SHANNON DALY: A lot of Aboriginal people that come in, you know, they see the hospital as a place where you come and die—or you come and you get bad news and then that's you for the rest of your life. And I just love trying to, teaching my people about, you know, what we're actually here for. We're here to make you well.
CAMILLE MERCEP: Welcome to Pomegranate, a CPD podcast from the Royal Australasian College of Physicians.
With NAIDOC Week taking place from the third of July, this episode focuses on issues in Aboriginal and Torres Strait Islander peoples’ health in Australia. Life expectancy for Aboriginal and Torres Strait Islander people is a decade lower than that of the non-Indigenous population. Addressing this disparity is one of the key priorities of the Closing the Gap initiative agreed upon by the Council of Australian Governments. Today’s speakers discuss where progress has been made and where resources are still lacking.
Dr Joshua Francis is a paediatric infectious diseases specialist based at Royal Darwin Hospital. He works as a medical advisor for remote communities in the Northern Territory and also in Timor. He often works alongside Aboriginal Health Practitioner Shannon Daly, who helps bridge different cultural conceptions of illness.
But first we hear from Associate Professor Noel Hayman, Clinical Director of the Inala Indigenous Health Service in Brisbane. He was the first Aboriginal GP in Queensland, and the first Aboriginal and Torres Strait Islander person to become a Fellow of the Australasian Faculty of Public Health Medicine at the RACP.
NOEL HAYMAN: I've been working in the field of Indigenous health for 20 years now. The major changes, trends that I've seen over the years, has been improvements in infant mortality. But the one that contrasts that is the worsening mortality in middle age—we see high rates of mortality in Aboriginal people in their 40s and 50s. And this is due to chronic disease, particularly diabetes, ischaemic heart disease and chronic kidney disease. And this accounts for about 70% of Indigenous mortality.
But it's not all gloom and doom. I think if we all work strongly together, I do believe we can improve Aboriginal and Torres Strait Islander health significantly. For example, what we've been able to do is we've actually got Aboriginal people to attend primary care. But more importantly now, my aim is to integrate specialist care.
So now we have a visiting endocrinologist, we've got a paediatrician, we've got a cardiologist, we've got a registrar from rehabilitation medicine, we've got an ophthalmologist. So private physicians and also hospital-based physicians, and the ones that are hospital-based, they come out here. The cardiologist, for example he does two sessions a month. He does his echocardiograms here and also exercise stress tests.
To me, integrating specialist care into a centre of excellence is to me is a "one stop shop" and Aboriginal people are more likely to attend. And we've actually shown that. And we've got better outcomes and we've got data on that through continuous quality improvement.
JOSHUA FRANCIS: I'm Josh Francis; I'm a paediatric infectious diseases specialist at Royal Darwin Hospital, and over the last two and a half years I’ve had a more intensive involvement in Indigenous health particularly.
So I think as a paediatrician thinking about “the gap”— when we talk about “the gap,” people are usually talking about the gap in life expectancy. And so the infant mortality rate amongst Indigenous people in Australia has dropped significantly, the childhood mortality rate has also dropped. But the reality is that so much of the adult morbidity and mortality that occurs amongst Indigenous people has its roots in childhood.
So we don’t see many children with such severe chronic kidney disease that they require dialysis or a transplant during childhood. But what we do see is we see children with poststreptococcal glomerulonephritis, and recurrent urinary tract infections, and all these things that sort of set them up then for chronic kidney disease later in life and the impacts of that. And so there's this huge role to play in trying to look at ways of promoting health in childhood in terms of addressing the gap.
CAMILLE MERCEP: Providing effective care to Aboriginal and Torres Strait Islander people is sometimes hampered by mutual misunderstanding of cultural concepts of illness and treatment. Aboriginal Health Worker, Shannon Daly:
SHANNON DALY: What I love about my job is being able to work with my people. I love teaching them to navigate through the system; I love to be involved in that making sure my people really understand what's happening with their treatment, with their diagnosis, with their admissions.
You know, a lot of Aboriginal people that come in, they see the hospital as a place where you come and die—or you come and you get bad news and then that's you for the rest of your life. And I just love, trying to just teach my people about what we're actually here for. We're here to make you well.
I'll just use the Yolngu people as an example. So the song lines and story lines dictate the world from the beginning—so how it was created to now, and how they as a people were created and came to be. So when they come into hospital they struggle with new concepts. We're a very acute setting and we kind of just, when we see a patient come in, it's like, “OK, what can we do to get this patient well?” “This is what you’ve got; this is what you need to get to do well.”
But with the Yolngu they want to know from the beginning—how did this happen first of all? So there's a lot of spiritual stuff that goes on there, so with any of our Aboriginal mob there's things like pay back, traditional singing, so people putting curses or pointing the bone at each other. So when an Aboriginal person comes in here, internally that's what they're thinking of and processing inside is, you know, “What have I done wrong? Has someone pointed the bone at me, how could I be in this state?”
