TRAINING FOR WORK

The contribution pharmacists can make to the National Close the Gap day to be held on 2 April is to commit to training an Aboriginal person to work in the pharmacy of an AHS and help to develop a system whereby Aboriginal people can understand medicines and their role in the management of chronic diseases.

Recent research in the Medical Journal of Australia (1) has shown that Aboriginal children are not predisposed to chronic diseases such as renal failure, diabetes or circulatory diseases and that these conditions are brought on by lifestyle choices in later life.

As the Nation focuses on Close the Gap pharmacists too should be examining what they can do to contribute in a way that is more than just supplying medicines and feeling the day’s work has been done.

There is one trap that can easily be fallen into and that is imagining that everything should be done in the same way as it has been for western society – making the assumption that “they” can be like us. “We” have developed our culture - its norms and its customs after thousands of years of living in a world that has been constantly changing and with advances in transport, mode of living (houses), food sources and industrial activity. Aboriginal people too have developed there culture through the same time period but with the dramatic difference of being isolated from the rest of the population of the world. It is so different when there are no means of transport (the wheel was not even there); no metallic objects; no materials for housing; and food that had to be found day by day. To many of these people, especially in remote Australia, access to the developed world has only been available for the past 100 years and in some cases in the last 50 years. This is a minuscule period of time and the change to a different way of thinking has to be done gradually, with sensitivity to their beliefs, and in a manner that takes account of their view of the world. This was well described in the book by Richard Trudgen , “Why Warriors lie down and die” (2), and that has become a standard reading text for anyone entering the Aboriginal health industry across the North of Australia.

We have to understand where Aboriginal are coming from in their understanding of disease states, why they occur, what can be done to overcome the onset and the management practices (that suit their ways) and which will maintain a life that is symptom free.
It is not just a matter of devising a training course that embraces subject areas that have worked in western culture because they are there. There is little evidence to show that VET Certificate courses in business administration, community health, community services, health administration and others have produced workers who are able to understand the tasks needed to improve the workplace and its clients. Often Aboriginal people attend training because it is a condition of receiving a Centrelink benefit and afterwards do not even remember what the training course was or upon receipt of a certificate cannot recall having done the course.

The Department of Education Employment and Workplace Relations (DEEWR) is stacked with principles, guidelines, protocols and acronyms that point towards funding for training. The only trouble is there are not the jobs to be undertaken when the training is finished and whatever was learnt is quickly forgotten.

Pharmacy is at the sharp end of a revolution that will try and close the gap. It (pharmacy) is in an ideal position to develop WITH Aboriginal people training programs that help to bridge the gap and provide knowledge in a manner that can be used. It is no use trying to teach anyone the mode of action of an ACE inhibitor to control blood pressure and increase the flow of blood through the kidney without knowing:

a. What the kidney does?
b. How it does it?
c. Why it is important?
d. What causes it to malfunction?
e. What needs to be done to prevent this?
f. How people should live to avoid kidney damage?
g. And finally what the drug will do in contribution to a good functioning kidney given that all, preventative measures have been exhausted.
Without this understanding the elements in training for a pharmacy technician in an Aboriginal Health Service could be useless because it is not relevant to the needs of the client.

In developing any training program the main focus has to be on the client (patient) and not what conforms to the downloadable training package available from the National Industry Training Council. Sure there is funding available for mainstream training packages but what use is that if the patient will still not understand why their kidneys have packed it in. There is a lot to be done in devising training programs that meet the needs.

The time to start is now. Play your part. Help to close the gap by demanding that training meets the needs of the client – not the criteria that works in mainstream.

Whether it is pharmacy technicians at urban Aboriginal health services, remote health clinics or as an adjunct to other health professionals make sure it meets the need – and that is not necessarily an already established training package.

Footnotes
1) Patterns of mortality in Indigenous adults in the Northern Territory, 1998–2003: are people living in more remote areas worse off? Karen Andreasyan and Wendy E Hoy. MJA 2009; 190 (6): 307-311

2) “Why Warriors Lie Down and Die” by Richard Trudgen. Aboriginal Studies Press. ISBN: 0-646-39587-4

Ends

The Trachoma issue – what does it take?

