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Health service needs

Characteristics of Miwatj Health’s Clients

The Aboriginal clients of Miwatj Health typically have English as a third or fourth language, have low incomes, are strongly linked with traditional culture, may have little Western schooling, often live in overcrowded accommodation and probably do not have stable ongoing employment. Of course there are many individual exceptions to this picture, but in a population sense it is broadly accurate.

The western economy of the region is dominated by two large mines, one on Groote Eylandt and the other near Nhulunbuy. Historically, Aboriginal people have been excluded from active participation in the mining economy, and there are indicators that that Aboriginal communities closest to the mining towns, especially Nhulunbuy, may in fact have worse health status than many of the more isolated (homeland) communities. In recent years the mining company has set up a training scheme for Aboriginal people, but the overwhelming majority of mine workers remain non-Aboriginal.

Nevertheless, a hybrid economy has emerged in recent years based on a combination of small-scale tourism ventures, commercial art and craft, land management activity, mining royalties, a range of local enterprises including a regional airline and the annual Garma Festival. In this way, and through some very articulate spokespeople, Aboriginal people from the region are engaged with the modern world while also tied to land and tradition.

The health profile of the Indigenous population of the Miwatj region accords with the generally poor health status of Aboriginal people in the NT as a whole. Often disadvantaged from the start by a low birthweight, an Aboriginal child from this region typically faces a much higher risk of infectious diseases, anaemia, pneumonia, otitis media, skin diseases such as scabies, rheumatic heart disease, lack of dental care and so on than a non-Indigenous counterpart.

In the causal interplay between child health and chronic illness, the longer-term outcome is very high rates of chronic disease, particularly Type 2 diabetes, cardiovascular disease, renal disease, lung and other cancers.

Chronic illnesses dominate the client files at Miwatj Health. But it was not always like this: 50 or 60 years ago these diseases were rare among the Aboriginal people of this region. In this sense the cause of today’s poor health is obvious - the creation of centralised settlements, the ready access to junk food and tailor-made cigarettes – these and other aspects of western society undermined the resilience which traditional lifestyles had developed over a very long period.

The health needs of Miwatj Health’s clients

A traditional Aboriginal view of health is that the underlying cause of illness is disruptions in social relationships – which are ultimately based on the relationships between humans and land – and many see the poor health they have experienced since the opening of the mines and the construction of the non-Indigenous mining towns in the late 19060s/early 1970s as evidence of this.

Historically, the main response of Yolngu to threats to their health and wellbeing has been to develop their homeland centres, small family-based settlements on traditional land away from the alcohol and other harmful influences of Nhulunbuy and the ex-missions. The understanding that homeland centres are a way to counter illness continues among Yolngu today.

As a community-controlled organization, Miwatj Health is bound to take this community perspective into account, and so must provide clinical individualized medicine while also tackling the social determinants of health.

From a public health perspective, the key point is that most of the chronic diseases which fill the files of Miwatj Health are preventable. The evidence from many populations over many decades is overwhelming: chronic diseases can be prevented, and also to a large extent managed once contracted, by modifying lifestyles – in particular, we know that changes in exercise, diet and cigarette smoking would prevent a major portion of today’s chronic illness deaths. Achieving such changes is, of course, not easy, but it is fundamentally important to note the agreement between the western view that diet and exercise are the answer and the Yolngu view that homeland centre life is the answer.

The conclusion from the above discussion is that an important part of Miwatj Health’s service provision must involve taking health outside the town-based clinics, delivering health services as close as possible to where people live – to bring it into people’s daily lives through education, health promotion and related activities. The community-based public health programs of Miwatj Health aim to achieve this in the areas of tobacco control, eye health and some mental health problems. Of course there is a need for more, particularly in the areas of nutrition and environmental health, if funds were available.

Improvements in medicine over the past two or three decades have meant it is now possible to manage many chronic diseases far more effectively than in the past. Modern drugs can drastically reduce mortality from such previously-fatal illnesses as cardiovascular disease, and the idea that patients can now self-manage their illnesses through compliance with medication regimes is seen as best practice in chronic disease care.

Recently-published data shows clearly that the nature of health problems has changed greatly in recent decades. The situation in the NT now is not only that Aboriginal people are dying at a relatively young age, but that much larger numbers of Aboriginal people are living longer while carrying a greater burden of ill-health. Any improvement in the burden of fatal outcomes has been more than offset by significant increases in the prevalence and severity of non-fatal conditions. This change has big implications for any primary health care service - more health care resources must now be devoted to longer-term conditions, and the method of delivery of health care must be more focused on prevention and patient self-management.

Yuejen Zhao, John R Condon, Stephen Guthridge and Jiqiong You, ‘Living longer with a greater health burden – changes in the burden of disease and injury in the Northern Territory Indigenous population between 1994-1998 and 1999-2003’, Australian and New Zealand Journal of Public Health, Vol 34 No S1, 2010.

In the past two years Miwatj Health has made a deliberate effort to increase the staff resources allocated to longer-term prevention, and to access people who do not normally attend a clinic. The main way we have achieved this is through the creation of a number of mobile teams, which operate out of specially-equipped vehicles and provide an outreach service to those communities where there is no fixed clinic and to people’s houses. There are mobile teams for chronic disease, child and maternal health, and men’s health. The men’s health team is a recent development, and is a response to clinic data indicating the proportion of our male clients is much smaller than the proportion of our female clients. The mix of services provided by Miwatj Health is therefore a combination of clinical services with a focus on long-term care planning, and the provision of acute care services when necessary. This is complemented by community-based programs aimed at the risk factors underlying chronic illness and poor child and maternal health.

Miwatj Health is confident we are on the right track with this mix of services – the causes of the main illnesses affecting our Aboriginal clients are not a scientific mystery, and our programs are based on strong scientific evidence of what works. But having the evidence is often not enough – to successfully deliver primary health care in remote parts of the NT requires an approach which is flexible and which recognizes the decentralized nature of Aboriginal populations. The challenge lies in applying evidence in the context of a highly mobile population which has its own way of viewing the world, and where the social determinants of health – housing, access to good food, land tenure, employment, smoking habits, and so on – mean the odds are stacked against us.