Been on a pocast…Dr Luke Crantock, Everyday Medicine
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 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.
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.