of weeks and I had drunk a fair bit of alcohol the night before. Could that be related. Then I moved to Alice Springs and reduced my manufactured food and drink intake to zero. I exercised a reasonably amount (3 hours per week) and ate as little sugar as I could. My fasting blood sugar returned to almost normal (5.6 mmol/L). It was surprisingly difficult to eat less sugar. My first trips to the supermarket took ages. Trying to find muesli with less than 10% sugar is difficult – and I had to change to nuts for snacks! I stuck with dairy, eggs, some meat, cheese, fruit and vegetables. Heading around the outside of the supermarket and avoiding the aisles.
[I have just been interrupted writing this on an early morning Virgin Australia flight from Darwin to Alice Springs and offered an apple muffin. Almost everyone accepted it and I read the contents: 25.7gm of sugar per 100gm. That is a quarter sugar by weight! I left it in the packet.]
I shop with Aboriginal people and we often chat a little about the specials. I have learned that a small box of Weetbix in a remote community costs up to 4 times what it does in Alice Springs. It has a very low sugar content compared to other cereals which is why it is the only cereal that ants won’t attack. Nuts are expensive even in town and I haven’t seen many people buy them. The trolleys heading out of the Yeperenye Shopping Centre are often stacked high with sweetened carbohydrates and sugary drinks. I notice as I come along behind that the bill for the trolley that towers over me is often less than I pay for a carry bag or two of what I consider healthy. How so? Why is water more than Coke? Who can explain that? Does Coke have cheap water in it?
I was visiting Ntaria to the west of Alice Springs for the day last week. It has a shop. I walked from the clinic to get some lunch. Tourists were lined up in front of me with a middle-aged local stockman sporting a quality USA cowboy hat which accentuates his “just do it” type of attitude. The tourists come to Hermannsburg to look at the wonderful old group of stone buildings from the mission days. They seemed to be looking for some good food. I struggled to find something to eat that wasn’t more closely related to a Mars Bar than a carrot, and that includes the cooked food. I settled for a shrivelled pie and a Farmer’s Union “Feels Good” ice coffee (skimmed milk and no added sugar but lots of other stuff) and headed for the checkout. The stockman was in front of me with his “basics card”, a smallish block of frozen meat, a few loose potatoes and a loaf of bread. He blew his cash limit on the basics card; computer says “No”. A couple of local people appear and one offered him another card but doesn’t know the pin. He accepted and walked across the store to the pay-phone and dropped a few coins in. No answer. The coins came out. He repeated this a few times but got nowhere. More tourists lined up so the staff opened a second check out. I declined to move to the new queue and stand in solidarity behind the stockman. I wondered if I should pay. Then he pulled a yellow bill and some other reds and blues from his pocket. This leads to an animated discussion with the local checkout person in yet another Australian language I haven’t heard before – Western Aranda no doubt. Bills went in and out of the pocket, others were offered. The discussion remained animated but courteous. This was a very serious business. I felt absolutely invisible. When the other queue has emptied the woman on that cash register called me over. I relented reluctantly to avoid appearing voyeuristic.
I heard a great presentation on the ABC Radio National on “Food Governance”. Corrina Hawkes, a sparkly professor from the UK, dazzled me with pop-culture lingo and a commitment to try to get countries and regions to institute food governance to preserve food production and drinking water. I can see how it might apply to a region like Alice Springs that has largely abandoned efforts to grow vegetables and to concentrate on export foods. There are kangaroos for consumption but even these are usually brought in from other cities. I think “food governance” is something I will go for. How would it work?
I was sharing some of these ideas with a senior man here in Alice. He laughed at the condensed milk story. He told me he still sneaks out and buys a tube when he feels the need. Sucks it dry. He roared with laughter as he told me how to make pralines by rolling it in Milo. Loves it. Maybe we should just accept that the joys of life and happiness involve some risk taking and some gastronomic pleasure. I think I will have some home-made pralines if invited. We are what we eat.