There are times when people involved in trying to close the gap in Aboriginal health hold up their hands in despair and scream “what does it take?”
Following the statement of achievements during February 2009 by Prime Minister Kevin Rudd to “Closing the Gap” the Aboriginal Medical Services Alliance of the Northern Territory has called for a way to get the dollars promised to the ground as directly as possible.
Congratulations to AMSANT for the suggestion that a single authority accountable to the Parliament be established to deal with all matters pertaining to Aboriginal health and the funds that are promised for this use.
It is so often the public forgets the announcements, makes a judgment at the time and then waits for the next one assuming the previous has been actioned. It does not work that way. By the time a policy proposal moves along the three levels of government a time space of years has gone by and governments have changed meaning the proposal as it stood is probably lost.
This is where the AMSANT proposal makes so much sense - a direct line from politician announcement to program implementation on the ground by community controlled (not government controlled) health services.
In reality there has to be an agency that is holding governments and politicians accountable for the promises that are made.
As an example of just how hard it is to make things happen take a look at the problem of trachoma – a debilitating eye disease that can send people blind if not treated properly (and simply) with improved personal hygiene and Azithromycin.
Mr. Rudd also announced during the week that $58.3 million would be made available for eye and ear health with a focus on eradicating trachoma, a disease that leads to blindness. It has been eliminated in all other developed countries.
The PMs Media Release said (interalia)
“Our objective must be clear: to eliminate trachoma among Indigenous Australians within a finite timeframe”.
Now wind the clock back to 1997 when in The Age 27th June it is stated:
“Dr Wooldridge said the Government would spend whatever was necessary to fix what was preventable blindness striking 100,000 Australians. The minister said he was angry that after so long little had improved in relation to the eye health of Aborigines in remote communities”
And then in the SMH on 18th November:
“Aboriginal eye health …has worsened, with the rates of the blinding disease trachoma found to be 80 per cent among some children, and indigenous people 10 times more likely to be blind than other Australians.”
This followed a study, by the head of Melbourne University's Department of Opthalmology, Professor Hugh Taylor - the first such review in two decades – which found the eye health of Aborigines in remote communities had barely improved in that time.
To which Minister Woolridge’s office responded that:
"These things take time," he said.
The amount of money the government committed in March 1998 was $4.8 million but who remembers what happened, whether it worked and ask why this is still going on. (See on left extract from "The Age" March 1998)
The price has now increased to $58 million although that does include ear health.
Professor Hugh Taylor, the long time advocate for action on eye health must be really wondering how much time it needs for what should be a simple undertaking. Read the transcript of ABC Ockhams Razor program on 1st July 2001 on the link to the title of this article.
Pharmacists involved in Aboriginal health will know that it was the desire to have Azithromycin made free to remote living Aboriginal people that lead to the Section 100 supply arrangements for the entire PBS Schedule Yellow Pages. It was during the PMs visit to Maningrida (NT) in 1998 that prompted the action that lead to the implementation of this change in April 1999 and now follows to all remote Aboriginal Health Services.
Picture on right shows the writer assisting the RFDS Nurse at Tablelands Station in the Kimberley administer Azithromycin suspension to children diagnosed by the visiting doctor with Trachoma.
This column supports the AMSANT call for a National Aboriginal Health Authority and calls on pharmacy organisations to give their support to the proposal by agreeing to work with it in ensuring the quality use of medicine is exemplary in whatever programs it administers.
Close the Gap is not just about life expectancy – it is about reducing the distance between the politicians announcements of money being available and that money then being used on the purpose for which it is intended with the minimum of administration in between.
With two levels of health bureaucracies (Australian and State/Territory governments) dealing with programs and even then it not being delivered the total sum quickly diminishes.
The Aboriginal community controlled sector needs support in responding to such calls.
In the Northern Territory there are 47 government controlled health clinics as against 26 community controlled. This gap needs to be narrowed also until they are all community controlled and using the money directly that is voted through the Parliament for spending on improving Aboriginal health.

Aboriginal towns stark contrast to mainstream

Governments must open their eyes and do something to create the infrastructure needed to have a thriving economy in remote Aboriginal towns across the north of Australia. There is no need to keep thinking that one store, a couple of takeaways and a fuel outlet is all that is needed and then say the people must move to the jobs if they want to work for a living!

Indications are something is going to happen - it is a matter of when and how!
There is no reason to believe that Aboriginal people do not need the retail outlets and service facilities that the rest of Australia takes for granted. Regrettably that is all many people know because that is all they have seen living in isolation to the rest of the population.

A comparison of an Australian country town, Boorowa in NSW, with Galiwin’ku on Elcho Island shows up some sharp contrasts.

Population of both places 2,000 people

If it looks as though Boorowa is the bigger

of the two – it is - in terms of number of houses. 950 for 2,000 people compared to Galiwin’ku with 152 houses.

Then you really know what over crowding” means! 8.5 persons per house at Galiwin’ku compared with 2.4 in Boorowa.

The biggest contrast in terms of retail opportunities is the number of
businesses - be they retail or service.

Galiwin’ku has just five retail outlets. One store, three takeaways and a fuel bowser.
Boorowa on the other hand has 15 retail outlets as well as three

hotels - (none at Elcho), three motels (none at Elcho), eight café/restaurants (none at Elcho) other retail stores including a pharmacy - pictured right - and the gathering of service clubs, special interest groups and supporting organisations mainstream Australians take for granted.
Overall the strength of social capital in Boorowa is huge compared with Galiwin’ku where it has been decimated over the past 100 years as a result of colonisation. There were people living in North East Arnhem Land in the 1930s who did not know the “south” had been settled by the British. They thought Japanese (from pearling) and Asians (from trepang) were the only other people on the planet.(1)
The people of Galiwin’ku are from 15 different clan groups that were at loggerheads years ago and have been thrust together in a “community” with no help in developing their alternative social networks, activities or sporting opportunities. There is football club run by a group under the auspice of the Council but with little opportunity for the player to have a say in how it is run.
The clan groups are the focus of social gatherings.
The 24 page booklet (pictured left) lists all the shops, services, clubs, festivals, history and attractions of Boorowa.
Galiwin’ku does not have ONE motel. Only a “guest house” that many walk away from on first sight. (Pictured right)
The following table gives a comparison of other indicators (2) :

It does not have to be this way and yet for some reason governments over the past 30 years have believed remote living Aboriginal people only need the most fundamental of services to make their communities thrive.
It is shameful that in 2009 these towns have chronic unemployment, illiteracy among children, poor health through overcrowded houses and phenomenal amounts of boredom that leads to domestic violence, drug abuse and general anti social behaviour.
This is the profile of a town where only 10% of the population has reached Year 10 level at school.
The retail store - with no competition - is under no commercial pressure to do better - although the one at Galiwin'ku is community controlled and does its best (pictured right).
It is hard to expect a child to want to go to school when all they see is chronic unemployment and no industries that attract their desire

as a future career path.

As Noel Pearson put it in an article in The Australian in August 2008:
"You can educate people as much as you like, but if they've got no jobs to go into, as a young Aboriginal 10 year-olsd told me"Why do we need to be educated if there's nothing for us, there's no future"."

The answer lies in developing enterprises which the people themselves want to see happen and where they are responsible for that development.

In the world of “Enterprise Facilitation”, and as promoted by Ernesto Sirolli through his Sirolli Institute (3) based in Canada, the facilitator has no original ideas of their own – they all come from the people – and – only work with people who want to be helped. It remains to be seen whether this approach will work in remote Aboriginal towns but it is worth a try.

