Issue 26 / 11 July 2016

ARE you sitting comfortably? Well, perhaps you shouldn’t be. When it comes to Aboriginal and Torres Strait Islander health, we’ve known the statistics showing the gap in health outcomes for a while now.

While there have been some improvements, they have not so far been at the rate required to meet the Closing the Gap targets.

As doctors, when we see a problem, we see a need for education. Education, of course, is helpful, but perhaps not all education, and it may well be that we get trapped in hidden curricula that obstruct us from making real progress.

In our thinking and teaching about Aboriginal health, we fall back on what makes us comfortable in medical education, and this leads us to think about Aboriginal health in ways which are incomplete and unhelpful.

Aboriginal health as a set of medical conditions

Medical education of course involves teaching about different diseases. Symptoms are related to differential diagnoses. History, examination and investigations are geared towards identifying the correct diagnosis to get the correct treatments.

This can lead us to think of Aboriginal health as a collection of diseases. We always include type 2 diabetes, renal disease, cardiovascular disease, otitis media, perhaps drug and alcohol abuse and mental health.

But what about systemic lupus erythematosis, which has a high prevalence? What about breast cancer, which has lower incidence but higher mortality? Are we not closing the gap because these diseases aren’t taught adequately? Shouldn’t we be able to manage our Aboriginal patients no matter what their presenting complaint or their diagnoses?

It’s rare that an Aboriginal patient will say that it was the clinical knowledge about their diabetes that was at fault. Placing Aboriginal health in the realm of a set of diseases is firmly within our own education comfort zones.

Aboriginal health as risk factor

When learning about diseases with no clear cause, we learn about the things that predispose people to those conditions – risk factors.

You know them all: smoking, sedentary lifestyle, junk food, cholesterol.

The problem with adding Aboriginal to this list is it makes us assume it’s another pathology to be cured. Rather than Aboriginal health being a collection of diseases, being Aboriginal is the disease.

In fact, the opposite is the case. People who are connected to their culture are healthier – being Aboriginal is the cure!

Aboriginal health as seeing lots of Aboriginal patients

We often assume that by working in the Northern Territory or other parts of rural and remote Australia with a high proportion of Aboriginal patients, we’re doing Aboriginal health.

In fact, we’re just seeing Aboriginal patients! Of course, we need to see them to make some sort of difference, but if all we’re doing is treating everyone the same, then we’re not meeting the need.

Cultural education is crucial, but too often we imply that “they” – those Aboriginal people, different to us – have a culture but we don’t, and if we get to know it better then we can teach them to be more like us.

We need to start from a position of recognising our own cultures, including our professional cultures and the cultures of our health services. Often they can be highly off-putting for many of our patients.

Then we need to recognise the parts we can change. For some of us that will be in the way we consult. Others may have control over the appearance of waiting rooms or billing policies. Some are able to choose to employ Aboriginal staff and to create management that allows Aboriginal decision making over our practice.

This recognition of our own cultures and attempts to do things differently isn’t easy and can make us uncomfortable. But let’s pause for a moment and think of our Aboriginal patients. How much more uncomfortable have they been, and for how much longer?

Dr Tim Senior works as a GP in Aboriginal and Torres Strait Islander health. These are his personal views. He says: “I refer to Aboriginal health, as that is where most of my experience lies. It is likely that these thoughts also apply to our thinking about Torres Strait Islander health as well.”

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When history-taking, doctors should routinely ask patients about their Aboriginality
  • Agree (25%, 18 Votes)
  • Strongly agree (22%, 16 Votes)
  • Neutral (22%, 16 Votes)
  • Disagree (21%, 15 Votes)
  • Strongly disagree (11%, 8 Votes)

Total Voters: 73

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9 thoughts on “Putting Indigenous patients before our discomfort

  1. mrk wenitong says:

    hey Marcus – try these –

    by wendy hoy,

    or this one google early life and chronic disease risk by prof paul zimmet (baker IDI)

    easiest solution is ramp up antenatal care and nutrition and family functioning – all do-able

  2. michael kennedy says:

    A lot of interesting comments.

