Cultural+Wealth+is+Healthy

Louise Elvin-Walsh n7511183 Tutor: Abbey Hamiltion

//“ I want to see children grow up into healthy adults, at the moment we don’t have a lot of healthy adults but if we can get these kids through their childhood with minimal diseases or chronic diseases then maybe they will grow up to be healthy strong adults”. // Eva Williams (2006) - Nurse, Bathurst Island, Australia.

**TOPIC OUTLINE**

 I will explore the importance of culturally appropriate health care, whilst acknowledging how the loss of their culture has directly and indirectly impacted on the health of Australian Indigenous people.

**ARTEFACT**  My chosen artefact was drawn by the English artist Ainslie Roberts (Roberts & Mountford, 1965). This book was given to me as a child not long after arriving in Australia from England. It gave me an idealised view of Indigenous people. Youthful naivety has been replaced with a greater understanding of the plight of Indigenous people. I was reminded of this drawing when I read the following quote: // "I always say that when we lose an old person, we lose a library… language and culture" // Lola Forester, (2008), Radio Presenter.

This artefact contrasts with current reality, by not reflecting a true state of affairs, but rather a naive and idealised representation of a way of life now lost to most.

**PUBLIC HEALTH ISSUE**

The Indigenous definition of health can be described as “the physical, social, emotional and cultural well-being of the entire community” Department of Aboriginal Affairs, (1989)

Over time, dispossession from land, loss of access to traditional foods and remedies, forced assimilation and domestication ultimately leading to loss of culture and which inexorably links to poor health and preventable chronic childhood diseases resulting in the large variation in life expectancy between Indigenous and non Indigenous people. The interrelationship of these factors is illustrated below (Robinson, 1996. p. 36) and explained further in the analysis of the reviewed literature although it isn’t possible in this piece to give each of these factors the focus that they deserve.



One simple example of how this chart links to a loss of culture is when ear disease results in deafness preventing children from learning traditional languages from their Elders as represented in my artefact.   **LITERATURE REVIEW** Focussing on some of the literature around culture enabled me to see the connection between socio-cultural factors, health and disease. Most people are aware that there is still a vast difference between the life expectancy of Indigenous people compared to non-indigenous people. The table below from the Australian Bureau of Statistics (2010) illustrates this disparity and the data includes everything from infant death to chronic disease to suicide.



With chronic disease affecting the Indigenous population across all age groups, Zhao and Dempsey (2006) sought to understand the causal reasons for the inequality of life expectancy between Indigenous and non-Indigenous people in the Northern Territory. In an examination of ABS mortality data over the period of 1981 to 2000 and utilising the international classification of diseases, they found that the main contributors were non-communicable chronic diseases and health conditions which are usually associated with an ageing population. The limitation wasn’t in their methodology but in their recommendation. Zhao and Dempsey (2006) suggest that a causal factor is poor access to primary health care services and the way to redress the issue is through management and prevention, but there is no mention of culturally sensitive methods to achieve this. Asserting that this analysis can be used to guide resource allocation and programs, the risk is in assuming that Indigenous people will want to be part of this solution. Several of the studies help to clarify what this means and the importance of culture to the success of improving Indigenous health.

**Cultural attachment and its relationship to health**  // "To us, health is about so much more than simply not being sick. It's about getting a balance between physical, mental, emotional, cultural and spiritual health. Health and healing are interwoven, which means that one can't be separated from the other”. // Dr Tamara Mackean, (2011), Australian Indigenous Doctors' Association

Dockery (2010) used an exploratory approach when looking at the relationship between cultural attachment and three specific areas including socio-economic wellbeing; health and contact with the justice system. According to Dockery retention of Indigenous culture will reduce Indigenous disadvantage in Australia since finding strong evidence between high levels of cultural attachments and comparatively better levels of health. The results hold true in reverse with lower levels of health reported in people with minimal or mid-range cultural attachment. Additionally a strong association with culture resulted in better educational and employment outcomes. Higher levels of cultural attachment where linked to fewer or no issues with the justice system.

