There have been many "explanations" for the outrageous discrepencies between the health levels of Indigenous Australians and the health of non-Indigenous people. Not so long ago, the possibility that Indigenous people are "genetically predisposed" to alcoholism was seriously entertained. Gary Lee looks at the confluence of factors which adversly affect Aboriginal health in remote settings, and argues for a culturally appropriate mix of Western medical science and Indigenous philospohies of healing
IT IS THE enormous discrepancies between the health of Aboriginal Australians, when compared to non-Indigenous Australians, which most starkly exposes the myth that Indigenous people enjoy anything like 'equality'. Indigenous people have levels of health which are significantly lower than that of any other definable group within the Australian population: as the Standing Committee on Aboriginal Affairs frankly expressed it in 1979, these standards "would not be tolerated if [they] existed in the Australian community as a whole".1
Improvements have been made: rates of eye disease, gastroenteritis, infant nutrition and infant mortality have all improved. Yet the Aboriginal infant mortality rate is still three times higher than for non-Aborigines. The life expectancy of Aborigines remains at least twenty years less than that of the non-Indigenous population, and Aboriginal people are more frequently hospitalised - particularly infants and children. The incidence of 'lifestyle' diseases like hypertension coronary heart disease and diabetes mellitus - in which alcohol plays a major role - have increased.
One view of these differences has been that racial characteristics are at the heart of the problem: that Aborigines are somehow "genetically susceptible" to disease and ill-health. Others have pointed to the nature of the physical environment, and to the severely impoverished socio-economic standing, particularly of Indigenous people living in isolated areas, as the conditions which give rise to these problems.
The inadequate provision of medical services is yet another explanation. When 'inadequate medical care' was originally spoken of, there was perceived to be a general lack in the quantity of health care delivered. At present, with a more extensive health service, but little sign that the discrepancies are going away, 'inadequate medical care' often refers to the way in which services are provided to Aborigines (that is, the quality of health care).
It has been argued that Western medicine, with its extraordinarily different cultural framework and focus, actually has a negative effect on Aboriginal health. In turn, certain aspects of Aboriginal culture are seen as a positive influence on Indigenous peoples' health.
Early ethnohistorical accounts record neither the presence of disease, nor that of poor health, among Aborigines in Australia. Later, Aboriginal populations were decimated by introduced diseases (among other things), supposedly due to racial susceptibility and/or to changes in their living conditions and lifestyle.2,3 The racial factor in this argument is a valid one, given the relative isolation of Aborigines from the rest of the world. However, the effect of race on the susceptibility of Indigenous people to disease is to say the least questionable as a contemporary "explanation" for high rates of illness, since Aborigines would have developed immunity to non-indigenous diseases comparable to that of the general population.
In a study of Indigenous people in the Bourke, NSW region, Kamien mentions the belief that Aborigines are 'genetically vulnerable' to alcohol - often used to 'explain' high the incidence of alcohol use and dependency.4 It has been claimed as late as 1974 that Aborigines, like Eskimos (Inuit), are deficient in the enzyme responsible for detoxifying ethyl alcohol.5 According to this account, alcohol is accumulated in the blood and tissues and has the effect of an overdose or poisoning.
There is little to substantiate this argument. It has been argued that the 'genetic vulnerability' account arises from the fact that drunken Aborigines tend to group together and are simply more conspicuous than drunken whites.6 Moodie also notes that in New South Wales, many 'part Aborigines' are actually more Caucasian than Aboriginal in their genetic make-up but nonetheless have mortality patterns which echo to those of 'full-blooded' Aborigines, rather than white people.?
The imposition of European 'settled life' on Aborigines, at contact, bestowed upon Aboriginal people in remote parts of the country a shocking lack of socio-economic power. It has been repeatedly and well documented that the transition to a European "settled" lifestyle, with its contempt for the traditional Aboriginal hunting and gathering economy, and for the dignity and autonomy of Aboriginal people, caused Aboriginal health to rapidly deteriorate.
Today, many Aborigines in remote Australia still do not have access to land - the basis of their traditional economy. At the same time, they are also denied full access to the economic sector of Australian society. Reasons for this include discrimination as well as the geographic distance of many Aboriginal communities from towns and regional centres.
A low socio-economic status within the otherwise prosperous Australian society in and of itself leads to health problems. For example, alcoholism among Aborigines is explained as an expression of an attempt to reduce the anxiety and frustration caused by unemployment, substandard housing, racism, low self-esteem, social inertia and alienation. Petrol-sniffing, which can have extremely serious side-effects, is one barometer of the degree to which a community has lost its sense of purpose and autonomy because of its impoverished status.
It also seems there is a relation between these factors and poor nutrition. Infestations, and gastrointestinal and respiratory tract infections, are generally associated with under-nutrition. Growth-retardation is also seen to result from protein-calorie deficiency, and Kalokerinas believes that some of the health problems of Aborigines are caused by a lack of vitamin C.8
The most remote Aboriginal communities have inadequate water and electricity, unsatisfactory sanitation and sewerage facilities, and inadequate or inappropriate housing (or none at all).
Diseases which have been elated to these conditions include intestinal infections and parasites, respiratory infections, trachoma, skin diseases, anaemia, leprosy, tuberculosis, and sexually transmissible infections. An example of this relationship is the correlation between high-density housing and respiratory diseases: overcrowding is related to increased transmission of infectious respiratory conditions.
Many Aboriginal children play in dirt around drains and taps - an environment which is contaminated due to poor sewerage facilities. Waterford believes that these Aboriginal health problems can be solved in much the same way as nineteenth century Australian ones were: by the provision of basic amenities, financial resources and adequate food.9 Though it is true that improvements in the living conditions and the socio-economic status of Aborigines are prerequisites to improved health, better health will be more easily maintained and strongly established and will occur without the destruction of Aboriginal identity and culture precisely if the culture, lifestyle and values of Aboriginal people are taken into account in the provision of medical care in remote Australia.