So for us as healthcare professionals I think it's really important that we try to acknowledge that, and in dealing with Aboriginal patients there's areas where I fall short as well and that's in the language barrier. My grandparents were Stolen Generation so I never grew up practicing my culture or speaking our language. And in the NT we've got so much diversity—like I know with the Yolngu people there's a region in East Arnhem that, you know, there's 30-something dialects of Yolngu Matha.
So you know, I find myself trying to break down barriers especially with the older staff around about communicating effectively with Aboriginal people, and how do we do that. And sometimes that means using an interpreter. Sometimes that means stepping back and really understanding what that person's role is within the family.
The other thing is sometimes patients decline using an interpreter, sometimes it's the way that they’ve been asked. Say for example—this is one of the ways that people, I've observed people ask is: "Do you need an interpreter"? And that's not a good way of asking. So when I speak with patients, I often talk to them about what they're in for: “Can you tell me what’s going on with you or what's going on with your baby? Tell me in your own words.”
And if I can work out that there's some sort of skewed information I will say to her, "Oh wow, that's a lot of information, how about we have a meeting with the doctors and how about we hear it in your own language, what the doctor has to say about what's going on with you?” And most of the time that's a big selling point for our mob because it's like creating that safe space for someone to be able to get true information without feeling…so a lot of our mob feel if they're asked to have an interpreter like they’re dumb or, you know, they’re not capable of living in a “white man's world,” if you like.
CAMILLE MERCEP: In one especially challenging episode, Shannon Daly was struggling to build a relationship with a pregnant woman who had been brought to hospital for a second Caesarean section. After surgery, the wound from the woman’s spinal block became infected and she was readmitted to the ER with meningitis. But the woman’s complete needs weren’t being heard.
SHANNON DALY: So the whole time she’s saying to me, you know, "I want a traditional healer, I want a traditional healer." Straight away I'm thinking, “How am I going to organise this, and how am I going to try and sell this to staff?” Because that's the trick of my job every day—I'm an advocate for my patients. Because obviously they're not empowered enough to be able to approach someone.
Actually some people are just scared and they don't know how to ask if they're going to be OK, they don’t know what this means for them, they don’t know if they’re dying. So, you know, do they want to talk to a stranger before they die? I don’t know.
So she absconded, had her head shaved and then she came back for treatment. So straight away the staff are thinking, “Oh my gosh,” you know, “she's got postnatal depression” or “she's had a psychotic episode,” when actually she'd just gone off to meet her traditional healer. She had a cleansing ceremony which involved shaving her hair, and then returned back to the ward for the rest of her treatment. And this is where the cultural barriers stand because there's no understanding on concepts of health and wellbeing for most cultures. I’ll say Aboriginal culture but there’s other cultures as well that access the hospital as well that I’m sure have the same issues.
NOEL HAYMAN: I've seen it in mental health, about diagnosis of depression when it wasn't actually really depression. It was the way the patient was acting and about Aboriginal people—they sometimes in cultural things, they look down and they look disengaged, and they look sad. In fact that could be cultural.
And I suppose it stands out, but I mean to improve Aboriginal health too is about having Aboriginal and Torres Strait Island health professionals too, because of our knowledge of culture. So that's another important aspect. A lot of our patients disengage with mental health because of the stigma. And at the moment we have an Aboriginal psychiatry registrar and look people just love him. When I say, "Look, he's an Aboriginal guy—he's a Murri, you know," and they say, "Oh OK, I'll go and see him.” And then they come back and say, "Oh that was really great, you know, we had a great talk"—and they felt very at home.
For example when I first came here—I work in a large community health centre—only 12 Aboriginal people accessed our general practice unit. So I did some focus groups and some feedback from community, you know, was Aboriginal people pick up on body language, and they said, "Oh look Noel, we just don’t feel welcome in that great big community health centre.”
And the other about "women's business”—I mean as an Aboriginal man I never do Pap smears. When I used to work up in the Torres Strait if any male doctors came out and went to the outer clinic to do Pap smears no women turned up, but if they had a female doctor they did turn up. So what they did up there was actually teach the health workers and nurses to do Pap smears.
CAMILLE MERCEP: Apart from the medical and cultural challenges, Josh Francis says many health issues are related to basic infrastructure needs.
JOSHUA FRANCIS: The social determinants of health that exist contribute across the board to a whole range of things. And so household crowding and poverty and poor nutrition sort of give rise to so much of the disease burden. And for me that is a massive priority when you’re looking at Indigenous health, certainly in our context up here in the Northern Territory. And when I look at some of the Indigenous Health Issues that I encounter on a day-to-day basis it can feel overwhelming, and when you look at the complex inter-generational trauma that exists and contributes to this it feels even more overwhelming. With that in the background, to me it is completely unjustifiable for us to not put the sort of investment in terms of resources into addressing those health challenges.