Let’s face it – nothing else has worked over the past 100 years so why not ENTERPRISE FACILITATION a la Sirolli.

Remote living Aboriginals need some dreams. The dreams they had have been destroyed by Governments with a passion to have them be like us.

What needs to be done is foster and facilitate their dreams so success can come and by example the children will at last see a reason to want to go to school.
The Enterprise Facilitator helps people to live their dreams and provide them with the answers they need to achieve their goals.
Aboriginal people in the main have been to Darwin, they spend a lot of money at stores of all types and sizes. K-Mart and Target are popular as is The Good Guys and Harvey Norman. The amount of money being spent is mind boggling for people who are allegedly living in a state of poverty. For the ones that do not waste their money on grog, gunja and drugs there is plenty of disposable income left for clothing, electrical goods and gadgets, sporting accessories and music.
The big retailers are benefitting but there is no reason why a wider variety of shops in the town would not succeed given the obvious demand.
A concerted effort on the part of the Australian society (including government) is needed to bring these Aboriginal towns up to the same level of services as the towns mainstream Australians call home.

This has to happen so the playing field is level when a comparison is made between the two cultures.

References:
1. Mcintosh, I., & Burrumarra, D. (1994). The whale and the cross: conversation with David Burrumarra MBE. Darwin, Historical Society of the Northern Territory.

2. Australian Bureau of Statistics: 2006 Census QuickStats. Boorowa and Galiwin’ku

3. Ernesto Sirolli: Ripples from the Zambezi: Passion, Entrepreneurship, and the Rebirth of Local Economies. New Society Publishing, British Columbia, Canada

Equity needed in PBS supply to Aboriginal patients

Let me tell you a story –
…the story of the Pharmaceutical Benefits Scheme and Aboriginal people in urban and remote areas.

Pharmacy services in Australia have evolved over the past 50 years following a model of retail dominance. Emerging from the 1960s when the compounding of medicines in all forms gave way to manufactured product the pharmacy profession ceased to be the wise old man of the mortar and pestle and exchanged this for the emerging technology of retail business management.
For a time in the early 1970s through to the 1990s the shop based dollar turnover dominated through the “front of shop” sales of anything from coffee and asparagus to health and beauty aids. The franchised style of branded chains came out of the individually owned businesses of the earlier “master pharmacists”.
More recently the pendulum has swung the other way and dispensary turnover is exceeding the front of shop due to the enormous change in retail shopping behaviour influenced by the supermarkets. In an attempt to counter this pharmacists’ have turned their stores into supermarkets. With some deft political maneuvering they too have been able to have legislation passed that means it is illegal to have a pharmacy in a supermarket but okay for a supermarket to be in a pharmacy!
The driver of the force that created a unique retail profile combining the retailing with the professional services was driven (and continues to be driven) by the union for pharmacy owners – the Pharmacy Guild of Australia. The organisation is now in its 80th year after having been initiated in New South Wales in 1928 in response to news that the powerful Boots the Chemist chain in the United Kingdom was considering entering Australia to overpower the dominance of a “pharmacist owned” policy. So it happened that bullions of gold were exchanged for political favors and the same principle still applies today as the powerbrokers of the ancient establishment continue to disperse their wealth in successful endeavors to maintain the highly anti competitive practice of retaining the pharmacist only owned policy in all jurisdictions except the Northern Territory.
In that “State” the law allows an Aboriginal health service to own a pharmacy business so long as it has Ministerial approval.
In 2004 the Pharmacy Guild convinced the NT Labor Government that it was out of step with the rest of Australia by not having a pharmacist only ownership rule. In point of fact and following National Competition Policy (NCP) principles it was the rest of Australia that was out of step with the NT (by default) being the only place that conformed to NCP guidelines.
A lobby to retain the opportunity to allow Aboriginal health services to own a pharmacy was successful and with the help of the Independent Member for Nelson, Gerry Wood MLA, the clause to allow this to happen was passed and the NT became the only place in Australia where someone other than a pharmacist could own a pharmacy. The remainder of the restrictions were carried into legislation by stealth following the Pharmacy Guild claims that it HAD to be changed to meet NCP principles.
The fact that the clause allowing AHSs to own a pharmacy has not been utilized to improve the way Aboriginal people access pharmacy services is more because of a lack of understanding of how to make it happen rather than an acknowledged acceptance that it is not needed.
In point of fact the manner in which pharmaceuticals are delivered to Aboriginal clients of AHSs does not match up to National Medicine Policy principles. Aboriginal health services (AHS) could well do with an injection of pharmaceutical know-how through the employment of pharmacists in their primary health services to close the gap between what is available to mainstream Australians compared to Aboriginal clients of community controlled health services.
The Pharmaceutical Benefits Scheme (PBS), the primary funder of essential pharmaceuticals to the Australian community, has discriminated against Aboriginal Australians living in remote places since the introduction of special arrangements in 1999 to allow AHSs in certain remote locations to access a full range of PBS items without having to pay a cost to the client but also without the full dispensing fee allowed to the rest of Australia.
Across Australia there is the legislative requirement to have a pharmacist employed at every pharmacy. This means the PBS supply is supervised by a pharmacist and a “professional fee” is built into the remuneration from the Australian Government to allow this to happen. It is the PBS that is employing the pharmacist through the remuneration structure.
From the 1st August 2008 the fee paid to pharmacists was $5.99 and in addition to that they receive $1.02 to record the safety net for a client on each prescription dispensed - a fee which is meant to be voluntary for the client but rarely offered. If the cost of the PBS medicine is below the threshold for Government subsidy the client pays the lot and the pharmacy builds into the cost an amount of $3.63 simply because it is not being subsidised by the Government. This is also meant to be voluntary and explained to the client but rarely is.
When a medicine listed on the PBS prices out at $20 it means that more than half the cost is going to the pharmacy in fees without even the cost of the medicine being covered. If that cost is less than $5.00 (which can easily be the case) the gross profit margin to the dispensing pharmacy is 300%.
Such charges are being incurred by Aboriginal clients across Australia who live in urban areas and access medicines through a retail pharmacy or from their AHS which in turn is paying these fees to their supplying pharmacy.
In remote areas the situation is different again and in most respects worse. Unlike the rest of Australians who access PBS through an approved pharmacy to dispense PBS the AHS will have a “pharmacy” of its own which accesses, stores and dispenses medicines under State/Territory legislation. The acquisition of the PBS medicines to the AHS is at no cost and the retail pharmacy (that is approved) will supply in bulk the medicines and not contribute to the dispensing process. In fact the supplying pharmacy will only receive $1.14 an item compared with the rest of Australia’s fee of $6.50 as outlined above.
The question can well be asked “what happens to the difference?”
The difference between $5.99 and $1.14 (= $4.85) is the amount the Australian Government saves when a PBS medicine is supplied to an Aboriginal client attending a remote health clinic.
National Medicines PolicyAddressing the National Medicines Policy (NMP) it is possible to determine how well the pharmaceutical service supply function to Aboriginal client’s matches up to that provided to the rest of Australia visiting a general practice clinic, multi purpose health service, GP Super Clinic or similar health service delivery facility. The pharmaceutical service will be supplied by a retail pharmacy or in a few instances a private pharmacy business on the site of the health facility.The Department of Health and Ageing website states the following re the NMP: The overall aim of the National Medicines Policy is to meet medication and related service needs, so that both optimal health outcomes and economic objectives are achieved. The Policy has four central objectives:
timely access to the medicines that Australians need, at a cost individuals and the community can afford;
medicines meeting appropriate standards of quality, safety and efficacy;
quality use of medicines; and
Maintaining a responsible and viable medicines industry.
ACCESS

