Although all Australian healthcare providers are acutely aware of the health outcomes for Aboriginal and Torres Strait Islander peoples, many general practitioners may feel unprepared to take on the challenge of working in an Aboriginal medical service or in a remote Indigenous community. To highlight the immense rewards, without minimising the challenges, AFP invited Dr Lara Wieland, a GP with longstanding experience in the front-line of providing primary care for Aboriginal peoples, to share her thoughts.
I’m a doctor who has been working in Indigenous health for most of my career. For the last 13 years I have worked in a remote Aboriginal community on Cape York where I have been a doctor, volunteer youth worker, have children boarding with me, and run a children’s charity and community garden. I have been deeply involved in my community on many levels. It has broken my heart many times, and it is a deeply embedded part of my life now, my second home, and the people are like family. Professionally, I may try other things in future but Indigenous health is always likely to be my first love. Some things I have experienced are terrifying, others are frustrating, most are challenging, some are deeply satisfying, and occasionally they are truly joyful; no day is boring.
How did my journey lead me here? When I was studying medicine I knew I wanted to work in a community where I would be needed and could help address injustice. This stemmed from a combination of my upbringing, my dad’s example and my strong faith. Africa seemed a logical choice. I had thought about Indigenous communities, mainly because of my exposure at school to so many Aboriginal children from a nearby community. Some were my friends and when I talked to them it seemed that many did not have the same opportunities; many were less healthy looking than the other children. I was a teenager so I didn’t really think about it a lot, but looking back I think those vague observations had started to influence my thinking and views.
I didn’t think much more about it and no one seemed to talk about Indigenous health in those days and it wasn’t a popular career choice. My life changed when a student placement in an Indian missionary hospital had to be cancelled and my backpacking plans put aside following a beach volleyball injury that ruptured a spinal disc a few months before. So off to Bamaga, near Cape York, and Thursday Island I went. While I think these communities are probably now a lot better off than most other Aboriginal communities, it was an eye opener to see people with such poor health on my back doorstep. Meeting the legendary Dr Peter Holt, who had fought so passionately for health services for what was then such a neglected area, opened my eyes to how much need there was in my own country and how much I could do as a doctor. And, more importantly, it was a need that so few seemed to want to fill. From then on, every door that opened or closed for me and the people I met along the way, such as the legendary and inspirational Drs Clive Hadfield and Richard Heazlewood, all seemed to be leading me to my ultimate destination in Indigenous health.
Dr Lara Wieland
My nature is to be constantly questioning, thinking and making sense of things around me. I wanted to understand why things were the way they were. I read all I could on the subject. I was yet to be actually exposed to any real Indigenous health issues but I wanted to prepare. Of course I thought it was so simple: all of the problems facing Aboriginal and communities now are related to colonisation and dispossession. At least that’s what all the articles and ‘experts’ said.
Reading the history and hearing some of the stories revealed horrific injustices and trauma in our early history as a country, some incredibly shameful behaviour. It made sense. I recall writing an essay as a medical student on Indigenous health for a competition. I received a special commendation. I regurgitated all I had read and heard about how history was the sole cause of all the current health and social problems in Aboriginal communities. I found my essay many years later and realised now how simplistic and naïve I was. I have learned many things since that time, and am still constantly learning. One of the main things I have learned is that not much is black and white. Our lives are made up of a thousand shades of grey.
I started thinking for myself. Is the horrific past enough of a reason for this inequity? Entire nations have experienced genocide, war, destruction and dispossession but somehow they have been able to build up their families again. What about Holocaust survivors? Although I could see a connection between past atrocities and injustice, it didn’t sit right with me as a sole explanation for the gap in heath standards.
As I moved into placements in Indigenous health in different communities, I started to meet incredible, inspiring, elderly Indigenous people. I’d listen to their stories. One told me about her childhood experience in a massacre in which their community had been ambushed and run off a waterfall. She survived, cushioned between the bodies of her mother and grandmother, and played dead as the remaining survivors were shot. Despite this childhood trauma, she and some of the other Elders are some of the strongest people I have met. They have been through some terrible times yet they raised good children, held their families together, remembered their traditions, were educated and bestowed a lot of love and guidance on the next generation. So many of these people are despairing of what has been happening to later generations.
I was no longer convinced that history is the only explanation. Part of me was relieved because I was starting to suspect that blaming something that cannot be remedied or undone could easily be an excuse to do nothing – to exclaim that it’s all too hard. Years later I came to learn from many Aboriginal Elder friends that despite the horrific things that happened in the past during colonisation (and there are some terrible stories) they believed they had started to build their lives back up again. Many had strong families who retained traditional knowledge despite the odds.
