Issues Magazine

Improving Health in East Arnhem Land

By Eddie Mulholland

Why do health problems seem so difficult when it comes to Aboriginal health? Listening and asking the right questions can be part of the solution.

As a regional provider of primary health care services in north-eastern Arnhem Land, Miwatj Health Aboriginal Corporation is on the frontline of some of Australia’s most difficult health problems. Or so it seems when the media and politicians describe the situation.

Prevalence rates of most chronic diseases – diabetes, cardiovascular disease, renal disease and so on – hover around 30–40% of the adult population; around half of Aboriginal children in the region have catastrophic hearing, lung and other problems by the time they reach three or four years; and the average age of death is in the 40s. How do these statistics make solutions anything but difficult, if not impossible?

In fact, the solutions are not hard. And this is a key point about Aboriginal health: the illnesses affecting Aboriginal people are not mysteries – western science knows how to stop them.

Here is an exercise anyone can do: go to any basic primary health care textbook and look up those illnesses. You will see they can all be prevented in the first place, and most can be effectively managed even after people have contracted them. So, if this is the case, why are so many Aboriginal people so sick?

In the case of north-eastern Arnhem Land, where Miwatj Health operates, the change from wellness to illness has been dramatic and fast.

The first white man to walk across Arnhem Land, Donald Thomson, noted in the 1930s the general robust good health of Aboriginal people there. Photos taken by Thomson at the time show breastfed babies with rolls of happy fat! They show lean and muscular adults with white teeth and healthy, gleaming skin. Anyone comparing them to photos of Aboriginal people from that region today can see the difference.

It cannot be just because of contact with outsiders. Aboriginal people from north-eastern Arnhem Land, who call themselves Yolngu, have long had contact with other cultures – Macassan traders visited the region frequently for hundreds of years before white men got there. Yet only in the past 30 or 40 years has the health of Yolngu deteriorated so dramatically. Why?

If we listen to mainstream commentators we hear the reasons listed below. They are all important barriers to be overcome before we can achieve genuine and sustainable improvement, but they are not new – most commentators have been saying these things for many years.

  • Compliance by Yolngu with medication regimes is patchy and unreliable – that is, Aboriginal people do not do what doctors and nurses tell them to. To some extent it is true that medication timetables have little relevance in Yolngu people’s lives, but it is often a matter of inadequate communication by medicos who do not speak the people’s language.
  • There are not enough doctors in Arnhem Land to meet the huge need for medical services generated by such a sick population. Certainly, more doctors would improve access to medical care. But doctors can only do so much – the reality of daily life in an Aboriginal health service is how to balance limited resources between providing medical care and public health programs that can tackle the underlying causes of ill health.
  • Many communities are hundreds of kilometres from the nearest clinic, over roads that are often closed in the wet season, so access is very difficult. Yes, travel is often difficult. But it has improved greatly in recent years and yet Aboriginal people are not healthier than they were years ago. In fact, the observation of Miwatj Health is that the health of Aboriginal communities improves the further they are away from the largely non-Aboriginal regional centre of Nhulunbuy.
  • Government support for Aboriginal health services is inadequate, in terms of the dollars provided, to fund these services and in terms of governments having no coordinated strategy to tackle the problem. In the experience of Miwatj Health, this has been a major issue. Drip feeding, lack of coordination between governments and lack of a strategic approach to health service development are some of the biggest hindrances to improving Aboriginal health in this region.
  • Aboriginal people in Arnhem Land have much higher rates of tobacco smoking than the rest of the Australian population. True, but tobacco has been used in Arnhem Land for hundreds of years (brought by Macassan traders since long before European settlement). Miwatj Health for a long time has been trying to get funds from governments to operate tobacco control programs, but without success.
  • Environmental health conditions, particularly housing, are so bad that a high level of illness is inevitable. Should housing be the responsibility of a primary health care service?
  • Medical staff employed by Aboriginal health services are unable to understand the culture of their clients or even speak to their clients in the client’s first language. This has been an ongoing issue of concern to Miwatj Health for many years, emphasised by the transient nature of many medical staff and the many languages spoken in the region. Solutions are not easy. Miwatj Health provides language courses for staff, but short courses do not often convey the depth of knowledge needed.

Miwatj Health believes we also need to look beyond those familiar reasons. In particular, we need to listen to what Yolngu have been saying about why they get sick and what needs to be done about it. And if we do listen to Yolngu, we find they have been saying the same things for 40 years with remarkable consistency.

Let’s go down that road now, and see where it leads us.

If you look at any map of Arnhem Land you will see that there is one large town, Nhulunbuy, surrounded by vast areas of sparsely populated Aboriginal land. Nhulunbuy came into being in the late 1960s and 70s, when the Commonwealth government leased a corner of Arnhem Land to a huge bauxite company. The leases were for 50 years, with a renewal option of another 50 years, and were issued despite the direct and loud opposition of Yolngu landowners.

The court case where Yolngu challenged this grant of land in the High Court, and lost, was the last statement of terra nullius before the Mabo decision.