– on the question of access there can be no dispute. Aboriginal clients in both urban and remote locations have ready access to PBS medicines through a nearby retail approved pharmacy.
STANDARDS

– there should be no question of doubt on quality as State/Territory Poisons legislation requires proper adequate and safe storage situations for all human medicines.
QUALITY USE OF MEDICINE

– this relates to the manner in which the client is supplied the medicine and whether they are assisted in understanding matters such as why it has been prescribed; what it will do; whether there are side effects; how it will assist them get better; the importance of dose related times and circumstances; and why it is essential for improving the diagnosed disease together with any co-related measures such as diet, exercise or avoiding foods, alcohol and other substances.

In the management of acute illness this is crucial especially with infections and antibiotics or topical treatments.In the case of chronic disease the QUM process will well make the difference between extending the life span of the individual or an early and premature death.A prescription for medicines in the treatment of chronic disease is usually a prescription for life and must be understood as such if the measure to “close the gap” to be successful. It should be of interest in this discussion that the responsibility of Government in the National Medicines Policy is stated as being:
Governments, their agencies and committees are responsible for:• developing and implementing the National Strategy for QUM; • coordinating relevant government programs; and• investigating and developing appropriate structures, funding mechanisms, legislation and environments that support QUM.
RESPONSIBLE AND VIABLE INDUSTRY

A “responsible” industry, both retail and manufacturing, should have some social responsibility apart from the required financial motive in its dealings. The fact that both sectors allow the current state of pharmacy services to Aboriginal people to continue with no proactive support in bringing about change indicates a lack of concern for this marginalised sector of the population.
It could well be said that Governments have failed to hold up their end of the NMP and QUM agreement when it comes to Aboriginal Australians in both urban and remote environments. In addition the retail and manufacturing sector have allowed a situation to continue which would simply not be tolerated if inflicted upon mainstream Australians in urban areas. The total thrust behind change for Aboriginal clients for the PBS must come from those sectors that know how it should be being provided. The AHSs themselves have never experienced a “good” pharmacy service and thus do not know what they don’t know.
The essential planks of a good pharmacy service at an Aboriginal Health Service could thus be summarized as follows:
ACCESS – ready access to all PBS medicines to provide optimum treatment for its clients.
STANDARDS – storage and transport of products in a safe and secure manner
QUALITY USE OF MEDICINES - information added to ensure client is able to take advantage of medicine to extend life expectancy
INDUSTRY co-operation to enhance the value of the pharmacy service from both the manufacturing and retail sectors of the pharmaceutical industry. Academia can also play a part in practice research to evaluate best practice models and evidence based outcomes.
Continual dialogue is needed between the Aboriginal health sector and Government policy makers. If the gap is to be closed pharmacists can play a big role in making it happen.
So far there is little evidence that this is taking place.

Jobs the best form of welfare

Provide empowerment through work
The best and most cost effective way of alleviating poverty and delivering social security to disadvantaged people is to help them get a job[1].
Sounds simple but true.
A job creates a feeling of empowerment as the person is at last in charge of their own future destiny and is not dependent on the State for a livelihood. Children brought up by parents without a job do not have role models to drive their intent to a better future and the state of poverty the family is forced to live under is detrimental to all concerned. ( 2)
So it was that since the mid 1970s when welfare payments Aboriginal people in Australia started there has been a decline of social capital in remote Aboriginal communities that has continued ever since with the jobs that used to be done by Aboriginal people now being done by non-Aboriginals.
Reverend Steve Etherington, pastor with the Uniting Church and school teacher for many years in a remote community in the Northern Territory summed it up this way in a paper prepared for the Bennelong Society[3]:
“IF YOU READ NO FURTHER THAN THIS…
It’s about jobs: not overcrowding.
It’s about jobs; not about culture or ethnicity or missions, or history.
It’s about jobs: not about grog and drug abuse.
It’s about jobs: it’s not even about child abuse.
All these are merely symptoms of long-term unemployment.
It’s about jobs.”
There is little evidence of anything being done towards encouraging communities to take charge of their own future. All that is evident is the old and long term frowned upon dominant culture wanting Aboriginal people in their communities to “be like us” – it will never happen.
There is a need for programs such as that announced on 4th August 2008 which are positive, focused on the individual and actionable at community level. While the planning still has to happen the prospect of real co-operation between the government, private corporate sector and Aboriginal communities is a plus.
It is probably time to go back in history and read the writings of people like A P Elkin in the mid 1930s. It is all there. We need to pay attention to the past to plan a better future and one of the failings of the past 30 years is to ignore what has gone before.

