Two ways to health by Tom Ganderton

Two ways to health Closing the gap on health in the Northern Territory

Darwin

Newcastle Waters

Tennant Creek WALPIRI language group (approximate area) ALYAWARR language group (approximate area) ANMATEYERR language group (approximate area)

Amperlatwaty Alparra

Ti Tree

Utopia Homestead Camel Camp

Alice Springs

EASTERN ARRERNTE language group (approximate area)

WESTERN ARRERNTE language group (approximate area) CENTRAL ARRERNTE language group (approximate area)

Map of Australia ÂŠ Commonwealth of Australia (Geoscience Australia) http://creativecommons.org/licenses/by/2.5/au/.

Elliot

In Australia, the life expectancy of Aboriginal and Torres Strait Islander Peoples is around 17 years lower than that of non-Indigenous Australians. The infant mortality rate for Aboriginal and Torres Strait Islander Peoples is twice that of all Australians. And Aboriginal and Torres Strait Islander Peoples are three times as likely to report some form of diabetes than non-Indigenous Australians.1

Indigenous Peoples have rights to specific measures to improve their access to health services and care

The Federal Government has committed to improving the health outcomes of Aboriginal and Torres Strait Islander Peoples and closing this life expectancy ‘gap’ within a generation. Significant political and financial investments in one-size-fits-all solutions, research proves that blanket policies cannot deliver the desired results. Instead, an integrated human rights solutions – one that empowers people and engages them to take responsibility for the solutions – is required. The success of this approach is exemplified by the Urapuntja Health Service, a community-controlled Aboriginal health service provider on the Utopia homelands in remote Australia. The Utopia homelands comprise 16 dispersed communities (or suburbs) spread over roughly 3,000 square kilometres north of Alice Springs in the Northern Territory. Amnesty International began working with the Alyawarr and Anmatyerr Peoples in Utopia in 2008. Over a period of three years, comprehensive research was conducted with the free, prior and informed consent of communities and using a participatory model, with Alyawarr and Anmatyerr people working alongside Amnesty International staff.

The right to health under international law All people have the right to the highest attainable standard of physical and mental health under Article 12 of the International Covenant on Economic, Social and Cultural Rights. The right to health does not necessarily translate as a right to be healthy, but states do have obligations to provide the conditions and services to ensure that people have the best chance to be healthy.2 The Committee on Economic, Social and Cultural Rights defines how this right should be implemented: •

The state has a duty to make available adequate healthcare facilities, with trained professionals and essential medicines.

•

Health facilities, goods, services and information on health must be physically and economically accessible to everyone, without discrimination.

•

Health facilities, goods, services and information on health must also respect medical ethics, be culturally appropriate and sensitive to gender and life-cycle requirements.

•

Delivery of health services requires, among other things, skilled medical personnel, scientifically-approved and unexpired drugs and hospital equipment, safe and potable water and adequate sanitation.

Indigenous Peoples right to health Under international law Indigenous Peoples have rights to specific measures to improve their access to health services and care:

Road sign showing direction to a few of the 16 Alyawarr communities in the Utopia homelands. © Mervyn Bishop/AI Map showing Alyawarr and Anmatyerr Aboriginal communities in Australia’s Northern Territory.

•

Services need to take into account traditional preventive care, healing practices and medicines – recognising and protecting the vital medicinal plants, animals and minerals necessary for the full enjoyment of health for Indigenous Peoples.

•

In Indigenous communities, the health of the individual is often linked to the health of the society as a whole and has a collective dimension. Any displacement of Indigenous Peoples from their traditional lands against their will denies them sources of nutrition and breaks their connection with the land. This has a deleterious effect on their health.

•

Importantly, resources should be provided for Indigenous Peoples to design, deliver and control health services.3

1. Australian Human Rights Commission 2008 Face the Facts AHRC, Sydney. 2. Committee on Economic, Social and Cultural Rights, General Comment 14, The right to health, UN Doc. E/C.12/2000/4. 3. Committee on Economic, Social and Cultural Rights, General Comment 14, The right to health, UN Doc. E/C.12/2000/4 para 27.

“We show the nurses two way” Joycie Jones Pitjara, Ngangkar, traditional healer and community health worker, Urapuntja Health Service

THE RIGHT TO HEALTH ON ALYAWARR HOMELANDS Urapuntja Health Service The Urapuntja Health Service is an Aboriginal Community Controlled Health Service that was established at Utopia in the Alyawarr homelands in 1978. It services approximately 1,400 Alyawarr people living on their traditional homelands across more than 3,000 square kilometres in the central desert region of Australia. The clinic is overseen by a board of elders and community leaders who govern the clinic and appoint staff including the CEO, doctors, nurses, Aboriginal community health workers, administrators and drivers.