    A family history is essential in almost all areas of medicine and it is interesting to find that  occasionally one mentions that their one of their grand or great grandparents was Aboriginal. These patients are probably not  included in any of the Aboriginal health statistics and are simply receiving standard specialist medical services.

    Dr Senior’s  should specify that his comments relate to Aboriginals in particular locations.His comments do not relate to all patients who are of Aboriginal origin many of whom have clearly “closed the gap” in their health care but seem to be missed in the statistics. 

  3. Marcus Aylward says:

    Cool article; thanks inky.

    All we need now is the translational article on clinical application so that we can improve outcomes for our Aboriginal patients, especially as now, according to Dr Fenelon, organs systems are apparently but a petty detail in the new medical paradigm.

  4. mark wenitong says:

    hey marcus – heres a link to the latest science – i mean its only “Nature mag”

  5. Dr Louis Fenelon says:

    I think what was being said is that if you don’t understand what matters to the health of indiginous people, you can’t  understand how to help. Getting into petty detail about organ systems and risks may be missing the mark of what is ailing. I really like what little I know about traditional culture and how that impacts health. The traditions of linking health to life, activity and the seasons and the space is cool. I understand alternate patient treatment and outcome priorities and basic rules of communication. It’s a start.

    What’s missing for me is being in that culture to be able to deliver appropriate health. It almost doesn’t exist where I am, I am not asked to be part of it and wouldn’t expect to be. To most Australian doctors, access to traditional Aboriginality is nil. That’s because most of us work in urban areas in ways expected of us (or dictated to us) without inclusion.

    I don’t know what the answer is, but I have learned you can’t compare traditional Australian culture. Not to Chinese, white Australian or any other culture. I also suspect the medical profession knows what it feels like to have your culture erode away into the sands of time. Change is not always for the better.

  6. Marcus Aylward says:

    Hey Inky, epigenetics is, for the 21st century, what psychoanalysis was for the 20th: a nice catch-all (but invisible) explanation. We can’t show it, we can’t prove it, but the theory sounds good so we’ll just assume that it’s bubbling away there somewhere underneath…

  7. mark wenitong says:

    re marcus alward – would have to disagree, cultural connectedness is not “alleged” to improve health and wellbeing of Aboriginal people – there is data. though agree that sometimes culture can make life harder for GPs managing their care – it is more likley that epigenetic causes (similar to all races) have a sig impact, rather than oversimplifying genetic causes. Aboriginal culture is quite compatable with western medical science, (just more sophistocated) but the point of he opirion piece is we doctors dont always ensure that we go the extra mile to support our Aboriginal pts in this way.

  8. Marcus Aylward says:

    You can deliver health care in non-threatening ways, but organ systems do not recognise ethnicity.

    Aboriginality is not the disease, but constitutes a genetic predisposition to certain diseases for which Western medicine has treatments; Aboriginality is certainly not a cure, and cultural connectedness may equally be alleged to increase health risks and impair response to treatment.

    Aboriginal culture and western medicine (indeed probably all western culture in general) are in fact incompatible: the discussion is directed therefore to what adequate compromise can be reached to achieve health outcomes.

  9. Stan Doumani says:

    Nice article! However, the arguments put forward to not simply apply to our indigenous population but to the ehtnicity of the people who have chosen to call us their doctor. Most of the arguments put forward could apply to any ethnic group. Take the Chinese as an example of a very different culture. One cannot be an effective GP to someone of Chinese origin without recognising the cultural differences and beliefs.

    This brings me to the nub of the question raised in the poll. I answered it “Strongly Agree” but it rankled! The real question posed by the poll should be:

    When history-taking, doctors should routinely ask patients about their ethenicity including their Aboriginality

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