It is all there.
We should use the experience of wise people who have been there and done that. The words of John Singleton back in 1979 still apply in 2008 as they did in 1979. He wrote in The Bulletin:
“…every time I look at one of those bearded university-trained southern do-gooders, I wonder if they will ever realise that they can never solve the Aboriginal problem because they are the problem”.
There is a need to engage with communities in a meaningful way. Stop “fly in – fly out” visits and genuinely be prepared to live amongst them to understand the way they think.
Government at the three levels needs to review what its role should be in enterprise/economic development. It is likely that the interference at the local level by trying to micromanage the spending of public money is having an adverse effect on motivating local people to act.
Mark Latham[4], writing in 2002 said “…inequality and social exclusion have become …entrenched in our society, despite high levels of welfare spending. The welfare state has been built around bureaucratic structures instead of around the capacities of people. It has placed its dead hand on innovation and self-help in disadvantaged neighborhoods.”
There is a need to provide “seed” funding to catalyse establishment of core business functions for emerging enterprises. The early availability of “seed” funding is necessary to build capacity at the local level and take the opportunity of initiatives that come from the grassroots.
A “bottoms up” approach is needed with government seeing its role as providing the infrastructure to allow enterprise to grow with the assistance of local facilitators paid by government in the same way that “business enterprise centres” came about 30 years ago in mainstream communities.
A pharmacy enterprise in a remote community has the opportunity of providing jobs, training and a cash flow from the provision of medicines under the government paid for Pharmaceutical Benefits Scheme. The opportunity to put to work all the knowledge a pharmacist has obtained through their undergraduate experience should make this a richly rewarding experience for young pharmacists. There are other opportunities especially if the industries that used to be there are listed and returned to produce the products they did in yesteryear. Things like a bakery, poultry farm, market garden, saw mill or cleaning service.
An analysis of the comparable shopping opportunities between an established country town in New South Wales with a remote community in the Northern Territory shows that for a comparable population base the NT community has only five retail outlets compared to 18 in the NSW country town. Another way at looking at this is to wonder how much of the retail spend stays in the town (in NSW) compared with the amount that goes out of the remote community because of the fewer businesses being owned by people external to the community.
If there is a budding entrepreneur in a remote disadvantaged community they only need to look around and see who is making the money out the products consumed and ask themselves why they could not be doing the same.
The jobs could be there if there was a planned co-operation between government, private sector and local people. It is possible that money put into job creation could have a more lasting impact on improving better health outcomes than money being put into new health clinics or the provision of primary health care staff, including doctors.
To look at the world through the eyes of the people is essential if useful opportunities are to be made available for those same people to develop their own potential. Young people especially need role models to look up to who work and set an example. Against all indicators this is not happening. By example they must be shown that there can be businesses in remote communities that will help the hours in a day pass more pleasurably than by doing nothing. This is also the ONLY way to solve the attendance at school problem. Show children why they must go to school. A child cannot be blamed for not seeing a need for school when the adults do nothing all day long.
The example is the key.

[1] “…the fact remains that the best way to get out of poverty is a job.” ACOSS president Andrew McCallum in Annabel Crabb, “Labor plan to help poor buy shares”, The Age, 7 May 2002.

(2) Cartoon acknowledgement Nicholson Cartoons at www.nicholsoncartoons.com.au "The Australian" newspaper.
[3] http://www.bennelong.com.au/occasional/etherington2007.pdf Accessed 2nd August 2008

[4] Mark Latham. “From the suburbs. Building a nation from our neighbourhoods”. Pluto Press 2003

12 months of frustration

June 2008 should not pass without a comment on the feature which dogged Aboriginal communities in the Northern Territory for the past 12 months – the NT Emergency Response or the “intervention”

This badly planned and poorly thought through political catastrophe was launched with the force of a tsunami on communities severely weakened by decades of government ineptitude and bad policy. The suspects, the first people of Australia, were stunned by the rigor of the force that Dr Sue Gordon, Major General Dave Chalmers and their Northforce compatriots stormed into communities erecting army tents, shipping containers as houses and massive communications dishes to tell the world that here was a disaster that had been waiting to happen for years.