Joycie Jones Petyarr and driver in a four-wheel drive used to deliver health services to the remote Utopia homelands communities. © Mervyn Bishop/AI Roselene from the Urapuntja Health Service clinic. © Mervyn Bishop/AI The Royal Flying Doctor Service transports a patient from Utopia. © Mervyn Bishop/AI Sarah Doherty, CEO of the Urapuntja Health Service. © Mervyn Bishop/AI Dorrie Jones Petyarr and Joselyn Jones Petyarr of Soapy Bore winnowing seeds. © Mervyn Bishop/AI

Amnesty International May 2011

Protecting, respecting and fulfilling the human rights of Aboriginal Peoples is fundamental to the philosophy of the health service and informs how health services are delivered in the Utopia homelands. The Alyawarr Peoples describe it as ‘two way’. Two way reflects a genuine partnership between Aboriginal people and health service providers. It combines Western, scientific and Aboriginal knowledge of health and healing, using both modern and traditional medicines. Services are delivered by doctors, nurses and Aboriginal community health workers in a way that reflects the reality of Aboriginal lives in remote Australia and respects Aboriginal culture and law. Two way also refers to the control of health services being shared between Aboriginal governance structures and the health service providers. This model is the embodiment of a rightsbased approach to healthcare delivery.

A DAY IN THE LIFE OF THE URAPUNTJA HEALTH SERVICE A trip to the suburbs

patients with Centrelink and medical forms and phones the Alice Springs hospital when families need to check on relatives. She says that it helps to be local and Aboriginal. And she loves her job.

Each day the Urapuntja Health Service visits one of its 16 homeland communities. A doctor, nurse, community health worker and community driver set out in a four-wheel drive and travel as far as 150 km over rough dirt roads. Each community has its own clinic building where consultations are held. The two way philosophy means that community health workers act as liaisons between members of the community and the other medical staff. They interpret between English and Alyawarr and manage kinship relationships and men’s and women’s health needs. This means that trusted conversations are held in the Alyawarr language and ensures that women speak to women and men to men.

Joycie Jones Pitjara is a community health worker. She loves her job because it helps her work within the two way philosophy and helps her people. One of the ways she works two ways is by making bush medicine the way she learned from her grandparents.

Back at the clinic

She is concerned about losing the traditional knowledge that has been passed down to her, especially if people move off their traditional homelands. “How will little kids know?” she says. “Move into town, we lose it.”

Roselene looks after the clinic. Her workload would probably fill three jobs in the city. Roselene knows everyone and knows who lives where – valuable knowledge in a sparsely-populated community scattered over thousands of kilometres with dusty corrugated roads and few telephones. She works closely with the Alyawarr drivers who pick up community people for clinic visits and sometimes take others to the Alice Springs hospital 260 km away. She also organises Royal Flying Doctor Service evacuations of patients to hospitals in Darwin or interstate. Roselene is an important bridge between members of the community and the government bureaucracies. She helps

She says that in order to keep making and using bush medicine, Alyawarr people need to live on their traditional lands. “We need country to work both way,” says Joycie Jones Pitjara. “If we move out somewhere else we forget about bush medicine. It’s important for us to know. Bush medicine help both way. Bush medicine is good for them [non-Aboriginal people] too.”

Joycie Jones Pitjara’s other important role is to help the doctors and nurses, “to know the Aboriginal way, to know Aboriginal law”. She knows what’s happening on homelands and goes out on visits with the other medical staff. She makes them aware of cultural protocols. She says that she “shows nurses two way”. Most importantly, Joycie Jones Pitjara says her relationship with the doctors and nurses is about mutual understanding and respect: “People who come to help us, we help them too," she says.

THE ORIGINS OF ‘TWO WAY’ HEALTHCARE The two way health philosophy emerged at the Urapuntja Health Service in the 1980s, when Alyawarr Peoples and Western doctors began working together. Since then, the Board has been vigilant in maintaining it. Dr Kamandra Suraswati (Dr Kam) has worked with the health clinic since 1984. Dr Kam works closely with his long-term friend and mentor, Aboriginal elder and chair of the Board Albert Bailey Kemarr. Together they train new doctors and nurses and encourage them to embrace the Alyawarr worldview and two way philosophy. “This is a viable Indigenous culture with the warmth and the spirituality and the incredibleness of that culture,” says Dr Kam. “No-one feels that, no-one understands that unless you sit down in it. “There’s all the very complex, obscure, tertiary-level medicine. It’s not that that’s going to save people … [it is] getting out there, working on the relationships, doing the basic primary healthcare … vaccinations, weights, de-worming, chronic medications, blood tests … that’s the kind of stuff that’s going to close the gap. This … is a different kind of speciality and we need spirited souls to take it on.” Sarah Doherty is the Chief Executive Officer of the Urapuntja Health Service. She is also committed to the two way philosophy: “When I deal with the Board for the Urapuntja Health Service, I’m working for a council of elders that have complete authority over what happens here at Utopia,” she says. “My philosophy around my role is to support community authority and ensure that the voice of Utopia is in the mix and in the wider conversations around health.”