Eckermann et al (2010) illustrate the interrelationship of culture and environment in the diagram below. In a very literal way this interrelationship was explored by Burgess et al (2009), when they tested the claim by Indigenous people that the cultural and social connection to “caring for country” promoted better health outcomes for their people. This was in response to Indigenous communities requests to assist with developing their own solutions for improving health and wellbeing. The data collected over 2 years suggested that there was a very strong positive link between caring for country and improved health outcomes. It was an important step forward, justifying enduring requests to the Government to allow Indigenous people to manage their country. During this study it was observed that ailing Indigenous patients often return to homelands to “make themselves well”. The apparent benefits traditional Indigenous healing methods and of bush medicine are extolled by Reid (1989), Hansen (2010) and Shahid, Bleam, Bessarab and Thompson (2011).Unfortunately, between 1951 and 1972, the eras of Assimilation and Integration, Indigenous foods and cooking styles were belittled and discouraged in an effort to integrate this population into dominant white society, resulting in mistrust and reluctance to discuss bush food and therefore changed, even in remote parts of Australia, the indigenous diet (Reid 1989). **Culturally appropriate Health Care**

// “I find when Aboriginal patients come into the hospital they see me as a bit of reassurance and someone they feel comfortable approaching”. // Anonymous Indigenous Nurse, (Stuart and Nielsen, 2010 p.99.).

Recent literature focuses on the need for cultural competence in the health care services, especially to ensure that Indigenous people avail themselves of these services. The table below shows the Social determinants of good health for all Australians (Robinson, 1996. p. 35). However the term ‘Good Health Services’ is highly subjective.



Indigenous patients generally view mainstream clinics with trepidation. Patients interviewed in 2006 by the Rural Health Education Foundation (RHEF) said “I don’t want to make eye contact”; “I feel embarrassed to talk about myself or be checked over”. In contrast, when a patient was asked instead about his experiences at a Townsville Aboriginal and Islander Health Service (TAIHS), he said “I feel comfortable here...” (Grant, 2006). Working at the same clinic, Aboriginal Health workers (AHWs) Mitchell and Hussey (2006) explained that they were proud to be working there, that the community have a sense of ownership over the program and personally as AHWs they know what is needed. TAIHS AHW’s are successful because they take into consideration the complexities of Indigenous health with cultural sensitivity (Grant, 2006). This was confirmed by Larkins, Geia and Panaretto (2006).Genat (2006) describes the wide range of demands and challenges that AHWs face on a daily basis. He suggests that the AHWs should be recognised for their hard work and included in development of policies and programs.  Stuart and Nielsen (2010, p. 100) are adamant that “Aboriginal nurses are the best suited to provide the best healthcare for Aboriginal patients”. Most Indigenous trainee Nurses are motivated to finish their degrees and help their own people as soon as possible and one specifically said that she wants to “close the gap with our people”. Stuart and Nielsen (p. 100). As at October 2010 the number of Indigenous medical practitioners was 153 which represent around 2% of total medical practitioners in Australia. Indigenous medical students are on the rise with 161 enrolled at the time these statistics were measured (AIDA, 2011).

Central Australian Aboriginal Congress (CAAC) who’s motto is “Aboriginal Health in Aboriginal Hands” (CAAC, 2011), have a number of programs and clinics for Indigenous people and provide health care their own culturally relevant way. They have a model which is “recognised as the most effective and most efficient way of delivering health services to Aboriginal people”. (CAAC, 2011). Alukura birthing service which respects the Indigenous women’s requirements to have female doctors, as traditional law dictates that a man should not be part of the birthing process. Places like Alukura are vital to ensure the babies’ best start in life as AHWs have found that “mothers have to trust the clinic otherwise they won’t show up”. (Grant, 2006).