Statements made by Yolngu leaders at that time to Parliamentary committees were very clear about what would happen as a result of the mining: Yolngu society would be undermined and marginalised, and people would get sick. Everything those leaders predicted in the 1970s has come true. And if we can understand the reasons why they made these predictions so confidently at that time, we will have gone a long way towards understanding why people are so sick today.

Yolngu society was, and is, founded on its connection to land. Kinship (gurrutu) relates specific people to other people and to their specific pieces of land. Yolngu dance and sing to their land, to their totems; they undertake ceremonies to renew the connection, and the basis of where each mala (clan) group lives and relates to depends utterly on these traditional connections.

In a Parliamentary committee hearing in the early 1970s the missionary at Yirrkala, Reverend Wells, was asked if Yolngu had any concept of what a mine site looks like. He answered that they think it will look like the moon. And there is no more apt metaphor. Any observer of the mine site at Nhulunbuy today would think the same thing – it is a desolate and barren moonscape.

The connection of this to health lies in the fact that Yolngu see good health as dependent on the proper functioning of their kinship and related social systems. And kinship, language and all proper social structures come from the land. If the land is disturbed and damaged, social relationships must be disturbed and damaged. If social relationships are damaged, people get sick.

For many Yolngu, this obvious formula has more relevance to their illness today than any number of epidemiological papers or any number of chronic disease plans. Anyone seeing the damage the mine has done to the land will not wonder why Yolngu are so ill: people are sick because the country is sick. Yolngu have been saying this to “whitefellas” for decades, yet somehow it does not sink in.

Of course, western health experts would not see things like this. Advocates of western public health models may say that with the arrival of a supermarket and the opening of a hotel in Nhulunbuy, Yolngu were exposed for the first time to tobacco, junk food, alcohol and similar health “risk factors” and that these are the underlying causes of most of the chronic diseases affecting Yolngu today. That is probably correct, but the question is:, where does that analysis lead us in terms of finding a solution to the health problems?

In reality, the only road that view takes us down is the failed “health promotion” road, where “whitefellas” tell Yolngu to stop smoking, or stop eating junk food, or get more exercise, and so on. History tells us that this approach to the health of traditionally oriented Aboriginal people – the approach of trying to alter demand for things like bad food and alcohol – seldom works. We need to look elsewhere for an answer.

It is the Yolngu themselves who have shown us at least part of the answer. Having lost two court cases – one opposing the mine and one opposing the introduction of alcohol to Arnhem Land – Yolngu voted with their feet. From the 1970s onwards they walked out of the mission at Yirrkala in small family groups to settle back on their own clan country – back on their “homelands”.

In these homeland centres, Yolngu built their houses, cleared roads and airstrips by hand, protected and built up their kinship systems, activated dance and paint to renew the country (and sell to the few “whitefellas” who valued the art). Today there are 20 or 30 homeland centres out from Yirrkala, all of them happy and healthy places, where there is no alcohol or drugs, where people live on their own clan country, kids go to school, bush tucker is a significant part of the diet, kinship is maintained and where people dance and sing to their ancestral spirits, which created the land.

And as could be expected from a Yolngu perspective on health, Yolngu living at homelands – where social relationships are correct, where kinship is strong and country is cared for – are generally healthier than Yolngu at the centralised settlements and ex-missions such as Yirrkala.

Miwatj Health is about to do some research comparing the health status of Yolngu at homelands centres with the health of Yolngu who live at the centralised settlements, and we are confident the results will conform with other studies of the health impact of the homelands movement in the Northern Territory: that the homelands movement, with its characteristics of small, decentralised populations living on their “correct” traditional country, is in effect a public health movement.

So the homelands story is a health success story. And there have been other successes. In March 2008, after 40 years of battling against licensees and governments, Yolngu women finally achieved an alcohol management plan for the Gove Peninsula, wherein a permit is required to purchase any take-away alcohol. Though yet to be properly evaluated, this management plan has made a huge difference to the violence and abuse in communities.

One has to ask why this took 40 years to achieve. And the answer obviously lies in the power of the vested interests – in this case the alcohol and mining industries against whose forces the Yolngu stood little chance.

Miwatj Health sponsored the alcohol management plan from its inception, and has always supported the homelands movement. These are not medical options, but it is important to appreciate that Miwatj Health is a health service, not a medical service.

In 2008 Miwatj Health is placing a strong emphasis on “quality improvement” in its clinical practices. The days when an Aboriginal health service could simply provide a bandaid service for anyone who walked through the door are gone. These days the emphasis is on long-term planning to tackle long-term chronic illnesses, on systems in the clinic, and on the integration of clinical and population health programs.

So Miwatj Health does this. But there are many barriers to the success of this approach succeeding, most of which have been mentioned earlier.

Meetings are currently being held in Canberra and Darwin between governments and community-controlled health services to roll out a major expansion of primary health care services across the Northern Territory. The details are not yet clear, but there is the promise of some “really big” advances taking place in Aboriginal health spending and coordination in the Northern Territory over the next year. So there are some very positive things amid the gloom.

Yet it still often seems that governments do not really listen. It is profoundly disappointing to Miwatj Health to learn that the homelands movement is now under threat from the Federal government. The one development in north-eastern Arnhem Land that has produced good social outcomes is now threatened with annihilation by a government that wants good social outcomes. Go figure.