(Government Business Managers residence - Maningrida pictured at right)
(“We are nothing to do with the Army…” Dr Gordon said in a subsequent TV interview!)
In point of fact the disaster had been there for decades and getting worse and it took an upcoming election for the “rabbit” to come out of the John Howard “hat” and be thrown onto the political landscape in the same way as the Tampa incident had some six years earlier.
The trick backfired, the Government lost the election and the two masterminds of the NTER lost their political seats in Sydney and Brisbane.
But what of the real sufferers who had to be humiliated by seeing the laws of the land precluding racism suspended so measures could be put in place which were clearly discriminating against them for being Aboriginal and living in a remote community in the NT. As if that in itself was a crime and now we find the suggestion (again) that some communities may be economically unviable. In other words people should not be able to live where their ancestors walked because the government cannot afford it. What a joke - those same ancestors did not need a government in the first place and it was not their doing that the British launched its raid on the country they called home 220 years ago.
Recently in the same country (Australia) it has been exposed of children dying in houses that were only fit for rodents and children killed (allegedly) by a parent that was taking action to prevent the other parent from seeing the children. How bad is that and where is the intervention?
Some will say that there have been good points to the NTER and so there should be. Let’s face it - years of neglect create a situation where there is a lot to do and to do it well means a lot of money – a helluva lot of money. 20 people to a house, children not attending school, no jobs for people to want to work and so it goes on. Of course there is a place for help and even an intervention – but not one that is racially motivated, rude and confronting to the subjects and lacking in the most suited piece of politeness – consultation.
Yes 12 months has passed, little has been achieved that should not have happened years ago and the anguish goes on for people who quite simply fail to be understood by politicians, bureaucrats and the rest of the dominant culture residing on the southern seaboard of Australia.
Remote living Aboriginals are entitled to housing, education, good nutrition and primary health care as a basic human right – not as an emergency intervention into their lives.

Live, learn and understand

You never stop learning

A personal journey with Rollo Manning

In the world of work with Aboriginal people one never stops learning.
Today we have a dispute between a Prime Minister and a former Minister for Aboriginal Affairs who thinks he should have been appointed to a National Policy Commission to develop innovative proposals to improve the provision of housing in remote Indigenous communities. The former Howard Government Minister, Mr. Mal Brough, believes his experience can contribute to the work of the Commission. To many people this is true because they applaud the intervention into Aboriginal communities in the Northern Territory. But to many others, and no doubt the majority, the intervention was a cynical political exercise intended to win votes for Howard et al in the November 2007 Federal Election. The result – out with Howard and Brough and the entire Liberal-NCP Government.

Mal Brough’s knowledge comes from nothing but “seagull” visits to a large number of communities and conclusions reached after sitting on the ground for the cameras apparently in deep discussion with community elders. His understanding and statements would have been formed after talking to advisers who form their opinions from similar exercises with Canberra bureaucrats renowned for flying in and out of communities for two hour visits and leaving to solve the problems of that world.

This is not the way to understand the Aboriginal “problem.” There are too many people in powerful positions influencing decisions on Aboriginal disadvantage with paper thin knowledge of the needs compared to white people who have spent years living among Aboriginal people and far have better deserve a seat on the PMs Commission for Aboriginal housing.

Something must be done to bridge the gap between the aspirations of the politicians and the effective delivery of resources to the people who need them most. This was the subject of recent comment in the National daily, The Australian newspaper.

When I think back to 1998 when I moved back to Darwin after 10 months in the Katherine region following my first exposure to remote Aboriginal life I thought I knew a lot – but now looking back I knew very little.

A colleague said to me before I started with the Tiwi Health Board – “you only start to understand Aboriginal people when you live with them” – a true anthropological approach and so much the truth.
Certainly today after over ten years of close contact and work with these ancient Australians I am still learning and marvel at the broad scope of subjects we take for granted and yet for my Aboriginal friends they have not embraced and even started to appreciate as a possibility.
Kids going to school – something we dream about before the child is born when we wonder whether we should book them into a school for five to six years hence or maybe just for secondary school. From the day the child is born we start teaching it and read to it and help it learn to count. For the Aboriginal child the parent may not be able to read, write or count let alone pass this knowledge on to the child. We have activities like little athletics on a Saturday morning where someone has to write down the names of the participants, count how many are in a race and then time the speed of the run. All educational in value and bringing parents together to be proud of their children and share the joy of parenthood with others. And yet on Saturday mornings in an Aboriginal community there is rarely anyone on the football field with it just waiting for the grown-ups later in the day for their single grade competition. There is not even a competition for the younger kids although they just love practicing their kicking and marking and pretend to be playing a game.
The value and place of money in our society is understood and we probably had our first money box before we started school and knew that it was to be saved, spared and spun out for as long a time as possible. Unlike the Aboriginal person who may not have seen money until they were 10 years old if born around 1960 and lived in a remote location. The view is to spend it as quick as you can before someone else gets it and if that means buying grog and ganja to not have any for food “tomorrow” then so be it. Someone will give us food.
It is necessary to develop an understanding of the people before you can make any significant contribution to improving the lot of remote living Aboriginal people.
For too long we have tried to make them like us but that will never happen. They are not like us, do not want to be us, and must passionately retain their strong and rich cultural values if they are to succeed in a modern developed world. Aboriginal people must be allowed to develop their own program of assimilation if that is what they want and to get there at their speed – not hurried because of some political aspiration of a person struck with a passion for their own ego.

A correspondent to the Sydney Morning Herald said in a letter this week:-
As a resident of the Tiwi Islands for the past 3½ years, I have been deeply saddened by the path that Brough and his supporters on the Tiwi Land Council are pushing Tiwi people onto. Brough often speaks about "what indigenous people want" and claims that they ask for the things that he puts forward. But how is he to know what Tiwi people want? In my time on the islands I have never heard a Tiwi person express a desire to own a house. Yes, they want better housing - they don't want to share a house with 15 other people. But does this mean they want to do away with communal ownership of land (which is central to their culture) as Brough suggests? Of course not.” (Rollo’s emphasis).
And Chris Graham, Editor of the National Indigenous Times had this to say:“…the problem is Aboriginal Australia doesn't need another showman, it needs solutions. Brough doesn't have any now, and he didn't have any in office. …. Brough may be fun to watch and he may make for great sound bites…. But he's all sizzle, no sausage. Hold your ground Kevin Rudd.”
The National Director of ANTaR, Gary Highland said:“…during his time as Minister, Mal Brough failed to act in a bipartisan way and alienated many Aboriginal people by his heavy handed tactics. He's therefore unsuitable for a bipartisan commission of this kind."
Next time you see or hear Mal Brough just remember- you have to live with them before you can understand them and commit yourself to pay a visit, stay awhile and then put your dreams for them into action.
In the words of Robert F Kennedy:There are those that look at things the way they are, and ask why? I dream of things that never were, and ask why not.
Remote living Aboriginals need some dreams. The dreams they had have been destroyed by Governments with a passion to have them be like us. It will not happen – they are people too – and they do have a conscience, a love for their children and a desire to move ahead. What we have to do is facilitate their dreams so success can come and by example the children will at last see a reason to want to go to school.
Darwin