I met a woman with two young children and a sore arm this week. Her husband broke it in a violent outburst and she took the plaster off because it was too itchy. It was healing well. Her husband was in jail. Later, at Ingkintja, the men’s clinic, I saw a man in his mid 30s who had taken on work and rented a flat since coming out of prison for violence and alcohol. He was bright and sophisticated. He didn’t want to go back but he had quit his job because his boss was unreasonable (long story with good insight). Centrelink could help him after 8 weeks. He was distressed, anxious and hyperventilating. What to do?
I see myself as a feminist, largely due to living with Merridy and letting her advice and thoughts through my defences from time to time. I am serious about it. Despite this, as a young man I slapped her once. On the face, hard. It was nauseating. I did it to my mother once too, as an adolescent. I never saw anyone else be violent to women; it was in me. I am ashamed to admit it, but when I do, occasionally others speak up. Once a dear and gentle friend told me how he lifted his young bride by the neck up against the wall. Just once. They both laughed as they told me the story. Merridy slapped me too, once. She’s quite strong. She immediately apologised; probably quicker than I did when I hit her.
Family violence has been gradually gaining attention over the past 40 years. My father could beat my mother with impunity; he didn’t, but he could have. Even watching in the emergency department as a young medical student in the 1970s doctors would not get involved with family stuff. Nor would the police. We would feel pity and patch it up. The first laws regarding family violence in Australia were national in 1975. At that time abused children were said by paediatricians to have Silverman’s Syndrome which was “discovered” in 1962 based on multiple healing fractures on Xray! We now call it child abuse. Reporting of child abuse became mandatory in the 1980s. In the NT family violence has been a mandatory report by any suspecting adult since 2009.
Now I am living in Alice Springs and there is apparently more violence about although I have not witnessed any. Rod Moss, the painter, has written a wonderful account of his relationships with local Aboriginal people called “The Hard Light of Day“. It is largely uncensored and observational, without much judgement. It is hard to read at times and tells stories of the shortened life of men who often spend time in jail, and their suffering women. This has a lot to do with family violence and a lot to do with alcohol.
Peter Sutton in his controversial work “The Politics of Suffering” has a more scientific angle and has investigated historical violence in the Wik people at Aurukun. He makes estimates of murder rates of women before contact, during the mission days and following that. Interestingly quite high rates dropped to virtually zero during the mission influence and have been higher still since. There is general concern about the level of death from violence in the NT. It appears to be warranted from anecdotal evidence and also from national statistics. Some years, such as 2010, all murders were of and by Indigenous people. One surprise, it affected both genders equally; the victims and perpetrators half male and half female. This is surprising to me. I looked on “GooGoo” and discovered there is a national effort to increase knowledge about male victims of family violence. Is this correct?
Australia as a nation has a very low homicide rate at 1.3 per 100,000, inherited from the UK which has been at this level since the 16th Century. The NT murder rate, as high as it is, is still far less than Brazil or many other countries and even when applied to the Indigenous population alone (15/100,000) is far below many cities in the USA such as St Louis, Baltimore or New Orleans which run at over 40/100,000. Alcohol is universally involved here. What are we doing about it? There appears to be one approach from the outside; we are incarcerating Indigenous men. Anecdotally, their assaulted partners visit them in jail and defy Restraining Orders to be with them once out.
There is more to this. My close Aboriginal friend, Ada, surprised me when we were working together in medical education in the 1990s. She had been the victim of domestic violence interstate and had separated from her partner. She attended a seminar on “Domestic Violence” with GP Registrars and came away quite perplexed. “I don’t call that violence”, she said to me. She had obviously been affected by the issues raised. We discussed the fact that it has only recently been seen as violence in the broader Australian society, and that I probably didn’t either until I was educated about it.
What happens when we apply our own legislation, based on an understanding arising from recently changed culture which aims to reduce already low levels of violence, to a population that has limited education in these matters and a relatively high pre-existing rate of violence? The answer would appear to be incarceration. Of men. To an unholy extent. To the shame of our country.
