Tue 22 Nov 2005
Presenters:
Dr John Daniels, director of health services and research
at Redfern Aboriginal Medical Service (AMS).
Mr Maurice Shipp, public health co-ordinator at Redfern AMS.
Case Histories: Dr Yianni Faros and Michael Englert, nurse unit manager, AMS.
This meeting began with an overview of the link between indigenous culture and health. Regardless of lifestyle choice in either a more traditional setting or westernised urban area, Aboriginal people are a separate cultural group linked by a sense of belonging to a specific locality or extended family. The three widely accepted components of Aboriginal cultural identity were outlined. These are self-identity as an Aboriginal person, being the descendant of an Aboriginal person and being accepted by a particular Aboriginal community as belonging to that community. Maurice Shipp emphasised how the latter point underlines the seamless continuity between the individual person and their community. He discussed how the traditional kinship systems continue to have a powerful influence over contemporary family structures. An example of this would be how the children of two brothers may call each other brother and sister, rather than cousin, and that a person could therefore have several mothers and fathers. For an Aboriginal person, their mother's sister is their mother, but their father's sister is not their mother, but their aunt. Various rights and obligations may be expressed by these relationships and, with regard to any one individual, involve many members of the family and community.
It was pointed out that all of the world's indigenous peoples have a legally enforceable power to obtain and protect their human rights, via the Universal declaration of Human Rights to which Australia is a signatory. However, there are significant anomalies between the Articles within this Declaration and the current situation of Aboriginal and Torres Strait Islander (ATSI) people.
Maurice Shipp talked about various aspects of Aboriginal culture that are shared by different Aboriginal groups. These commonalities include a "world view" that expresses itself in religion, art, dance, music, language and kinship, and individuals within different Aboriginal communities will share these links, though they may differ from one community to another. However, common to all Aboriginal communities is the regard that is given to custodianship, in which all aspects of Aboriginal knowledge are sacred. Certain types of knowledge may only be permitted to be transmitted by certain people. Within particular communities young people may be picked to go through law, even as young as thirteen. Kinship within community is central to Aboriginal conceptions of identity and Maurice Shipp emphasised that Aboriginal people know who their families are. Even cousins, "sixth removed" by western definition, are regarded as close. Historical continuity is another commonality linking all Aboriginal people together, and Australia's indigenous people have at least a 60,000 year history here, ie something like 2400 generations of family living in Australia of which 2392 passed before European settlement. This gives a very deep sense of attachment to family and land; a powerful sense of ancestry. Another commonality between Aboriginal communities is the preservation and renewal of culture, the emotional and spiritual development that has continued to evolve up to and including this present day.
It was pointed out that there are about 70 different Aboriginal language groups in NSW and about 600 nationally. There are even more dialects, around 1,500. They are all absolutely distinct from one another and stem from different root structures. They are grammatically very complex and difficult to learn. For example, the beginning, middle or end of a word may change according to its context, and the meaning of words change according to who is talking to who. There are several languages still spoken in their full context particularly in remote Australia, and urban Aboriginal people often pepper their speech with Aboriginal words from their particular community group. This Aboriginal English is formally recognised by linguists as a distinct form of English and is an important means of expressing Aboriginal identity. It has a distinctive range of accents, incorporates local Aboriginal words, and shows unique grammatical features.
Dr John Daniels outlined some of Australia's shame in his summary of current mortality facts pertaining to Aboriginal people. The life expectancy of Aboriginal men is only 56 years, almost 21 years less than their non-indigenous Australian counterparts. For Aboriginal women the life expectancy is 63 years, about 19 years less than their non-indigenous counterparts. Dr Daniels contrasted the causes of death for Aboriginal people versus non-Aboriginal people.
Circulatory diseases account for 27% of Aboriginal deaths, and this compares with 36% for non-Aboriginal. Aboriginal people between the ages of 25 and 44 have ten times the death rate from circulatory disease. External causes of death (self-harm assault, murder) account for 20% of all ATSI deaths, and for non-indigenous people this figure is 6%. Neoplasms account for 14% of Aboriginal deaths, compared to 29% in non-indigenous people. It was emphasised that Aboriginal health data is very similar between rural and urban communities, and that life expectancy is also the same. Disease patterns are also largely similar, with some variations between remote and urban settings noted for particular diseases. Trends in these patterns can only be assessed over a very long time-frame, and whilst the current situation is a national emergency, Dr Daniels did point out that better access to health promotion and health care services are at least positive influences.