The community I worked in was very functional; they met all their own needs – building, plumbing, food production, including meat, dairy produce and eggs. Things changed for the worse when the deadly combination of easy welfare and alcohol arrived. Most of my older Aboriginal friends identified this as the turning point. Some communities are still dealing with the fallout of that generation of chaos that resulted in alcohol-fuelled violence and child neglect.
I then started to think that perhaps if there were more services things would improve. And I absolutely believe that there should be access to good services commensurate with the need and have fought hard for that. That has really improved in the years since I started and yet health improvements do not seem to be correlating with increases in services. Dr Ernest Hunter who has been a psychiatrist for the Cape for 35 years has observed the same over that longer time frame. One could study, ponder and write on this ad infinitum and perhaps still not find the answer but perhaps it comes back to relationships and more whole-of-person care. The more we divide up healthcare into various funding streams, projects, teams and fragmented services, the more we lose sight of how important it is for us as healthcare providers to have relationships with our patients and the community. This division makes it harder and harder to see the patient as a whole person and not just pieces of mental health, diabetes, heart disease and so on. Our patients can only be increasingly confused and disenchanted by the endless stream of people who want to talk to them about tiny parts of their lives, which, in their fragments and out of context, don’t actually mean much to them.
I progressed through my resident years and training as a GP, trying my hardest to get as many Indigenous community or Aboriginal medical service placements as I could. I continued to think about the issues. I’m not big on ‘spooky moments’ but I thought I had one when I was relieving for a few weeks in an Indigenous community outside of Cairns. I met a lovely old lady and was chatting to her in the consultation. I asked her about her life, listened to her stories and sorted out her minor medical problem. No big deal. The next day she came back with a beautiful traditional necklace she had made to give me. Her words, which I will never forget, were ‘This is for you, because I can see in your heart you love Aboriginal people and you will help them’.
I could have read all kinds of things into that. Was this a sign? Did I have some kind of spiritual affinity with Aboriginal people that this Elder was sensing? Well at the time it did feel a bit weird and I remember thinking, I’m a reliever – how does she know my heart’s desire is to work long term in these places? I would reflect on this moment often in the years that followed.
More doors opening led me to the Aboriginal community I am now attached to. I was certainly led because while I love it now and cannot leave, it
would not have been my first choice. I occasionally ponder why I didn’t form an attachment to a more aesthetic community or one where the fishing is closer or there’s a nice beach to walk on after work, but it wasn’t meant to be.
My first years there were horrific, yet I was able to form many close relationships and develop a love for the community. In the early years, I felt a strong sense of injustice. So much was happening and the women and children especially were crying out for help, but no one was listening and help was not forthcoming. I listened to their stories and tried to place myself in their shoes. I came to realise how easily I could have made the same choices in the same circumstances.
I recall a lovely patient who became a close friend and whose children call me aunty. This person was poorly judged because of behavioural problems; they were constantly drunk and in trouble with the law, not uncommon in the community, and seemed especially fond of stirring up trouble. However, as our friendship developed, I learned that this behaviour was masking a dark history of abuse. This person’s pain was almost unbearable, made worse by public taunts, and I discovered this behaviour was a cry for help. Through counselling and support, the patient has moved on with their life and is a wonderful parent. If I had not taken the time to learn the patient’s history, I may have also just seen them as a ‘hopeless, trouble-making drunk’.
Frustrated at the lack of response through the usual channels and wanting to give voice to the women and children who were suffering, I became an outspoken advocate. This came at a great cost to me personally, but I have no regrets. In my mind, this is what was needed at the time and the cost to me was nothing when compared with what so many people in my community were going through. I learnt a lot through this experience. I learnt the power of advocacy and speaking out, but also that it is a power that is not to be overused. Many expected me to continue to be vocal and in the media after that time or to take on some high-profile consultancy or policy work or politics. I certainly had offers and the opportunity to do this. In fact, people are often surprised to hear that I am still quietly working away in this remote community all these years after my time in the media.
It became clearer to me as time went on that the best I had to offer the community, my patients, was my relationship with them, my love and respect for them and my professional skills, which I had spent many years acquiring. I was not going to be the dropout doctor who came here as a last resort and left when things got tough. I was going to be here by choice. I was going to be the best doctor I could be. I decided I would increase my qualifications, not to climb the ladder, but to provide top-quality care to my patients. I would value them as deserving of that quality care and I would show them love and respect and give them the best medical treatment possible. Dr Clive Hadfield, a legendary visiting general physician of Cape York with incredible medical and procedural skills, once said to me in a contemplative moment, ‘I’m starting to think that the best thing I offer my patients is kindness’.