Is there an alternative approach? I was very impressed with Judge Roger Dive running the drug court in the recent “Ice Wars” program on the ABC. He has been working since 2004 keeping drug users out of prison and has developed an almost parental relationship with those in trouble. Could senior Aboriginal people work with someone like that to get an alternative approach to the use of alcohol and violence? The reason to do this is to try and get some community authority into the mix and communication and education as well. Just like those using drugs in Sydney, locals are using alcohol and drugs with similar consequences; and if it goes on long enough then it escalates. Does incarceration help? It does not appear to.
Apparently, I learned very recently on Friday night at Monty’s, this has been tried before in 2011. The SMART Court (Substance Misuse, Assessment and Referral for Treatment) was established in 2011 but then removed by the CLP in 2013, labelled “do-gooder”. Megan, a nurse working now for Congress but who was one of the SMART Court clinicians, was mortified when it closed; couldn’t believe it. I told her that people must forget very quickly as no one had mentioned it to me!
If a judge and Aboriginal elders were to reconstitute a suitable alcohol, drugs and violence court in the model developed by Judge Dive and the SMART Court , it would have to be a long-term bipartisan or Federal commitment. The decision makers would have to learn how to influence young people setting off on a path of violence. Other agencies would need to understand their role. The range of sanctions might be broader and more culturally sensitive and possibly include:
Having intermediate educational and supportive environments which could take people who were doing well
Having secure social environments where fathers, mothers and children could mix safely and with zero tolerance of alcohol or drugs – this might include after school centres or other facilities with security precautions
Enabling community feedback to people with a history of alcohol or drug induced violence on a path to recovery in a safe way.
I have discussed this with some leading men at Congress. Steve, a visiting GP with a lot of experience in the NT, advised me to steer clear. He might be right, but I can only see opportunity. A lawyer from a women’s legal service came to see me and I raised this. Not sure what she thought. JL, the lead of the Ingkintja Clinic at Congress is talking to me about it, very aware that it can look like I don’t care about the women and children. That is what makes it so hard.
As a rural kid you learn that not everything comes past your door. I went away to school in the city and I could feel the difference. I didn’t like all of it but I liked the opportunities that seemed to present themselves. My parents had to move to a small house to keep it all going so I felt obliged to do my best. I road with Merridy to London and thrived; we spent 12 years there and had 4 children. It takes some bottle to head back to smaller places. The smaller the place, the more bottle.
Mutijulu is the furthest out of our (Congress’s) five remote clinics. I have learned all their names and some alternatives. (The Santa Teresa local names are still beyond me, but I have got Utju and Ntaria now). To get there Teena, Samarra (the team), Ann (from policy) and I take the 30 minute tourist flight west from Alice. I let some Germans have my window seat. The rain nourished African and Asian buffel grass works its tortured agar shapes as we come in to land, crowding out the bluer resident spinifex in many areas. Then there is the rock. Wow….. We get a car and drive through the park gate with a nod from Teena and the ranger. Everyone knows Teena.
Mutijulu is just to the east of Uluru where non-Aboriginal visitors gathered in the old days. Like Yulara for tourists today, Mutijulu is a centre for Aboriginal people from all around. No Sails or restaurants here for visitors though, just mats or cars as bedrooms. The population is running at about 3 times normal due to ceremony. We arrive at the clinic which is a Heath Robinson affair; disconnected, different parts in different styles, lean-tos and dongas tied together with electricity cables, all donning a modern shattered solar panel which has a pram on it! All this wrapped up in high fencing including a car park and a cage for the ambulance bay which leak with neat round human-sized holes at regular intervals. It looks like something from the war in the Iraq.
We meet the staff. A nod and a wry smile from Maria, the new clinic manager. She takes an angle on life which is not familiar. She has worked as a remote nurse for many years, diluting her angled Italian features with flavours from far flung places. A pair of sidelocks hang on each side of her friendly face like Hasidic payots. She is new here and an unknown to Sinead, a tall Irish nurse and midwife who has been working in remote and deprived parts of the world forever. They have two colleagues who are relieving for a while. Dr Julie is here too. She is an experienced remote doctor who survived taking care of the victims of the boat disaster on Christmas Island in 2010. She lives in Yalara with her husband who is the Park Ranger. Robby and his sister are working here; two locals who really know what is going on. Robby is busy with ceremony and his sister chats about how things are going. So many people wandering around town, awake all night, playing cards and having fun. Some break ins and damage by some of the young people. The shop too.
