"It's difficult for aboriginal people to leave country when they are sick or for births or deaths because country is their place for healing and their source of spirituality and support. For some remote communities, everyone knows where they fit and how they relate to everyone. It must be very difficult to come to Perth where no one cares about you and you don't fit. There is assistance for people who need to travel to give them an escort. That's up to the gp. Administrative stuff happens at the hospital and the hospital argues sometimes even when the gp says they need the escort. I had a man who was 70 years old who hadn't been to Perth for 50 years and all that the clerk wanted to know was if he could walk or not to go to his appointment. Particularly if people are going down for a test, they are outpatients so their accommodations are separate from the hospital. We have very limited services to help people get from the airport to their accommodations to their appointments. People lack the savvy to do this. A family was given a voucher for the public transport but they had never seen a bus in their life so they walked a couple kilometers to the train and didn't understand how to pay and then they got a fine. If they had a German accent they would have been tolerated but because they look aboriginal they were not tolerated. A young family couldn't find accommodation in Perth. The husband was from over 3000 km away. We helped him transfer to Darwin because it was closer to home. He was quite grumpy and bit snappy, but he was in his mid-30's suffering renal failure. It's not reasonable to expect him to be nice under those circumstances and" In the end he went home to be with family when he needed to and got an infection and died.
"I remember when we first went into the region people said you get to Perth in a plane and you return in a box. Our mob doesn't seek services until they're quite unwell which contributes to that perception. The understanding may need to be two way."
Next I asked Laura about the relationship of health care to traditional community healers, She said, "The aboriginal medical service because they're part of the community are able to link into traditional healers though they don't employ them. Often families do that off their own back [meaning pay for healers with their own funds]. Some willingness exists in mental health to work with traditional healers. Coverage doesn't exist for the moment. We have an expanding statewide mental health service. It will take a while to filter out what that means. We're not really sure what the status of their obligation is.
"It depends upon what region you're from whether or not you have healers. Sometimes it's the willingness of a particular staff member to see something like that especially for acute mental illnesses. The person might require an acute place to stay. People have to go a long way from home to access anything. That's hard for their recovery and for the family engagement. A lot of services say that social emotional wellbeing is not a part of what they provide. For example, the 70 year old man who needs an escort being told he doesn't. When someone doesn't have the means to get to the hospital for their appointment, that's a problem. Culture is treated as a layer you put on the end to make it seem a little nicer. They don't understand that people might not access service at all because it conflicts terribly with their own beliefs."
That seemed to be the theme of this week. Culture is not an afterthought. It is all important. Here is where the health system and the community disconnect. For the health system, culture is just cute art, because science has the answers and patients should just do as we say. Of course, even the recent history of medicine reveals that what medicine believes to be absolute fact turns out to be incorrect. We are curiously without history in medicine. Whatever we believe today, we act as if we have always believed it.
Here is an example from the United States. The cost of treating people who have had at least one hospitalization for depression and are on public funding has increased by 30% over the 10 years from 1996 to 2006 in a study just published. During that time no improvement in outcome was seen. Hospitalization frequency dropped, and so did psychotherapy from 58% to about 35%. Medication use increased from 81% to 87%. The increase in cost was attributed to the use of more expensive drugs, such as the adjuvant use of antipsychotics to treat non-psychotically depressed patients. Are we doing the right thing if costs go up with no improvement in outcome?
Implicit within the appreciation of culture is the understanding that medicine itself is just a story. Theories are stories and stories change. Treating the story is often more important than treating the disease because the disease is the story and the story is the disease. Our stories about the world arise from our bodies and represent our bodies' ways of communicating internal states. Change the internal state, change the story. Change the story, change the internal state. This is not obvious at all from within the biomedical paradigm.