ABC Radio produced a series on rural doctors and one segment was about me. The producer interviewed a few of the Elders from the community and Tania Major (who is a young person from the community who later went on to become Young Australian of the Year). I was with Tania when she was interviewed and I remember being taken aback as she described her first impressions of me. Tania said many nice things but she exclaimed, ‘…and this woman was treating us like anybody else, like we were equals!’ I looked up at her in surprise and as the tape recorder was turned off I said, ‘It never occurred to me that you weren’t’.
I thought it was so telling that it was seen as something outstanding to treat the people of that community the same as I would treat any other patient and treat them like equals! I guess it never occurred to me that there was another way, but clearly there was, as the Elders’ comments reflected the same theme. This gave me plenty to think about yet again.
Time spent in the community, not just as a doctor, but as a friend, mentor, ‘aunty’, ‘carer’ (and no doubt I’ll soon get ‘granny’ as the hair gets greyer) has taught me that, yes, we all want to be loved and valued and that we are more alike than we are different. But it has also taught me that there are a thousand shades of grey. Each person’s story is complex. The way out for each person may be different and most likely they have to find it themselves, but, as doctors we can be a part of helping them find the capabilities to do this and unlocking their potential. We can help ensure good health for mothers and their children, who can learn and be capable of making decisions, and ensure good health for fathers, who can be there for their families. We can help people through tough times and support them to make better choices. Some doctors try too hard to do more than that but in doing so they are undervaluing their patients’ ability and need to make their choices, and undervaluing and/or underutilising their skills as medical professionals.
Understanding culture is also important. But I believe that in a way that is probably different to what many think. I understand now that culture is not static; it is always changing for all of us. We all are products of our cultures. All cultures have positives and negatives. History tells us that people groups that ‘thrive’ are those that can adapt, rejecting negative aspects of their culture that no longer work and adopting positive aspects of surrounding cultures that do work, while maintaining the positive aspects of their own culture. That works for all cultures, including my own mainstream Australian one. There are certainly very negative aspects of our culture that I would hope we could reject and move on from and that Indigenous peoples will not adopt. However the fear of being seen to criticise a culture that has already suffered so much and been oppressed unfortunately stifles any discussion about aspects of culture that in the present context damage health and emotional wellbeing. Of course those discussions and decisions are for each culture and individuals within that culture to have themselves. The women of Papua New Guinea have recently started discussing how their Wontok culture and culture of payback and fear of spirits is holding back their progress as a nation. Mainstream Australian culture probably needs to start discussing more about how our binge drinking, ‘easy going’ culture is damaging us as a nation as we become less educated, less healthy and less productive. Each culture needs to have these discussions and suggesting that Aboriginal peoples are the only ones exempt from this reflection is not helpful. On an individual level, I’ve found there can be quite subtle cultural differences that do influence people’s way of thinking and acting in the community I work in. But again there are shades of grey and it can’t be taught in a cultural awareness course. I see so many different aspects of it in different individuals and believe I only get to see and understand some of this because of the long-term relationships I have formed that are built on love and respect. Cultural awareness training has a valuable place in our professional development but it does not replace going to a place, working there, getting to know people, observing, caring and, most of all, listening.
Over the years, I have looked back to that moment when the old lady gave me that necklace and I’ve realised it wasn’t such a ‘spooky moment’ after all. She had given me a summary of what was the most important lesson I was to learn. All I had done was take the time to listen and be kind and that felt special to her. Yes, of course, there are cultural differences as there are with so many different cultures and we need to be aware of and sensitive to them wherever we are or whoever we are dealing with; but showing a person love and respect, listening to them and giving them all the benefit of your medical expertise and skill regardless of their culture or background is the most powerful thing you can do.
Advocacy and speaking out are also crucial aspects of working with disempowered people and there is a time and place for that too. But if you can show love and respect, and use your skills and expertise to lead people to better health as individuals and families then you are assisting them to be able to speak up for themselves and make better decisions for themselves, their families and community. As a generation comes through who have been so severely traumatised by years of chaos and neglect this has never been more important. This is some of what I have learnt so far on my journey into Aboriginal health, a journey that is not over yet.
Competing interests: None.
Provenance and peer review: Commissioned; externally peer reviewed.