Friday, July 6, 2012

Celebrating NAIDOC Day - a suggestion for health professionals

This week is NAIDOC week, with events around the country celebrating Aboriginal culture. It’s an excellent opportunity to learn more about something uniquely Australian. After all, we should be proud that the first people of this country have longest surviving culture in the world.
We all know the disparities which Aboriginal and Torres Strait Islander people often have in terms of health and educations outcomes, and these spring directly from a history of dispossession and racism. However, connection to land and culture is a real strength and we all benefit from learning about this.
Reconciliation comes with awareness, understanding and respect, and then with changes in behaviour. Nothing ever changed by carrying on doing what we always did. So when we celebrate NAIDOC week, we need to then move on to celebrating Aboriginal and Torres Strait Islander cultures in other weeks as well. We need our political, social and economic systems to take on some Aboriginality. We talk about the benefits of “diversity” but this is one way we can actually do this.
What might this look like? The example I know most about would be in health – and actually could be adopted in health now. If you ask a health professional what the definition of health is, probably most would come up with the fine WHO definition coined at the Declaration of Alma Ata:
·         “Health is a a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”
It’s quite a good definition, although probably unobtainable – who could say they have are currently in a state of complete physical, mental and social wellbeing right now? Treasure it if you can!
·         Aboriginal health is not just the physical well being of an individual but is the social, emotional and cultural well being of the whole community in which each individual is able to achieve their full potential thereby bringing about the total well being of their community. It is a whole-of-life view and includes the cyclical concept of life-death-life.

Take a moment to read that again.

There are two things that strike me as being fundamentally different,. The first is that health is inextricably linked to connection to community. You can’t be healthy if your community is sick.
The other thing that strikes me is that there is no mention of disease in there. Health is not defined by the presence or absence of disease. The WHO definition is defined by the absence of bad stuff and then some. On the Aboriginal definition, you could actually have a disease or illness and still be healthy – community health and reaching your potential in that community is the measure of health.
So far, so abstract. But they say there is nothing as practical as a good theory. Let’s see what would happen if health workers took this definition up.
Imagine seeing someone with type 2 diabetes. Under the WHO definition, health is not obtained until the diabetes is made to disappear, and then some. Health is the absence of disease and more. Knowing we can’t achieve this (though the search continues) we try to control the disease. Because this definition concentrates on the individual, that’s where our attention is. We think about this as a disease, about pancreases, insulin and insulin resistance. All our efforts are directed at this – the solution is medication concentrating on insulin secretion, on diet and exercise, as a mediator of insulin function and health. We can then label people as “non-compliant” when they don’t do this. They are failing their pancreas!
None of this is wrong, of course, but it does distance us from the patient, who learns some new words like pancreas, insulin and HbA1c, but is unlikely to use these words in telling their life story!
But if we treat someone using the Aboriginal definition of health, our attention is directed more broadly. Health is about being able to reach your potential in connection with community. Successful management is directed towards this – treating the pancreas is only useful in how it allows people to do what they need to do in the community. Successful treatment will require more than just seeing a range of health professionals to give advice, though it may include this. Successful treatment will be measured by connection to others, the ability to look after community and country. Dietary advice becomes about connection to culture, not a lecture on saturated fats.
We can do the same with, say, smoking cessation. We’ve become sort of trapped in the notion that smoking is just a problem of addiction to nicotine, which makes us think the solution is Nicotine replacement or medication. And then we stop looking for solutions. However, re-read the Aboriginal definition of health, have a peek at this debate in the MJA, and read this from Iona Heath:
“I believe that all my patients are fully informed of the dangers of smoking.  Sadly, many continue to smoke because they lead lives which are so materially and emotionally constrained that cigarette smoking is one of pitifully few sources of pleasure and relief.”
Perhaps there are solutions to stopping smoking, which, remember, kills and disables many people before their time,  are about creating strong, healthy communities, and removing the ability of the tobacco companies to undo this. It’s hard to do in a consultation, but more effective than medication alone.
Clearly, the issues are similar for mental health – even starting to call it social and emotional wellbeing broadens our perspective from an issue of just medication and counselling for an individual to a community approach addressing inclusion, loneliness, acceptance of everybody.
If you look at how an Aboriginal Community Controlled HealthService tries to “deliver health” (as if that were even possible) they include medical services, but they do so much more. Women’s groups, community kitchens, exercise groups, Link-Up – all based around that definition of community connection.
Many of us, particularly those in General Practice, understand something of this approach. The Aboriginal definition of health puts words to this and allows it to be practiced and taught. NAIDOC day would be an ideal time to try it out.

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