Australia

29th May 2008

Please – look beyond doctors and nurses

Please – look beyond doctors and nurses

The headline of the story in The Age on 20th March 2008 said “Sharing a load to close the health gap”. The opening par read “… Prime Minister Kevin Rudd and Opposition Leader Brendan Nelson signed the Close the Gap Statement of Intent along with a coalition of health leaders. The statement committed Australian governments to close the indigenous health gap by 2030.”

But please, will someone tell the policy makers, speech writers and “health leaders” that improving the health of Aboriginal people goes a lot further than doctors and nurses, signed statements and extra funding to Aboriginal health services.

The real risk factors that are keeping the life expectancy down to a 20 year plus difference to mainstream Australia lie in the fundamental provision of adequate housing, good personal hygiene, better domestic hygiene, improved diet, exercise and above all improved education.

It is all very well to improve infant mortality and have more children living to age five but of little sustainable help if by that age they have had a scabies infection that settles in the kidney or heart muscle to go on to cause end stage renal failure or rheumatic heart disease. This is the reality of Aboriginal disadvantage. Bigger and better housing will result in a clean living environment devoid of mangy dogs, mattresses on the floor, malfunctioning toilets and with food security.

It matters not how good the primary health care service is in a community if these external environmental factors are left unattended. It is the opinion of this writer that unless the environmental factors are fixed the downward spiral in Aboriginal health will continue.

Education of children (and adults) has got to improve to a point where this marginalised population in Australia can understand the consequences of their actions and are able to take an informed view of their living environment.

When bad health is normal it is hard for anyone to understand what good health means. It will take a generation to make a difference and that is assuming the education of children takes on a new meaning. When the majority of primary school age children fail to attend school it is hard to see this happening.

The health policy planners must come out of their silo and place pressure on the nearby cells of government administration to encourage them to adopt a “housing for health” policy. Social marketing strategies need to be boosted and programs such as the WHO “hand washing” campaign given a lot more exposure. It is futile to expect a change in behavior when the advertising industry is so heavily sponsored by unhealthy choices. Any Saturday afternoon during the football season the household is bombarded with ads for fast foods at a time when most are watching their favorite team.

Unless there is a concerted effort towards the environmental factors causing long term ill health no agreement towards the year 2030 will work.

It’s more than doctors and nurses and new health clinic buildings. More and better housing to suit the lifestyle of the people is the biggest factor that needs fixing along with better education.

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The Federal intervention into remote Aboriginal communities - Learning from children

A child’s education depends on the motivation of a parent to assist
them in going to school, help with reading and teaching basic discipline
and values in the culture in which they live.
By the same token a child can influence an adult to live a healthy and happy life with joy shared by each party as the years go by.

In the world of remote living Aboriginal people the children are left in many instances to fend for themselves as the parents pursue a lifestyle that their culture has only just discovered. The parents are still experimenting to see if it stacks up better than the traditional life of looking for food and shelter for the present and not worrying too much about the future. The pleasure of being able to have food readily available at a store or takeaway and the ready availability of alcoholic beverages make it a tempting lifestyle to pursue.
It could be said that there is no greater gift for a child than a healthy parent who lives long enough to see their grandchildren able to carry on the culture of the clan. As some say in the NT – “I want to live long enough to
watch my grandson play football”.

In mainstream Australia the life expectancy at birth is one that Third World countries will envy while the Aboriginal person is not sure what this is all about. They never knew when a birth date was to know the meaning of life expectancy. In fact the life expectancy of the remote living Aboriginal is as low as 47 years in many communities. The average that is quoted far and wide is across the entire population that claims to be Aboriginal with the majority of these people living in urban areas. The statistic is correct. It is just that the definition of Aboriginal person casts the net over a far greater cross section of the community than those Aboriginals that are being subjected to the Federal Intervention into Aboriginal Communities in the Northern Territory. In fact only 7% of the Aboriginal population in Australia lives in remote communities in the Northern Territory.

It is necessary, when taking a holistic view of the world of the remote living Aboriginal, to acknowledge that that the children hold a very special place in the demographic. It should be obvious that with such a low age at death the average age of a population will be lowered and children under the age of say 15 years will comprise a much larger proportion of the total than where the age at death is around 77 years.
Aboriginal populations are made up largely of children and therefore attention should be focused on them if the future is to improve.
The influence children can have over their parents in this scenario should not be underestimated. Just like any other culture the child is special as shown through the title of the report - “Little children are sacred”.

It is fair to suggest that if a child learns about healthy lifestyle choices there is every chance this will be passed on to the parent and other family members.

It should also assist the young child understand what choices in education, food, exercise, sleep, happiness and good companionship can have on good health.

Unfortunately the parents of the young children in communities in 2008 have lived their entire life in a community with health status on the decline.

To the parent it is normal for a friend to die at 40 years of age; for a grandparent to have to go on renal dialysis; for a younger brother or sister to have to go to Adelaide for a heart operation; and, for a lot of people to have to go to an alcohol and drug rehabilitation program to withdraw from an addiction.
To the parent born in the last 40 years this is normal and never having experienced good health – bad health becomes normal.
The Federal Intervention is about stabilizing communities (Phase One) and then “normalizing” those (Phase Two) – but what is normal?