A study by Hayman, White and Spurling (2009) focussed on a mainstream general medical practice in Inala, Queensland, which had only 12 Indigenous patients in 1994. In order to increase patient numbers, particular strategies were undertaken including increasing the number of Indigenous staff, providing all staff with cultural awareness training, modifying the waiting room with Indigenous decor and music, informing the community of the services offered and collaboration with the Aboriginal Community Controlled Health Services (ACCHS). By 2008, their registered patients increased to over 3000.The level of growth within a period of 13 years is remarkable given that the census data reflects a stable population over that time (Hayman, White & Spurling, 2009). As is the case with Indigenous healthcare services, once the trust has been established, patients will avail themselves of a one-stop-shop and access to other health care services. The clinic still maintains strong links with the Inala Elders which has bolstered attendance rates and shows promise in working towards reducing mortality rates (Hayman, White & Spurling, 2009). The Inala success story is a rarity mainstream health clinics, which they believed was possible through adopting ACCHS concepts such as “health as holistic; the right to self-determination; recognition of the centrality of kinship; recognition of different communities and needs; high-quality health care services, and equitable funding.” (Hayman, White and Spurling, 2009)

Durey (2010) asserts that confronting the effects of racism in health services at a policy and practice level will reduce the inequality between Indigenous and non-Indigenous Australians. Whilst this has been addressed to a degree there is still inherit racism in no indigenous society which will be hard to eliminate. A “checklist for the culturally competent GP” (Nguyen, 2008, p. 993), was developed of as an educational tool for doctors interacting with all culturally and linguistically diverse populations. Nguyen’s aim was to increase patient compliance by reducing the likelihood for poor doctor-patient interactions.   **Preventable Chronic Childhood diseases leading to life of disadvantage**

Indigenous children do not get an equal start in life as many suffer from a variety of preventable diseases such as anaemia, scabies, skin infestations, respiratory diseases and ear infections, the latter being the most debilitating in the long term. (Rogers, 2004). “Chronic otitis media is rare in first world countries. However in 2004 the WHO noted that the prevalence of eardrum perforation due to infection among Australian Aboriginal children was the highest in the world and urgent attention was needed to deal with this massive Public Health Problem”. (de Plevits, 2010)

The following graph (ABS 2010) shows predominance of Indigenous population ‘hearing loss and diseases of the ear’ is consistent across all age groups except ‘55 and over’ where the impact of Indigenous mortality is obvious.



Where non Indigenous children recover from otitis media, many Indigenous children, up to 90% in some communities are plagued with repeated bouts which cause eardrum perforation resulting in deafness (de Plevits (2010). This leads to decreased learning capabilities at school which reduces the likelihood of graduation, leading to unemployment, poverty and often due to misunderstandings, altercations with the police which can result in incarceration. Many Indigenous people have gone through life with no support or recognition of their disability (Parliament of Australia, Senate, 2010). de Plevits links hearing heath to all of the socio-cultural factors outlined earlier. She describes how Indigenous people were free from disease before white settlement and a long history of good health was impacted due to a lack of immunity to these introduced illnesses. This is not a new problem and has been at Epidemic proportions for more than 40 years (de Plevits). In this thorough study de Plevits suggested tackling this major health issue with a human rights based approach, urging the Government to adhere to the recommendations in ’Declaration of Rights of Indigenous Peoples, 2007’, which was signed by Australia in 2009.

The Australian Greens, created an ‘Indigenous hearing health policy’ in 2009, are now lobbying the federal government to create their own policy following the Indigenous Children’s Hearing Health Forum in Canberra, September 2011 chaired by Greens, Senator Rachel Siewert (Australian Greens, 2011). The Indigenous hearing health epidemic has been studied and documented widely but despite the extensive range of information it fails to attract mainstream media attention, leaving most Australians unaware and ill prepared for how to deal with people living with this disability, which sadly leads to unfair judgements and misconceptions.  **CULTURAL AND SOCIAL ANALYSIS**

// “ //// Indigenous people have been marginalised by the dominant white culture in a land that was originally theirs”. // (Robinson, 1996, p. 209).