Amnesty International May 2011

Success of two ways A study by the Medical Journal of Australia published in 2008 found that despite the steady rise of obesity and diabetes nationally, the people living on the Utopia homelands were significantly healthier than other Aboriginal and Torres Strait Islander Peoples. Alyawarr Peoples have worked to address the problems of obesity, diabetes and smoking so successfully that adult mortality rates from all causes have been consistently 40 per cent lower in Utopia than among Aboriginal people in the Northern Territory generally. Deaths from cardiovascular disease are 50 per cent lower.4 The study concludes that contributors to lower than expected morbidity and mortality are likely to include the nature of primary healthcare services as well as the decentralised mode of living, with its attendant benefits for physical activity, diet and limited access to alcohol. Connectedness to culture, family and land are also important factors. The evidence shows that living on homelands and using a two way approach to the design, delivery and control of health services has tangible health outcomes that close the gap in Aboriginal and Torres Strait Islander life expectancy. As Dr Kam explains: “It [the study] demonstrates that if people are given a chance to be in charge in their own context, there is the capacity within that culture to make life-affirming decisions; healthy decisions about the way that they do things. This is a living example that it can. It doesn’t mean there are not a lot of problems; there’s still a huge [life expectancy] gap. But we’ve shown that our gap is 30 to 40 per cent less that the gap anywhere else. From a purely pragmatic point of view, 30 to 40 per cent less chronic disease … that’s 30 to 40 per cent less hospital time and less money spent.”

The Urapuntja Health Service model is an example of a rightsbased approach to health. The evidence shows that when health services are accessible, available, appropriate, of a good quality and function in true partnership with Aboriginal peoples, it is possible to close the health gaps that exist between Aboriginal and Torres Strait Islander peoples and other Australians. As Sarah Doherty says: “I’m not talking about anything new but what I’m saying is that to close the gap … it’s not about more pills, more vaccines, more emergency nurses. It’s about more people who are willing to sit down with people and ask them what their health needs are and how they can meet those needs. That’s what will close the gap … working with community and deeply listening to the community and developing a health service that’s appropriate for that community, because you can't do one model that fits all”. 4. Kevin G Rowley, Kerin O’Dea, Ian Anderson, Robyn McDermott, Karmananda Saraswati, Ricky Tilmouth, Iris Roberts, Joseph Fitz, Zaimin Wang, Alicia Jenkins, James D Best, Zhiqiang Wang and Alex Brown 2008 "Lower than expected morbidity and mortality for an Australian Aboriginal population: 10-year follow-up in a decentralised community" Medical Journal of Australia 188 (5): 283-287

CONCLUSION It is incumbent on all levels of government to realise that closing the gap is not simply a health issue. It requires a whole-ofgovernment approach – an approach that places human rights at its centre and allows Aboriginal and Torres Strait Islander Peoples to exercise all their rights. Active engagement for longterm solutions must be made local, personal and perennial. A rights-based approach is inclusive of Aboriginal and Torres Strait Islander governance and the two way philosophy for all areas of service delivery. As Alyawarr elder Rosalie Kunoth Monks says: “What we need and demand is our dignity and rightful situation in Australia. We are Australians. We are not reluctant to take up the challenge and own a journey which might take us closer to closing the gap which the Prime Minister talks about. But they do not have to destroy the spirit or ethos of who we are.”

RECOMMENDATIONS Urapuntja Health Service staff. © Mervyn Bishop/AI Dr Kamandra Saraswati, one of the doctors working with the Urapuntja Health Service. © Lucas Jordan/AI Alyawarr elder Rosalie Kunoth Monks. © Mervyn Bishop/AI Albert Bailey Kemarr, Chair of the Urapuntja Health Service Board and senior elder of the Anterrengeny homeland. © Rusty Stewart/AI

That the Federal and Northern Territory governments recognise that one-size-fits-all health service delivery does not work and commit to designing health services in partnership with Aboriginal communities, based on the realities of the location in which people actually live. That the Federal and Northern Territory governments acknowledge that Aboriginal people are committed to their homelands and support those communities in closing the gap in the Northern Territory.

Amnesty International is a global movement of more than 2.8 million people in more than 150 countries and territories who campaign to end grave abuses of human rights. Our vision is for every person to enjoy all the rights enshrined in the Universal Declaration of Human Rights and other international human rights standards.

Cover: Joycie Jones Petyarr, community health worker with the Urapuntja Health Service, showing traditional bush medicine she produces as part of the ‘two way’ health philosophy. © Mervyn Bishop/AI

We are independent of any government, political ideology, economic interest or religion – funded mainly by our membership and public donations. Publication date: May 2011 Amnesty International ABN 64 002 806 233 Locked Bag 23 Broadway NSW 2007 1300 300 920 supporter@amnesty.org.au www.amnesty.org.au