The Balanda (white person) view of a normal community is not necessarily the way the Aboriginal person living in 75 locations across the Northern Territory and which are subject to the Federal Intervention wants to live.

The change planning process must come from a close evaluation of the needs as seen by the Aboriginal people themselves – and not just because some Balanda thinks it should happen or try and become a “normal” community like the suburbs of a city. This should go without saying but is being said because it is one principle that the government policy planners have failed to do over the past 40 years.

2008 is the opportunity for the Australian Government to acknowledge that this is the year to start planning with the Aboriginal people a community that meets their values and culture and thus has a distinct “look” of its own. The time has come to stop trying to put these people into little boxes in the same way as Balanda like to live. The often claimed fact that houses are overcrowded implies that the Aboriginal people are at fault because they have too many people in the one house. The real fact is that this is how they want to live as a family unit and the roof was simply not big enough in the first place.

There needs to be model programs established that test a whole host of concepts and beliefs that bring together the wisdom of the Balanda and the vision of the Aboriginal older person who can see the way the decline is affecting their culture.

To take pharmacy as an example and the role pharmacists can play in both public health and primary health care it is possible to build a curriculum that if conveyed to children could have a significant impact on the health of the adult population. It could impact on those suffering from chronic diseases and the ongoing burden of illness due to the environment in which the people are living.

In taking the example of pharmaceutical care it should be possible for children to learn some of the following principles that are inherent in achieving adherence through pharmaceutical management:

1. Understand the condition and what put it there in the first place before starting to look at management through pharmaceutical care. This involves explaining to children through interactive media the common chronic disease states in the community.

2. The use of medicines in managing chronic diseases and the fact that medicines are for sick people and if well people take drugs they might get sick.
This poster (left) was drawn by Linda Joshua from Numbulwar during a pharmacy training session for Aboriginal Health Workers at Bachelor Institute. Input to programs by Aboriginal people is essential to success.

• 3. The importance of adherence – sticking to the doctors recommendations for dosing and when to take them. This would also cover the use of Dose Administration Aids and that Websterpaks (or similar) are the lifeline to a healthy life and should not be tampered with by anyone but the person for whom they have been prescribed.
• 
  4. The dangers of chemical substances when not used correctly or stored properly.”If its poison you can’t kiss it better” should be the slogan (or similar) to bring the message of safety home to young children.
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  5. Substance abuse and the problems inherent in drug and alcohol abuse by learning about the effect that these substances, along with cigarettes, have on the health of the individual.

6. Misuse of medicines and the way over use of some medicines can cause serious problems. Emphasis can be given to the need to follow the directions on a pack or label. Paracetamol is the most used drug in communities and overuse of it combined with other liver damaging choices can create an insidious illness of hepatic failure that could easily be put down to simply “not feeling well”.
7. Public health programs through education on subjects such as smoking, nutrition, breast feeding, immunization, sexually transmitted diseases and healthy skin are all ones which a pharmacist can contribute to because of their understanding of the treatment processes.

It is to be hoped that in Stage Two of the Federal Intervention there will be the opportunity for pharmacists to be involved. The record of the health authorities at both State/Territory level and nationally is not great in giving pharmacy a status of much more than a supply agent. The value pharmacists can add to primary and public health education can be finally tested on an exercise such as the NT Intervention into Aboriginal communities.

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It’s a new world with new diseases – don’t expect me to understand

A novel way is needed of remembering to take medicines - seriously
It is less than 50 years since many remote living Aboriginal people were living in a traditional way; obtaining their food largely from hunting and supplementing this with the basics of western diet such as flour for making dampers. In 2008 the Australian health authorities are faced with an epidemic of chronic diseases brought on by too rapid a change to fast food, TV advertising of junk food and alcoholic beverages. During this period tobacco was first portrayed as an appropriate and smart thing to do. Then advertising was banned and the message has turned around.
Australian Aboriginal people have been abruptly confronted with a totally different world to the one in which they were raised. Their children, born in the last 30 years, are growing up in an environment where most of their elders suffer ill-health, with an epidemic of diseases such as diabetes, cardio-vascular diseases, renal failure, asthma and heart failure.
These are not diseases understood by the traditional belief systems of the Aboriginal people or their traditional healers. There are no traditional remedies for clearing hardened arteries, or reducing blood cholesterol. By the same token, the concept of lengthening the life span of a person already feeling bad may conflict with beliefs that welcome the chance to pass away and have their spirit return as a better being.
The task of introducing western concepts of ongoing medication a group of people who do not understand why they are feeling sick is made more difficult by virtue of the fact that the people have English as a second language. The younger generations have better English skills but do not have the disease and medication knowledge, the doctors do not have the skills in local languages. The present generations of Aboriginal Health Workers have not been trained to address medication adherence.
The successful use of medicines to manage chronic disease will only occur when the person understands their illness, their body and how it is affected by life style choices that oppose healthy living. So little has been achieved over the past 30 years that people who are growing up in 2008 will only experience a community that is in a constant state of ill health which then becomes perceived as normal. Children will expect to get overweight and diabetic.
Australian Aboriginals with chronic disease will be confronted with the medical jargon of the doctor or the need for exercise by the diabetic educator; and, if there is the opportunity in the mix of allied health professionals, the pharmacist or pharmacy assistant on the notion of taking medicines as directed, regularly, at the time specified and with or without food.
The mix is already confused with language meaning that understanding is poor and adherence minimised to a dangerous level that leads to avoidable complications and hospitalisation.
The consequent temptation to spend the available money on quick fixes is too great for the uneducated person. That means the purchase of fast food for an unbalanced diet and the hazards of alcoholic beverages and other drugs (especially marijuana) to take the stress out of an otherwise boredom riddled day.
Strategies to address medication use in Aboriginal people, especially those from remote areas, must be founded upon their view of the world.
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