Loss of culture and its influence on Indigenous health outcomes goes hand in hand with cultural and domestic violence which has afflicted Indigenous people. "By cultural violence we mean those aspects of culture, the symbolic sphere of our existence - exemplified by our religion and ideology, language and art, empirical science and formal science...- that can be used to justify or legitimise direct or structural violence" (Galtung, 1990,p. 291 in Eckermann et al, (2010).

A consequence of removing Indigenous people from their lands was an immediate loss of access to the lands natural medicines and benefits. According to de Plevitz, (2010) the impact of being sent to cities and settlements for domestication and assimilation has had far reaching impacts on generations of Indigenous people. Eckermann et al (2010) discuss cultural violence and how the cycle of stress and spiritual poverty has endured for over 220 years whereby unsatisfactory interaction with European culture has impacted on the health and wellbeing of generations of Indigenous people. This table outlines only the first 184 years of European settlement and paints a clear picture of the clash of cultures and the actions and reactions.



It wasn’t until 1967 that Indigenous people were recognised as Australian citizens under the constitution (Mazel, 2009). Today there is still a disparity as various Government Policy makers fail to address the mistakes made by previous generations in linking ill health with dispossession of land. The Greens policies for Indigenous people do acknowledge the link between health and dispossession of land and have outlined specific clauses which enable “access to lands to enhance wellbeing” and respectfully recognise “traditional knowledge and biodiversity of their own lands and waters”; “culturally appropriate services and resources for Indigenous people based on language, cultural aspects and community priorities”. (Australian Greens, 2011).

It is clear from the success stories highlighted in the cultural health research that Indigenous people thrive when given the empowerment to do so. This requires the Government listening to and respecting the opinions of communities, providing funding for Indigenous managed health care programs and practices, training more culturally sensitive Doctors and Nurses and ultimately involving Indigenous people in solutions. When there is trust built between healthcare providers and patients great inroads can be made. An example of this is Nurse Eva Williams from the Nguiu Clinic describing some of her patients as living in third world conditions on Bathurst Island, and while they are paying rent, the houses they live in are not being renovated because they have been condemned. Babies born into this environment often suffer from malnutrition and commonly become ‘failure to thrive’ infants and children. To resolve this, Eva will approach the islands ‘strong women’, who in turn will talk to the mothers about the benefits of bush foods and traditional medicines then encourages them to attend the Jirnani childcare centre for help with feeding their children. In William’s experience mothers need to be shown what to do, not just told (Grant, 2006). The Jirnani Child care centre not only feeds the children nutritious foods (meeting up to 80% of their RDI), provide health education to children and their parents but also participates in the Menzies School of Health Research ‘Ear Program’ checking the children’s ears on a daily basis. They sing songs to the children in native Tiwi to keep their culture alive and make them feel proud to be Tiwi (Rogers, 2004).

**ANALYSIS OF THE ARTEFACT AND LEARNING REFLECTIONS**

My eyes have been opened to particular indigenous health issues like hearing heath, and enabled me to understand with a little more depth, what is lacking in the current health care system and how a step in the right direction in regards to cultural sensitivity and fostering mutual respect between Indigenous and non Indigenous people results in a broader positive effect in health outcomes among the general Indigenous population.

While my artefact is an idealised view, Roberts and Mountford (1965) described ‘Aborigines’ at the time, as living off the land, hunting and gathering and sharing dreamtime stories of cultural significance. Mountford acknowledged the profound connection that Indigenous people have had with the rhythm of their country and marvelled at the efficient functioning of “one of the most primitive cultures of mankind” and of people, self-governed by ancient laws to maintain harmony and balance (Roberts & Mountford (1965, p. 2).

This view is not far removed from the goals of CAAC, “until our right to run our own health services under our own control is recognised in principle and supported in practice by Australian non-Aboriginal government, our health will not improve” (CAAC, 2011).

**DISCUSSIONS**

Jonathan Mills, Dealling with Multiculturalism within Health Care !

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Julia Finnane, Digital Natives - the impact of Technology on Gen Y

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**REFERENCES**

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