There was some discussion of the current situation with regard to blood-borne viruses in Aboriginal people. There are 190 notifications of HIV nationally in Aboriginal people, and 68% of these are in men. Two-thirds of the positive people live in Sydney and there have been about 19 notifications per annum since 1995. The overall prevalence of the HIV is therefore similar to that seen in the non-indigenous population, however whilst Aboriginal people are not over-represented nationally in HIV statistics, this obscures the experience of Aboriginal communities and health service providers in the focal outbreaks that have occurred. Dr Daniels gave an example of this when mentioning a cluster that occurred in Redfern in 1984. It is also important to understand that the pattern of occurrence of HIV in indigenous people is different. Heterosexual transmission is three times higher among Aboriginal people than non-Aboriginal people and 32% of people who are positive are women (compared to 11% for non-indigenous women.) 14% of Aboriginal people who are HIV positive are IVDU compared to only 3% in the non-indigenous population. Between 1995-2004 there were 22 cases where IVDU was the sole method of transmission, and an additional 12 cases where IVDU was a co-risk factor with sexual transmission.
Collection of data on incidence and prevalence of hepatitis C in Aboriginal communities needs to be improved, as many reports don't comment on Aboriginal status. However, Dr Daniels told us that there is almost certainly a higher prevalence of hepatitis C in the Aboriginal community, and that we are yet to see the real burden of disease.
The session finished with some excellent case presentations by Dr Yianni Faros with commentary also from Michael Englert (see below). Optimism for the future was inspired by the creative and thorough way in which the Redfern team deliver health care to the ATSI people who visit their dependency service.
Summary written by Dr Jenny James. Daruk AMS.
Case Studies
Dr Yianni Faros presented three case studies from the Aboriginal Medical Centre at Redfern.
The first was a 29yo man with a history of IDU since his teens, and large heroin habit, whose buprenorphine treatment was unsuccessful owing to poor attendance. Despite accepting only low dose methadone, which he supplemented with heroin, his attendance improved. He later experienced symptoms of withdrawal and received inadequate analgesia when hospitalised for gunshot wounds, due to loss of this illicit opiate intake, his partner bringing in Buscopan for his symptoms. He and his partner perceived suspicion and hostility by hospital staff which they attributed to racism and his being "already on methadone".
The next case was a 34yo woman, homeless with two children, yet also looking after the children of her sister. She had been injecting for ten years and had a $250 per day heroin habit. After being stabilised on methadone, she changed to buprenorphine because of the stigma of methadone. With a coordinated team approach to her care, over 4 years she established housing away from area of drug use, dosing at a community pharmacy, developed improved parenting skills through contact with local community health centre, received instruction in financial planning skills, hepatitis B immunization and hepatitis C assessment, formed a new stable relationship, and managed to move back to the area she grew up in and remain abstinent.
The last case study was a 29yo man with bipolar disorder, renal impairment secondary to lithium toxicity and $200/day heroin dependency. After unsuccessful methadone treatment, he received buprenorphine with variable periods of abstinence following. Written reports were provided for Section 32 applications in relation to outstanding warrants, and he spent reduced time involved with the Justice System. A drop-in service was negotiated for care after many failed attempts for psychiatry appointments. After four years, his drug use was down to once a week, he was compliant with psychiatric medications, and was talking of getting a job as a gardener.
These case studies illustrated points of particular relevance to Aboriginal people, such as the importance of unpressured, respectful communication, the importance of extended family ties, and the value of coordinated approaches to health based in culture and community. There were also lessons applying to all people on opioid replacement treatment, such as the need for adequate analgesia, and the differing sorts of treatment retention and compliance issues with methadone and buprenorphine.
Next year's program is being finalised presently. We will start on Tues Jan 31 with Dr Adam Winstock speaking about drugs, alcohol and driving. "Do we have to inform authorities about such matters?" (eg. RTA as well as DOCS, Medical/Nursing Boards, etc?).