Robby has started training as an Aboriginal Health Practitioner and will be in Alice in a few weeks. I help with some stuff I promise not to talk about. It changes my view of myself as Australian, like my brain grew a little, pressing on my skull.
The toilet is blocked so patients have to use the one entered through the doctor’s room. You can hear and smell the consequences – sometimes there is a rush into the room and an accident. Dr Julie is not sure how long she can take it. The blocked toilet is part of the Heath Robinson construction with drains added to drains. It’s not going away. Bob the (local) builder charges $400 to clear it but it blocks again. It makes everything I take for granted seem so fragile and temporary.
We drive to dinner in Yulara and pass the Mutijulu swimming pool which is exploding with golden spray and gleaming children as we squint against the massive setting desert sun. The rock provides mood lighting above its recent rain nourished green beard.
The staff, like the locals from Mutijulu, are not allowed to drink at Yulara as Mutijulu is a prescribed community under the rules of the Intervention. This is not law but regulation to prevent upsetting tourists with intoxicated locals. Take-away alcohol is illegal. Sitting in the excellent restaurant we have many young Aboriginal people serving fine food and we hear about Sinead’s life. From Ireland to Africa to Canada and all over then to Australia and Mutijulu. She has been a fierce advocate for home birth, particularly in Canada where she did her midwifery training and her remote practice. We share a lot of heroes including Yehudi Gordon and Janet Balaskus who took care of Merridy and I when our children were born. The day I spent with Michel Odent is interesting to her. We share birthing stories – her’s are far more exotic than my London and Darwin homebirth stories. Respect.
I work as the Malpa that night, supporting Sinead on a call out. Two staff have to go to every call-out now due to a recent murder of a nurse in the PTY lands to the south west. Sinead works her web of magic with the family, slowly carefully, showing mother, aunty and grandmother care and attention. The febrile child settles and heads home in arms, cooler for the outing.
I vow to do what I can to get everyone I know to contribute to getting a beautiful clinic at Mutijulu, a place that reflects the values of our Board and managers. It is, after all, our most visible remote community and should reflect in part the offerings we make to our overseas visitors, many of whom have made less effort to get here than their Aboriginal shadows behind the grand ol’ rock. Now that’s a job.
Time to put some cards on the table so people can feel my aspirations, knock the edges off and gather shape. I came with some ideas about what I might achieve, and I presented them to the clinic staff. I feel a little at risk sharing my ideas early on but I want to take people with me if the innovations might be helpful.
My themes are simple but derived from my reading and experience both within and outside medicine. First, I want us (Congress) to be the best in the world at some things, and if we are already, for that to get known. We need to do things well to have an impact in health. I have chosen dealing with people with multiple health problems or co-morbidities as a genuine opportunity for Congress to stand out. A search on the internet (“GooGoo”) finds a number of papers and an Australian literature review confirming that no one really knows how to deal with patients like this, that is, many of our mob. If we just treat each separate condition according to the guidelines our patients will have no life other than health care. We amplify the patients’ burden of disease as they either soak up all sorts of outpatient visits and investigations or just turn away and get on with their already multi-dimensional and complex lives. How to compromise on patient effort and give some real benefit? How to feel it all from the other perspective?
Second, I want to change the idea of team to a dynamic concept; the team that suits the person we are with at that moment. It will vary a great deal depending on the personality, experience, the conditions, the person’s family and other supports. We need also need to vary our role; offer different knowledge and skills to different people at different times. It is maximising the relevance of the resources we have to hand at each encounter. I learned it at Palmerston Super Clinic from Chris Harnden and Sue Chambers. It requires preparation and focus. Patients then vote with their feet.
Third, I want to see if we can consult more effectively with multiple people at the same time and with the same sort of conditions (known as shared medical appointments). Will people like that? Will it impinge on their privacy? I think it will allow them to discuss what is going on and why. How did she get a better reading than me? What does it mean if your kidneys are not working as well as they might? What can we do that makes a difference? It is definitely a foreign concept in Australian medical practice but many of us have seen it work in special circumstances.