And some of those things are actually quite low hanging fruit. We have communities up here in the Northern Territory with quite large populations, up to sort of two and three thousand people, without a hospital service, without permanent GPs, without 24/7 nurses.
SHANNON DALY: And I think it's about healthcare providers understanding as well where these patients come from, especially if they’ve got a chronic condition. So we've got remote communities but we've also got outstations which are, they don’t have a store or a shop on them, sometimes they're 200 kilometres outside of the community and there’s only a small clinic there.
JOSHUA FRANCIS: And so are they accessible by phone? Maybe not. Do they have a fridge that they can put their insulin in? Maybe not. Do they have access to the sort of foods you tell them they have to eat because of their new diagnosis of diabetes? I mean maybe not. And so yeah, that awareness is really important, isn't it?
SHANNON DALY: And I think that unconsciously, you know, we get stuck as healthcare providers because we know that if we deliver that full amount of information to try and empower that patient, the reality is they go back home and none of that's available. Or, you know, broccoli is like fifty bucks a kilo.
CAMILLE MERCEP: Noel Hayman has been conducting research into public health questions specific to his client base around Brisbane.
NOEL HAYMAN: There really isn't much literature about compliance, about Aboriginal people and medication. And I think that's one thing that's a misconception, that Aboriginal people will be non-compliant. I don’t find that to be true, and I do things to actually maximise compliance. So I was part of a polypill trial and the polypill consisted of four medications: aspirin, a statin, and two blood pressure tablets.
We found that the people were more adherent to the polypill, they were more likely to take it than four single medications. And a few patients when we stopped the trial said, "Oh I still want to go on the polypill," but we didn’t have access to the polypill anymore. So I would encourage all physicians to actually do daily dosing or combination drugs and try to have less numbers of medications as possible, and I think that improves compliance too.
At the moment we're doing a randomised control trial about antibiotics used in otitis media. In the general population they’ve shown that antibiotics are, you don’t need them in acute otitis media, you just control the pain. But with Aboriginal people you know our experience from the Kimberly, and especially in the NT about runny ears—I mean, a lot of Aboriginal people if you don’t treat with antibiotics they get perforated drums and their ears just discharge all the time. I mean, is that the same in an urban setting? So we're actually doing that. So some of our kids have been randomised to amoxicillin and hopefully we’ll have the data to show that our kids shouldn’t be given antibiotics with otitis media.
And all these projects, research projects, go through a community jury. So we have a community jury here chaired by an elder, so that gives community, you know, some voice and empowerment of what research we do here. And I tell you, I've been to some community juries and researchers that present what research they want to do…it's not a, you know, a lay down misère where it's just rubber stamped. I mean, even though our jury members, a lot of them are laypeople, they really come out with some good constructive criticism about the cultural aspects of the research. And that's one of their biggest beefs—it’s about, you know, if you do this research how is it going to influence health outcomes for our community? So it's about translating research into practice.
And not only that, you know, our centres influence policy. You'll find coming up the retinal photo is going to be an MBS item number in primary care—I mean, we did the research in that. At our annual diabetic check we'd take photos, and we've built up the evidence to say that, you know, if you do photos in primary care you prevent people from going blind.
SHANNON DALY: I think a lot of people get frightened with the word “culture,” there's some fear around dealing with Aboriginal people so because of cultural reasons, because of the educational background, because of the language barrier, because of the difference in lifestyles. So I think people get really afraid of that and I think just to have just a real human approach I guess, and just speaking normally with somebody and, you know, finding out what they’re worried about.
JOSHUA FRANCIS: And realising we've got so much in common, you know, you sort of get this idea that there is a massive difference—and there are things that are definitely different, but there are also I think in any conversation, as a doctor any conversation with a patient, with their family, it's possible to find some common ground and to make a human connection. It's one of the privileges of the job, I think.
NOEL HAYMAN: So, you know, I would strongly recommend any person becoming a Trainee to actually try and get that exposure—not only do those cultural awareness programs but also exposure. Exposure to me is the best teacher.
CAMILLE MERCEP: Many thanks to Noel Hayman, Shannon Daly and Josh Francis for sharing their experiences with us on today’s episode. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians.
For CPD resources on Aboriginal and Torres Strait Islander people’s health, visit the Pomegranate website at racp.edu.au/pomcast. And please join in the conversation using the hashtag #RACPpod, or write to us at firstname.lastname@example.org.
Pomegranate comes to you from the College’s Learning Support Unit. The program is presented by Camille Mercep, and this episode was produced by Anne Fredrickson and Mic Cavazzini.
Next month, we unpack the National Disability Insurance Scheme, a new way of funding disability care that will be rolled out from July. We hope you can join us then.