Metaphysics vs. mechanics
In traditional Aboriginal society, diseases were generally seen as having magical or supernatural causes. Thus, Aboriginal modes of treatment occur within an all-embracing context of mythology and social organisation, and are quite unlike those employed by Western institutions. For example, while Western medicine is biophysical and mechanistic in its approach to health, focusing on the specifics of illness and disease, traditional Aboriginal medicine is holistic, metaphysical and socially embedded. Western medicine concentrates on disease; Aboriginal medicine is health oriented. Medical knowledge in Western society is specialised and restricted to a small elite; this knowledge in Aboriginal society is more widely diffused - though healing specialists exist - and is comprehensible to all.10
Even though traditional beliefs about the cause of disease, and healing, have not been affected to a great extent, most remote Aborigines now consider Western medicine to be an appropriate source of treatment for sickness. It also appears that this treatment is readily available for those who desire it, even in remote Australia. As has been noted in the United States, the quality of medical care received can be affected by the patient's race or specialised.ll In the Aboriginal case, an acceptance of western medicine does not necessarily mean that Aborigines will receive all the benefits envisaged, because this acceptance is not based on the adoption of western medical philosophy, but rather on trust and observed positive results, ignorance of the theory behind Western medicine, and the virtually obligatory use of medical services. One of the reasons that Western medicine works in Australian society is that patients generally understand the premises behind treatment - Aborigines may not. Health is not simply the receipt of medical care: even with better-funded health services in remote Australia, Aboriginal health status is still very low - why?
Europeans have transposed their medical practices and institutions onto those of Aborigines. This entails a concomitant projection of alien concepts of illness and treatment and opposing values and social forms onto Aboriginal culture.l2 This method of delivery of medical services to Aborigines in remote Australia contains 'cultural handicaps to good health' in which Aborigines are the only ones required to cope with and attempt to understand the opposing culture.13 This is seen as a de facto application of the assimilation concept and puts Aborigines at a distinct disadvantage in receiving adequate medical care.
Aboriginal beliefs and practices which affect health status need to be considered in the design and implementation of health care programs. The HOP Standing Committee on Aboriginal Affairs suggested that Aborigines' fear of hospitalisation, their attitudes to pain and surgery, the roles of traditional healers and the differing needs of Aboriginal men and women all need to be included when structuring health care programs. For example, obstetric and gynaecological matters were traditionally dealt with by women. Thus, many Aboriginal women may have reservations about approaching male doctors for pre- or post-natal care; therefore, the health of infants and their mothers can be seen to be affected byAboriginal culture and Western medicine's subsequent failure to accommodate itself to that culture. Female doctors should be made available if expectant mothers in the community desire them. Likewise, men may decline to see female nurses about genitourinary problems; it may be inappropriate for female Aboriginal health workers to care for elderly or senior men; or people may refuse to use a health service if members of a different clan or tribal group are employed there.
The use of traditional healers in conjunction with Western medical practices is also a desirable development, as it accords to healers the respect that is given them in the community. M. Tonkinson notes that these healers can offer an explanation for a condition to a patient that is based on a theory of illness, it can provide comfort and reassurance while the patient is under Western medical care and thus speed recovery.14 There is little evidence to suggest that the practices of these traditional healers conflict with the medical services provided by the government and other agencies. In fact, there may be times when traditional cures may work, such as when the cause of distress is 'supernatural' (eg. sorcery). Some research warns, however, that traditional healers should be used with discretion. It is possible to frighten the patient or anger his or her family if the doctor's invitation to the healer is inappropriate.
By taking account of the relationship between culture and health when designing health care programs, it is probable that these programs can begin to reduce levels of poor health. To promote autonomy and self-determination, there should be maximum participation by Aborigines in all stages of planning and delivery of health services, including employment, as well as the opportunity to determine which type of services are wanted. *
GARY LEE is the Indigenous Gay and Sista Girl/Transgender Project officer at AFAO.
I. Australia: Parliament. (1976) HOP Standing Committee on Aboriginal Affairs. Aboriginal health in the south-west of Western Australia. Canberra: AGPS.
2. Butlin N. Our original aggression: Aboriginal populations in Southeastern Australia 1788-1850. Sydney 1g83: Allen and Unwin.
3. Moodie P. (1g73) Aboriginal Health. Canberra: ANU Press
4. Kamien M.(1978) The dark people of Bourke: a study of planned social change. Canberra: ANU Press
5. Kalokerinas A. (1g74) Every second child. Melbourne: Nelson
6. Brady M.(1984) A study ofthe impact of alcohol use in the town of Tennant Creek NT. Darwin: NT Department of Health.
7. Moodie op. cit.
8. Kalokerinas op. cit.
9. Waterford J. (1982) A fundamental imbalance: Aboriginal ill-health. In: Reid J. (ed). Body, Land and Spirit. St Lucia: University of Queensland Press pp 8-30
l0. Nathan P and Japanangka DL. (1983) Health Business. Richmond Victoria: Heinemann Educational
I I. Institute of Medicine. Health care in the context of civil rights. Washington 1981: National Academy Press
12. Nathan P and Japanangka DL. Op. cit.
13. Moodie op. cit.
14. Tonkinson M. (1g82) The Mabam and the hospital: the selection of treatment in a remote Aboriginal community. In: Reid J. Body, Land and Spirit. St Lucia: University of Queensland Press. pp. 225-41
ANWERNEKENHE II: Us Mob'
AMONG, WITHIN AND BETWEEN
FOR ALL AUSTRALIANS?
VAST DISTANCES...VAST DIFFERENCES
BOYS TO MEN
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