Finally, health care for chronic disease means very little to many people in the community; there is no experience of benefit from all of our interventions, except perhaps in late stages. It has to be accepted on trust and requires considerable health literacy. Congress carries a lot of trust; it belongs to and works for our patients and community. We can gain further trust in two key ways: an ongoing satisfying relationship with individual patients and effective management of acute illness. Both are palpable and offer clear value.
I think I did OK. It was a big audience for a GP and a lot more Aboriginal people than I usually speak to in such a setting. Some Aboriginal health practitioners, general practitioners, nurses, interpreters, receptionists, Aboriginal liaison officers, podiatrists, dieticians and drivers. A number of people drop past my room after this. I made a few friends. I hear some concerns and some ideas from a variety of people. Glen, the interpreter tells me about his after hours efforts to get a new opportunity out of town for kids who are niggling the police or courts. I promise to go out with Tony the bus driver. I confess I haven’t done that yet but I know my reputation will depend on it. But first I’ve got to meet the people working and living in our remote townships.
I started work. Well, I have been in a wash of information and glimpses of what is to come. Fortunately Samarra started on the same day and will be a key part of the team I am ostensibly leading. And Teena, another key team member, was there too. Both have been in Alice for a very long time and seemed to know everyone. Teena has done most jobs in Congress and is the local Wikipedia; she takes (great) care of the remote teams. We are to oversee the 3 town clinics and 5 bush clinics . Mutijulu is the furthest out at Uluru (“the rock”). We also have doctors at Alukra (women), Ingkintja (men), Headspace and in a variety of teams for the frail aged, disabled and people with kidney disease.
My introduction to the workplace and town is spread over five days, organised by Victoria. She is youthful, helpful and sharp; if in doubt, “Look it up on GooGoo!” Despite training from 12 grandchildren I have yet another vocabulary to learn here. A sort of international creole. Everyone is friendly, smiling, laughing. Its still raining so we can talk about the grass which is growing tall like spear grass in the very wet north. Not just snakes that I have to prepare for but moths, mosquitoes, locusts and, to the horror of many, mice.
I am clearly working for a mature and Aboriginal organisation. My boss Tracey is Aboriginal, as is her boss, the CEO. I am introduced to people passing by, or some just come into the room. My impression is that there is joy in the place, lots of energy. Commitment is obvious with concern for the Mutijulu community which has been flooded and now has an influx of people involved in ceremony that outnumbers the local inhabitants. Maria, the new clinic manager is having to swim against a lot of currents to keep things operational. She is the long distance type.
I have a phone and a car and a desk and a computer. I have brought my tools of the trade and have rescued them from boxes of guitar and microphone leads. I put them into empty draws in my desk. Stake my claim on reality. I have to learn to use Communicare, the health record system. I used it in the late 90s at Bagot in Darwin for a while but it has developed a great deal. No one seems to know exactly how to use it for everything, and some of the remote clinics had their own installation before joining Congress and the alignment is taking time. I know I can help with this.
This organisation is definitely a 21st century operation in a place of wonder and ancient ways. Aboriginal culture, mixed with Central Australian religious influences and business best practice; as a result a young Aboriginal man named Jonah fixes all my IT concerns. I get an email asking for feedback. What can I say?
There are some other cultural influences. Eric from South Africa runs the business department and is a very active and influential character. He knows how much Medicare each clinic claimed last week. I sense he has changed many things. Chipo from Zimbabwe manages risk. She is a force, managing accreditation, incident reporting and work health and safety. And Bipin, who runs CQI (continuous quality improvement) gets the data people need. In the clinics there are doctors from Australia, New Zealand, Belgium, Sri Lanka, China, Britain, Myanmar and Zaire. Many working here for more than 10 years and one over 20. I am the oldest though.
I am meeting an old place that has always been threaded with colour. I’ve got to choose my depth of field and focus. Best find a few people to help me with that.